Abnormal Psych Notes
Abnormal Psych Notes Psyc 3330 - 01
University of Louisiana at Lafayette
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Date Created: 03/06/16
Chapter 6 SOMATIC SYMPTOM, RELATED, AND DISSOCIATIVE DISORDERS DISORDERS FOCUSING ON SOMATIC AND DISSOCIATIVE SYMPTOMS Additional disorders from stress / anxiety: Disorders that - at least initially - seem to be physical disorders Disorders Focused on Somatic Symptoms Formerly Somatoform Disorders: Illness Anxiety Disorder (formerly Hypochondriasis) Conversion Disorder Slides 3-8 CONVERSION DISORDER • Presence of one or more symptoms/deﬁcits that affect voluntary motor control or sensory functioning • Symptoms are found to be inconsistent or incompatible with known neurological or medical disease • Causes signiﬁcant distress • May initially look like a neurological problem, but symptoms may be “at odds” with the way the nervous system is known to work; with less education, the less symptoms are consistent with known medical causes • Examples: • “hysterical blindness”; numbness; “hysterical” aphonia; fainting, loss of pain sensation; loss of hearing; weakness; loss of use of a limb; “psychogenic seizures” ILLNESS ANXIETY DISORDER (FORMERLY, HYPOCHONDRIASIS) • Preoccupation with having or acquiring a serious illness • Somatic symptoms are absent or only mild in intensity • Anxiety and easily triggered alarm about one’s health • Performance of excessive health related behaviors (e.g., checking one’s body for signs of illness) • Preoccupation with health is chronic, although not necessarily continuous, lasting at least 6 months • NOTE: • Based on misinterpreting bodily symptoms • Persists despite medical evaluation / reassurance of health ILLNESS ANXIETY DISORDER (HYPOCHONDRIASIS) • Estimated 1-5% of the population • In treatment settings, up to 6.7% in one study • Can emerge at any time during life • About the same numbers of women and men • Onset spread across life span • Anxiety becomes a preoccupation with bodily symptoms and over-interpretation of them • Symptoms may be vague or speciﬁc • “Disease conviction” is strong - the person is convinced some disease is present • Persistent “doctor shopping” to obtain a diagnosis • Frequently demand unnecessary treatments SOMATIC SYMPTOM DISORDER • Presence of one or more somatic symptoms that are distressing and/or signiﬁcantly disrupting to daily life • Excessive thoughts, feelings, and behaviors regarding the somatic symptoms(s) or related health concerns, including one of the following: ◦ Disproportionate and persistent thoughts abut the seriousness of the illness ◦ Persistent and high anxiety about health or the symptoms ◦ Excessive time and energy devoted to the symptoms or to health concerns ◦ Symptoms are persistent, although not necessarily continuous, typically lasting more than 6 months • Most commonly develops in adolescence, more women than men (2:1), often unmarried, lower SES backgrounds • Course is chronic and very hard to treat • Observed in multiple family members (women with a female relative who has this has an estimated 20X greater chance of developing this disorder) • Occurs across cultures and with similar sex ratios • Overuse the health care systems (medical bills estimated up to 9 X more than the average patient) • *It is crucial to rule out genuine health problems SOMATIC SYMPTOM DISORDER PREDOMINANT PAIN PATTERN • May begin with illness or injury that has legitimate pain associated with it (but persists after recovery) • Pain is a major issue, long after recovery takes place • May not seek treatment but always feel weak and ill • Condition takes on a “life of its own,” and usually causes the person to seek treatment • If Pain is the primary feature of Somatic Symptom Disorder, there is a predominant pain pattern • Source of pain may be known or unknown • Genuinely in pain • Causes clinically signiﬁcant distress in social, occupational or other functioning • Psychological factors have important role in onset, severity, exacerbation or maintenance of pain CONVERSION DISORDER • Psychosocial conﬂict (with traumatic event) is “converted” physical symptoms that affect voluntary or sensory functioning (may be dramatic) • Symptoms seem to have neurological basis (e.g., paralysis, blindness, loss of feeling) • Usual onset late childhood/young adulthood • 2:1 ratio of diagnosed women to men (more likely among men who experience extreme stress) • More common with less educated, low SES, low knowledge of illness, often adopt familiar