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Chapter Notes 6-8; 20; 14

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University of Toronto Scarborough
Connie Boudens

Chapter 6 – Anxiety Disorders • Anxiety – an unpleasant feeling of fear and apprehension accompanies by increased physiological arousal. In learning theory, it is considered a drive that mediates between a threatening situation and avoidance behaviour. Anxiety can be assessed by self-report by measuring physiological arousal and by observing overt behaviour • often someone with one anxiety disorder meets the diagnostic criteria for another disorder as well, with the possible exception of OCD • Identify two reasons for comorbidity in anxiety disorder. o Symptoms of the various anxiety disorders are not entirely disorder specific o Etiological factors that give rise to various anxiety disorders are probability applicable to more than one disorder • Anxiety disorders are the most common psychological disorder o One year and lifetime prevalence rates for total anxiety disorders of 10.6 and 16.6% o An early onset, typically during childhood o More common in woman than in men across all age groups... quite common among university students o Social anxiety disorder is the most common anxiety disorder with a lifetime prevalence of 8.12% o Those with an anxiety disorder (and those with a substance-related disorder) were less likely to see help from mental health services relative to those with a mood disorder o Strong co-occurrence of anxiety disorder, such as PTSD, panic disorder, GAD, and SAD, and chronic pain, especially musculoskeletal pain o Comorbidity strongest with depressive disorder.... strong relationship at both genotypic and phenotypic levels... two elements of a general affectivity factor o Anxiety and depression share a common component of negative affect... however they can be differentiated by high physiological hyperarousal associated with anxiety and by low positive affect associated with depression o PTSD, SAD, and specific phobias have greater activity in two areas associated with negative emotional responses: the amygdale and insula  It is the right amygdale that is implicated with PTSD • Phobias – a disrupting, fear mediated avoidance that is out of proportion to the danger actually posed and is recognized by sufferers as groundless o Psychoanalysts focus on the content if the phobia and see the phobic object as a symbol of an important unconscious fear (symbolic value); ego’s way of warding off a confrontation with the real problem...while behaviourists focuses on its functions o Specific phobias – unwarranted fears caused by the presence or anticipation of a specific object or situations o Subdivided according to the source of fear: blood, injuries, and injections; situations, animals, and the natural environment o Most common in order, animals, heights, being in closed spaces, flying, being in or on water, going to the dentist, seeing blood or getting an injection, and storms, thunder, or lightening. o Social phobias – persistent, irrational fears linked generally to the presence of others  earlier age in onset and more comorbidity, such as GAD, panic disorder, avoidant personality disorder, and mood disorders  especially vulnerable to marijuana related problems  lower self-esteem and a disturbed body image • Summarize three behavioural theories of phobias. o Avoidance conditioning –reactions are learned avoidance responses. Based on a two factor theory where phobias develop from two related sets of learning:  Via classical conditions – fear a neutral stimulus (CS) if it is paired with intrinsically painful/fearful event (USS)  Operant conditioning – the response is maintained by its reinforcing consequence of reducing fear o Modelling – the learning of fear by observing others (vicarious learning), can also be accomplished through verbal instruction... anxious-rearing model is based on the premise that anxiety disorders in children are due to constant parental warning that increase anxiety in the child o Prepared learning – people tend to fear only certain objects and events but not others.... certain neutral stimuli (prepared stimuli) are more likely those others to become classically conditions stimuli.... • What is the general limitation of behavioural theories and why would it be helpful to add the idea of diathesis to them? Describe four possible diatheses for phobias (social skills, cognitive, autonomic, and genetic). o Limitation: why some people who have traumatic experiences do not develop enduring fears... diathesis allows for consideration of multiple factors  Cognitive diathesis – a tendency to believe that similar traumatic experienced will occur in the future, may be an important in developing a phobia... not being able to control the environment o Social skills – a behavioural model of social phobia considers inappropriate behaviours or a lack of social