Abnormal Psychology Durand Barlow (PowerPoint)

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					         2008 / 1
  Abnormal Psychology
V.M. Durand & D.H. Barlow

  Sungshin Women’s University
    Jungkyu Kim Ph.D
        Table of contents
1.    Classification and diagnosis of
      abnormal behaviors

 I. Anxiety Disorders

     1. Generalized Anxiety Disorder
     2. Panic Disorder with (without)
        Agoraphobia
     3. Specific Phobia
4. Social Phobia
5. Post Traumatic Stress
   disorder (PTSD)
6. Obsessive Compulsive
   Disorder
II. Somatoform Disorder and
    Dissociative Disorder

1. Somatoform Disorder
    1. Hypochondria
    2. Somatization Disorder
    3. Conversion Disorder
    4. Pain disorder
    5. Body Dysmorhic disorder
2. Dissociative Disorder

 1. Depersonalization Disorder
 2. Dissociative Amnesia
 3. Dissociative Fugue
 4. Dissociative Trance Disorder
 5. Dissociative Identity Disorder
III. Developmental and Cognitive
     Disorder

1. Developmental Disorder
   1. Attention Deficit and Hyperactivity
      Disorder
   2. Learning Disability
   3. Communication and related Disorder
   4. Autism
   5. Mental Retardation
2. Cognitive Disorder
    1. Delirium
    2. Dementia
    3. Amnestic Disorder


IV. Mood Disorders
    1. Depression
    2. Bipolar Disorder
V. Schizophrenia and related
   Psychotic Disorders

   Positive Symptoms
   Negative Symptoms
   Disorganized Symptoms
I. Classification and diagnosis of abnormal
                  behaviors

    Reliability => If the same results come out
     shown to multiple doctors. If the results
     remain the same over the time.

     Validity => If the test measures what the
     test promises to
     concurrent validity, predictive validity

     Standardization => To make a norm against
     which to compare the individual score and
     interpret the meaning of it
       The procedures of making a
               Diagnosis
1.     Clinical Interview

     A. Appearance and Behavior
       Clothing, Posture, Facial expression,
       Movement, Voice etc.
     B. Thought Process
       Speed of Speech, Consistency,
       Cohesion, Fluency, Delusion,
       Hallucination
C. Mood State
   Appropriateness of mood,
   Depression, Elation, Blunt, Flat

D. Intellectual Functioning
 Comprehension, Use of Language,
 Memory

E. Perception of Environment
   Date, Space, Perception of Self
2. Behavioral Assessment

   Direct assessment by means of
    behavioral observation
   Patient’s statements are often not
    enough or distorted
   So, this is the most direct and
    effective way to get accurate
    informations
           II. Classifications
   Causes of psychopathology are complex
    For example, psychological, environmental,
    and physiological
    -> classical categorical approach is
       inappropriate

    Dimensional approach
    -> assessing various dimensions
       for example cognition, emotion,
       behavior
    -> this is not complete either, because
       there are no agreed on dimensions
       among the assessors
   Prototypical approach
    => integration of the categorical
    approach and dimensional approach
    Used most often recently
    -> used in DSM-IV
                   DSM-IV
   Reorganized together with ICD-10
   The most salient difference between DSM-IV
    and its previous versions => eliminating the
    distinction    between    organically  based
    disorders     and     psychologically  based
    disorders
   Axis I : various psychopathologies, pervasive
    developmental disorders, learning disorders,
    motor skills disorders, communication
    disorders
   Axis II : Personality disorders, mental
    retardation
   Axis III : Medical conditions
   Axis IV : Psychological and
       environmental problems that might have
       an impact on the disorder
   Axis V: current level of adjustment
    From 0 to 100 scale (100 indicating
    superior functioning in a variety
    of situations)
    Other optional Axes: Defense mechanisms,
    coping styles, social and occupational
    functioning, and relational functioning
    < Criticisms of DSM-IV>

