February 4th, 2014
Video: Lost in the Mirror- D.I.D
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80% of doctors believe this disease is real
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Rare
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Three faces of Eve: Eve White, Eve Black, and Jane
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Over a period of 44 years she had 22 personalities
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Attacks could be painful. Severe headache, then a dark period which lead into a change
in personality
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The amount of time you stay in these alternate personalities varies
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Some personalities don’t know other alters exist or what they do when they are present
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Ages differ with personalities. These personalities develop at certain ages for certain
reasons and the age that personality develops is the age that alter remain throughout
their whole life
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With Eve personalities were at competition with each other
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There is a obvious change inside the brain when scanned with each alter
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Different alters can have different problems i.e. being blind or deaf that don’t come out
with the other alters
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One personality given a tranquilizer is put to sleep but can change into another alter that
isn’t effected
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Alternate identities are seen as fragments of one personality
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Come time protective dissociative identity doesn’t get change back due to trauma
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These people are punished for things and happen to change back during and are then
confused why they are being punished because they don’t remember doing anything
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Authentic multiple personalities are possible. Doctors get over excited and they produce
more personalities by encouraging or assuming a new personality has come out which
then makes the patient want to make the doctor happy so it develops
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Found that it can be cured by focusing on functioning on who they truly are, the core
personality rather than bringing out the different personalities
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Some alters actually said good bye after this treatment
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Lucy is still dealing with personalities
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Majority of people diagnosed with this disease are women
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Losing time
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Psychiatrists say child alters represent separate painful memories
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Possible biological susceptibility
Dissociative and Somatoform Disorders
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Up to DSM IV: four disorders for dissociatice
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The DSM V takes a few away or combines them. Diffential Dissociative disorder,
differential amnesia combined with fugue and depersonalization
Dissociative Disorders
History
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Characterized by severe disturbances or alterations of identity, memory and
consciousness
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Dissociation is the defining symptom
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Little empirical research exists re these disorders
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Believed to be quite rare but higher rates have been reported
Dissociative Amnesia
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Involves real and complete memory loss for extensive and important actions or
impersonal information in the absence of any physical/medical causes
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Five patterns of memory loss:
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Localized amnesia: person fails to remember information during a specific time
period
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Selective amnesia: only parts of the trauma are recalled
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Continuous amnesia: person forgets information from a specific date to present
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Systematized amnesia: only certain categories of information are forgotten
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Generalized amnesia: the person forgets their entire life
Dissociative Fugue
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Loss of memory, including personal history
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Persons travel far from home and adopt new identities and occupations
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Two important features of diagnosis are: sudden and unexpected travel away from home
or work; and the inability to recall one’s past
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Fugue state must be distinguished from malingering
Depersonalization
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Experience characterized by sense of unreality and detachment from self (derealization)
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Usually appear in adolescence, tends to be chronic in nature
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No impairment in memory loss, or identity confusion
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Brain abnormalities in perceptual pathways have role in the process
Dissociative Identity Disorder
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Most severe and chronic of the dissociative disorders
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Characterized by the existence of two or more unique personality states that regularly
take control of the patients behavior
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Each personality, or alter, may be very distinct and have different behaviors, tones of
voice, age and gender
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One is defined as “host”
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Alters may/may not be aware of others
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DID diagnosis: must be at least two alters which exert control over behavior
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Transition from one alter to another is called a switching: generally results from stress or
some cue in the environment
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DID was believed to be quite rare but incidence has increased
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Ages of these alters never change and they are different than the core personality
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Tend to be very creative people
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Suggestibility: can be hypnotized and can get benefit to bring alters together. Not all
population is suggestible
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Many can hold jobs but also many aren’t capable
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During treatment it can cause many more personalities to show
Etiology
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Some sort of trauma severe enough usually at a young age, that they break off to protect
themselves
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Tends to be sexual abuse but it can be any kind of trauma
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Socio-cultural model: therapist begins to believe another person has come out whether
they have and the client then begins to believe it and more identities appear
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Vast majority of dissociative disorders are results of intense psychological trauma
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Controversy over nature and etiology of DID
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Some critics suggest that it might be manufactured in therapy
Treatment
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Psychotherapy involves several stages
