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Konstantine Zakzanis

Chapter 6 phobia at the end. This would seem to indicate that we Disorder Description know the origins of the illness, but it’s just jargon. The Phobia Fear and avoidance of objects that aspect of the phobia studied depends on the paradigm. don’t present any real danger Psychoanalysts believe phobias come from specific Panic Disorder Recurrent panic attacks involving a symbolic value of what they fear; Behaviorists believe sudden onset of physiological phobias develop from function of that which they fear. dizziness, trembling… usually accompanied by agoraphobia  Specific Phobias: unwarranted fears caused by GAD Persistent worry about minor things presence/anticipation of a specific object or situation. These are divided (in order of most common) into: OCD Experience of uncontrollable thoughts (obsession) and repetitive animal phobias, heights, closed spaces, flying, water, behavior (compulsion) dentist, seeing blood/injections, and storms. PTSD Aftermath of a traumatic experience Furthermore, they can be divided empirically into: Acute stress Same as PTSD but only last >4 weeks  Agoraphobia (fear of public places) Drugs: Category Name Use  Fear of heights/water  Threat fears Benzodiazepine Valium, Xanax… GAD, PTSD, Panic MAO inhibitors Nardil Social Phobia  Fears of being observed SSRI Prozac, Zoloft Social phobia,  Speaking fears panic, OCD, PTSD So, now there’s the specific fears category, and the Tricyclic Tofranil GAD, OCD, PTSD, social fears category. Specific fears are cross cultural antidepressants panic (pa-leng: fear of cold or loss of body heat; Taijin Kyofu- Azapirone BuSpar GAD, OCD, panic sho: fear of embarrassing others).  Social Phobia (aka SAD): persistent, irrational fears Anxiety: unpleasant feeling of fear and apprehension. linked generally to presence of other people. There Anxiety disorders: diagnosed when subjectively are 3 types of this: experienced feelings of anxiety are clearly present. The  Social interaction fear above are the 6 categories in DSM-IV. There is a high comorbidity between them (not as much with OCD)  Observation fear  Public speaking fear (the one different from the because (1) some symptoms (like somatic ones: heart rate…) are not disorder specific, and (2) etiological above 2; aka performance-only SAD). These have high comorbidity with other disorders factors are applicable to more than one. As a group, (including alcoholism and substance-abuse). The they’re the most common group (1 in 5 diagnoses). This disorder affects 16% women and 9% men. The most average age of onset is 13. Etiology of phobias: proposals about the causes: common of the group is Social Anxiety Disorder (SAD) followed by PTSD. Comorbodity is strongest with  Behavioral Theories: focus on learning as the way in which fears are acquired. depressive disorders. The common theme across these disorders is that dysfunctional levels of anxiety reflect o Avoidance conditioning: holds that phobias cognitive evaluation processes contributing to the develop from: 1. Classical conditioning. A person can learn to fear perception of anxiety, and physiological factors that render some people more vulnerable. when a neutral stimulus is combined with an unconditioned stimulus, and becomes a Current biological work examines brain structures and neurological processes. Most focus is on right amygdala conditioned stimulus (CS). (cerebral structure in temporal lobe) and insula. 2. Operant Conditioning: Person can learn to reduce conditioned fear by escaping from the CS. PHOBIAS Phobia: disrupting, fear-medicated avoidance that is Limitation of avoidance conditioning: Little Albert’s experiment shows that conditioning is a possible out of proportion to the danger actually posed; 5% of women are affected. Most phobias have a Greek suffix way to develop phobia, but not the only way (translated from the name of the fear) and the word o Modelling: through vicarious learning: people can deficient. They also experience post-event processing learn fear through imitating reactions of others. (PEP) of negative social experiences. The anxious-rearing model is based on this idea o THERAPY: it’s hard for cognitivists because these (children develop phobias because their parents therapists believe that client already knows his warned them about the situation/object). fears are irrational. They work mostly for social o Prepared Learning: there are certain stimuli phobias. Therapists teach clients to more (prepared stimuli) that are more likely to be accurately appraise people’s reactions (a frown classically conditioned (we are physiologically may mean the person is having a bad day) and prepared). This shows the avoidance modeling increase client’s sense of self-worth. These are ideas to not be complete better than drugs because they last longer. o Diathesis is needed: Why do some people with Homework (between-session learning) is important trauma not experience fear? A predisposition that too. Also, a cognitive-behavioral case formulation similar experience will develop in the future is also framework can be used. needed to develop a phobia. This also shows  Biological factors: people have biological avoidance model to not be completely true predispositions to developing a specific disorder. because some people aren’t conditioned to have o Research looks at the autonomic nervous system fear, yet they develop it. (ANS): studying