symptoms • Appears suddenly; relatively rare • Comorbid with depression and anxiety disorders • Outcome is poor even with treatment CASE EXAMPLE • Husband and wife, Dennis and Helen were spending a summer day sailing. They didn’t notice the threatening sky until a storm began. Neither was wearing a life jacket. As they struggled to put life jackets on, the boat capsized. Dennis got his life jacket on and got back to the overturned boat but Helen, not a strong swimmer, was swept away and drowned. After the storm, Dennis was able to get to shore. Genuine back problems prevented him from walking properly and by the next day his legs were paralyzed and numb. It was initially assumed he had sustained a serious injury. After extensive testing, no medical/ biological reason was found to explain his severe physical impairment. As weeks went on, Dennis became increasingly withdrawn and unable to take care of his own needs or settle Helen’s affairs. His treatment team described him as “self-absorbed, drained of emotion, and unable to look back and unable to move forward.” FACTITIOUS DISORDERS • Imposed on Self (also called Munchausen Syndrome): ◦ Deceptive falsiﬁcation of physical or psychological symptoms or deceptive production of injury or disease, even in the absence of external rewards ◦ Presentation of oneself as ill, impaired or injured • Imposed on Others (Munchausen by proxy) : ◦ Deceptive falsiﬁcation of physical or psychological symptoms or deceptive production of injury or disease in another person, even in the absence of external rewards ◦ Presentation of another person (victim) as ill, impaired or injured • The motivation is to be a patient (“sick role”) • People with a factitious disorder can go to extreme lengths to create authentic looking symptoms of illness: ◦ Some take medications to produce symptoms ◦ May research the ailment(s) they have chosen and are usually well informed about medicine ◦ Will seek painful testing, treatment, and even surgery • Difﬁcult to determine prevalence /incidence ◦ Patients hide the true nature of their problem and seek medical help not psychological treatment ◦ Will “shop” for doctors who will “truly understand” them • More common in women than men ◦ Onset in early adulthood ◦ Often have extensive medical treatment for a medical condition in childhood; common family problems or physical or emotional abuse in childhood ◦ Grudge against medical profession or professionals ◦ May be nurses, laboratory technicians, or medical assistants ◦ Underlying personality disorder or characteristics, such as extreme need to depend on others FACTITIOUS DISORDER MUNCHAUSEN BY PROXY • Munchausen syndrome – extreme, chronic factitious disorder: ◦ The child has a history of many hospitalizations, often with a strange set of symptoms. ◦ Worsening of the child’s symptoms generally is reported by the mother and is not witnessed by the hospital staff. ◦ The child’s reported condition and symptoms do not match results of diagnostic tests. ◦ There might be more than one unusual illness or death of children in the family. ◦ Child’s condition improves in the hospital; symptoms recur when child returns home. ◦ Blood in lab samples might not match the blood of the child. ◦ There might be signs of chemicals in the child’s blood, stool, or urine. ◦ If remove children from care of their parents, ◦ symptoms disappear ◦ A second child may become ill when ◦ the ﬁrst gets better ◦ NOTE: Mortality rate ranges from 6% to 10% • The most lethal form of child abuse and based • on signiﬁcant premeditation • About 75% of perpetrators are moms MALINGERING • Different from the other problems in this category. • On some level the person understands that they are “faking it”. • Create symptoms that allow the person to obtain some advantage: ◦ Insurance beneﬁts ◦ Monetary damages ◦ Winning lawsuits DISORDERS THAT HAVE SOMATIC SYMPTOMS Disorder Voluntary control of symptoms? Symptoms linked to Psychosocial factors? Has an apparent goal? Malingering Yes Maybe Yes Factitious Disorder Yes Yes Yes (medical attention) Conversion Disorder No Yes Maybe Somatic Symptom Disorder No Yes Maybe Illness Anxiety Disorder No Yes No Body Dysmorphic Disorder No Yes No Physical illness No Maybe No DISSOCIATIVE DISORDERS • Identity – the sense of who we are, including our preferences, strengths, values, ideas, needs, is preserved in memory • Connection to the past informs our reactions to the here & now and functions as guide to future • Major disruptions of memory: • Cannot