1. Establishing trust with the person in front of you whether core or alter
2. Assistance in developing new coping skills to work through their difficult history.
Help them be aware of other alters and why this is happening
3. Final stage: integration of personalities using hypnosis contact alters; medication
is helpful in treating comorbid disorders ex. Depression but not in the direct
treatment DID
Somatoform Disorders
History
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Occurrence of physical symptoms for which there is no known physical cause, excessive
preoccupation with minor physical symptoms, or excessive concern about normal bodily
functioning
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People with this disorder don’t consciously produce or control the symptoms which take
many forms
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Two conditions in which the individuals intentionally pretend to be ill: malingering and
factitious disorders: few epidemiological studies exist on the prevalence of this disorder.
But disorder is diagnosed in 5 to 40 percent of patients attending mental health clinics
Somatization
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Characterized by multiple and recurring complaints of physical ailments with no organic
basis
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Patients attribute symptoms to serious medical illness and resist suggestions that
psychological factors contribute to illness of disability
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Patterns tend to be observed early in life, with differing symptoms across cultures
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Understanding the socialization of the individual is an important feature in the diagnosis
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Something they feel all the time
Conversion
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Person experience motor symptoms or disturbances in sensory functioning that appear
to be caused by a neurological problem, but no physical cause if present
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Motor deficits may include paralysis, impaired balance, inability to speak, urinary
retention, or a sensation of a lump in the throat
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Classical pattern has been conversion stoking or glove anesthesia (when hands and feet
become numb)
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Difficult to diagnose – people show lack of concern about severity of symptoms (la belle
indifference)
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La belle indifference: these people don’t care about what has happened or their loss. No
distress
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Placebos given to help
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Convert trauma they have been through into a loss of that sense they used
Pain Disorder
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Diagnosed using the DSM-IV-TR when psychological factors are important in the onset,
exacerbation, severity, or maintenance of the patient’s pain complaints or disability
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Iatrogenic, or treatment-caused problems as a result of the use of pain medications are
not uncommon among these patients
Hypochondriasis
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Excessive preoccupation with fears of having a serious illness despite assurance that
fears are groundless
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Diagnosed when a individual misinterprets minor bodily symptoms as evidence of a
serious illness
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Patients will often resist referrals to mental health professional
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Usually identified in early adulthood and may be associated with an early loss of a
significant person or childhood illness
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This is if there is a preoccupation with the FEAR of a serious illness
Body Dysmorphic Disorder
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Individual is unusually and excessively preoccupied with an imagined defect
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Or an exaggeration of some aspect of his or her personal appearance
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Frequently feel like everyone else notices the “defect”
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Preoccupation causes distress or impairs functioning
Etiology
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Over time moved away from psychoanalytic positions
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Possibilities exist for influences in life history or the current life circumstances
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Socialization and prior experiences with illness may also play a role in development of
somatoform disorders
Treatment
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Focus on affective, cognitive and social processes that maintain excessive or
inappropriate behavior
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Cognitive-behavioral approaches and treatment programs that focus on social skills
training, relaxation, and scheduling activities, have been used to treat patients with
Somatoform disorders
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CBT: help them cope with the thought of severe symptoms
Chapter 7: Psychophysiological Disorders
History
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Idea that psychological processes can have impact on bodily states, even to the extent
of producing physical disease, has a long story
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Medical and psychological activities converged in psychosomatic medicine concerned
with psychosomatic disorders
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DSM-II introduced the term psychopysiologic disorders
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Covered in a brand of psychology called: behavioral medicine or health psychology
Issues
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When a major element of a disorder is a diagnosable medical condition, that condition
will be noted on Axis III of the DSM-IV
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Indicates that there is a psychological factor affecting a medical condition
Psychosocial Mechanisms of Disease
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Illness= symptoms (subjective reports by the patient)
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Disease= signs (objective indications that are in the textbook)
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Endocrine: HPA axis highly responsive to psychosocial variable
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ANS: sympathetic and parasympathetic (relaxed)
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Immune system: psychoneuroimmunology finds the immune system can be affected by
learning experiences, emotional states and personal characteristics
Psychology of Stress
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Hans Selye: general adaptation syndrome (GAS)
I.
