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PSYB32 - Lecture 05 Notes.docx

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Konstantine Zakzanis

PSYB32 – Lecture 05 (Chapter 7) WebOption – Summer 2013  With all of the vocabulary stuff out of the way, we’ll now be looking more in depth at the actual disorders  First guest speaker later in lecture – will be talking about anxiety disorders and Gestalt therapy o *Will not be tested on what guest speaker says so I won’t take notes on it  However, this lecture begins with a look at Somatoform and Dissociative Disorders Slide 3 – Somatoform and Dissociative Disorders  They’re both presented in the same chapter, but difference b/t them is Somatoform disorders are much more common o Dissociative Disorders are very rare  Looking first at Somatoform Disorders Slide 4 – Somatoform Disorders Pain Disorder  Psychological factors play a significant role in the onset and maintenance of the pain experienced by the patient  DSM includes 3 subtypes of Pain Disorder: o Pain Disorder associated with Psychological Factors o Pain Disorder associated with a General Medical Condition o *Pain Disorder associated with both Psychological Factors and a General Medical Condition  Prof says this last subtype is important  Nobody diagnoses the first two because Pain is a biopsychosocial process  Thus, pain is a complex symptom for which there’s no known objective way to diagnose  In other words, it’s impossible to figure out whether there are ONLY psychological factors or ONLY general medical conditions involved in its presentation, thus a biopsychosocial approach is taken in diagnosing it  Remember, for a Pain Disorder to be diagnosed it has to be causing patient distress and disability o For ex: the pain has to have some sort of impact in their occupational or social functioning  Patients with Pain Disorder will often have a comorbid diagnosis o This comorbidity is typically what results in the disability that patients experience  It often has a Temporal relationship to a stressor in the patient’s life o For ex: the disorder can follow some sort of injury (breaking an arm) – it appears after a stressor such as this  However, the temporal relationship is especially important because over the course of the disorder, when the person starts to have these complaints of pain, a condition called Iatrogenic Disability develops: he gives a case example…  Overweight, middle aged woman. Verbally abused by her husband and none of her children had respect for her; Did miserable minimum wage work in a factory  Supposedly no previous history with psychological illness before the accident  She was bombarded with household tasks and chores (maintenance, cleaning of the house, finances)  Her husband took no responsibility for any of these daily stressors, or any for that matter. He lounged around all day  Then she gets into this car accident, which shouldn’t have resulted in any chronic pain condition o Because her injuries were deemed to be soft tissue damage (ie injuries you can recover from within 3 or so weeks)  So none of these details indicate anything that should result in the amount of physical pain she was expressing  Yet, there she is with the Prof 6 years after her accident complaining of pain through every part of her body o She had to use a cane, needed an assistance all the time  She never spoke of the pain much, just that she was well-tended to by handsome massage therapists, she was chauffeured around everywhere, and she was treated with respect and courtesy by the ppl who worked at the clinic she visited  She also had housekeeping benefits where others would do the cleaning and cooking for her  Her children were also much more sympathetic towards their mother since her illness and the husband started to pitch in around the house as well  She didn’t have to work anymore because of the amount of pain, and she was not found to be malingering (will discuss more about this later) either  Thus, this is a case of Iatrogenic Disability: patient avoids unpleasant activities to secure attention and sympathy o This is why you can never diagnose a pain disorder based solely on a psychological cause or solely on a medical condition  How to distinguish them from someone with actual physical pain? Ppl with Physical pain will:  localize their pain more specifically o In the iatrogenic cases such as the one above, people are less specific about their pain (ie will complain about pain everywhere)  Talk more about moderating variables: They’re more specific in what makes the pain worse or better o ie “bending really low makes my back hurt a lot” o whereas an iatrogenic would just say “everything I do makes the pain worse”  DSM specifies pain disorders by Acute (less than 6 months in duration) and Chronic (more than 6 months) Slide 5 – Somatoform Disorders (continued) Body dysmorphic disorder: someone with a preoccupation with imagined or exaggerated defects in physical appearance  Gender differences o Men’s most common preoccupations: penis size, hair, height, muscles o Women’s most common preoccupations: breasts, hips, legs, skin, face  Remember, again, (always remember) it has to result