2008 / 1 Abnormal Psychology

V.M. Durand

&

D.H. Barlow

Sungshin Women

’

s University Jungkyu Kim Ph.D

Table of contents

1.

Classification and diagnosis of abnormal behaviors I. Anxiety Disorders 1. Generalized Anxiety Disorder 2. Panic Disorder with (without) Agoraphobia 3. Specific Phobia

4. Social Phobia 5. Post Traumatic Stress disorder (PTSD) 6. Obsessive Compulsive Disorder

II. Somatoform Disorder and Dissociative Disorder 1. Somatoform Disorder

1. Hypochondria 2. Somatization Disorder 3. Conversion Disorder 4. Pain disorder 5. Body Dysmorhic disorder

2. Dissociative Disorder

1. Depersonalization Disorder 2. Dissociative Amnesia 3. Dissociative Fugue 4. Dissociative Trance Disorder 5. Dissociative Identity Disorder

III. Developmental and Cognitive Disorder 1. Developmental Disorder 1. Attention Deficit and Hyperactivity Disorder 2. Learning Disability 3. Communication and related Disorder 4. Autism 5. Mental Retardation

2. Cognitive Disorder

1. Delirium 2. Dementia 3. Amnestic Disorder

IV. Mood Disorders

1. Depression 2. Bipolar Disorder

V. Schizophrenia and related Psychotic Disorders

Positive Symptoms Negative Symptoms Disorganized Symptoms

I. Classification and diagnosis of abnormal behaviors  Reliability => If the same results come out shown to multiple doctors. If the results remain the same over the time.

 Validity => If the test measures what the test promises to concurrent validity, predictive validity  Standardization => To make a norm against which to compare the individual score and interpret the meaning of it

1.

The procedures of making a Diagnosis

Clinical Interview A . Appearance and Behavior Clothing, Posture, Facial expression, Movement, Voice etc.

B. Thought Process Speed of Speech, Consistency, Cohesion, Fluency, Delusion, Hallucination

C. Mood State Appropriateness of mood, Depression, Elation, Blunt, Flat D . Intellectual Functioning Comprehension, Use of Language, Memory E. Perception of Environment Date, Space, Perception of Self

2.

Behavioral Assessment

   Direct assessment behavioral observation by means of Patient’s statements are often not enough or distorted So, this is the most direct and effective way to get accurate informations

II. Classifications

 Causes of psychopathology are complex For example, psychological, environmental, and physiological -> classical categorical approach is inappropriate 

Dimensional approach

-> assessing various dimensions for example cognition, emotion, behavior -> this is not complete either, because there are no agreed on dimensions among the assessors

 Prototypical approach => integration of the categorical approach and dimensional approach Used most often recently -> used in DSM-IV

DSM-IV

    Reorganized together with ICD-10 The most salient difference between DSM-IV and its previous versions => eliminating the distinction between organically based disorders and psychologically based disorders Axis I : various psychopathologies, pervasive developmental disorders, learning disorders, motor skills disorders, communication disorders Axis II : Personality disorders, mental retardation

  Axis III : Medical conditions Axis IV : Psychological and environmental problems that might have   an impact on the disorder Axis V: current level of adjustment From 0 to 100 scale (100 indicating superior functioning in a variety of situations) Other optional Axes: Defense mechanisms, coping styles, social and occupational functioning, and relational functioning

< Criticisms of DSM-IV>      There are categories many overlaps among Too much emphasis on the reliability the -> ignoring the validity Tendency categories to stick to the traditional Needs to classify on the basis of more researches in the future The problem of the labeling

< New diagnostic categories >  Mixed anxiety-depression ; currently being studied  It belongs neither to Anxiety disorder nor to Depression, but shows symptoms of both

I. Anxiety Disorders

      Characteristics of anxiety negative emotion, bodily tension, worrying over the future Knows that he or she doesn ’ t need to worry so much Related closely to depression Positive aspect of anxiety => protection, improve achievement Increase of heart rate , blood pressure, dilation of pupil , muscle tension etc.

Autonomous Nerve system => flight or fight

< Cause >

Physiological aspects    Multiple genes are interrelated GABA-benzodiazepine sytem of brain Shortage of the neurotransmitter GABA (Gamma-Aminobutyric Acid) -> anxiety   The noradrenergic system and serotonergic system are involved also The brain region which is most closely related to anxiety -> lymbic system



Lymbic

system mediates between brain stem which is in charge of body functioning and cortex which is responsible for cognitive processes Psychological aspects   Feeling of uncontrollability Initially caused by external stimulus -> associated with various internal and external situations Social aspects  Social pressures, marriage, divorce, occupation, death of close person

Integrative model   Anxiety cannot be explained by genetic factors alone The thought of uncontrollability causes anxiety Social and environmental pressures   Once the anxiety become chronic, it doesn ’ t go away even if the external factors disappear -> it becomes automatic

1.

Generalized Anxiety Disorder

(GAD)

      Overly concerned and worrying Worries about every thing in the life Difficulties in making decision Future oriented At least persisted more than 6 months Days of feeling uncontrollable exceeds those of controllable

 Tension, irritability, easily tired, nervous, insomnia, difficult to concentrate  Worry about minor things such as family members, health, appointments etc.

In case of the children => academic, athletic, or social performance and physical injuries.