the ease with which ANS becomes o Social skills deficit: lack of interpersonal skills may aroused. The function used to measure it is the cause social phobias. Limitations: it might be the stability-lability (lability: jumpiness). Since other way around, but either way, it’s important to autonomic lability is biological, anxiety disorders take into account when planning therapies. are genetically determined. o THERAPY: systemic desentization to the phobia was o Genetic factors: blood/injection disorder is 64% found to be more effective when in vivo (live). It familial. Yet, this may also mean that the disorder has outperformed psychotherapy and placebo is learnt through imitation, or a bit of both. affects, yet it has a high dropout rate. Virtual o THERAPY: drugs to reduce anxiety are called reality treatments were just as effective. These sedatives, tranquilizers or anxiolytics. The classes work well for flight and height phobias, but not of drugs include: barbiturates (discontinued blood and injection phobias. Part of the because of high overdose rate and addiction), physiological response of those is low blood propanediols and benzodiazepines. Drugs to pressure and fainting, so trying to relax as part of reduce depression (monoamine oxidase-MAO; virtual reality will contribute to that. So, they’re SSRI) were also used. encouraged to tense instead. For social phobias,  Psychoanalytic theories: believe that phobias are learning social skills and modelling can help. defense mechanisms against anxiety produced by id Another is flooding (intense exposure of fear). impulses, and this fear is moved unto an object with Therapists who look at operant conditioning treat symbolic meaning. phobias with shaping through successive o THERAPY: they believe it’s from an earlier problem, approximations. Secondary gain: person’s phobia so the only thing they can do is encourage patient reinforced with the acceptance of others. to face the phobia.  Cognitive theories: focus on how people’s thought PANIC DISORDER processes can serve as a diathesis on how thoughts Panic Disorder: sudden and inexplicable attack of a host can maintain a phobia. People with anxiety disorders of jarring symptoms: laboured breathing, heart tremors, have (1) an attentional bias to focus on negative social nausea, chest pain, feelings of choking, dizziness, information and interpret ambiguous signs as trembling, depersonalization (feeling of being outside negative, (2) perfectionistic social standards for one’s body) derealisation (feeling that world is not accepted social performances, and (3) high degree of real), fear of losing control, going crazy and of dying. public self-consciousness. They believe their selves are They’re referred to as ‘cued’ panic attack when strongly associated with specific situations, ‘situationally 3. Exposure to internal cues that trigger panic. predisposed’ attacks when moderate relation, and ‘un- GENERALIZED ANXIETY DISORDER (GAD) cued’ when in unexpected situations (sleep). To be a GAD: all-encompassing worry. 7% for women; 4% men. panic disorder, not just phobia, client needs to have Etiology of GAD: experienced recurring un-cued attacks and worry about  Cognitive-Behavioral Views: they look to the having attacks in the future. Panic disorder usually environment. Anxiety is regarded to have been happens with agoraphobia. It affects more women than classically conditioned. Control is an essential factor in men. GAD. GAD is linked with the 2 factor model of the Etiology of Panic Disorder: approach-avoidance conflict (the 2 factors being  Biological Theories: physical sensations caused by an intolerance of uncertainty and a fear of anxiety). This illness (like mitral valve prolapse syndrome) lead some means that people with GAD have a desire to people to develop panic disorder. It runs in families approach behaviors to reduce uncertainty, but they and has a strong heritability component (higher also engage in avoidance methods to reduce anxiety. concordance in identical twins). It was shown that people use worry as a negative o Noradrenergic Activity: panic caused by over punishment (it distracts them from emotions). activity in noradrenergic system (neurons that use o THERAPY: exposure may be a treatment (if the noradrenaline as neurotransmitter) either focusing cause becomes understood). Otherwise, usually on the locus coruleus (in pons), or a problem in intensive relaxation treatment. Another technique GABA neurons that generally inhibit noradrenergic is to teach client skills that make him feel in control activity (also causing overactivation in the system). (assertiveness…). Exaggerated exposure also helps o Cholecystokinin (CCK): peptide found in cerebral in extinguishing anxiety (client would have been in cortex, amygdala, hippocampus and brainstem, anxiety for 30 min, and it will fade), and it will show suggesting that changes in CCK produce changes in the client how unrealistic his thoughts are. CBT expression of panic. treatments are much better than drugs (even when o THERAPY: treatment of choice is SSRI. Many people both are used together). self-medicate with anxiolytics or alcohol (bad),  Biological views: Most common is benzodiazepines. ranging from 8 (social phobia) to 36% (GAD) These release GABA and inhibit anxiety.  