PSY 301 INTRODUCTION to PSYCHOPATHOLOGY

PSY 301 INTRODUCTION to PSYCHOPATHOLOGY
Dr. İlkiz Altınoğlu Dikmeer Fall 2014 © 2012 John Wiley & Sons, Inc. All rights reserved.

Abnormal Psychology, Twelfth Edition
PowerPoint  Lecture Notes Presentation Chapter 8 Dissociative Disorders and Somatoform Disorders (ch 6 in 11th edition) Abnormal Psychology, Twelfth Edition by Ann M. Kring, Sheri L. Johnson, Gerald C. Davison, & John M. Neale Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.

© 2012 John Wiley & Sons, Inc. All rights reserved.
4/27/2017 Chapter Outline Chapter 8: Dissociative Disorders and Somatic Symptom Disorders I. Dissociative Disorders II. Somatic Symptom Disorders Anxiety is the predominant cause of the symptoms although not always observable. Due to the unobservable nature of anxiety these two disorders became seperate diagnostic categories. © 2012 John Wiley & Sons, Inc. All rights reserved.

Dissociative Disorders
All the Dissoc. Dis.s are presumed to be caused by a common mechanism: dissociation. Dissociation  Some aspect of cognition or experience becomes inaccessible to consciousness Mild Dissociative experiences are common, Dissoc. Dis.s result from extremely high levels of dissociation. © 2012 John Wiley & Sons, Inc. All rights reserved.

Sudden disruption in the continuity of: Consciousness (lacks to perform the usual role of integration of cognitions, emotions, motivations and other aspects of experience in our awareness) Emotions Motivation Memory Identity © 2012 John Wiley & Sons, Inc. All rights reserved.

Dissociation and Memory
How does memory work under stress? Psychodynamic Traumatic events are repressed. Memories are forgotten because they are so aversive. Cognitive Extreme stress usually enhances rather than impairs memory  memory for emotionally relevant stimuli is enhanced by stress, while memory for neutral stimuli is impaired Interference memory formation Not accessible to awareness later © 2012 John Wiley & Sons, Inc. All rights reserved.

Table 8.1: Diagnoses of Dissociative Disorders
© 2012 John Wiley & Sons, Inc. All rights reserved.

Dissociative Amnesia Inability to recall important personal information Usually about a traumatic experience Not ordinary forgetting Not due to physical injury May last hours or years Usually remits spontaneously w/ complete recovery and small chance of recurrence. © 2012 John Wiley & Sons, Inc. All rights reserved.

Dissociative Amnesia: Dissociative Fugue Subtype
First documented case of dissoc fugue  in 1887 in France Amnesia and flight and new identity Latin fugere, “to flee” Sudden, unexpected travel with inability to recall one’s past Assume new identity May involve new name, job, personality characteristics More often of brief duration Remits spontaneously After recovery, able to remember the details of life except for the period of fugue. © 2012 John Wiley & Sons, Inc. All rights reserved.

Proposed DSM-5 Criteria for Dissociative Amnesia
Inability to remember important personal information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness The amnesia is not explained by substances, or by other medical or psychological conditions Specify dissociative fugue subtype if: the amnesia includes inability to recall one’s past, confusion about identity, or assumption of a new identity, and sudden, unexpected travel away from home or work Note: Changes from DSM-IV-TR are italicized © 2012 John Wiley & Sons, Inc. All rights reserved.

Memory Deficits and Dissociation
Memory deficits in explicit but not implicit memory Explicit memory Involves conscious recall of experiences e.g., senior prom, mom’s birthday party Implicit memory Underlies behaviors based on experiences that cannot be consciously recalled e.g., playing tennis, writing a check © 2012 John Wiley & Sons, Inc. All rights reserved.

Memory Deficits and Dissociation
Distinguishing other causes of memory loss from dissociation: Dementia Memory fails slowly over time Is not linked to stress Accompanied by other cognitive deficits Inability to learn new information Memory loss after a brain injury Substance abuse © 2012 John Wiley & Sons, Inc. All rights reserved.

Depersonalization/Derealization Disorder
Perception of self is altered Triggered by stress or traumatic event No disturbance in memory No psychosis or loss of memory Often comorbid with anxiety, depression Typical onset in adolescence Chronic course © 2012 John Wiley & Sons, Inc. All rights reserved.