1.

statistics       Prevalence rate 4% Among the elderly; 17-21.5% Visit clinics less often than panic disorder or social phobia patients.

Female patients outnumbers male patients with 55 - 65% Develops slowly and become chronic in most cases Benzodiazepine , a sedative that is prescribed often to old people => risk of hip injury

2.

Cause

(integrative model)

 Heredity research proved by monozygotic twin  A heredity of a general anxiety proneness rather than that of GAD  Increase of EEG beta activity in frontal lobe observed in recent research => a strong information processing in this region

 Worrying helps defend negative affects and images, but it prevents adaptation to them  multiple causes => physiological factors, stress, habit of worrying, incompetence of problem solving

3.

Treatment  Most often used drug is Benzodiazepine questionable in its long term effects risk factors => impairment in cognitive , motor functioning => driving, falling down  D ependency; psychologically, physiologically helpful in crisis intervention  There is reports that anti-depressant are effective.

psychotherapies are more effective on long term based

 Patients have tendency to avoid negative affects and images => confronting them and relaxation at the same time ; Borkovec and Costello(1993)  Inducing and then confronting the worry process in CBT + various coping strategies and cognitive therapy (Craske and Barlow )  Combined with family therapy -> very effective in children  PRO meditation (Gregory Kramer)

2. Panic Disorder with and without Agoraphobia

    Normal in relationship with people Avoid unsafe situations for fear of not being able to escape in case of panic => stay at home Not all panic experience leads to panic disorder Unexpected experience of panic => extreme fear of re-experiencing the panic

  Feeling of dying in panic attack Avoid such places as shopping mall, bus, train, subway, open street, tunnel, restaurants, theater etc agoraphobia can appear later independent of panic experience   Arise according to patients’ thoughts or expectations rather than by their actual experiences Endures the feared place or situations if necessary

  Avoid not only specific place or situation, but particular physical experiences For example, ascending stairs, walking around under hot weather, dancing, making love, watching horror movies, having a quarrel, taking hot sauna, climbing mountains  This is called intero-ceptive avoidance (cf. intero-ceptive exposure)

1.

statistics

   P revalence 3.5% female outnumbers 3:2 Onset : from middle of 10~40 mostly after puberty In case of severe agora phobia proportion of the female 89%  Men mostly tend to develop alcohol abuse => the problem become worse

  Prevalence stay constant throughout various cultures Similar prevalence rate among various ethnic groups in the States    Black people show hypertension together 60% of the patients experience panic attack at night Early morning between 1:00 and 1:30 AM

 Night panic takes place during delta wave of EEG => deepist phase of sleep  Extreme fear of death  Different from night mare, which takes place during the REM phase and it comes much later.

 Also different from the sleep apnea, which puts the person to sleep again

2. Cause

  After unexpected panic experience Mediated by social and cultural factors  Affected by physiological and psychological components  Physiological responsiveness to stress inherited => it associates specific environmental and internal stimuli to panic attack

 Misinterpretation of a neutral stimulus as dangerous => anxiety of reexperiencing panic attack 

8-12% of people experience intermittently panic

-> in most cases don

’

t develop panic disorder -> attribute to conflicts with friends, ingested foods, by chance etc

 Only 3% of people leads to panic disorder  These people have cognitive vulnerability -> misinterpret a normal bodily reaction as dangerous => sympathic nervous system aroused => perceived as dangerous => vicious circle

3. treatment

 Imipramine, a tricyclic antidepressant -> influences on serotonin and noradrenalin -> has effect on panic disorder -> but not on GAD  Benzodiazepine decreases anxiety -> but not panic disorder => So, anxiety and panic disorder are two independent illnesses (Donald Klein, 1964).

 But in follow up benzodiazepine had a similar effect as Imipramin or SSRI (Serotonic specific reuptake inhibitors; Prozac, Paxil), if the dose is enhanced.

 Imipramin has such side effects as dizziness, dry mouth, sometimes low sexual functioning, which causes patients to refuse medication.

 Good effects, if there is no complications

   SSRI is used widely because of low side effects But it lowers sexual functioning Alprazolam (Xanax) is high density Benzodiazepine => Good effect, but high dependency   Benzodiazepine affects cognitive and motor functioning => difficulties in learning and driving It can decrease 60 % of panic attack during medication, but relapse rate of 20-50% if stop

 Psychological treatment is also effective mainly exposure therapy

- Systematic exposures on the hierarchic tasks

-

> visiting shopping malls 30

-

> eating in a restaurant alone

-

> going to the cinema alone

minutes -

> walking 5 blocks alone from home

-

> driving 5 miles on the high way

 Barlow & Crask’s Panic control treatment (PCT) > deals with panic disorder directly    Direct exposure to the stimuli that patients are afraid of Going up and down the step in the office Turning around on the chair   Blood dizziness pressure increasing , > habituation Combining cognitive therapy, training and breathing exercise inducing relaxation

< Comparison of effectiveness of drug and psychotherapy >  Barlow(1998)’s NIMH research 304 panic disorder patients PCT alone, imipramine alone, PCT + imipramine, PCT+ placebo, placebo alone => PCT + imipramine and PCT+ placebo showed most effective However, the two showed no differences => drug has no additional merits

3. Specific Phobia

< clinical descriptions >  Irrational fear of specific object or situations that impairs daily functioning of the individual  It was called in the past as “simple phobia”    At a closer look, it is not that simple Many people suffer from it Give up work or move out

 Objects of fear are innumerable - Insects, darkness, heights, wind, wide space, streets, sharp objects, cars, pains, dusts, injury, men, women, society, flood, infinity, physical contact, thunder, lightening, chaos, ruins, aurora, being alone etc.