    There are many overlaps among the
    categories
    Too much emphasis on the reliability
     -> ignoring the validity
   Tendency to stick to the traditional categories
   Needs to classify on the basis of more
    researches in the future
   The problem of the labeling
    < New diagnostic categories >

   Mixed anxiety-depression ; currently
    being studied
   It belongs neither to Anxiety disorder
    nor to Depression, but shows symptoms
    of both
         I. Anxiety Disorders

   Characteristics of anxiety
    negative emotion, bodily tension, worrying
    over the future
   Knows that he or she doesn‟t need to worry
    so much
   Related closely to depression
   Positive aspect of anxiety => protection,
    improve achievement
   Increase of heart rate, blood pressure,
    dilation of pupil, muscle tension etc.
   Autonomous Nerve system => flight or fight
                < Cause >
-   Physiological aspects

   Multiple genes are interrelated
   GABA-benzodiazepine sytem of brain
   Shortage of the neurotransmitter GABA
    (Gamma-Aminobutyric Acid) -> anxiety

   The noradrenergic system and serotonergic
    system are involved also
   The brain region which is most closely
    related to anxiety -> lymbic system
   Lymbic system mediates between brain stem which
    is in charge of body functioning and cortex which is
    responsible for cognitive processes


-   Psychological aspects

   Feeling of uncontrollability
   Initially caused by external stimulus
    -> associated with various internal and
        external situations

-   Social aspects

   Social pressures, marriage, divorce, occupation,
    death of close person
Integrative model

 Anxiety cannot be explained by        genetic
  factors alone
 The    thought of uncontrollability   causes
  anxiety
 Social and environmental pressures

 Once the anxiety become chronic, it   doesn‟t
  go away even if the external          factors
  disappear
 -> it becomes automatic
        1. Generalized Anxiety
            Disorder(GAD)

   Overly concerned and worrying
   Worries about every thing in the life
   Difficulties in making decision
   Future oriented
   At least persisted more than 6 months
   Days of feeling uncontrollable
    exceeds those of controllable
   Tension, irritability, easily tired,
    nervous, insomnia, difficult to
    concentrate

   Worry about minor things such as
    family members, health,
    appointments etc.

    In case of the children =>
    academic, athletic, or social
    performance and physical injuries.
1. statistics

    Prevalence rate 4%
    Among the elderly; 17-21.5%
    Visit clinics less often than panic disorder
     or social phobia patients.
    Female patients outnumbers
     male patients with 55 - 65%
   Develops slowly and become chronic
      in most cases
   Benzodiazepine, a sedative that is
     prescribed often to old people =>
     risk of hip injury
2. Cause (integrative model)

   Heredity   proved   by   monozygotic     twin
    research

   A heredity of a general anxiety proneness
    rather than that of GAD

   Increase of EEG beta activity in frontal lobe
    observed in recent research
    => a strong information processing in this
    region
   Worrying helps defend negative affects
    and images, but it prevents adaptation to
    them
    multiple causes => physiological factors,
    stress, habit of worrying, incompetence of
    problem solving
3. Treatment

   Most often used drug is Benzodiazepine
    questionable in its long term effects
     risk factors => impairment in cognitive, motor
    functioning => driving, falling down

   Dependency; psychologically, physiologically
    helpful in crisis intervention

   There is reports that anti-depressant are
    effective.
    psychotherapies are more effective on long
    term based
   Patients have tendency to avoid negative
    affects and images => confronting them
    and relaxation at the same time ; Borkovec
    and Costello(1993)

   Inducing and then confronting the worry
    process in CBT + various coping strategies
    and cognitive therapy (Craske and Barlow )

   Combined with family therapy -> very
    effective in children

   PRO meditation (Gregory Kramer)
    2. Panic Disorder with and without
               Agoraphobia