Alarm (adaptation challenge) situation perceived as stressful and if the challenge
persists then,
II.
Resistance (fighting or coping) use resources and stress still doesn’t go down and
with continued challenge,
III.
Exhaustion (resistance fails) which lowers the immune system and organism become
susceptible to disease
Psychosocial Factors of Disease
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Social status
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Controllability: internal/external
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Social support: lack of
Disease and Psychosocial Factors
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Infectious disease especially viruses
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Ulcers: influence on development of ulcers
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C.V disease: type A personality- hostility, obsessive compulsive, driven
Treatment
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Two classes of intervention that characterize work in this field:
i.
Generic approaches of management of stress related to the problem. Manage the
overall problem and,
ii.
Interventions directed toward specific psychosocial variables thought to play a role in
disease etiology
February 7, 2014
Ch. 9: Schizophrenia
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People who don’t understand this type of mental illness misinterpret what is going on
and associate it with D.I.D
History
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The lifetime risk is about 1% of the whole Canadian population
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Most frequent between 20 and 40 years of age
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Early onset is after 15 or 16 years of age
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Men and women are at equal risk: men display symptoms earlier and more severe
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Individuals less likely to complete their education or maintain a job; more likely to
develop other psychological issues like depression and alcohol abuse
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Lack of historical evidence seems to suggest that schizophrenia was extremely rare until
the late eighteenth century. It has been speculated that industrialization and
environmental changes may be related to this emergence
Symptoms: Positive
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More obvious symptoms of psychosis, such as, delusions, hallucinations, thought and
speech disorders; grossly unorganized catatonic (ridged) behavior
Negative
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Absence or loss of typical behaviors such as speech and with social withdrawal, avolition
(lack of will, just don’t care) and anhedonia (lack of pleasure, no emotions, no sense of
happiness)
Diagnosis and Assessment
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Based on five diagnostic criteria of combination of symptoms and clinical features
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Some symptoms given more weight: bizarre delusion
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Important to distinguish between bizarre delusions and mood congruent, which would be
mood disorder not schizophrenia
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Five types: Paranoid type, disorganized type (bizarre behavior), catatonic type (ridged
behavior), undifferential type (falling into all categories), residual type (with at least one
prior psychotic episode with negative symptoms and not currently experiencing an
episode)
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Critique: diagnosis currently relies on presenting symptoms and history as the main
indication of the illness – significant drawback is the subjectivity of the diagnosis
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Objective diagnosis: possible if measurable disease markers occur
Etiology
Biology
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Genes: biological relative with schizophrenia increases the risk
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Birth-related complications (lack of oxygen, 24-30 weeks premature) have been
proposed as one kind of environmental and biological factor
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Exposure to a parent with schizophrenia increases the risk of developing the disorder
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Frontal lobe: believed to be impaired by illness: research supports a consistent
deficiency in patient samples
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Other brain regions of interest to schizophrenia are left temporal lobe and associated
structures such as the amygdale and hippocampus
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The dopamine hypothesis states that abnormal activity of dopamine, a member of
catecholamine family of neurotransmitter, is involved in schizophrenia
Treatment
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Medication: Chlorpromazine one of the initial drugs but caused horrible side effects,
improved medications such as risperidone, and olanzapine that provide symptom control
with fewer side effects
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Psychotherapy and skills training:
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CBT useful in reducing the severity and frequency of psychotic symptoms in
schizophrenia
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Most recent evidence indicates that CBT has its greatest effects in reducing
negative symptoms
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Social skills training and stress management is a learning-based intervention model for
the treatment of functional disabilities associated with schizophrenia
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Family therapy may benefit some schizophrenia patients who have the support of family
members. Treatment aims at the active involvement of the family in the therapeutic
process
Ch. 8: Mood Disorders
History
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Hippocrates first to extend the ideas on the relations between bodily fluids and emotional