 Before publication of was no meaningful classification of specific phobias existed DSM-IV in 1994, there  Currently 4 major subtypes of specific phobia identified 1) animal type 2) natural environmental type 3) blood-injury- injection type 4) situational type

<

Animal phobia

>

  Fear of animal and insects It restricts the individual ’ s activity severely  Cannot read magazines for fear of unexpectedly coming across a snake or mouse  Cannot take a trip  Early onset around 7 years old

< Natural environmental phobia >

 Fear of heights, thunder, water  Temporary fear is excluded  Persistent and severe restrictions of daily life  Early onset around 7 years old

< Blood – injury – injection phobia >   Fears of losing control and going to faint, if exposed to a feared situation But this doesn ’ t happen, because the blood pressure and pulse rate goes up  By the way, blood-injury-injection phobia patients can really faint, if they are confronted with the feared situations, because their blood pressure and pulse rate drop   Genetic influences Onset around 9 years old

< situational phobia >

  Fears of being trapped in transportations or in a closed space public Used to be thought as similar to Panic Disorder with Agoraphobia (PDA)   On the closer look, it shows quite different modality Situational phobia shows phobic reaction in reaction to the specific situations  PDA shows panic reaction in unexpected situations

< Other phobias >

    Overly cautious behaviors against becoming infected or getting sick Extreme restriction of activities in fear of getting contaminated from AIDS Avoiding public restrooms, restaurants Choking phobia ; avoiding intake of foods > marked decrease of weights degeneration of teeth and the gums

< separation anxiety >

 Unique anxiety occurring during childhood  Unrealistic and persistent worry that something might happen to their parents or themselves that will separate them from their parents  Refuse going to school  Not because they dislike the school, but because they fear the separation

 Refuse to sleep alone, night mare, physical symptoms, anxiety symtoms  Must make sure, if the anxiety is abnormally strong  To be differentiated from school phobia, which is related to concrete situations in the school.

 They can go to the places alone other than schools

1.Statistics

  Relatively easy to see. prevalence 11 % More female than men ( 4:1)  snake phobia and heights phobia is most common  Persists lifelong  To be differentiated from temporary phobia in childhood such as fear of new face, fear of darkness, fear of ghost etc.

 Hispanics develops twice as often as whites  Chinese show “ fear of the cold ” => Pa-leng They have morbid fear of losing balance between yin and yang.

They ruminate over loss of body heat and may wear layers of clothing even on a hot day.

2.

Cause  In the past, it was thought to be influenced by trauma experience. Not proved yet.

There are several ways to develop a phobia 1. Direct experience choking phobia, claustrophobia 2. Observing someone else experience severe phobia. (vicarious experience) 3.

Being told about the danger 4. Panic experience in a specific situation (false alarm)

 Anticipatory anxiety danger -> phobia about certain  “preparedness”, that is, inherited tendency to fear situations that have been dangerous to human race, such as being threatened by wild animals or trapped in small places.

 Cultural factors male -> phobic feeling not accepted

3. Treatment   structured and consistent exposure under the supervision  Individuals who attempts to carry out the exercises alone attempts to do too much, too soon and ends up escaping the situation, which strengthens the phobia.

 When treating blood -injury-injection phobia must offer exposure with muscle tension -> because the patient might faint.

 therapist offer exposure spending most of the day together with the patient -> later the patient can do alone -> being checked by the therapist

4. Social Phobia

< clinical description >  Marked and persistent fear of one or more social or performance situations that involve exposure to unfamiliar people or possible scrutiny by others, with the fear that one will be embarrassed or humiliated.

 Performance anxiety public speaking, eating in a restaurant, signing a paper in front of a clerk, urinating in a public rest room etc.

 S ocial phobia generalized type or social anxiety disorder => individuals who are extremely and painfully shy in almost all social situations.

 Exposure to the feared situation almost always provokes anxiety, sometimes as a panic attack

 Recognition (in adult) that the fear is excessive and unreasonable  The feared social or performance situation is avoided or endured with intense anxiety or distress  The avoidance, anxious anticipation, or distress interferes significantly with the person ’ s life and healthy functioning

1.

Statistics     prevalence rate 13.3% most common psychological disorder currently the sex ratio favors women a little (1.4:1) sex ratio of social phobics appearing at clinics is 50 : 50 => males seek help more frequently, because of career related issues

 Onset mostly in adolescence (15yrs old) more among young, undereducated, single, and low socio-economic class  Relatively equally distributed among different ethnic groups.

2. C

ause  H eredity; some infants are born with a trait of inhibition that is evident as early as 4 moths of age

 Anticipatory anxiety after unexpected experience of panic attack against similar situation  T rauma experience in childhood  vicarious learning of fear through parents  prepared fear of social blame, assault, rejection etc 

 We learn more quickly to fear angry expression than other facial expressions, and this fear diminishes much more slowly than other types of learning  social phobics remembered critical expressions more, whereas normals remembered the accepting expressions.

3. T reatment  Rehearsal in front of patient group

  The rest play a supporter role observing the performance Therapist helps the patient to find and correct his or her automatic perceptions.