   Normal in relationship with people
   Avoid unsafe situations for fear of not
    being
     able to escape in case of panic
     => stay at home
   Not all panic experience leads to panic
    disorder
   Unexpected experience of panic
    => extreme fear of re-experiencing
        the panic
   Feeling of dying in panic attack
   Avoid such places as shopping mall,
    bus, train, subway, open street, tunnel,
    restaurants, theater etc agoraphobia
    can appear later independent of panic
    experience

   Arise according to patients’ thoughts
    or expectations rather than by their
    actual experiences
   Endures the feared place or situations
    if necessary
   Avoid not only specific place or
    situation, but particular physical
    experiences
    For example, ascending stairs,
    walking around under hot weather,
    dancing, making love, watching horror
    movies, having a quarrel, taking hot
    sauna, climbing mountains

   This is called intero-ceptive
    avoidance (cf. intero-ceptive
    exposure)
    1. statistics

   Prevalence 3.5%
    female outnumbers 3:2
   Onset : from middle of 10~40
     mostly after puberty
   In case of severe agora phobia
     proportion of the female 89%
    Men mostly tend to develop alcohol
    abuse => the problem become worse
   Prevalence stay constant throughout
    various cultures
   Similar prevalence rate among various
    ethnic groups in the States

    Black people show hypertension
     together
   60% of the patients experience panic
     attack at night
    Early morning between 1:00 and 1:30
     AM
   Night panic takes place during delta
    wave of EEG
    => deepist phase of sleep

   Extreme fear of death
   Different from night mare, which takes
    place during the REM phase and it
    comes much later.
   Also different from the sleep apnea,
    which puts the person to sleep again
                 2. Cause

   After unexpected panic experience
   Mediated by social and cultural factors

   Affected by physiological and
    psychological components

   Physiological responsiveness to stress
    inherited
    => it associates specific environmental
       and internal stimuli to panic attack
    Misinterpretation of a neutral stimulus
     as dangerous
     => anxiety of reexperiencing
      panic attack

     8-12% of people experience
        intermittently panic
     -> in most cases don’t develop panic
        disorder
    -> attribute to conflicts with friends,
        ingested foods, by chance etc
   Only 3% of people leads to panic
    disorder
   These people have cognitive
     vulnerability
      -> misinterpret a normal bodily
         reaction as dangerous
       => sympathic nervous system
          aroused
       => perceived as dangerous
       => vicious circle
               3. treatment
   Imipramine, a tricyclic antidepressant
    -> influences on serotonin and
        noradrenalin
    -> has effect on panic disorder
    -> but not on GAD

   Benzodiazepine decreases anxiety
    -> but not panic disorder
    => So, anxiety and panic disorder are
      two independent illnesses
      (Donald Klein, 1964).
   But in follow up benzodiazepine had a
    similar effect as Imipramin or SSRI
    (Serotonic specific reuptake inhibitors;
    Prozac, Paxil), if the dose is enhanced.

   Imipramin has such side effects as
    dizziness, dry mouth, sometimes low sexual
    functioning,
     which causes patients to refuse medication.

   Good effects, if there is no complications
   SSRI is used widely because of low side
    effects
   But it lowers sexual functioning
    Alprazolam (Xanax) is high density
     Benzodiazepine
    => Good effect, but high dependency

   Benzodiazepine affects cognitive and motor
    functioning => difficulties in learning and
    driving
   It can decrease 60 % of panic attack during
    medication, but relapse rate of 20-50% if stop
   Psychological treatment is also effective
    mainly exposure therapy

    - Systematic exposures on the hierarchic
       tasks
       -> visiting shopping malls 30 minutes
      -> walking 5 blocks alone from home
      -> driving 5 miles on the high way
      -> eating in a restaurant alone
      -> going to the cinema alone
   Barlow & Crask‟s Panic control treatment
    (PCT)
     -> deals with panic disorder directly

   Direct exposure to the stimuli that patients are
    afraid of
   Going up and down the step in the office
   Turning around on the chair