Depersonalization/Derealization Disorder
Lose sense of self Unusual sensory experiences Limbs feel deformed or enlarged Voice sounds different or distant Feelings of detachment or disconnection Watching self from outside Floating above one’s body Derealization World has become unreal World appears strange, peculiar, foreign, dream-like Objects appear at times strangely diminished in size, at times flat Incapable of experiencing emotions Feeling as if they were dead, lifeless, mere automatons (robot-like) © 2012 John Wiley & Sons, Inc. All rights reserved.

Proposed DSM-5 Criteria for Depersonalization/Derealization Disorder
Depersonalization: Persistent or recurrent experiences of detachment from one’s mental processes or body, as though one is in a dream, despite intact reality testing, or Derealization: persistent or recurrent experiences of unreality of surroundings Symptoms are not explained by substances, another dissociative disorder, another psychological disorder, or by a medical condition Note: Changes from DSM-IV-TR are italicized © 2012 John Wiley & Sons, Inc. All rights reserved.

Dissociative Identity Disorder (DID)
Two or more distinct and fully developed personalities (alters) Each has unique modes of being, thinking, feeling, acting, memories, and relationships Primary alter may be unaware of existence of other alters Most severe of dissociative disorders Recovery may be less complete Typical onset in childhood Rarely diagnosed until adulthood More common in women than men Often comorbid with: PTSD, major depression, somatic symptoms + amnesia, depers. Has no relation to schizophrenia No thought disorders or behavioral disorganization © 2012 John Wiley & Sons, Inc. All rights reserved.

Proposed DSM-5 Criteria Dissociative Identity Disorder (DID)
A. Disruption of identity characterized by two or more distinct personality states (alters) or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others or reported by the patient B. At least two of the alters recurrently take control of behavior C. Inability of at least one of the alters to recall important personal information D. Symptoms are not part of a broadly accepted cultural or religious practice, and are not due to drugs or a medical condition Note: The DSM-IV-TR criterion A is less detailed. It specifies the presence of two or more identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self) © 2012 John Wiley & Sons, Inc. All rights reserved.

Dissociative Identity Disorder (DID)
Epidemiology No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006) Major increases in rates since 1970s (1.3% in Canada in 1991, 0.4% in Sivas, TR in 1999) DSM-III (1980) Diagnostic criteria more explicit Appearance of DID in popular culture Sybil The Three Faces of Eve Book and movie received much attention © 2012 John Wiley & Sons, Inc. All rights reserved.

Etiology of Dissociative Identity Disorder (DID): Two Major Theories
Almost all DID patients report severe child abuse Both theories suggest severe physical or sexual abuse during childhood: Posttraumatic Model DID results from severe psychological and/or sexual abuse in childhood Sociocognitive Model DID results from learning to enact social roles. Occurs in response to prompting by therapists or media No conscious deception © 2012 John Wiley & Sons, Inc. Al rights reserved.

Etiology of Dissociative Identity Disorder (DID): Two Major Theories
Evidence raised in theory debate DID can be role-played Hypnotized students prompted to reveal alters did so (Spanos, Weekes, & Bertrand, 1985) DID patients show only partial implicit memory deficits Alters “share” memories (Huntjen et al., 2003) DID diagnosis differs by clinician A few clinicians diagnose the majority of DID cases For many, symptoms emerge after therapy begins © 2012 John Wiley & Sons, Inc. All rights reserved.

Treatment of Dissociative Identity Disorder (DID)
Most treatments involve: Empathic and supportive therapist Integration of alters into one fully functioning individual Improvement of coping skills Psychodynamic approach adds: Overcome repression Use of hypnosis Age regression Can actually worsen symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

Somatic Symptom Disorders (DSM-5) Somatoform Disorders (DSM-IV-TR)
Excessive concerns about physical symptoms or health ‘Soma’ means body In DSM-IV-TR physical symptoms have no known physical cause Nearly impossible to know actual cause DSM-5 removes requirement that symptoms not be medically caused Three major somatic symptom disorders: Complex somatic symptom disorder Illness anxiety disorder Functional neurological syndrome © 2012 John Wiley & Sons, Inc. All rights reserved.