temperament, including depression
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Roman physician Galen: depression was thought to result from an excess of black bile
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Freud conceptualized depression as a result of a fixation at the oral stage
Diagnostic Issues
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Two important criteria for clinical diagnosis of mood disorder: duration- the length of
symptoms and the severity of the symptoms
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Major depressive disorder: total of five symptoms for at least two weeks
Major Depressive Disorder
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Mood disorders are classified by the DSM-IV into two broad categories: unipolar
(lowered mood recovering to normal mood) and bipolar (change occurs in both
directions: mood lowering and elevating aka mania)
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Symptoms: persistent feelings of sadness, loss of interest of ability to feel pleasure
(anhedonia), difficulty making decision or concentrating, difficulty sleeping, fatigue,
feelings of worthlessness and guilt, suicidal thoughts, and either agitation or slowing
down
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Prevalence and course: 8% of Canadian suffer from depression at one point in their
lives, and 4% are affected within one year
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Prevalence: about twice as high for women as for men
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Typical age is mid-twenties
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Course is variable
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Comorbidity: most frequent is anxiety
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Overlapping: poor concentration, irritability, hypervigilance, fatigue, guilt, memory loss,
sleep difficulties, worry
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Often present with obsessions and phobias, difficulty in relationship, substance abuse
Dysthymic Disorder
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Manifest many of the same symptoms as major depressive disorder – less severe
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Distinguishing feature is persistent for at least two years with only brief times when mood
returns normal
Bipolar Disorder – Mania
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Hallmarks are flamboyance and expensiveness
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Manic individuals often display pressure of speech, excessive self-esteem, or
grandiosity, risky physical feats, outlandish business practices, increased sexual
behavior
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Unlike most other mental disorders, some people describe certain symptoms associated
with mania as enjoyable
I & II
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Hypomanic episodes are similar to mania but are less extreme and have no psychotic
features
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When episodes alternate this is called bipolar disorder
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Two types: Bipolar I- one or more manic episodes and one or more depressive episodes;
bipolar II- at least one hypomanic episode and one or more depressive episode
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Must involve a depressive episode
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Bipolar less common than major depressive disorder
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Creative individuals tend to be over-represented with bipolar disorder
Cyclothymia
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Long-standing pattern of alternating mood episodes not meeting criteria for major
depressive of manic episode
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Criteria for a diagnosis include duration of at least two years with recurrent periods of
mild depression alternating with hypomania
Rapid Cycling
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Person moving very quickly in and out of depressive and manic episodes; particularly
server type of bipolar disorder called rapid cycling depression/mania
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Do not respond as well to pharmacotherapy, which may relieve only some of the
symptoms
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Rapid cycling linked to head injury, hyperthyroidism, antidepressant drug treatment, and
some neurological symptoms
Seasonal Affective Disorder
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Vulnerable to environmental changes in sunlight
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Show a pattern of mood problems that are cyclic and time-limited
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May be unipolar or bipolar
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Present with atypical symptoms: oversleeping, overeating, cravings for carbs, and
weight gain
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Treated with light treatment simulating sun
Post-Partum Depression
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Up to 70% of women experiencing mood swings and sad feelings lasting up to two
weeks after childbirth
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In some women the mood swings are chronic and severe enough with psychotic
features and may impair functioning
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In more serious cases result in infanticide
Psychological Theories
Psychodynamic
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Depression is due to attachment issues
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Attachment: secure (good attachment), anxious (resistance, don’t like to be held to
touched or left alone), anxious avoidant (antisocial, seed of depression)
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Anaclitic (attached to other people at the hip. Someone else makes all their decisions for
them. Depressed because of this)
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Introjective depression: feelings of inferiority, inadequacy, self-criticism and guilt.