recall new information • Cannot recall information from the past • When these changes in memory lack a physical cause, called “dissociative” disorders (some part of memory dissociates) DISSOCIATION • Feel detached from self, as though living in a dream, or moving in slow motion • Mild form of this may be experienced by many in overtired or sleep-deprived states or after an extremely stressful experience • Estimates of 31% to 66% of those who have a traumatic event may have a transient dissociative experience • Some have speculated that about half the population will probably experience a transient dissociative event in their lifetimes and most will not be bothered by it (being able to associate it with a factor that is physical concern (lack of sleep) or psychological issue (shock with serious threat or an accident) DISSOCIATIVE DISORDERS • Dissociative disorders: ◦ Depersonalization-Derealization Disorder ◦ Dissociative Amnesia ◦ Dissociative Identity Disorder • Dissociative symptoms are often found in cases of acute stress and posttraumatic stress disorders MOST FORGOTTEN: • What we most commonly (and ‘normally’) forget: ◦ Internet passwords ◦ Where I left my cell phone ◦ Where I put my keys ◦ Where the remote control was left ◦ Phone numbers ◦ Name(s) of people I should know ◦ Dream content ◦ Birthdays, anniversaries • From a survey of what people most commonly report that they struggle to remember. Depersonalization-Derealization Disorder • Does not include a deﬁcit of memory • Typically triggered by high stress • Onset as early as adolescence, usually chronic • Often related to childhood trauma history, may be comorbid with anxiety disorders • Lose sense of self: ◦ Unusual sensory experiences – perceive their limbs, voices, are not their own ◦ Believe something has changed drastically ◦ Loss of “real me” ◦ May feel as though they are outside their own bodies watching themselves ◦ May complain that surroundings seem unreal, confusion about whether they just did something or thought it, sees the world as “through a fog” • The disorder occurs most frequently in adolescents and young adults, it is hardly ever seen in people older than 40 ◦ The disorder comes on suddenly and tends to be chronic • There are few theories and little research to explain depersonalization ◦ Neuropsychological evidence indicates difﬁculties with attention (easily distracted), problems processing new information (“sense of mind emptiness”), deﬁcits in short term memory, and spatial reasoning. ADAM DURITZ • Frontman for Counting Crows • Dated famous actresses (Jennifer Anniston, Winona Ryder, Emmy Rossum). • Has Depersonalization Disorder, that makes him feel disconnected from reality. •" This was not depression. This was not workaholism. I have a form of dissociative disorder that makes the world seem like it's not real, as if things aren't taking place. It's hard to explain, but you feel untethered." • He has continued to struggle to ﬁnd an effective medication that didn't have side effects like a 70 pound weight gain, memory loss, and narcolepsy. After losing the weight and ﬁnding more effective drugs, Duritz said, "I've never been this healthy before. Now I can have all the things I want." DISSOCIATIVE AMNESIA 1. Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is beyond ordinary forgetting 2. Signiﬁcant distress or impairment 3. Symptoms are not attributable to substance abuse or medical condition • Dissociative amnesia may be: • Localized– most common type; loss memory for all events occurring during a speciﬁc time period • Selective –memory loss for some, but not all, events occurring within a period • Generalized – loss of memory, beginning with an event, but extends back in time; may include loss of identity; may be unable to recognize family and friends • Continuous – forgetting of both old and new information and events; this is rare • Note: Below are typical with brain damage • Anterograde amnesia -loss of the ability to create new memories after the onset of amnesia • Retrograde amnesia -unable to recall events that before the onset of amnesia • Amnesia primarily impacts episodic memory (autobiographical memory for personal material) • Semantic memory – memory for abstract or encyclopedic information – remains intact (usually) • Although it appears to be rare, rates of dissociative amnesia increase during times of serious threat to one’s health and safety (e.g., war) DISSOCIATIVE FUGUE • A. Sudden unexpected travel away from home or customary place of work, with