  According rehearsals are more effective than cognitive therapy part.

to research, behavioral Tricyclic antidepressant MAO inhibitor is effective, but high probability of relapse when stopping

5.

Posttraumatic

Stress Disorder;

PTSD

< clinical description >  Enduring, distressing emotional disorder that follows exposure to a severe helpless - or fear inducing threat such as rape , violence, traffic accidents, natural disaster, sudden death of family members or friend etc.

 Reexperiences extreme fear, helplessness that the patient experienced at the time of

traumatic event through memories and nightmares.

 flash back => when memories are suddenly and the victims find themselves reliving the event  Victims avoid anything that reminds them of the trauma  They display a characteristic restriction or numbing of emotional responsiveness.

 They repress emotion, sometimes unable to remember certain aspects of the event    Chronically over-aroused, easily startled, and quick to anger First diagnosed in DSM-III But history goes long back   Insomnia, continuous memory of the event Apathy and stupor  = > dissociation Can ’ t remember part or all of the event  feeling of unreality or de-realization

  Acute PTSD event -> 1 month after the Chronic PTSD -> after 3 months more prominent avoidance behaviors usually comorbid with social phobia  Delayed symptoms afterwards.

PTSD after -> shows trauma, but few later develop full-blown PTSD. Often years  Acute stress disorder -> until a month after event

40% of the acute stress disorder => keep PTSD Acute stress disorder in D SM-IV was diagnosed first to help these people get insurance coverage 1.

Statistics  Rachman(1991): only few who endured air raid during the world war II , fire, earth quakes, floods etc. developed later PTSD

1.

Kilpatrick(1985): experienced violence rape, 2,000 women molesting, who robbery, 32% of rape victims -> PTSD 19.2% 44% -> attempted suicide -> suicidal ideation  Resnick 의 연구 (1993) ; 17.9% of American women 7.8% -> PTSD of the whole American -> PTSD

  Male -> mostly due to war experience 15-20% of those involved in car accidents PTSD -> 2.

Cause     Interaction of biological, psychological and sociological factors Vulnerability according to genetic disposition Monozygotic twin concordance rate -> .28-.41

D izygotic twin -> .11-.24

 Excessive secretion of corticotropin releasing factor ( CRF; a and cortisol ( neurotransmitter of olivo cerebellar climbing fiber system) stress hormon ) -> damage to hippocampus  Prepared -> torture victims in turkey -> political vs non political groups with a support group after a trauma -> low rate of PTSD

 High rate of PTSD for the veterans of the Vietnam war -> lack of social support and acceptance

3. T

reatment   Facing the trauma situation Systematic re-experiencing with guidance of a therapist

 Behavior therapy with a child bitten by a dog -> first the brother models the treatment lying on an examination table -> Marcie tried each one in turn -> the therapist took instant photographs so that she kept it after completing the procedure ->she was asked to draw pictures of the situations -> supports of the family members  SSRI ( Prozac , Paxil) -> reducing anxiety

6. Obsessive-Compulsive Disorder; OCD

< Clinical description >   Most severe form of anxiety disorder High comorbidity with GAD, Panic disorder, Major depression  Objects of avoidance Other anxiety disorder -> external situation, animal, traumatic event etc OCD -> his or her own thought, image, impulse

 Obsession => thought, image, impulse that come to consciousness against one’s will  The contents of Intrusive and persistent thoughts and impulses -> sex, aggression, religious contents  Compulsion => thoughts or behaviors that are used to suppress the obsession such as repetitive checking, washing, ordering and arranging, magical ritual, counting numbers, praying, which helps reduce stress and prevents imagined disaster.

< Obsession >  Jenike, Baer and Minichiello(1986); most common obsession -> contamination (55%), aggressive impulse(50%), need for symmetry (37%) sexual content (32%), somatic concerns (35%), 60% of patients showed multiple symptoms

    Need for symmetry refers to keeping things in perfect order Careful not to step on cracks in the sidewalk Impulse to yell out a swear word in church A woman

was afraid to ride a bus for fear that if a man sat down beside her she would grab his crotch.

< Compulsion >  The most common ritual => checking, ordering and arranging, washing and cleaning    Most of OCD patients show washing and cleaning or checking rituals.

Washing or cleaning -> gives patients a sense of safety and control checking rituals -> disaster or catastrophe prevents imagined  Certain kinds of obsession are strongly associated with certain kinds of rituals

 Aggression and sexual obsession lead to checking rituals.

Obsessions with symmetry leads to ordering and arranging or repeating rituals.

Obsession with washing rituals.

contamination lead to some people compulsively hoard things, fearing that if they throw something away, even a 10-year old newspaper, they then might need it.

1. statistics    lifelong prevalence 2.6%( Karno Golding, 1991).

& Frost et al (1986) ; 10-15% of “normal” students engaged in checking behavior To experience occasional intrusive or strange thought is regarded normal.

 many people experience bizarre sexual or aggressive thought when bored.

 For example, impulse to jump out of a high window  Idea of jumping in front of a car  Impulse to push someone in front of a train  Thoughts of catching a disease from public pools  Wishing a person would die  While holding a baby thought of dropping the baby

 Idea of swearing or yelling at my boss  Thought of unnatural sexual acts   Thought that I ’ ve left the heater and stove on Idea that I ’ ve left the car unlocked when I know I ’ ve locked it.