skills as the cause of social anxiety o Cognitive – focus on how people’s thought processes can serve as a diathesis and on how thoughts can maintain a phobia or anxiety.... anxiety related to being more likely to attend to negative stimuli, to interpret ambiguous information as threatening, and to believe that negative events are more likely than positive ones to occur in the future  Socially anxious people are more concerned about evaluations, more aware of the image they present to others, and are preoccupied with hiding imperfections and not making mistakes in front of others ... fundamental core fear is that the self is deficient.... excessive criticism o Autonomic – autonomic liability is the tendency for the autonomic nervous system to be easily aroused... to some degree genetically determines.... o Genetic – blood and injection phobia is strongly familial • Summarize the behavioural (five techniques), cognitive and psychoanalytic approaches to the therapy for phobias. What do all these techniques have in common? What is the key problem with the common biological treatment? o Behavioural  Systematic desensitization – individual with a phobia imagines a series of increasingly frightening scenes while in a state of deep relaxation  Blood and injection phobias are more severe fears and avoidances... relaxation tends to make matter worse because they often experience a sudden drop in blood pressure and heart rate and faints... now encourages to tense  In vivo exposure – superior to techniques using imagination... an exercise at home that requires the phobic person to be exposed to the highly feared stimulus or situation... high dropout rate and lowe treatment acceptance  Virtual exposure – just as effective as in vivo exposure.... involved exposure to stimuli that come in the form of computer-generated graphics.... can be tailored to involve graded exposures to threatening stimuli in a hierarchy  Flooding – a therapeutic technique in which the client is exposed to the source of the phobia at full intensity; the extreme discomfort is inevitable discourages therapists from suing this technique, except perhaps as a last resort when graduated exposure has not worked  Modelling – fearful clients are exposed to filmed or live demonstrations of other people interacting fearlessly with the phobic object  Operant techniques – attend to the overt avoidance of phobic objects and to the approach behaviours that must replaces it.... treat approach to the feared situation as any other operant and shape it via the principle of successive approximations o Cognitive – there is scepticism because “the phobic fear is recognised by the individual as excessive or unreasonable” (acknowledges that the fear is harmless, what use can it be to alter the person’s thoughts about it  No evidence that the elimination of irrational beliefs alone, without exposure to the fearsome situations, reduce phobic avoidance  With social phobias, its more promising... many people with social phobias have adequate social skills but do not use them because of self-defeating thoughts  Superior to a combination of exposure plus applied relaxation in the treatment of social phobia  Homework – between session leaning that typically involves get practice in engaging in specific behaviours or thoughts... an essential component o Psychoanalytic – attempted to uncover the repressed conflicts believed to underlie the extreme fear and avoidance.... more on encouraging the client to confront the phobia o Biological treatment – the client may find it difficult t discontinue their use, relapse being a common result.... severe withdrawal syndrome (benzodiazepines) • Describe the basis of the cognitive behavioural case formulation framework. o Approach behaviours – contact with anxiety-eliciting stimuli often occurs as a consequence of the person’s behaviour o Stimulus – feared stimuli can be drawn o Hypervigilance to stimulus – people attend to threatening stimuli o Perception of danger – elicits anxiety o Neuroticism – a stable, pervasive personality dimension that predisposes people to experience negative affective states and that influences both cognition and anxiety symptoms o Information/experience – stimuli can come to be appraised as threatening through direct experience, observation, and verbal acquisition o Increased anxiety o Reduced self-efficacy – perceptions of ability to cope with anxiety-provoking stimuli and consequent symptoms have been implicated in the anxiety disorders o Anxiety reducing behaviour – the person needs to refrain from the behaviours usually used to relieve anxiety, circumventing negative reinforcement and strengthening perception of coping ability o Safety signals o Reduced anxiety and reinforcement of anxiety reducing behaviors o Punishment of approach behaviours – during exposure, habituations occurs and the punishing effects of anxiety are diminished • Summarize the basic biological