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Abnormal Psych 2

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Department
Psychology
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01:830:340
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Mc Kenna

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CH. 5 SOMATOFORM AND DISSOCIATIVE DISORDERS Somatoform Disorder • They are not anxious or worried, though they are concerned • They go to the doctor and focus on their symptoms, not the disease • They are sort of passive about the potential for a disease • They feel a connection with the medical staff because they don’t feel a connection with their family or they don’t get the attention/ belief from their family. The doctors are the only ones that might believe them • How you perceive your body • They feel that they have a disease even if the doctor says they don’t • Not intentional, they truly believe something is wrong • They are not pretending to have a physical bodily pain, though sometimes they will fake it for gain • Treatments: There are not a lot due to the fact that they are very rare and they don’t go to a psychologist, but instead to a physician who doesn’t know it is a disorder o Sometimes medication (SSRI’s) o Cognitive behavioral therapy can sometimes help certain people Hypochondriasis • Usually comorbid with mood and anxiety disorders or depression o They don’t always get addressed because they don’t recognize its psychological and go to a physician instead • Characterized as having a serious disease • Believe that they have a disease and believe that they are seriously ill • They are very anxious, and go from doctor to doctor looking for someone to believe them • Not intentional, they truly believe something is wrong • A woman who is so absolutely desperate to get pregnant that she has convinced herself that she is, and the hypothalamus starts releasing hormones that are only released when pregnant so she shows all of the signs that she is • Etiology: there isn’t a concrete etiology o Trigger: faulty information or interpretation of physical signs and sensations as evidence of physical illness.  Hypersensitivity: They are over sensitive. Their heart races and their body interprets it as danger o Genetic contribution o More in adolescents o Disproportionate incidence of illness or disease in their family when they were children  It is not all genetic, they are learning it and notice that they get the attention when they are ill  Learned behavior  Benefits of “sick role” o Develops in stressful life events o Course: chronic • Treatment: education and reassurance o Cognitive behavioral therapy (CBT)—teach patient to “create” symptom  Education them that it is possible to create symptoms strictly from the determination of the mind  Tell the patient to focus on part of their body and then they start to feel pain there and realize its all in their mind o As the physician you can tell them there is absolutely noting wrong with them, though that will only be a short-term solution o Teach them how to cope with it o Medications for some people—SSRI’s • Cultural differences: o Koru (china): they feel that they are sexually lacking o Dhat (India): o (Africa): hot sensations or crawling sensation on the head o (India): burning in the hands and feet Somatization Disorder: • Don’t think about consequences (no one wants to be their friend because they always have problems) • Impulsive, there is a sexual component (their behavior can be wrong and they don’t know (she had 20 partners, some of whom were her physicians)). • Doesn’t show a conscience. • They identify with the medical staff and get to know everyone in the office • May only have a headache, but are convinced that they have a tumor • Statistics: o Mostly among women than men o Lower income bracket o Unmarried o Usually during adolescence • Etiology: o Share some of the same family history as hypochondriasis o Linked in families to anti-social personality disorder  Serial killers, Dwight K Schrute  They climb the ladder and don’t care who they step on  Impulsive, devious, back-stabbing, don’t think about consequences o Course: chronic o Age of onset: 30 • Treatment: o Difficult to treat since they frequent many specialists o Gatekeeper: One doctor is assigned to be that person’s “gatekeeper” for every time they come in for whatever reason they have o Control them and limit the amount of doctors they go see Conversion Disorder • Physical malfunctioning such as blindness, paralysis, but without organic pathology—usually suggesting neurological impairment o They act blind and think that they are, but will catch something if caught off guard • Taking on the sick role • Mainly neurological concerns • There is a crisis, and emotional concern that precipitates their concern o Were in a car accident and cant walk, but the doctor says they are completely fine • Some symptoms are somewhat transient, leaving and returning due to a traumatic event as different symptoms o EX: woman who married another man, she found out he was sleeping with her daughter and she enjoyed it which was too much for her to deal with so her right arm went numb: conversion o Numbness, inability to feel pain, urinary retention, poor coordination, paralysis of limbs… • Have a history of sexual abuse • Statistics: o Mainly in females and adolescents o Financial problems • Treatment: o Attend to the underlying traumatic situation (the woman needed to address the fact that she