 Most people let these thought pass by

 Certain individuals are horrified by such thoughts, considering them as “ bad thought, bad and evil ” and try to defend against them     More females (55-60%) are inflicted by OCD than male In case of children, more boys suffer than girls.

Maybe because male’s onset begins earlier.

In adolescence the sex ratio equalize

  Average age of onset ranges from early adolescence to mid-20s, but typically peaks earlier in males(13 to 15) than in females(20 to 24) Once OCD develops, it tends to become chronic  Contents of obsession and that of compulsion differ from culture to culture. Nevertheless, OCD looks remarkably similar across cultures.

Showing similar types and proportions.

  In Arabic countries, obsessions are primarily related to religious practices, specifically the Muslim emphasis on cleanliness.

Contamination prevalent in India themes are also highly 2. Causes   Many people experience intrusive thoughts or impulses. But don’t develop OCD.

We must develop anxiety focused on the possibility of having additional intrusive thoughts.

  OCD needs fear of fear as in Panic disorder GAD or However, why do OCD patients develop fear of intrusive thoughts rather than of situation ?

panic attack or other external  Because they have learned that some thoughts are dangerous and unacceptable.

 They bestow special meaning on their thoughts and regard them as equivalent to reality.

 Similar dogma to fundamental religious  Thinking of abortion is the same as doing abortion  Thinking of homosexuality is the same as doing the action  Try to suppress the frightening thoughts or impulses -> distraction, praying, or checking

 Biological, psychological vulnerability and environmental stress interact together -> OCD 3. Treatment  SSRIs have effect on 60% of patients  The average treatment gain is moderate at best and relapse occurs when drug is discontinued.

 Most effective method -> exposure and ritual prevention (ERP)

The rituals are actively prevented and patients are systematically and gradually exposed to the feared thoughts or situations.

 Washing and checking behaviors are prevented   Therapist watch over patient behavior Seeing the feared result not ensuing emotional learning ->

 Medication and psychotherapy combined together -> better effect  Severest patients => psychosurgery (surgical lesion to the cingulate bundle) -> 30% of patients benefited

< Two pathways related to memory >

 Papez circuit : cingulate gyrus/retrosplenial cortex - cingulate bundle -- subiculum / entorhinal cortex -- hippocampus --- fornix --- septal area / mamillary body -- mamillothalamic tract -- anterior n. of the thalamus -- cingulate gyrus

 The lateral limbic circuit: anterior temporal cortex --- amygdala --- dorsomedial n. of the thalamus-- posterior orbitofrontal cortex



II.

Somatoform

and Dissociative Disorders

 Excessive concern about physical health or appearance 

Somatoform disorders

pathological concerns of individuals with the appearance usually in absence of any identifiable medical condition or functioning of their bodies,



Dissociative disorders

Disorders, in which individuals feel detached from themselves or their surroundings, and reality, experience, and identity disintegrate.

 Historically two disorders have been studied together.

 Two disorders show many commonalities and in the past had been called under the same name “hysterical neurosis”

 Hysteria -> wandering uterus (Greek, Egyptian)  The term ‘ hysterical ’ came to refer more generally to physical symptoms without known organic cause or to dramatic or “ histrionic ” behavior thought to be characteristic of women.

 Freud suggested that in a condition called conversion hysteria unexplained physical symptoms indicated the conversion of unconscious emotional conflicts into a more acceptable form.

 The historical term

conversion

remains with us ; however, the prejudicial and stigmatizing term hysterical is no longer used.

 The term

neurosis

was eliminated from the diagnostic system in 1980, because it was too vague and applying to almost all non-psychotic because it implied disorders, a specific unproved cause for these disorders.

and but

1. Somatoform Disorders

 Five basic somatoform disorders are listed in DSM-IV : hypochondriasis, somatization disorder, conversion disorder, pain disorder, and body dysmorphic disorder.

 In each individuals are pathologically concerned with the appearance or functioning of their bodies.

1. Hypochondriasis

< clinical description >  Characterized by anxiety or fear that one has a serious disease.

 The essential problem is anxiety but its expression is different from that of the other anxiety disorders.

 The individual is preoccupied with bodily symptoms, misinterpreting them as disease.

indicative of illness or  Normal bodily functions such as heart rate or perspiration or cough etc are considered to be indicative of serious illness.

 Assurances from doctors that all is well and the individual is healthy don ’ t help.

 Overly concerned in response to slight uncomfortableness in body   Respond very sensation in body sensitively to Don ’ t drink and exercise for fear of becoming ill physical  Some people even don ’ t laugh and cannot fall asleep for fear of stopping breathing.

  Similar to panic disorder Frequently co-morbid with panic disorder

 60% of illness phobia went on later to develop hypochondriasis and panic disorder.

 Illness phobia => individuals who have marked fear of developing a disease  Hypochondriasis => individuals who mistakenly believe they have a disease.

 Core feature of hypochondriasis is the disease conviction.

They misinterpret physical symptoms.

 The latter has a later onset  Panic disorder have immediate expectation of catastrophe, whereas hypochondriasis have relatively delayed expectation of catastrophe.

 The number and art of feared body symptoms are more and diverse in hypochondriasis than in panic disorder.

 Panic disorder => focused on about 10 symptoms of sympathetic nervous system 1.

statistics   prevalence 3 % ; sex ratio 50 : 50 spread fairly evenly phases of adulthood across various  cultural specific syndromes => koro Chinese genitals are retracting into the abdomen.