Figure 8.3: DSM-IV-TR and Proposed DSM-5 Somatic Symptom Disorders

Table 6.2 (edition 11) Summary of Somatoform Disorders
Copyright 2009 John Wiley & Sons, NY

Table 8.2: Diagnoses of Somatic Symptom and Related Disorders

Pain Disorder (DSM-IV-TR)
DSM-IV-TR Criteria Pain that is severe enough to warrant clinical attention Psychological factors are thought to be important to the onset, severity, or maintenance of pain The pain is not intentionally produced or faked The pain is not explained by another psychological condition Copyright 2009 John Wiley & Sons, NY

Somatization Disorder (DSM-IV-TR)
First noted by Pierre Briquet in 1859 Known as Briquet’s syndrome Multiple, recurrent somatic complaints with no apparent physical cause Must have multiple symptoms which cause impairment Seeks treatment, usually from multiple physicians Hospitalization, medications, surgery common Exaggerated presentation of symptoms and complaints Copyright 2009 John Wiley & Sons, NY

Somatization Disorder
Lifetime prevalence less than 0.5% More frequent in women Especially Hispanic and African American Higher prevalence rates in South America and Puerto Rico Cultural differences Symptom presentation Burning pains in hands more common in Asia and Africa Culture may also influence how people seek treatment Psychological distress presented in physical terms Typical onset early adulthood Often accompanied by behavioral and interpersonal problems e.g., marital discord, poor work history Copyright 2009 John Wiley & Sons, NY

Somatization Disorder
DSM-IV-TR Criteria History of seeking treatment for many physical complaints beginning before the age of 30 and lasting for several years At least four pain symptoms, as well as at least two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom (e.g., unexplained paralysis) Symptoms are not due to a medical condition or are excessive given the person’s medical condition Symptoms do not appear to be faked Copyright 2009 John Wiley & Sons, NY

Complex Somatic Symptom Disorder (DSM-5)
DSM-IV-TR separates the diagnoses of Pain Disorder (in which the primary symptom involved pain) and Somatization Disorder (which involves multiple somatic symptoms from various body systems) DSM-5 merges these two diagnoses into Complex Somatic Symptom Disorder DSM-5 places more emphasis on distress and behavior accompanying somatic symptoms, rather than the number or range of somatic symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

Proposed DSM-5 Criteria for Complex Somatic Symptom Disorder
At least one somatic symptom that is distressing or disrupts daily life Excessive thoughts, feelings, and behaviors related to somatic symptom(s) or health concerns, as indicated by at least two of the following: health-related anxiety, disproportionate concerns about the medical seriousness of symptoms, and excessive time and energy devoted to health concerns Duration of at least 6 months Specify: predominant somatic complaints, predominant health anxiety, or predominant pain © 2012 John Wiley & Sons, Inc. All rights reserved.

Hypochondriasis (DSM-IV-TR)
Preoccupation with fears of having a serious disease This headache must mean I have a brain tumor! Despite medical reassurance, fears persist for at least 6 months Critical of medical professionals Incompetent and uncaring Typical onset early adulthood Tends to be chronic Often comorbid with mood and anxiety disorders Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY
Hypochondriasis DSM-IV-TR Criteria Preoccupation with fears about having a serious disease The preoccupation continues despite medical reassurance Not explained by a delusional disorder or body dysmorphic disorder Symptoms last at least 6 months Copyright 2009 John Wiley & Sons, NY

Illness Anxiety Disorder (DSM-5)
Illness anxiety disorder is a new diagnosis in the DSM-5, but it has some parallels with the DSM-IV-TR diagnosis of hypochondriasis. © 2012 John Wiley & Sons, Inc. All rights reserved.

Proposed DSM-5 Criteria for Illness Anxiety Disorder
Preoccupation with and high level of anxiety about having or acquiring a serious disease Excessive behaviors (e.g., checking for signs of illness, seeking reassurance) or maladaptive avoidance (e.g., avoiding medical care or ill relatives) No more than mild somatic symptoms are present Not explained by other psychological disorders Preoccupation lasts at least 6 months Note: Criteria that differ from the DSM-IV-TR diagnosis of hypochondriasis are italicized. The DSM-IV-TR criteria for hypochondriasis specify that the preoccupation must continue despite medical reassurance. © 2012 John Wiley & Sons, Inc. All rights reserved.