approaches to the treatment of phobias. o Drug that reduce anxiety (anxiolytics)... o Barbiturates were the first major category, but they were highly addictive and present great risk of a lethal overdose o Benzodiazepines o Monoamine (better than benzodiazepines for social phobias)( weight gain, insomnia, sexual dysfunctions and hypertension) o SSRIs, like fluoxetine (Prozac)... • Describe the characteristics of panic disorder and its relation to agoraphobia. Summarize the overall findings with regard to the incidence of panic symptoms in Canadian university studies. How comparable are clinical and subclinical forms of panic? Evaluates four biological and two psychological factors or hypotheses about panic disorder. o Panic disorder – a person suffers a sudden and often inexplicable attack of a host of jarring symptoms: laboured breathing, heart palpitations, nausea and chest pain, feelings of choking and smoldering, dizziness, sweating, and trembling and intense apprehension, terror and feeling of impending doom o Depersonalization – a feeling of being outside one’s body... derealisation – a feeling of the world’s not being real o Referred to as cued panic attacks when they are associated strongly with situational triggers (most likely reflects the presence of a phobia)… when their relationship with stimuli is present but not as strong, they are referred to as situational predisposed attacks… Can also occur in seemly benign states, such as relaxation or sleep and in unexpected situations (uncued attacks) o 35% of undergraduates reported experiencing at least one panic attack in the previous year… 22.1% of students reported experiencing a panic attack within the past year… non-clinical panic suggests that students who experience frequent panic attacks in a three week period demonstrate phobic avoidance and psychological distress while students who are less frequent attackers do not show these symptoms… o Agoraphobia – a cluster of fears centring on public places an being unable to escape or find help should one become incapacitated… those with panic disorders typically avoid the situations in which a panic attack could be dangerous or embarrassing; if the avoidance becomes widespread, panic with agoraphobia is the result o Also linked to physical conditions, such as asthma (believed that the panic exacerbates the asthma and vice versa) o Biological factors  Physical sensations caused by an illness lead some people to develop panic disorder (ex: mitral valve prolapse syndrome causes heart palpitations and inner ear disease causes dizziness, both can be terrifying, leading to the development of panic disorder)  run in families…. Greater concordance in identical-twin pairs than in fraternal twins… increased risk of 5- 16% among relatives of those with panic disorder and early onset is associated with increased rick for family members  noradrenergic activity – panic is caused by overactivity in the noradrenergic system (neurons that use norepinephrine as a neurotransmitter).. one theory focuses on a nucleas in the pons called locus ceruleus (although there is studies where the drug yohimbine can elicit panic attacks in people, there is inconsistent findings though)…. Another idea is that it results from a problem in the GABA neurons that generally inhibit noradrenergic activity (fewer GABA receptor binding sites in clients)  cholecystokinin – a peptide that occurs in the cerebral cortex, amygdala, hippocampus, and brain stems, induced ansiety-like symptoms and that can the effect can be blocked with benzodiasepines, suggesting that changes in CCK produce changes in the development or expression of panic o Psychological factors  The fear-of-fear hypothesis – suggests that agoraphobia is not a fear of public places per se, but a fear of having a panic attack in public… as for panic attacks themselves, the foundation of their development may be an ANS that is predisposed to be overly active couples with a psychological tendency to become very upset by these sensations…. The frequency of panic attacks was strikingly high in participants who feared their bodily sensations, breathed air containing a high concentration of carbon dioxide, and did not expect it to be arousing (unexplained physiological arousal in someone who is highly fearful of such sensations leads to panic attacks)  Evidence that anxiety sensitivity acts as a risk factor…. People with the disorder have an extreme fear of losing control, which would happen if they had an attack in public. • Identify three disadvantages to biological treatments for panic disorders. Describe two general psychological treatments and compare their effectiveness to biological treatments. o Biological – the use and abuse of drugs is common…. Self-medication range from 8% (social phobia) to 36% (for GAD)… self-medication is linked with suicidal ideation and suicide attempts… relapse when they discontinue prescribes medications o