Guilty have about severe anxiety excessive that the masturbation, unsatisfactory intercourse, or promiscuity ;

 Hot sensations in the head or senation of something crawling in the head, specific to African patients.

 Sensations of burning in the hands and feet in Pakistani or Indian patients.

2.

Causes  Misinterpretation of body sensations of signals

 A disorder of cognition or perception with strong emotional contribution  Excessive focusing on body -> increase of body symptom -> misinterpret -> excitement -> excessive focusing -> increase of body symptom

  Similar to process found in panic disorder Genetic and psychological vulnerability learned behavior => family members often show the same symptoms   Related to stress events Reinforced through patient role in family history and affection -> exempt from responsibility and getting attention

3. Treatment

 Identifying and challenging illness - related misinterpretations of physical sensations and on showing patients how to create “ symptoms ” by focusing attention on certain body areas.

 Bringing on their own symptoms persuaded many patients that such events were under their control.

 Caring in support group is helpful.

 Some people are helped by physician’s reassurance. However, doctors don’t usually find enough time to offer reassurance.

2. Somatization

disorder

 < Clinical description >       French physician the name in 1859 Pierre Briquet gave first “Briquet's syndrome” In 1980 it was changed into somatization disorder Complain innumerable number of body symptoms Suffer chronic pain Disease make up one ’ s identity Visits clinic again and again with similar list of symptoms

   Different from hypochondriasis, they are not so afraid that they have a disease.

They are concerned with the symptoms themselves, not with what they might mean They do not feel the urgency to take action but continually feel weak and ill, and they avoid exercising, thinking it will make them worse.

1.

statistics   prevalence rate : 4.4% onset in adolescence

 More female, economic class  single, low proportion of female : 68% socio  accompanies anxiety, depression  Suicidal attempt to manipulate others  Mostly chronic, continues through old age  In some cultures sex ratio is equivalent or even higher prevalence among male.

2.

causes   A history of family illness Related with Anti social personality disorder  Both begin early in life, typically run a chronic course, predominant among lower socio economic classes, are difficult to treat, and are associated with marital discord, drug and alcohol abuse, and suicide attempts.

 Both group are common in their tendency to seek short term gratification, and impulsivity.

 Temporary attention , care     => isolation in long term Genetic common factors Differences in identification of sex roles Antisocial personality disorder -> masculine, aggressivity Somatization disorder -> feminine, non-aggressivity

3. Treatment        Very difficult Reassuring, caring Reducing stress Decreasing dependency Allowing visiting clinics after consulting ‘ gate keeper ’ doctor Frustrating reinforcement through showing symptoms Encouraging independency => getting job

3. Conversion disorder

< clinical description >

 Disorder of bodily malfunction such as paralysis, blindness, aphonia, loss of the sense of touch, seizure etc. without physical pathology.

  Feel weak and can ’ t walk Another relatively common symptom globus, the sensation of a lump in the throat that makes it difficult to swallow, eat is or sometimes talk.

< closely related disorders >   Indifference to the symptoms. But not always.

Sometimes indifference.

real patients show also  Usually precipitated by marked stress.

 therefore must check, if the appear without any preceding stress.

symptoms => real physical problem

 Although symptoms people can with usually normally, they seem sensory input.

conversion function unaware of -> people with symptom of blind or paralysis of leg -> normal function in emergency  Sometimes misdiagnosis of physical disorder as a conversion

  Difficult to distinguish conversion disorder malingering Malingering aware of their own motivation (factitious disorder by proxy) and => economic interest  factitious disorder -> just to draw other people ’ s attention -> sometimes making their children sick

< Unconscious processes related to conversion disorder >

 Anna. O nursed her father for a long time.

 visual hallucination of a black snake crawling up father ’ s bed => at the moment of catching the snake, the arm was paralyzed  While praying, English came out of her mouth instead of German, which was her mother tongue

 Gradually right part of her body paralyzed and then spread to the other parts of body  Dr.

Breuer hypnotized her and let her re experience the trauma -> recovered her sensation and could speak German again. Dr.

Breuer called this => ‘catharsis’ treatment.

 according to recent research, we can process various informations (visual and auditory) without being aware of it.

1. statistics       Comorbid with other disorders, especially with somatization disorder Prevalence rate range from 1% to 30% More females are inflicted Males can also be attacked when stressed extremely Onset mostly in adolescence Often group found in specific religious

2. Cause  Freud explained in 4 steps 1) experience of a trauma 2) repress it, because it is unacceptable 3) increase of anxiety and conflict > converted into body symptom > reduction of anxiety -> primary gain 4) Attention and sympathy from the environment + exempt from difficult work and responsibility -> secondary gain

 Indifferent attitude of patients -> because of primary gain  Not supported by research data  Could be only preoccupation of the therapist  Socio-cultural influences => low education and low economic class  Familial influence => imitation of family member’s real diseases

   Recently low prevalence => change of social situation resulting in decrease of secondary gain Interpersonal factors problems, psychological Inter-related with other somatoform disoders

3. T

reatment Very similar to somatization disorder => similar treatment

    Let a patient talk about trauma event => encouraged to re-experience the trauma => catharsis Remove the secondary gain Often conspiracy with the family members Without collaboration of the family => relapses after treatment  Elois who can’t walk -> expectation of the mother who was busy with her store