Cognitive: Beck
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Beck’s sociotropy and autonomy are personality constructs related to depression
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Sociotropy: focuses on positive interactions with others
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Autonomous: individuals are more preoccupied with individualism
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Pattern of depressive symptoms are different for these two types: for sociotropyrequest for help, crying and loneliness; for autonomous- social withdrawal,
hostility and active modes for suicide attempts
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See the world negatively due to negative schemas
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Negative cognitive triad: negative thoughts about the future, the world around them and
the self
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Common types of cognitive distortions are: overgeneralization, black-and-white thinking,
and selective abstraction (selective in what they think and feel)
Cognitive: Seligman
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Hopelessness theory of depression based on early animal studies
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Individuals who exhibit a pessimistic or hopeless attributional style are at risk for
developing depression
Rumination Model
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Poor coping style leading to increasingly severe and prolonged depressive episodes
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Tendency to focus on depressive symptoms, possible causes and consequences
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Ruminative coping style “stir” in negative mood
Interpersonal
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Self-verification theory: tendency for depressed individuals to seek confirmation from
others that is consistent with the negative self-view and gravitate towards individuals
who will evaluate them negatively
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Tend to experience negative interpersonal situations
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Depressed people chose inappropriate topics of discussion
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Excessive reassurance seeking without satisfaction and repeated request for more
reassurance
Life Stresses
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Diathesis stress model: seen as developing from the interaction between a constitutional
vulnerability and marked levels of stress
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Even low levels of stress can trigger the disorder in a person who is extremely
vulnerable constitutionally
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Role transition such as, change of careers or becoming a parent may also trigger
depression
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Response can be self-limiting and resolves when the stressful event has resolved called adjustment disorder with depressive mood
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Distressing life events may trigger long-term effects
Biological Theories
Genetic
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Evidence supporting a genetic contribution to unipolar and bipolar depression comes
from family, adoption and twin studies
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Higher concordance rates for identical twins
Neurotransmitter
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Catecholamines and serotonin have been implicated most directly in models of
depression
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Monoamine hypothesis differing levels of these neurotransmitters can disrupt mood
regulation and bring on other symptoms of depression
Endocrine System
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Functioning of the pituitary gland causing release of a hormone called ACTH, which
moderated the secretion of cortisol
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Treatments to reduce cortisol often resulted in alleviation of depression
Structures
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Decrease in hippocampal volume
Sleep Disturbances
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Frontal asymmetery: increased right frontal (negative affect and avoidance behavior)
and decreased left-frontal activity (positive affect and approach behavior)
Treatments
Psychology: CBT
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Focuses on thinking common in depressed individuals
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Tend to challenge negative thinking to reduce the symptoms of depression
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Focuses on the disruptions occurring in the person’s interpersonal world
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Interpersonal disputes, role transition, grief and interpersonal deficits
IPT
Pharmacology: unipolar
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Trycyclics: among the first drugs to be used
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Monoamine oxidase inhibitors: neurotransmitters broken down to stay in synapses
longer
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SSRIs leave serotonin in the synaptic cleft
Bipolar
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Lithium: toxic levels in the body. Even out behaviors
Physiology: ECT
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Better outcome for depression than schizophrenia
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Side effects such as loss of memory
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Last resort type of therapy
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Produces a general cerebral seizure and has been found to effectively treat patients with
major mood disorders
Physiology: Light therapy
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Patients exposed to very bright light for one to two hours
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Results in remission of symptoms
Mood Disorders
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Combination of treatments important to help recover
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Relapse is a significant problem from depressed people
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Medication taken till one year after somatic recovery
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Mindfulness helpful in prevention of relapse