Psychological  Exposure-based treatments are often useful in reducing panic disorder with agoraphobia  In vivo exposure  Barlow and associates – (1) relaxation training, (2) combination of Ellis and Beck type CBT interventions including cognitive restructuring and (3) exposure to the internal cues that trigger panic… clients learn to reinterpret internal sensations, no longer seeing them as signals of loss of control and panic rather than sues that are intrinsically harmless and can be controlled with certain skills • Describe the characteristics of generalised anxiety disorder. Summarize one psychoanalytic, four cognitive- behavioural, and two biological views on its cause. o GAD – persistently anxious, often about minor items… chronic worry about all manner of things is the hallmark of GAD… most frequent worries concern their health and the hassles of daily life… difficulties concentrating, tiring easily, restlessness, irritability, and a high level of muscle tension….lifetime prevalence fairly high (4.2% M and 7.1% M)…  Typically begins in mid-teens… stressful life events… high level of comorbidity with other anxiety disorders and with mood disorders… difficult to treat successfully  Lifetime prevalence increases by 40% when the “excessive and uncontrollable worry” requirement of the DSM is removed o Psychoanalytic  Regards the source of generalized anxiety as an unconscious conflict between the ego and the id impulses…. The impulses are struggling for expression but the ego cannot allow their expression because it unconsciously fears that the punishment will follow… o Biological  Both a heritable and an environmental component… may result from some defect in the GABA system so that anxiety is not brought under control o Cognitive-behavioural  Anxiety is regarded as having been classically conditions to external stimuli but with a broader range of conditioned stimuli  Emphasizes the perceptions of not being in control as a central characteristic of all forms of anxiety… it is sufficient for the control only to be perceived by the subject; control need not actually exist  Unsignalled and therefore unpredictable aversive stimuli may lead to chronic vigilance and fear  The role of intolerance of uncertainty in the experience of chronic worry and GAD… those with intolerance of uncertainty have a desire to engage in approach behaviours to reduce their feelings of uncertainty, but they are also characterized simultaneously by a fear of anxiety that promotes the use of avoidance… being intolerant of anxiety and also fearful of anxiety results in greater worry than either factor by itself  Highly sensitive to and cognitively preoccupied with threat cues…. Attention is easily drawn to stimuli that suggest possible physical harm or social misfortune  Worry is actually negatively reinforcing… it distracts people from negative emotions (cognitive avoidance) • Summarize four cognitive-behavioural components in treatment of GAD. Compare the effectiveness of these approached to drug therapies. Identify the advantages and disadvantages of drug therapies. o Behavioural – if clients can construe the anxiety as a set of responses to identifiable situations, the free-floating anxiety can be reformulated into one or more phobias or cued anxieties, making it easier to treat…. Tend to prescribe more generalized treatments… o CBT  If a feeling of helplessness, the therapist will help the client acquire skills that engender a sense of competence, such as assertiveness, verbal instructions, modelling, or operant shaping.  Main ingredient in CBT approaches to worry is exaggerated exposure to the source of one’s overly anxious concern.  CBT appears to be superior that drug treatment o Anxiolytics have been the most widespread treatment for GAD, especially benzodiazepine (Valium and Xanax), as well as buspirone (BuSpar) are often used because of the disorder’s pervasiveness… antidepressants also are helpful… atypical antipsychotics, serotonin-norepinephrine, etc….  Undesirable side effects, ranging from nausea, dizziness, memory loss, and depression to physical addiction and damage to body organs… discontinue use = high risk for relapse • Define and give several examples of obsessions and of compulsions. How are these definitions different from the way we commonly use the terms. Summarize views on the causes of obsessive-compulsive disorder (two psychoanalytic, three behavioural and cognitive, and three biological views). o OCD – an anxiety disorder in which the mid is flooded with persistent and uncontrollable thoughts (obsessions), such as fears of contamination, fears of expressing some sexual or aggressive impulse, and hypochondrial fears of bodily dysfunctions, and in the individual is compelled to repeat certain acts again and again (compulsions), such as checking, pursuing cleanliness and orderliness, avoiding a particular objects, performing repetitive, magical, protective practices, or