inability to recall ones’s past • B. Confusion about personal identity or assumption of new identity (partial or complete) • C. Not exclusively part of another dissociative disorder, substance use, or medical condition • D. Clinically signiﬁcant distress • ~ 0.2% of the population experience dissociative fugue ◦ It usually follows a severely stressful event, although personal stress may also trigger it • People with dissociative fugue forget their personal identities and details about their past, and also ﬂee to different location • The fugue may be short term: may travel somewhere else but do not take on a new identity • The fugue may be more severe: may travel thousands of miles, take a new identity, build new relationships, display new personality characteristics FAMOUS CASES OF FUGUE • Author, Agatha Christie disappeared on 12/ 3/1926 She reappeared 11 days later in a hotel in Harrogate. She had no memory of the events which happened during that time. • Jody Roberts, a reporter for the Tacoma News Tribune, went missing in 1985, only to be found 12 years later in Sitka, Alaska, living as "Jane Dee Williams." Initially people thought there was some reason for her to “disappear,” however experts have come to believe that she genuinely suffered a protracted fugue state. • In a very unusual case, David Fitzpatrick, 25, from the United Kingdom, entered a fugue state on 12/ 4/ 2005. He has not been able to trigger memories of his past, and is still working on regaining his entire life's memories (free documentary on-line) HOW ARE DISSOCIATIVE DISORDERS TREATED? • How do therapists help people with dissociative amnesia and fugue? ◦ The leading treatments for these disorders are psychodynamic therapy, hypnotic therapy, and medication Psychodynamic therapists ask patients to free associate (rapidly respond to word which uncovers associations) and search their unconscious ◦ In hypnotic therapy, patients are hypnotized and guided to recall forgotten events ◦ Sometimes intravenous injections of barbiturates are used to help patients regain lost memories • Often called “truth serums,” the key to the drugs’ success is their ability to calm people so they relax and free their inhibitions DISSOCIATIVE IDENTITY DISORDER • Dissociative Identity Disorder (DID; formerly multiple personality disorder) – the person develops two or more distinct personalities (alters) each with unique memories, behaviors, thoughts, and emotions • Onset in late adolescence/early adulthood ◦ Symptoms generally begin in early childhood after episodes of abuse; typical onset is before age 5 • Women 3 to 9 times more likely to be diagnosed MULTIPLE PERSONALITY DISORDER • MPD Captures the public’s imagination: ◦ Chris Sizemore is considered the ﬁrst documented case of Multiple Personality (20 alters) Disorder (1950s) ◦ Dr. Corbett Thigpen, U. of Georgia was treating her ◦ Joanne Woodward DISSOCIATIVE IDENTITY DISORDER • At any given time, one of the alters dominates the person’s functioning ◦ Usually one of these personalities – called the primary, or host, personality – appears more often than the others ◦ The transition from one alters to the next (“switching”) is usually sudden and may be dramatic • Do “alters” know and interact? ◦ Relationships among alters differs ◦ Three kinds of relationships: • Mutually amnesic relationships – none of the alters have awareness of others • Mutually cognizant patterns – all alters aware of all others • One-way amnesic relationships – most common; awareness varies: some alters are aware of others, but the awareness is not mutual ▪ Those who are aware (“co-conscious alters”) are usually “quiet observers” • Previously believed that most cases of the disorder involved 2-3 alters but average number has been demonstrated to be much higher – 15 for women, 8 for men (cases with more than 100) • Alters can show dramatically different characteristics, including: ◦ Demographic characteristics • Alters may differ in age, sex, race, and family history • Abilities and preferences ◦ Encyclopedic knowledge is unaffected by dissociative amnesia or fugue, in DID it is often disturbed ◦ Alters can have different abilities, areas of expertise such as driving a car, speaking foreign languages, or playing a musical instrument • Physiological responses ◦ Researchers have discovered that alters can have signiﬁcant physiological differences, including autonomic nervous system activity, blood pressure levels, and allergies Eating Disorders Major Types of Eating Disorders Major eating