Psychological Theories: suggests that agoraphobia o THERAPY: benzodiazepines (an anxiolytic) and isn’t a fear of public places, but that of having a panic antidepressants can treat this. Antidepressants are attack in public. They believe that for panic attacks, usually preferred because depression usually people may be predisposed to an ANS that is overly comes with GAD. active, but they worry too much about that, and make  Psychoanalytic View: GAD unconscious conflict the attack worse. Experiments show that unexpected between id and ego. People with phobias are luckier bodily arousal in people who are fearful of such because at least their ego chose something to sensations leads to panic attacks. Anxiety sensitivity: represent conflict, and these people know what makes shown to predict symptoms of PTS and distress. Panic them anxious, unlike GAD-patients. disorders are both heritable, and passed on through o THERAPY: Treatment is like that of phobias parenting and modeling. Perceived control also affects OBSESSIVE COMPULSIVE DISORDER (OCD) the disorder (more control, less panic). OCD: mind is flooded with persistent and uncontrollable o THERAPY: exposure treatment (in vivo) is most thoughts and individual is compelled to act on them. suitable. One program is the mindfulness BCT Early onset is more common in men, but overall, the (MBCT). Another uses these steps: disorder is more common in women. Obsessions: 1. Relaxation intrusive and recurrent thoughts that come and appear 2. Beck-type treatment (changing thoughts) with irrational and uncontrollable. Compulsions: repetitive cognitive restructuring and monitor thoughts behavior that person feels driven to perform to reduce during the attack distress caused by obsessive thought or prevent calamity. Primary obsessional slowness: when slowness  Psychoanalytic theory: they believe that obsessions is the central problem, not from another OCD symptom. and compulsions result from childhood fixations (anal 3 checkers that intensify OCD: sense of personal stage: harsh potty training cause person to be responsibility, probability of harm if compulsion goes compulsively neat). Other psychoanalysts believe that unchecked, and predicted seriousness of harm. True fixations result from highly doting parents or overly compulsions are ego-dystonic (foreign to their dominating ones, and the compulsions make the client personality), so since compulsive eater, gambler… get seem in control of at least that. pleasure, they don’t really suffer from OCD. OCD- o THERAPY: like phobias and GAD: lift repression and related disorders include hypochondriasis, chronic tic allow client to confront fears. Such methods disorder, and body dysmorphic and eating disorders. haven’t been effective in treating OCD. The Etiology of OCD: ultimate focus is now to gain insight into  BC theories: compulsions are viewed as operant unconscious determinants of the symptoms. escape-response that reduces obsessions. It was also POST-TRAUMATIC STRESS DISORDER (PTSD) proposed that compulsions result from memory PTSD: discovered after Vietnam War in DSM-III; deficits (you don’t remember if you turned off the extreme response to a severe stressor. PTSD is different stove). A cognitive bias was identified: though-action- than acute stress disorder in that the acute stress fusion (involves 2 beliefs: thinking about unpleasant disorder lasts only for less than a month. It’s things increases their likelihood to happen, and controversial, because at first PTSD was defined by the thinking something unpleasant is the same as having event. Now, it’s believed to be a bit from the event, and actually carried it out. So, it blurs the line between a bit from the person. Another controversial part is that thinking and doing). Research shows that trying to definition that includes ‘indirect, information exposure’ inhibit a thought is paradoxical (you’ll think more as a qualifying trauma. Now, there are 3 groups of about it). symptoms to present themselves from more than a o THERAPY: Most common is Exposure and Response month: (1) re-experiencing traumatic event, (2) Prevention (ERP): You expose yourself to obsessive avoidance of stimuli associated with event/numbing of situation and refrain from compulsion. This is really responsiveness (estrangement), and (3) symptoms of painful for clients, so high dropout rate and refusal increased arousal (difficulty sleeping, concentrating, to treatment are a problem. Another method is hypervigilance, and exaggerated startle response). One- cognitive restructuring. Another approach is the month prevalence is 1 in 25 Canadians. For Hurricane inference-based approach where clients are helped Katrina, the prevalence of mental disorders increased in eliminating the obsessional inference. over time, as opposed to decrease like in past studies.  