performing a particular act (that activity is not realistically connected with its apparent purpose and is clearly excessive) o Clinically, obsessions are a strong force and frequent that interfere with normal functioning… compulsions is viewed as somehow foreign to a person’s personality (ego-dystonic) o Psychoanalytic  Obsessions and compulsion are from instinctual forces that are no under control because of overly harsh toilet training; fixated at the anal stage  OCD as a result of feelings of incompetence…. Children are kept from developing a sense of competence by doting or excessively dominating parents… they develop an inferiority complex and may unconsciously adopt compulsive rituals in order to carve out a domain in which they exert control and can feel proficient o Behavioural and cognitive  Compulsions are learned behaviours reinforced by fear reduction  Compulsive checking results from a memory deficit… suggests deficits in retrospective memory (ability to remember recent events and experiences) and prospective memory (the ability to look forward and to remember at the right place or time to perform an intended action)  Cognitive biases may only exist among the subset of OCD people with contamination concerns  Most people occasionally experience unwanted ideas that are similar in content to obsessions and unpleasant thoughts increase during times of stress, but for normal individuals they can tolerate or dismiss these cognitions, but those with OCD can’t… Persons with OCD have trouble ignoring stimuli  Obsessions often involve catastrophic misinterpretations of the importance and significance of negative intrusive thoughts  Inflated sense of personal responsibility for outcomes and cognitive bias involving thought=action-fictions (involves two beliefs: the mere act o thinking about unpleasant events increases the perceived likelihood that they will actually happen and at a moral level, thinking something unpleasant is the same as actually having it carried it out)  They engage in too much thinking about thinking itself…. Intrusive thoughts are distressing especially if they are inconsistent with values aspects of the self and they are perceived as personally meaningful and significant  Trying to inhibit a thought may have the paradoxical effects of inducing preoccupation with it o Biological  Some evidence for a genetic side to OCD… prevalence is higher among the first-degree relatives of OCD clients  Encephalitis, head injuries, and brain tumours have all been associated with the development of OCD….  Increased activation in the frontal lobes, perhaps a reflection of the persons’ over concern with their own thoughts…  Basal ganglia (a set of subcortical nuclei including the caudate, putamen, globus pallidus, and amygdala)… a system linked to the control of motor behaviour… relevant to compulsions as well as the relationship between OCD and Tourette’s… samller putamen…. • Briefly summarize five treatments for obsessive-compulsive disorder, including two biological treatments. How effective are treatments for OCD generally. o Exposure and Response prevention (ERP) – most widely used and generally accepted behavioural approach  The person exposes him or herself to situations that elicit the compulsive act and then refrains from performing the accustomed ritual… assumption is that the ritual is negatively reinforcing because it reduces the anxiety, thus preventing the person from performing the ritual will expose him or her to the anxiety- provoking stimulus, thereby allowing anxiety to be extinguished.  Arduous and unpleasant for clients… refusal to enter and dropping out are problems  Therapist-guided exposure is better than therapist-assisted self-guided exposure and in vivo exposure coming with exposure via imagination being superior to exposure alone o CBT – evaluate whether not performing a compulsive ritual will have catastrophic consequences. The client must stop performing the ritual… involves esposure and response prevention  Cognitive procedures, such as cognitive restructuring, can eliminate the dysfunctional beliefs that contribute to the OCD’s client’s faults appraisals  Focus on the OCD client’s conviction that imaginary events may actually come true… modification, known as the inference-based approach is geared toward identifying and ameliorating the obsessional inference o Biological  Drugs that increase serotonin, such as SSRIs and some tricyclicis, are the biological treatments most given… the symptoms usually return when the drugs are discontinued  The occasional use of psychosurgery…. Cingulotomy (destroying two to three cm of white matter in the cingulum, an area near the corpus callosum)… deep drain stimulation, where clients showed 40% reduction in symptoms o Psychoanalytic – resembles that for phobia and generalized anxiety… namely, lifting repression and allowing the client to confront what he or she, presumably, truly