in distress and disability o For ex: A lot of us may be preoccupied with some of these things, but if it doesn’t impact our daily living/functioning, it isn’t a disorder  When is it a disorder? - When a person spends so much time trying to fix this “defect” to the point that it leaves them: o Financially poor o With Other health risks  ie most common way these ppl deal with their preoccupations is cosmetic surgery, which is very expensive and can lead to other health complications  Usually found in women; typically starts in late adolescence when we become more self- conscious  It’s often comorbid with other types of psychological conditions including: o Depression o Social phobias  the disabling aspect of the disorder o Agoraphobia  person becomes so afraid of judgements that they’ll be afraid to leave their house o Eating disorders o Suicide o Substance abuse  Reliance on drugs to deal with their imagined defect or the stress it causes o Personality disorders  Usually Borderline personality disorder  However, a Narcissistic personality disorder (person who thinks highly of himself) would NEVER be associated with a body dismorphic disorder  Prof gives case of someone with Body Dismorphic disorder – The case of “Elephent Man”:  Chris, 31 year old carpenter who was hospitalized after putting his head in a plastic bag (suicide attempt)  distress + disability  Asks to meet psychiatrist in a darkened room where he sits with a baseball cap covering his head and most of his eyes while looking down at the floor most of the time  No friends, fired from job, rejected by girlfriend  distress + disability  When asked what the problem is, he says it’s all because of his nose. More specifically, these “huge marks” on them o “I look like a monster, I’m as ugly as the Elephant Man, these marks on my nose are all I can think about. I’ve thought about them everyday for the past 15 years” o “I have nightmares about them and I think that everybody laughs at me because of them, that’s why I wear this hat at all times and why I didn’t want to see you in a bright room…you’d see how ugly I am”  Psychiatrist couldn’t see this marks Chris was referring to, even after seeing him in a brightly lit room later on  Psychiatrist says that Chris is actually handsome with normal pores  Chris says he doesn’t tell anyone about the marks because he’s too embarrassed o People w/ this disorder typically don’t tell anyone about their preoccupation  Other people have also told him that the marks aren’t visible, but before that could convince him, he’ll look in the mirror and see the huge marks and be convinced that everyone is just laughing about them or trying to make him feel better  Got so anxious about people judging that he stayed in his house all the time (Agoraphobia)  Prof now shows youtube clip on slide of an extreme example of this disorder Slide 6 – Somatoform Disorders (continued) Hypochondriasis: preoccupation with fears of having a serious illness  Recall the email from former student in (I think) first lecture  Typical onset is early adulthood  An individual will make enormous evaluations from the most minor “abnormalities” they experience Slide 7 – Somatoform Disorders (continued) Somatization disorder: a long history of recurrent, multiple somatic complaints with no physical cause, and for which the individual will seek multiple medical treatments  The disorder has to satisfy the following criteria: o 4 pain symptoms in different locations o 2 gastrointestinal symptoms o 1 sexual symptom other than pain o 1 pseudoneruological symptom  Pseudo meaning there is no neurological evidence for the neurological symptom  Again, disability and distress must be evident  Comorbidity – this disorder often accompanies: o Anxiety o Mood disorders o Substance abuse disorders  ie Pain medications or anything else to try and relieve their perceptions of pain  Lifetime prevalence is only 0.5. More common in women  Onset is typically in early adulthood Slide 8 – Somatoform Disorders (continued) Conversion disorder: Sensory or motor symptoms without any physiological cause  Different from Somatization disorder because Conversion disorder is limited to neurological symptoms  Can include sudden loss of vision, or a paralysis of some part of the body, seizures, balance problems, tingling sensations, Aphonia (loss of voice), Anosmia (loss of sense of smell); o Again, all of these complaints are perceived. No evidence of them upon neural imaging. All believed to be psychologically caused Malingering vs Facitious Disorder  Main difference is that in Malingering: the complaints (whether they’re neurological, physical, cognitive or psychological) are consciously produced o In other words, the person is purposely telling you they have these symptoms and they know that they’re lying in order to gain some external incentive  Factitious Disorder: reporting the same symptoms as above, but they’re unconsciously produced o in this disorder people will intentionally produce symptoms, but with no external incentive to do so o The motivation here is the patient wants to take the role of a sick person, because this role results in attention and sympathy o Sounds like