couldn’t handle her family dysfunction) o Encourage more independence, do something distracting that is non-medical related o CBT helps some people o Social support o Remove the gain that might be there. Taking on the sick role allows to let go of other things Body Dysmorphic disorder (DSM) • Extreme obsession with a flaw in their body and over dramatic reaction to it • Preoccupation with a minimal or imagined defect in appearance (Michael Jackson and all his surgeries) o Something no-one else notices or something very small that they blow up to be bigger than it is • Preoccupation causes significant distress or impairment in functioning o Won’t go to school because you don’t want people to see your misshapen nose • Preoccupation is not better accounted for by another mental disorder • Comorbid depression; possible suicidal thoughts and attempts o People who couldn’t afford plastic surgery, so they do it themselves—their thinking is distorted • Ideas of reference: Psychotic symptom (usually seen in schizophrenic)—everything in the world relates to them and their problem • No matter what they do to change their body, they will never see it as fixed and will never be satisfied. There is no cure o They will move on to another thing to obsess with if they are semi-satisfied with the surgery they had. But 95% will not be satisfied with it • Involves mostly face and head o May or may not be body dysmorphic disorder • They bypass the psychologists and go straight to the surgeon • Treatments: few o Maybe CBT to address their thinking…. • Course: chronic unless they somehow get satisfaction, sometimes age helps as well • Etiology: teens, young adulthood o If you were picked on for something Dissociation: Lack of connection between memories, thoughts, and emotions • Depersonalization: a symptom that comes and goes in life and can happen once. Achemical imbalance in the brain o Your person has changed, you no longer associate yourself with your body (I was looking down upon myself) o Sensation that you are not connected to your body. You see yourself doing the action. o You may feel mechanical, and not a real person o Usually only lasts a few minutes o You may look at your hand and not recognize it as your hand • De-realization: people walking down the street don’t look real to you. Environmental o Things in your environment look distorted o A car goes by and it looks distorted, people don’t look normal o Lasts for a short while, least likely days • Dissociative amnesia: a trauma based event. The person goes through a trauma but can’t remember anything from that period at all. o Your body basically shuts down because it can’t take in the trauma. o Amechanism to protect the psyche. o Memory will come back eventually with time • Dissociative fugue: to flee or run away. Temporary. o There is a situation that is difficult to deal with, and the person runs away and doesn’t realize it. They get a new identity and new life, and don’t remember a thing about their past life. o They do it to fill the void where they seemed to have lost their identity o It is not conscious o A man left the state; his family was looking for him. The police found him, and when he saw his family, he didn’t remember any of them or recognize them o Treatment: bring in objects to trigger their memory Dissociative identity disorder (DID): commonly misdiagnosed as schizophrenia • Usually get misdiagnosed about 7 times before it is properly identified • They interact with the environment in different ways through their voice, hand writing, mannerisms, but all in the same body • There isn’t even one personality, its all fragmented—can be due to abuse or trauma o Extreme trauma, or torture even and didn’t get it handled early on in life • Host alter: the host is dissociative, they block parts of themselves and it becomes amnesia o Very weak and sad, so they come up with these “alters” to fill that in and make it up • Alter personalities o 15 on average alters, but minimum is 2 o Authentic DID alters try not to be discovered. They do not want to come forward o “Switch” triggered by something in the environment  Eyes usually flutter, cough….it is very quick o Protector alters: the personality that acts as the protector of the body and emerges during fear/threats  In a woman, she can take on the mannerisms of a man (voice, stance)  She sees herself as the man o Sexualized alters: very dangerous, usually due to a lot of stress/trauma sexual abuse  Don’t use protection, dress provocatively o Child alters: you must take what they say seriously  Woman scared half to death because she thought that the Santa Clause head in her trunk was real and trying to kill her o Iatrogenic alters: therapist created alters. Can be hypnotized very easily  This alter doesn’t have any history • Ocular changes between alters • MRI changes in hippocampus and temporal activity • Psychophysiological difference when tested on EEG • Can be faked • Comes from different parts of the brain • Comorbid disorders—can manifest in certain alters o PTSD-flashbacks o Depression/suicidal ideation o Panic attacks o Sexual addiction o De-realization o Depersonalization • Problems that arise: o Academic-due to sleep deprivation o Headaches when switching o Amnesia for various periods of time o Wide array of different clothes • Treatment: o Building of the therapeutic alliance—MUST earn their trust  Their parents have been inconsistent and disorganized and un-trustworthy  Takes time and patience, around 10 years o