fears… • How is post-traumatic stress disorder defined different from most disorders? Describe three main characteristics. Describe risk factors, including severity of trauma, dissociative symptoms, and coping style. Describe three theories about its cause. What does Canadian research suggest about variables that contribute to the severity of PTSD symptoms and the length of time that symptoms can persist? o Post-traumatic stress disorder – entails an extreme response to a sever stressor, including increased anxiety, avoidance of stimuli associated with the trauma, and numbing of emotional responses o the definition of PTSD includes party of its presumed etiology, namely a traumatic event or events that the person directly experienced or witnessed involving the death other others, threatened death to oneself, serious injury, or a threat to the physical integrity of self of others (events must have created intense fear, horror, or helplessness)… also prolonged abuse can trigger symptoms o Acute stress disorder – if the stressor causes significant impairment in social or occupational functioning that lasts for less than one month…. o Major characteristics  Re-experiencing the traumatic event  Avoidance of stimuli associated with the even or numbing of responsiveness  Symptoms of increased arousal (symptoms include difficulty falling or staying asleep, difficulty concentrating, hypervigilance, and an exaggerated started response) o Risk factors  Previous exposure to trauma is regarded as one of the strongest predictors of whether the individual is exposed subsequently to trauma  ***having high intelligence seems to be a protective factor, perhaps because it is associated with having betting coping skills  Dissociative symptoms, including amnesia and out-of-body experiences, at the time of the trauma also increases the probability of developing PTSD, as does trying to push memories of the trauma out of one’s mind  An insecure attachment style that involves a negative view of the self  A tendency to take personal responsibility for failures and to cope with stress by focusing on emotions rather than on the problems themselves o Psychological theories  Learning theorists – arises from classical conditioning… based on classically conditioned fears, avoidances are built up and are negatively reinforced by the reduction of fear…  Cognitive theorists – a disorder of memory with the hallmark feature being the constant involuntary recollection of the traumatic event… a robust association between PTSD and memory impairment and this tendency is stronger for verbal memory than visual memory  Involves a hyporesponsive prefrontal cortical region or hyporesponsive amygdala region…. Reduced hippocampal volume escalates the risk  Psychodynamic theory proposed by Horowitz, posits that memories of traumatic events occur constantly in the person’s mind and are so painful that they are either consciously supressed or repressed… engaged in an internal struggle to make some sense of a trauma by integrating it into their existing beliefs about themselves and the world o Biological theories  Exposure to certain kinds of trauma is influneces by genetic and environmental factors, but environmental factors contributed to other types of trauma…. A personality characterized by trait neuroticism might be the genetic vulnerability factor that serves as a diathesis for PTSD  Trauma may activate the noradrenergic system, raising levels of norepinephrine and thereby making the person startle and express emotion more readily then is normal o Canadian research  In Calgary, Foothills Hospital found that PTSD was diagnosed in 12 of 14 adolescents with a history of physical or sexual abuse  High levels of comorbidity and symptom similarity suggest that cognitive vulnerabilities for anxiety and depression might also serve as vulnerability factors of PTSD  Lifetime prevalence in Cana is almost 1 in 10 an the one month prevalence is about 1 in 25 Canadians… prevalence varies depending on the severity of the trauma experiences (3% amonf civilians exposed to physical attack, 20% people wounded in Vietnam, and about 50% amonf rape victims and POW) • Identify two basic principles in treating PTSD. Describe two early approached to treating veterans with PTSD and the current generally approach. Describe three variations on this idea and the use of drugs. o It is best to intervene as soon as possible after a traumatic events, well before PTSD has a chance to develop… intervening when people are in the acute phase of a post-trauma period and are at risk for developing is referred to crisis interventions, which includes such procedures as recreating the event by having participants discuss with each other as many details they can remember, encouraging them to describe their thoughts at the time of the event, and normalizing their anxiety reactions by reminding them that they have just been through an event that causes extreme