4. Pain disorder < clinical description >

 Somatoform disorder featuring true pain but for which psychological factors play an important role in onset, severity or maintenance  Overlaps with physical illness therefore was considered remove from DSM-IV seriously to



Three subtypes

1) pure psychological origin 2) psychological and physical factors combined 3) pure physical origin   I

n all three psychological factors involved

Pain is real and very hurts, regardless whatever causes it was initiated

     Abdomen, head, muscle pain Temporary or chronic pain Psychological treatment combined with a physical treatment Relaxation meditation training, group therapy, Increased interest in health psychology  5-12% of the population meets the criteria for pain disorder (Grabe et al., 2003)

5. Body dysmorphic disorder

< Clinical description >    Disruptive preoccupation with some imagined defect in appearance ( “ imagined ugliness ” ) Hair, nose, skin, eyes, head, face, bone structure, lips, chin, stomach, waist, teeth, legs, knees, breast, ears, cheeks, buttocks, penis, arms, wrist, neck, forehead, facial muscle, shoulders, hips Relative normal looking people imagine

 they are so ugly that they cannot interact with others An attractive young man feared to go out, because he imagined his head was square formed.

     Checks frequently mirror to see if there is a change in appearance In other cases avoids mirror often suicidal attempts Ideas of reference (in BDD related with appearance) In the past regarded as a psychotic delusional state

 50% of patients real -> think their belief as => in such cases an additional diagnosis of Delusional disorder: somatic type will be given 1. statistics      Prevalence now well known But widely spread than known No spontaneous remission when not treated Similar distribution in both sex In a Japanese research 62% were male

      Onset age ranges from early adolescence to twenties usually don ’ t visit clinic according to up to 24% Veale et al(19 96) suicidal rate influenced by social and cultural standards In some cultures, prolonged or enlarged face are regarded beautiful In other cultures long neck or flat nose is seen as beautiful

 Small feet in china, tale ( Cinderella) also in European fairy

2. Cause and treatment

  Not very well known No research results as to genetic and psychological cause   Psychoanalytic theory assumes repressed conflict displaced into bodily concern Comorbid often with OCD

  Checking behavior related with appearance Similar onset and process    Clomipramine(Anafranil) and Fluoxetine (Prozac) are effective to some patients, which are also effective to OCD Like in OCD , exposure and prevention are effective response cultural influences => in Japan and Korea, it could be diagnosed as social phobia

  2% of plastic surgery patients are BDD According proportion to recent research higher  Nose, chin, eyebrow surgery no satisfaction after surgery => resurgery or surgery of other parts - Of the 25 patients who received the surgery only 2 showed relief and in more than 20 cases, the severity of the disorder increased ( Philip et al., 1993)

2. Dissociative Disorders

    Feels detached from oneself or one’s surroundings, as if they are dreaming or living in slow motion The sense of things and the external reality is lost Loses sense of one ’ s own reality Depersonalization => feels change in identity one’s  Derealization => the individual loses his or her sense of the reality of the external world  The latter being followed by the former

1.

Depersonalization disorder

       Sense of severe unreality Making an individual unable to carry out normal daily life makes him or her frightening as if one observe oneself from outside main symptom being depersonalization and derealization According to Simeon(1997), average onset 16.1

age Mostly become chronic

 50% of the patient additionally diagnosed with anxiety disorder and mood disorder

2. Dissociative Amnesia

     General amnesia => forgets totally who one is Localized amnesia => a failure to recall specific events, usually traumatic, that occurred during a specific period In most cases occur after severe traumatic events Sometimes remembers the even itself, but not the emotion related to it.

More prevalent than general memory disorder

3. dissociative Fugue

      Fugue means escape or flight Move from a place associated with trauma to a different environment Can ’ t remember how he or she came to the place Often gets a new identity Usually begins at an adult age Found in various cultures with different names

4. dissociative Trance Disorder

       Dissociation experienced with ecstasy Sudden changes in personality In some cultures -> believed mediated by spirit => Possession to be Like in other dissociative disorder, related to current stress or trauma rather than past trauma More often in female Regarded as normal in certain religion Common in India, Thailand, American Indian, in South America Africa,

5. Dissociative Identity Disorder

< Clinical description >

   Former multiple personality disorder Certain aspects of a person ’ s identity are dissociated.

A person ’ s identity is fragmented  => many identity simultaneously in a person can exist Separate identities with characteristic behaviors, voices, gestures

  Sometimes with only partial characteristics Mostly develops after experiencing violence or other traumatic events  A man changed identity every time he had a head ache - He became aggressive and violent.

Afterwards he did not remember the incident - A third identity who was promiscuitous Each identity except host personality don’t know about each other

 Host personality is rational and calm It is also host who seeks help.

 Host tries to integrate other personalities. But it fails and will be overwhelmed.

 Host is usually not the personality, but develops later.

original  Some times a DID patient shows male and female identity at the same time.

 Facial expression, voice, body posture or even optical function changed, when another identity appears.

 According to the patients handedness Putnam showed et al.

(1986) 37% of changes of the   The Hillside Strangler, Kenneth Bianchi raped and murdered 10 young woman in 1970s in Los Angeles and left their body naked in full view in various hills.

Despite overwhelming evidence he denied the criminal act.

 some professionals raised the question he might have a DID.