Introduction of alters, type, age, trauma experienced by each  Write everything down and map their system  Takes a lot of time  Once trust is earned, try to get them to coordinate times for switching alters o Behavioral contracts for safety, time ‘out’in control of the body, respect for the property of others (alters, therapist, other people) o Indirectly deliver the diagnosis-ongoing  Must time it properly, must earn their trust  If they are in the child alter, do a height test and acknowledge it  You expose their alter (and why it makes no sense) and they can sort it out themselves  Don’t debate with them, let them work it out and understand and accept it o Establish communication between alters (journaling, co-conscious) o Abreaction work, screen technique  Re-visiting their painful memories can be very painful o Integration or fusion:  They don’t like the idea of it.  Hopefully it will happen naturally after lots of therapy, but it might not happen at all  Telling them is like death because you are trying to eliminate parts of them  As long as they can operate in life and function semi-normally CH. 6 MOOD DISORDERSAND SUICIDE Mood Disorder: disturbance in emotion. They are transitory • Sadness, happiness, anger, elation, hostility • This is what makes us human • Must have about 2 weeks of a depressed attitude • It can manifest as agitation • Significant weight gain/loss • Isolate from family and friends and it is abnormal • Negative thoughts, they way they view the world and the future • Attribute any positive things in life and put a negative spin on it • Extreme amounts of guilt • Low sex drive Major Depression: “the common cold of mental depression” • Depressed mood, sadness, irritability • Diminished interest or pleasure in activities once enjoyed o The worst characteristic you could possibly have because it is the only thing that can help you get over it • Significant weight loss or weight gain without the intent • Insomnia or hypersomnia (not sleeping or sleeping way too much) • Fatigue or loss of energy nearly every day o The depression starts to affect those around them and no-one wants to be with them because it’s a downer so they end up isolating themselves o Their body is drained from their emotions and what’s going on in their head  When you are studying really hard and you just collapse at the end of the day • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think, concentrate, or indecisiveness • Recurrent thoughts of death • Prognosis: good if you are being treated • Statistics: o Women: men  2:1 • Loss of pleasure—severe cases • Culture: everywhere, may appear slightly different but mainly the same • Course: chronic, episodic • Age of onset: variable. Usually due to a stressor o It is decreasing because our lives today are much more stressful from day to day that it was 50 years ago which we grow up with and get used to and learn to deal with o Sometimes in adolescence  The myelin sheath in children is not cordlete, so the entire brain is not completely coated so it allows the child is impulsive  why it is the 3 leading cause of death amongst adolescents • Specifiers: o Mild, moderate, severe o Severe with psychotic features  Hallucinations (severe) o Severe without psychotic features  Severe depression, cant function o Mood congruent—congruent delusions/HA  Hallucinations make sense with the depression  Delusions that make sense o Mood incongruent—incongruent delusions/HA  Brighter affect  Woman thought she was sent from god to fulfill this great thing o In partial remission Depressive symptoms (loss of sleep or poor concentration)  leads to still greater levels of depression, despair and negativity, with still worse symptoms  which leaves us less able to cope…and so on… Kindling affect: when you have a stressor early in life (dad leaves and you are left with mom so you blame yourself for it). Then you grow up and you are in a relationship and your significant other just decides to end things randomly. Because it is similar to the early trauma, it makes the break-up significantly more traumatic to them than normal and lead to depression Dysthymia • Most of the same symptoms as major depression but less severe • They don’t really realize that they have it, it almost appears to be their personality o They don’t know what normalcy is, you just think that everyone is the same o They are always below the norm in happiness • Course. Chronic, but episodic o At least 2-year duration of episode. Sometimes can last for 20-30 years • Eventually experience a major depressive episode • Double depression: their depression gets worse. They have major depression with an underlying dysthymia o Patient comes in and the doctor asks them questions and they realize that they haven’t been eating much lately or sleeping on top of their daily depression mood • Age onset: 7-11 years old, but really at any time in life o Sometimes diagnosed as a personality disorder • Prognosis: same as depression. It can lift, but usually it just lasts a long time • Statistics: o Women • Treatment: o High comorbidity requires combination of treatments;  Cognitive behavioral therapy (CBT) 70% success • CBT used as a maintenance therapy as well  Selective serotonin re-uptake inhibitor (SSRI) CBT: thoughts  emotions  behavior CBT: situation thoughts moods/feelings/physical reactions behavior SeasonalAffective Disorder: depression due to the changing seasons. Winter makes them more depressed • Usually happens to older people • Prognosis: good