distress for most people o CBT strategy involves exposing clients to trauma-related cues in imagination, teaching them relaxation, and helping them think different about what happened o A key to treating PTSD is exposure to thoughts and images of the frightening event… helpful to education clients about the nature of PTSD and the kinds of symptoms most people experience; such knowledge can help reassure tham that they are not losing their minds o Veterans with PTSD were often treated by narcosynthesis (sedated with an intravenous injection of sodium pentothal to cause extreme drowsiness where the trauma was relived and the client my act it out)… the therapist encourages the discussion of the terrifying events in the hope that the client would realize that they were in the past and no longer a threat  Exposure-based therapy – fears are best reduced or eliminated by having the person confront whatever he or she most ardently wished to avoid….exposure works because it leads to the extinction of the fear response but it may also change the meaning that the stimuli have for people o Eye movement desensitization – the client imagines a situation related to his or her problem… the client following with his or her eyes the therapist’s finger that goes back and forth… this process continues for a minute or so until the client reports that the horror of the image has been reduced…. Verbalize negative thoughts… therapist encourages the client to think a more positive thought o Meichenbaum…. CBT with constructive-narrative approach  People construct and reconstruct accounts or stories about important events in their lives…. Client stories are considered to be open to chance and in treatment, the meanings attached to traumatic event…. Works with their constructive-narrative, intervening strengths and resilience and foster “survivorship”, coping processes, and competence for future adaptive behaviour and though…. Clients write a new script, a new, more adaptive narrative (they re-story their lives) o Horowitz…. Psychodynamic approach has much in common with the CBT approach… emphasizes the manner in which trauma interacts with a client’s pre-trauma personality and the treatment proposes also has much in common with other psychoanalytic approaches, including discussions of defences and analysis of transference o Psychoactive drugs, including antidepressants and tranquilizers  Very little information about the relative efficacy of drug and psychological interventions for chronic PTSD  It’s important to assess clients’ preferences since they potentially affect outcome and to rethink “one-size fits all approaches to treatment” Chapter 7 – Somatoform and Dissociative Disorders • What are the general characteristics of somatoform disorders? Describe and distinguish among the three types somatoform disorders. o Somatoform disorders – the individual complains of bodily symptoms that suggest a physical defect or dysfunction – sometimes rather dramatic in nature – but for which no physiological basis can be found o Psychological problems take a physical form and are not under voluntary control… o Panic disorders – the person experiences pain that causes significant distress and impairment…. Psychological factors are views as playing an important role in the onset, maintenance, and severity of the pain… dependent on painkillers or tranquilizers…. Pain may have temporal relation to some conflict or stress or to avoid some unpleasant activity and to secure attention and sympathy not otherwise available…  Not somatoform – clients with physically based pain tend t localize it more specifically, give more detailed sensory descriptions, and link their pain more clearly to situations that increase or decrease it  Significant grey-matter decreases in the prefrontal, cingulated, and insular cortex, regions of the brain known to critically involved in the modulation od subjective pain o Body dysmorphic disorder – a person is preoccupied with an imagined or exaggerated defect in appearance, frequently in the face… women tend also to focus on skin, hips, breasts, and legs, whereas men are more inclined to believe they are too short, too much body hair, and that their penises are too small  Some spend hours looking at the defect, while others try to avoid it… some try to camouflage the defect  Those who go as far as surgery are never satisfied with the results…. Occurs mostly in women and typically begins in late adolescence and is frequently comorbid with depression and social phobia, eating disorders, thoughts of suicide, and substance abuse and personality disorders o Hypochondriasis – preoccupied with persistent fears of having a serious disease, despite medical reassurance to the contrary.  