disorders • Bulimia Nervosa and Anorexia Nervosa ◦ Serious disruptions in eating behavior ◦ Intense fear of gaining weight • Binge-eating disorder ◦ Individuals may binge repeatedly ◦ They ﬁnd it distressing, but they do not attempt to purge the food ◦ New to dsm-v • Sociocultural origins ▪ Westernized views but spreading Let’s Start With Discussing Obesity • Not an eating disorder under DSM-V • Epidemic in the US: ◦ 70% of US adults are overweight, and more than one-third of U.S. adults (35.7%) are obese (2011) ◦ Problem bc health becomes compromised ◦ Percentage is increasing ◦ Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death. ◦ In 2008, medical costs associated with obesity were estimated at $147 billion (91% of U.S. healthcare costs); the medical costs for people who are obese were $1,429/yr. higher than those of normal weight Obesity—Statistics • Rapid increases in prevalence ◦ U.S. adults • 1991 = 12% • 2000 = 30.5% • 2002 = 30.6% • 2004 = 32.2% • 2008 = 33.8% • 2010 = 35.7% ◦ Developing nations Causes of Obesity • Spread of ”modernization” ◦ Inactive, sedentary lifestyle + high fat foods • Genetics ◦ Accounts for only about 30% of the cause • Biological factors ◦ Initiation and maintenance of eating • Psychosocial factors ◦ Impulse control, affect regulation, attitudes Obesity and Food Sources Obesity—Statistics Disordered Eating Patterns in Cases of Obesity • Night eating syndrome: ◦ People get up and snack during the night ◦ Body starts to shut down functions so when you eat, your digestive system is shutting down to burn calories: more readily converted to fat ◦ Associated with obesity ◦ On average, 1/3 of daily calories consumed ◦ Patients are awake and aware of eating ◦ Not synonymous with binge eating The negative effects of obesity on your health and your life • Lower life expectancy • Fewer employment opportunities • Bone probz • Deep vein thrombosis - blood clots that form then detach and cause major strokes; can be fatal • Cancer • Hernia • Join problems • Heart attacks • Breathing probz • High blood pressure • Type 2 diabetes • Increased sweating • High cholesterol • Arthritis • Lower self esteem • Depression • Limited mobility • Social discrimination Obesity Treatment • Progression from least to most intrusive ◦ Self-directed weight loss programs ◦ Commercial self-help programs ◦ Behavior modiﬁcation programs ◦ Bariatric surgery • 15% of patients who have bariatric surgery fail to lose signiﬁcant weight • Efﬁcacy ◦ Moderate for adults ◦ Higher for children and adolescents • Family involvement Bulimia Nervosa • Binge eating: ◦ Excess amounts of food ◦ Perceives self as ‘out of control’ ◦ They usually plan it, go buy a shit ton and eat them all then they do something to compensate • Compensatory behaviors: ◦ Purging (self-induced vomiting, diuretics - dangerous bc mess up electrolyte balance, laxatives - ineffective, not really damaging) ◦ Excessive exercise (prolonged daily, or multiple daily sessions) ◦ Fasting then go back to binging, not signiﬁcant weight less like anorexia • Beliefs: others’ impressions, their popularity and self-esteem are determined by weight and body shape Bulimia Nervosa – Clinical Description • Two Subtypes ◦ Purging (most common) • Vomiting, laxatives, or diuretics ◦ Nonpurging • Exercise and/or fasting • 6-8% of those with Bulimia • The majority of those who have this disorder are within 10% of ‘normal weight’ for their height and age Bulimia nervosa • Medical consequences: ◦ Salivary gland enlargement (face looks chubby) ◦ Erosion of dental enamel (inner surface of front teeth) ◦ Electrolyte imbalance – very dangerous condition • Kidney failure - usually have dialysis • Cardiac arrhythmia - not funcitoning normal; can damage heart • Seizures - basically brain function ◦ Intestinal problems (especially with laxative abuse) ◦ Permanent colon damage ◦ Hand calluses (from stimulating gag reﬂex) • Comorbid psychological disorders ◦ Anxiety (80.6%) ◦ Mood disorders (50-70%) ◦ Substance abuse (36.8%) - pushes ppl to do things that they may not want to do in addition to that, potential for suicide goes up Anorexia Nervosa • “Out of control and overly-successful” weight loss ◦ 15% below expected weight (by time of treatment the average person diagnosed with this disorder is 25-30% below expected weight for body type) ◦ Intense fears t h g i e w g n i n i a •G • Losing control of eating • Relentless pursuit of thinness • Often begins with dieting • Two Subtypes ◦ Restricting – limit caloric intake through