- his lawyer brought in a clinical psychologist, who hypnotized him and asked whether there were another part of Ken with whom he could speak. Then somebody called Steve answered and said he had done all the killing. Steve also said that Ken knew nothing about the murders. With this evidence, the lawyer entered a plea of not guilty by reason of insanity.

- The defense called on the late Marti Orne, a distinguished clinical psychologist and psychiatrist who was a leading experts on hypnosis and dissociative disorders.

- Orne gave him psychological tests to find no significant differences among the personalities. By interviewing Bianchi ’ s friends and relatives, Orne couldn ’ t find any independent corroboration of different personalities before his arrest.

 And several psychopathology text books were found in Bianchi life in prison. ’ s room, which suggests he studied the subject and faked DID. On the basis of Orne ’ s testimony, Bianchi was found guilty and sentenced to     DID patients usually have high suggestibility to hypnosis.

by experimental research it is found that people can fake the symptoms.

Faking subjects remembered far less than those who were hypnotized. Various identities ( alter) showed different physiological responses (GSR, EEG)

1. statistics       mostly case studies in average 1 5 identities onset : early childhood (before age 9) sex ratio 1 : 9 in favor of female prevalence in clinical group 3-6% in general group 0.5-1 %

 Show high comorbidity with other disorders such as drug addiction, disorder, eating disorder etc.

depression, somatization disorder, borderline PD, panic   Complex disorder due to childhood taumatic experiences Similar to borderline PD self destructive, suicidal impulse, emotional instability

 Frequent hallucination => often misdiagnosed as a psychosis.

But different from the psychosis they hear the voice from inside.

   Knowing that the voices are hallucination, they don ’ t respond to them.

In some cultures, they are thought to be possessed Distributed in various cultures 2. causes  In most cases, they experienced severe childhood abuse

 Escape into a fantasy world, if pain is unbearable and they can do nothing to stop it. Our mind has the ability to create a new identity  Putnam et al.(1986): of 100 DID patients, 97 had experience of sexual abuse or physical abuse.

 68% had incest sexual abuse experience   Some children had witnessed their parents blown to bits in a minefield.

Familial support consitutes an important variance.

 Psychological vulnerability plays also an important role.

 Recently researchers tend to see DID as an extreme subtype of PTSD  The difference is that greater emphasis in on the process of dissociation rather than on symptoms of anxiety, although both are present in each disorder.

 After around 9 years of age, DID is unlikely to develop, although severe PTSD might.

  Heredity is not yet proven Seizure disorder patients experience many dissociative symptoms  About 50% of temporal lobe epilepsy displayed some kinds of dissociative symptoms => related to brain physiology  Dissociative symptoms of epilepsy patientsare not related to trauma experience.

< Suggestibility >    Dissociation and suggestibility hypnosis are similar phenomenon in People in trance tend to be focused on aspect of their world, and they become vulnerable to suggestions by the hypnotist.

People with high suggestibility can use dissociation as a defense against anxiety.

 50% of DID reports of imaginary playmates in childhood (Beautiful Mind)  When the unbearable, splits into identities.

the trauma person’s multiple becomes identity dissociated   As the ability of the children to distinguish fantasy from reality increases, around 9 years old, the developmental window closes for DID People with low suggestibility develop PTSD ?

< Real memory and false >  Accuracy of trauma memory is very controversial  Suggestions by therapists ?

 In case of real trauma, it is important to re-experience the trauma  False Memory Syndrome Foundation => to help innocent victims

 Loftus et al.(1996): an imaginary event was told to a 14 years old boy that he was lost at the age of 5 and then rescued by an old man.

Several days after receiving this suggestion, the boy reported remembering the event and even that he felt frightened when he was lost.

 Bruck et al.(1995): of the 35 three years old girls of experimental group who received medical examination, 60% did not remember examination of sexual organ.

 Whereas of although they the control group, 60 % reported on examination of sexual organ, didn’t receive the examination.

 Ceci et al.(1995, 2003): preschool children were asked to actively imagine both a real event and a fictitious event during 10 consecutive weeks.

=> another researcher interviewed them.

58% of children described the fictitious event as if it had happened.

27% of the children claimed remembered the event, even after they were told their memory were false.

that they

-On the other hand, there are many cases where childhood abuse cannot be remembered.

Williams(1994): 129 real childhood victims of abuse were interviewed.

=> 38% did not remember the abuse event The younger the child was at the time of abuse and in case of knowing the abuser, the more likely was that the event was not remembered.

3. T

reatment      Dissociative amnesia, dissociative fugue => usually spontaneous recovery the episodes are clearly related to current life stress Removal of stress , strengthening personal coping strategies Recalling what happened amnesic or fugue states during the In case of DID, long term psychotherapy is needed Only about 20% accomplished integration of their identities.

full

   Methods that were developed in PTSD treatment could be applied also to DID treatment.

Cues or triggers that provoke memories of trauma are identified and then neutralized.

Confront and relive the early trauma and gain control over the horrible events  Help the patient visualize and relive aspects of the trauma until it is simply a terrible memory instead of a current event.

  Hypnosis could be utilized to help patients to access unconscious memories Process of hypnosis is similar to that of dissociation  As trauma memory reemerge, it can trigger further dissociation    The trust in therapy process is very important Some times medication is combined with therapy, but there is little indication that it helps.

Antidepressant helps to some patients