Typically begins in early adulthood and has chronic course  Overreact to ordinary physical sensations and minor abnormalities and catastrophic interpretations of symptoms  Prevalence in about 5% of the population…. Change to “health anxiety disorder”  Hypochondriasis is a fear of having an illness while an illness phobia is a fear or contracting an illness  Health anxiety was moderately heritable but most of the variance is due to environment… mostly learned  Health anxiety increases in the perceived probability of illness and the perceived cost, awfulness, and burden of illness… decreases as a function on the perceived ability to cope and the perceived presence of rescue factors • Give some examples of conversion symptoms involving (a) muscular and (b) sensory functioning. Why is it difficult but important to distinguish between conversions and medical conditions? o Conversion disorder – physiologically normal people experience sensory or motor symptoms, such as sudden loss of vision or paralysis, suggesting an illness related to neurological damage of some sort, although the body organs and nervous system are found to be fine o Muscular – paralysis of arms or legs… seizures and coordination disturbance… a sensation of prickling, tingling, or creeping on the skin… insensitivity to pain; sensory function – aphonia – loss of the voice an all but whispered speech… anosmia – los or impairment of the sense of smell… anesthesias – loss or impairment or sensations o Symptoms are demonstrated by the fact that they appear suddenly in stressful situations, allowing individuals to avoid some activity or responsibility or to receive badly wanted attention o Conversion derived from Freud who thought that anxiety and psychological conflict were believed to be converted in physical symptoms o Hysteria was used to describe what are now known as conversion disorders o Symptoms usually develop in adolescence or early adulthood, typically after undergoing life stress o Prevalence is less than 1% and more women than men are given the diagnosis… frequently comorbid with other Axis one, such as depression ,substance abuse, anxiety, and dissociative disorders o Since the majority of paralyses, analgesias, and sensory failures do have biological causes, true neurological problems may sometimes be misdiagnosed as conversion disorder o Malingering – an individual fakes an incapacity in order to avoid a responsibility or to achieve a goal  Le belle indifference – a relative lack of concern or a blasé attitude toward symptoms... malingerers are likely to be more guarded and cautious....  Factitious disorder – people intentionally produce physical symptoms... in contrast with malingering, symptoms are less obviously linked to a recognizable goal... the individual for some unknown reason wants to assume the role of the client... may involve a parent treating physical illness in a child (factitious disorder by proxy or Munchausen syndrome by proxy) • Describe somatization disorder. How it is similar to and difference from conversion disorder? List several proposed causes of somatization disorder. o Somatization disorder – characterized by recurrent, multiple somatic complaints with no apparent physical cause... to meet diagnostic criteria, the person must have:  Four pain symptoms in different locations  Two gastrointestinal symptoms  One sexual symptom other than pain  One pseudo neurological symptom o Clients often present their complains in a histrionic, exaggerated fashion, or as part of a long complicated medical history o Lifetime prevalence estimated at less than 0.5% of the population... may be more frequent in cultures that de- emphasize the over display of emotion o Causes  Those with the disorder are more sensitive to physical sensations, over attend to them or interpret them catastrophically  May also have a memory bias for information that connotes physical threat  Behavioural view: various aches, discomforts, and dysfunctions are manifestations of unrealistic anxiety about bodily symptoms  High levels of cortisol, which is an indication that they are under stress  Might be learned responses acquired via exposure to parental illness and health anxiety in childhood • How did the study of conversions lead Freud to his initial theories? Summarize Freud’s early theory of conversion and his later revision of it. o Proposed that a conversion disorder is caused when a person experiences an event that creates great emotional arousal, but the affect is not expressed and the memory of the event is cut off from the conscious experience... o Hypothesized that conversion disorder in women is rooted in an unresolved Electra complex.... anxiety is transformed or converted into physical symptoms • Summarize contemporary psychodynamic and cognitive research on conversions and the resulting revision of Freud’s theory. o Sakeim – two-stage defensive reaction  Perceptual representations of visual stimuli are blocked from awareness and on this basis people report themselves blind  Information is nonetheless extracted from the perceptual representations
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