an external incentive, but the clinical distinction is external incentives involve things like monetary incentives (ie money from insurance), getting out of going to work o Whereas the factitious patient’s reward doesn’t have this concrete sort of incentive. The reward for these patients is the sympathy that accompanies being in the role of a sick person o Another way of differentiating is that factitious patients don’t show concern for their symptoms  ie “I lost my sense of smell, oh well life goes on” o Whereas a malingering patient will sound more like:  “I lost my sense of smell and it’s disabled me, I want to kill myself because it’s so bad”  Factitious disorder is sometimes called Munchausen syndrome: when the person purposely makes themselves sick and assume role of sick person in order to receive sympathy and attention o ie ingesting something toxic to make yourself sick  Munchausen by proxy: o Eminem’s mother instilled different types of illnesses into him with the purpose of taking on the role of a caring parent who wants to do all she can for her son (case study in textbook) Slide 9 – Malingering  There are tests which can be used to differentiate those with Factitious disorder from those who are Malingering Slide 10 – Checklist  A checklist prof made to differentiate between people who are consciously malingering or unconsciously feigning  Found that it was typically the Malingering people who would say yes to the implausible symptoms on the slide o Factitious patients who weren’t consciously producing these symptoms would say no  This is one way to differentiate b/t these two types of patients Slide 11 – Malingering (continued)  The other way to differentiate by way of tests is the Forced choice recognition o The task from one of the previous lectures where he asked us to remember the images on the following slides then answer correctly when asked to recall which images we’d seen Slide 22  Those who are Malingering would perform below chance (they’ll have impossibly low scores well below chance) o Even those who have severe trouble remembering the images they’d just seen would still score around 50% o Malingering patients would force choose the wrong answers and end up with 5% for example o Those with a Factitious Disorder won’t perform below chance  So this and the checklist test on the previous slide are two ways to determine whether the patient’s symptoms are under voluntary control  He skips slide 23 Slide 24 – Dissociative Disorders  These are incredibly rare  Dissociative Disorders are mainly based on case studies o Not many experimental studies because the sample sizes of people who present with these types of disorders are so small Dissociative Amnesia: Person is unable to recall important personal information  Usually occurs SUDDENLY after some stressful episode/event o ie death of a loved one, severe abuse which triggers this type of amnesia  Two types of amnesia to note: Anterograde and Retrograde  *Retrograde amnesia: can’t remember anything before the event o *This is NOT Dissociative amnesia  **Anterograde amnesia: inability to remember anything after the event o No new learning/memory formation occurs after the event o **This type of amnesia occurs when someone suffers from Dissociative Amnesia  Individual remembers everything about the stressful event  Full recovery does occur (memory loss does disappear); these amnestic states do not last very long  Different from true memory loss which is more complete memory loss, more progressive, less sudden and unrecoverable o In Dissociative Amnesia, other cognitive abilities are still intact  Prof gives case of “The Sailor” to illustrate Dissociative amnesia:  18 year old male brought into hospital by Police. Referred for psychological evaluation  He appears exhausted and shows evidence of prolonged exposure to the sun  Identifies the current date incorrectly (says Sept 27 instead of Oct 31 )  Difficulty focusing on certain questions, but with encouragement he does supply some facts:  He recalls sailing on Sept 25th with friends on a weekend off the coast where they encountered a storm (notice there’s no retrograde amnesia)  Unable to recall subsequent events and what happened to his companions (anterograde amnesia)  Has to be reminded constantly that he’s in a hospital (complete loss of ability to learn any new memories; again, anterograde amnesia), he’s surprised everytime he’s told where he is  No apparent injuries or signs of dehydration  No previous instances of substance abuse o This is important; Can’t be classified as dissociative amnesia if substance abuse was involved  Because of the patient’s sound physical condition, a sodium amytal interview is performed o A truth serum that psychiatrists sometimes resort to  During the interview he says how none of them were experienced enough sailors who could deal with the ferocity of the storm they encountered  He took precautions of securing himself to the boat and with a lifejacket, but his companions didn’t and were washed overboard into the water  He lost control of the boat and says he was only saved because of the precaution
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