Conversion Disorder (DSM-IV-TR)
Sensory or motor function impaired but no known neurological cause Vision impairment or tunnel vision Partial or complete paralysis of arms or legs Seizures or coordination problems Anesthesia Loss of sensation Aphonia Whispered speech Anosmia Loss of smell Copyright 2009 John Wiley & Sons, NY

Conversion Disorder DSM-IV-TR Criteria One or more symptoms affecting motor or sensory functioning and suggesting a neurological or medical condition Symptoms are related to conflict or stress Symptoms are not intentionally produced and cannot be explained by a medical condition Symptoms cause significant distress or functional impairment or warrant medical evaluation Copyright 2009 John Wiley & Sons, NY

Conversion Disorder Hippocrates Believed disorder only occurred in women Attributed it to a wandering uterus Originally known as Hysteria Greek word for uterus Freud Coined term conversion Anxiety and conflict converted into physical symptoms Copyright 2009 John Wiley & Sons, NY

Conversion Disorder Onset typically adolescence or early adulthood Often follows life stress Prevalence less than 1% More common in women than men Often comorbid with: Major depressive disorder Substance abuse Personality disorders Copyright 2009 John Wiley & Sons, NY

Functional Neurological Disorder (DSM-5)
Conversion Disorder in DSM-IV-TR Sensory or motor function impaired but no known neurological cause Vision impairment or tunnel vision Partial or complete paralysis of arms or legs Seizures or coordination problems Aphonia Whispered speech Anosmia Loss of smell © 2012 John Wiley & Sons, Inc. All rights reserved.

Proposed DSM-5 Criteria for Functional Neurological Disorder
One or more neurologic symptoms affecting voluntary motor function, sensory function, cognition, or seizure-like episodes The physical signs or diagnostic findings are internally inconsistent or incongruent with recognized neurological disorder Symptoms cannot be explained by a medical condition Symptoms cause significant distress or functional impairment or warrant medical evaluation Note: DSM-IV-TR criteria for Conversion Disorder specify that symptoms are related to conflict or stress and are not intentionally produced © 2012 John Wiley & Sons, Inc. All rights reserved.

Etiology of Somatic Symptoms Disorders: Neurological Factors
No support for genetic influence Concordance rates in MZ twin pairs do not differ from DZ twin pairs Why are some people more aware and distressed by bodily sensation? Anterior insula and anterior cingulate hyperactive Somatic symptoms influenced by emotions and stress © 2012 John Wiley & Sons, Inc. All rights reserved.

Etiology of Somatic Symptoms Disorders: Cognitive Behavioral Factors
Two important cognitive variables: Attention to bodily sensations Automatic focus on physical health cues Attributions (interpretation) of those sensations Overreact with overly negative interpretations Two important consequences: Sick role limits healthy life alternatives Help-seeking behaviors reinforced by attention or sympathy © 2012 John Wiley & Sons, Inc. All rights reserved.

Figure 8.5: Mechanisms Involved in Somatic Symptom Disorders

Etiology of Functional Neurological Disorders: Psychodynamic Perspective Unconscious psychological factor cause Blindsight Not consciously aware of visual input Failure to be explicitly aware of sensory information © 2012 John Wiley & Sons, Inc. All rights reserved.

Etiology of Somatic Symptoms Disorders: Social and Cultural Factors
Decrease in incidence of conversion disorders since last half of 19th century Higher incidence may have been due to more repressed sexual attitudes or low tolerance for anxiety symptoms More prevalent In rural areas In individuals of lower SES In non-Western cultures © 2012 John Wiley & Sons, Inc. All rights reserved.

Treatment of Somatic Symptoms Disorders
Few controlled treatment outcome studies Cognitive Behavioral Treatment Identify and change triggering emotions Change cognitions about symptoms Replace sick role behaviors with more appropriate social interactions Antidepressants Tofranil Effective even at low dosages that do not alleviate depressive symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

COPYRIGHT Copyright 2012 by John Wiley & Sons, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner. © 2012 John Wiley & Sons, Inc. All rights reserved.

PSY 301 INTRODUCTION to PSYCHOPATHOLOGY

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