if they get treatment • Treatment: o SSRI’s o Lighting that simulates the summer light when reading to give exposure • Course: chronic • Can see it more pronounced in areas of the world that get least amount of sunlight, usually in high latitude. Mania • Excessive energy, racing thoughts o Forced speech, they talk so quickly that they cant speak fast enough o May be in the middle of saying something and switch to another topic • Euphoria—life couldn’t get any better • Feeling restless or irritable • Irrational or impulsive behavior, aggressive, drug abuse, hyper sexuality, no judgment • Delusions of grandeur o Believe that they can fly. May jump off of a building that they can fly o Believe in anything • Treatment: MUST have a medication because it cannot be regulated without it Bi-polar: the most severe type with the most severe symptoms • Chemically based disorder, not trauma induced • Manic stage: o Pressured speech, they talk really fast and you can’t understand them. o Thoughts are tangential o Energy is increased, no need for sleep o Sexuality enhanced, they don’t think about protection  Judgment is terrible—may be happily married and for some reason just go out • May drive 80 mph in a neighborhood o Agitated o Chemically imbalanced—cant go to work or sit in a class • Hypomanic stage: o Chemically imbalanced o Cant function o Energetic—use towards work they need to do o Agitated o Fleeting o Not suicidal • Course: chronic—episodic • Statistics: o Men earlier than women, but equal amongst both o Men: 18-19 years o Women: 20-21 • Occurrence of 1 or more manic or mixed episodes o Has a depressive element • Volatile or erratic rather than consistent manic state o They just act out erratically, tangential, doing a lot of things o Lots of energy—her patient would do a lot of work in this state, but they don’t do a good job • Bipolar 2—bipolar lite—hypomanic episodes o Less severe symptoms than bipolar 1 o One or more alternating depressive episodes • Cyclothymia—low grade chronic bipolar disorder o Difficult to identify o 2 years of several cycles of hypomania and depression that do not meet criteria for depression o Course: chronic  Episodes are longer • Flight of ideas—the tangentiality • Distractibility • Increased goal activity • Excessive involvement in pleasurable activities with potential for painful consequences • Decreased need for sleep • May masquerade as a problem other than mental illness • If left untreated, tends to worsen • Treatment: medication, must check which SSRI will work best for the person o High comorbidity requires combination of treatments  CBT 70% success  CBT used as a maintenance therapy as well  Selective serotonin reuptake inhibitor (SSRI) and lithium  Cognitive therapy—addresses the negative attritional style of thinking common  Family education • Allowing the family to understand so that they can support as best as they can  ECT (electroconvulsive therapy)—current of electricity passes through the frontal lobes  Trans-cranial magnetic stimulation—magnetic coil interacts with neurotransmitters in the synapse • Stimulates brain stem and limbic system (emotional processing) effects the production of neurotransmitters • FDAapproved  Vagus nerve stimulation—implanting a pacemaker-like device that generates pulses to the vagus nerve influences NT production  Medication—tricyclic medication has not shown to be as effective • Lithium: does really well with mania, however gain weight is common • Tricyclic antidepressants o Imitiptyline—neurogenesis in hypocampus • MAO inhibitor—block enzyme MAO that breaks down norepinephrine and serotonin o Only used if nothing else will o Carries a heavy dietary restrictive diet. Cannot have alcohol, cheese….. • St. Johns Wort- herb. Not FDAapproved Rapid cycling bipolar: • Mainly in children • 4 cycles a year, very fast moving, flipping over a lot • Same genders • Treatment same Hypomania: • Can initially present itself as something else such as depression • May feel good to the person who experiences it • Can be masked by other things o Drugs Warning signs for depression • Alcohol abuse • Isolation • Moodiness Suicide • 8 leading cause of death among ages 25-34 • Recent increase in the elderly o Older person doesn’t know how to function without spouse alive so feel isolated o Their memory is less and more friends are dying and your family become more busy o May overdose on their medication by accident • Males are more likely to complete suicide than women • They have a flat affect, low motor activity, cant think, talk slowly • Etiology: o Family history o Early onset of mood disorder o Family member completed suicide o Inherited trait: Impulsivity o Low levels of serotonin o Alcohol abuse o Prevalence of previous attempts o Stressful life events (abuse) o Suicidal talk o Giving away important possessions o Seems to have found a new energy • Prevention: o Treat the person as a normal human being o Don’t consider the person too vulnerable or too fragile to talk about the possibility of suicide. Raise the subject yourself by asking the person directly. o Show the person you care about them even if you don’t know them very well o Help the person talk about and clarify the problem. Those who are depressed may have difficulty pinpointing the problem and may feel frustrated and confused o Listen carefully. People who are considering suicide are in mental and physical pain, although you may not be able to guess
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