Biological Views: biological factors may predispose It’s more likely in women, and it causes substance- people to OCD. 2 areas were identified to be related related abuse. to OCD: (1) frontal lobes and (2) basal ganglia Etiology of PTSD: (subcortical nuclei including caudate, putamen, globus  Risk factors: it’s important to look for risk factors of pallidus and amygdala). Serotonin system is believed developing PTSD as well as of exposure to trauma. to be related, yet 40-60% of people don’t respond to Research shows that men are more likely to be SRI treatment exposed to trauma (except for child sexual abuse – o THERAPY: SSRIs and tricyclics are the most CSA) but women are more likely to develop PTSD. common treatments, but symptoms usually return Other risk factors: threat to life, early separation from when drugs are discontinued. Both drugs and ERP parents, family history of disorder, previous trauma was shown to reduce activity of the caudate (and exposure, pre-existing disorder, attachment style, thus reduce OCD). An invasive procedure is dissociative symptoms. cingulotomy (destroy 2 meters of cingulotom, near  Psychological theories: learning theorists believe it the corpus callosum). comes from classical conditioning of fear. It takes on to Mowrer’s 2-factor theory (avoidance-approach theory). Cognitivists believe it’s to do with involuntary Disorder Description act of recollection and memory. A psychodynamic Dissociative Memory loss following stressful approach believes that people are so traumatized that Amnesia experience they consciously repress it. The internal struggle Dissociative Memory loss accompanied by leaving Fugue home and establishing a new identity comes when they try to make sense of the events. Depersonalization Altered experience of the self o THERAPY: crisis intervention is necessary before Dissociative Have at least 2 distinct ego states that trauma develops PTSD. This includes re-enacting Identity Disorder act independently. the scene from the recollections of client and Somatoform and dissociation disorders were classified telling them that they survived what most people with anxiety disorders because back then, classification can’t. CBT methods like relaxation, imaginary cues, was based on observations, not on etiology (they were and thinking differently are also useful. Another known as neuroses disorders). method is to use narcosynthesis, in which client Somatoform (complain of bodily symptoms that suggest was given sodium pentothal (drowsiness), and the physical defect but have no physiological basis) vs. client would recollect events just to get out of that SOMATOFORM state and realized it was in the past and now he’s It’s a controversial set of disorders and people believe safe. Another method is imaginal flooding. Here, they should be removed from DSM-V because: clients became temporarily worse, then improved. Terminology is unacceptable to patients (stigma) Exposure is greatly effective. One such type is the The distinction is only apparent, not real Eye Movement Desensitization and Reprocessing The disorders are very distinct (only linked with (EMDR). It’s also a fast one. Rational-emotive the psychogenic origin) therapy is also used here. Another CBT is They`re incompatible with other cultures Miechenbaum`s narrative construction, and adding There`s ambiguity in them new positive meaning to the ever-changing There`s no reliability in the categories accounts of the trauma. Psychotherapy is highly They lack clearly defined thresholds effective here (it involves exposure too). Pain disorder: experience of pain that causes personal  Biological: twin studies show a heritability factor. A distress, and psychology of the individual plays a role in study (unique in that it included non-military onset, maintenance and severity. The client may participants, as well as women) found that become dependent on pain killers. It`s hard to diagnose neuroticism trait might be the diathesis vulnerability it (when is pain considered to be psychological?). factor. Trauma was found to activate the Neurologically, it’s seen in grey-matter decreases in noradrenergic system (increasing startles). prefrontal, cingulated and insular cortex. o THERAPY: Antidepressants (to deal with comorbid Body Dysmorphic Disorder (BDD): worrying about depression) and tranquilizers are used. Yet, it`s imaginary defects in appearance, mostly in the face more effective for people who choose it, as (wrinkles, facial hair…). opposed to people who prefer exposure as Hypochondriasis: people worry about having a serious treatment. For all psychologists, social support is illness, even if they’d been reassured they don’t. It`s 5% an important factor in treatment. of the population. The name of the disorder has too Chapter 7 much negative stigma, they want to rename it as Disorder Description `health anxiety disorder` (hypochondriasis is different Pain Disorder Onset/maintenance of pain from from illness phobia, in that it is fear of having an illness, psychological factors Body Dysmorphic Worry about imagined/exaggerated and the phobia is fear of contracting it). It has been linked to the trait neuroticism. It`s moderately defects in physical appearance heritable, but mostly environmental (it`s learned). Hypochondriasis Worried about having an illness Conversion Symptoms with no physiological cause Conversion Disorder: physiologically normal people Somatization Recurrent physical complaint with no experience sensory or motor symptoms with no biological basis physiological/neurological basis (paralysis, blindness…). Anesthesias (loss of sensations), aphonia (loss of all but perceptual representations. People can really ‘see’ but whispering speech and voice), anosmia (loss of sense of not know it, and it’s called blindsight (lesions in visual smell) may result too. Freud coined the term, believing cortex, not eyes). that when an individual is stressed, the ego  Behavioral theory of conversion disorder: proposes unconsciously converts the psychological distress into that conversion is behaviourally, like malingering. physical one. The older term of conversion disorder was People can learn to behave as though they had an hysteria (believed to