diet and fasting ◦ Binge-eating-purging – around half of anorexics; unlike bulimic who is close to normal weight, these ppl maintain very low weight; huge body image distortion • Associated features ◦ Body image disturbance – believe they are fat ◦ Pride in diet and control – thinner = success ◦ Rarely seek treatment – do not recognize problem • NOTE: pro-ana (and pro-mia) promoting this disorder ◦ Expecations are young teens and young women are most likely to develop this, but recent research has indicated that older women are also at risk • Medical consequences: ◦ Amenorrhea – although relatively common, dropped from DSM-V (prevented male diagnosis) ◦ Dry skin ◦ Brittle hair and nails ◦ Sensitivity to cold temps ◦ Lanugo – downy hair on limbs or face ◦ Cardiovascular problems ◦ Electrolyte imbalance – can be fatal • Comorbid psychological disorders are common: ◦ Anxiety • OCD – may use rituals to avoid eating ◦ Mood disorders (71%) ◦ Substance abuse • Suicide is a risk and increased with use of alcohol and other substances Childhood Onset of Eating Disorders • It has been estimated that one in every 10 cases of an eating disorder occurs in boys/ men. • Research and anecdotal evidence indicates that up to 25% of middle school and high school students who are affected by an eating disorder are male. However the number of males diagnosed and seeking treatment is very low • Can resemble a traditional eating disorder or involve use of drugs and supplements, according to U.S. researchers, and it tends to go along with depression, binge drinking and recreational drugs use • A lot of males may be striving for something different than females. "They may be engaged in something different than purging. (Field, 2013) ◦ Two groups - athletes and homosexuals Binge-Eating Disorder • Marked distress because of binge eating but do not engage in extreme compensatory behaviors and therefore cannot be diagnosed with bulimia ◦ Often seek weight-control programs (estimated 20%) ◦ 50% among candidates for bariatric surgery ◦ Better response to treatment than other eating disorders • Associated Features ◦ Many are obese ◦ Tend to be older at onset ◦ Tend to have more psychopathology ◦ compared to non-binging obese ◦ Very concerned about shape and weight Bulimia and Anorexia: Statistics • Bulimia ◦ 90-95% female • Caucasian, middle to upper class ◦ Onset = age 10 to 21; but people can develop later ◦ Chronic, if untreated • Bulimia in men ◦ 5-10% male • Caucasian, middle to upper class • More likely to be gay or bisexual • Athletes with weight regulations, models, actors ◦ Onset = older than for females • Anorexia ◦ More female than males • Caucasian, usually middle to upper class ◦ Onset = age 13 to 18 ◦ Chronic and often lifethreatening ◦ Resistant to treatment Cross-Cultural Considerations • North American minority populations • Immigrants to western cultures - signiﬁcant changes in eating and in foods available ◦ Increase in eating disorders ◦ Increase in obesity • Cultural values • Standards for body image Developmental Considerations • Developmental considerations ◦ Adolescent onset • Parent, peer and cultural pressures • Upset with weight gain associated with normal hormonal changes and changes in body associated with puberty and maturation • Interaction with social ideals – media impact Causes of Eating Disorders • Social dimensions • Cultural imperatives – media driven? ◦ Thinness = success, happiness ◦ People teach each other • Ideal body size standards ◦ Change rapidly • Media = artiﬁcial standards • Social and gender standards ◦ Internal and perceived Causes of Eating Disorders • Social dimensions ◦ Dieting – an obsession in this country ◦ Perceptions of fat ◦ Social and peer groups ◦ Dietary restraint • Family inﬂuences: ◦ The perception is that a “typical” or desirable family in the US is: • Successful • Driven • Concerned about appearance • Values and maintains harmony among members* (which becomes a problem!) ◦ History of dieting, eating disorders • Mothers model and teach to children • Biological dimensions ◦ Heritability studies (.56) ◦ Inherited tendency to be emotionally responsive to stress, eat impulsively (or to soothe self?) ◦ Perfectionism ◦ Hypothalamus responses: • Serotonin • Psychological dimensions ◦ Low sense of personal control ◦ Low level of self-conﬁdence (only as good as you look?) ◦ Perfectionistic attitudes ◦ Distorted body image ◦ Preoccupation with food and appearance ◦ Mood intolerance
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