affect only women). These usually illness (you can induce blindness, anesthesia, and develop at adolescence in stressful times. Carpal Tunnel paralyses with hypnosis). syndrome has symptoms of glove anesthesia (part of  Social and Cultural factors for conversion: these the arm covered by gloves is desensitized). Glove disorders are now rarer than before, so it must be the anesthesia was always believed to be part of hysteria, culture. Also, it’s more common in people with low but now, it’s seen that the carpal syndrome is biological. SES. Also, it’s more common in less developed The problem is that sometimes, biological disorders are countries (but this could either mean that increased instead classified as conversion ones. Conversion sophistication about mental health is what helped; or disorders are hard to separate from malingering (fakes that we have better medicine). incapacity to avoid responsibility). One way to  Biological views for conversion: there is NO genetic differentiate between them is la belle indifference (lack basis for these disorders. There are brain structure of concern toward symptoms; only 1/3 of people with relations: they’re more common to have problems in conversion disorder experience it; malingers are left side than right of the body (so right hemisphere). generally more cautious). Another related disorder to Also, since right hemisphere is responsible for conversion is factitious disorder (people get sick on emotions, it may explain overreactions in the patients. purpose, but the difference is it’s harder to recognize Also, when the paralyzed arm/foot was stimulated, because all the people want is to play the sick role). there was no somatosensory activity in brain, but Another form of the factitious disorder is the when normal one was activated, there was activity. Munchausen syndrome by proxy (get your child sick to THERAPY: it’s important to recognize and treat comorbid show that you’re a good parent in taking care of them). conditions with these disorders. Psychotherapy is usually Somatization disorder: aka Briquet’s syndrome: used, yet it only works in reducing anxiety, not treating diagnosis needs to be based on: disorders. Cognitive therapies work with exposure and  4 pain symptoms in different locations changing thoughts, and teaching skills. Pharmacological  2 gastrointestinal symptoms (diarrhea…) treatments for BDD focus on SSRI’s, although CBT is  1 Sexual symptom (indifference to sex) more effective and more preferred. CBT is also the most  1 pseudoneurological disorder (like conversion). effective treatment for hypochondriasis (SSRIs are also Etiology of somatoform disorders useful for this, but only on the short-term).  Theories on somatization disorders: patients with this DISSOCIATIVE DISORDERS over-attend to physical sensations and misinterpret Dissociative disorders (experiences disruptions of them. They also face a lot of anxiety and stress (they consciousness, memory, identity…). They’re grouped have high cortisol levels). together because both are brought about by stress, and  Psychoanalytic theory of conversion: conversion not much is known about them. They usually co-occur. disorders are important to Freud because they Janet coined the term, because it was believed that allowed him to explore more of the unconscious. It’s consciousness is usually unified, and only in stress does believed that this disorder relates causally to the the brain dissociate the stressful thoughts to protect the trauma that caused them. Freud relates this to the person from finding them. females’ Electra’s complex. A 2-stage defense theory Nick Spanos contributed 3 things to research in the area: was proposed: (1) perceptions of visual stimuli are 1. Most psychiatrists who diagnose DID are the only blocked from awareness (so people believe they are ones who diagnose it. They’re specialists in that field blind), and (2) information is still extracted from the so they see it everywhere 2. He demonstrated that role-playing can help develop usually hypnotized (even with drugs) and asked to go ‘DID’ when the situation needs it through role- back to the time it happened (mostly in childhood, so playing the Hillside Strangler case. it’s called age regression). A guideline revision task force 3. He showed that cognitive constructions could from Vancouver suggested a 3-step treatment: (1) operate false memories and cause people to believe safety, stabilization and symptom reduction, (2) work in anything (like UFO’s for example). directly and in depth with traumatic memories, and (3) Dissociative Amnesia: unable to recall important identity integration and rehab. Iatrogenesis: inducing a personal information, after stressful experiences. The change in the client inadvertently by a therapist or his information is temporarily lost, until amnesia is gone. treatment (in this case, separate identities). This is one Dissociative Fugue: more extensive memory loss. This factor for decreasing validity of DID diagnoses. includes the person leaving home and assuming a new identity. Individual doesn’t recall what had happened Chapter 8 during flight. Mood disorders: disabling disturbances in emotion Depersonalization: person’s perception of the self is from sadness of depression to the elation and irritability disruptively altered. of mania. The presence of other disorders may increase Dissociative Identity Disorde
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