   Blood pressure increasing, inducing dizziness
    -> habituation
   Combining cognitive therapy, relaxation
    training and breathing exercise
    < Comparison of effectiveness of drug
           and psychotherapy >

    Barlow(1998)’s NIMH research
      304 panic disorder patients

     PCT alone, imipramine alone, PCT +
     imipramine, PCT+ placebo, placebo alone
    => PCT + imipramine and PCT+ placebo
      showed most effective

   However, the two showed no differences
=> drug has no additional merits
      3. Specific Phobia
< clinical descriptions >

 Irrational fear of specific object or
  situations that impairs daily
 functioning of the individual
 It was called in the past as “simple
  phobia”
 At a closer look, it is not that simple

 Many people suffer from it
 Give up work or move out
   Objects of fear are innumerable

- Insects, darkness, heights, wind,
 wide space, streets, sharp objects,
 cars, pains, dusts, injury, men,
 women, society, flood, infinity,
 physical contact, thunder, lightening,
 chaos, ruins, aurora, being alone etc.
   Before publication of DSM-IV in 1994, there
    was no meaningful classification of specific
    phobias existed

   Currently 4 major subtypes of specific phobia
    identified

    1) animal type 2) natural environmental type
    3) blood-injury- injection type
    4) situational type
         < Animal phobia >

   Fear of animal and insects
   It restricts the individual‟s activity
    severely
   Cannot read magazines for fear of
    unexpectedly coming across a snake or
    mouse
   Cannot take a trip
   Early onset around 7 years old
      < Natural environmental
             phobia >
   Fear of heights, thunder, water
   Temporary fear is excluded
   Persistent and severe restrictions of
    daily life
   Early onset around 7 years old
    < Blood – injury – injection phobia >
   Fears of losing control and going to faint, if
    exposed to a feared situation
   But this doesn‟t happen, because the blood
    pressure and pulse rate goes up

   By the way, blood-injury-injection phobia
    patients can really faint, if they are confronted
    with the feared situations, because their
    blood pressure and pulse rate drop

   Genetic influences
   Onset around 9 years old
        < situational phobia >

   Fears     of    being     trapped   in public
    transportations or in a closed space
   Used to be thought as similar to Panic
    Disorder with Agoraphobia (PDA)
   On the closer look, it shows quite different
    modality
   Situational phobia shows phobic reaction in
    reaction to the specific situations
   PDA shows panic reaction in unexpected
    situations
           < Other phobias >

    Overly cautious behaviors against becoming
     infected or getting sick
    Extreme restriction of activities in fear of
     getting contaminated from AIDS
    Avoiding public restrooms, restaurants
    Choking phobia ;
    avoiding intake of foods
    -> marked decrease of weights
        degeneration of teeth and the gums
           < separation anxiety >

   Unique anxiety occurring during childhood
   Unrealistic and persistent worry that
    something might happen to their parents or
    themselves that will separate them from their
    parents
   Refuse going to school
   Not because they dislike the school, but
    because they fear the separation
   Refuse to sleep alone, night mare,
     physical symptoms, anxiety symtoms
   Must make sure, if the anxiety is
    abnormally strong
   To be differentiated from school
    phobia, which is related to concrete
    situations in the school.
   They can go to the places alone other
    than schools
                    1.Statistics

   Relatively easy to see. prevalence 11 %
   More female than men (4:1)
   snake phobia and heights phobia is
    most common
   Persists lifelong
   To be differentiated from temporary phobia
     in childhood such as fear of new face,
     fear of darkness, fear of ghost etc.
   Hispanics develops twice as often as
    whites
   Chinese show “fear of the cold”
    => Pa-leng
    They have morbid fear of losing balance
    between yin and yang.
    They ruminate over loss of body heat
     and may wear layers of clothing even
     on a hot day.
                    2. Cause

   In the past, it was thought to be influenced
     by trauma experience. Not proved yet.

    There are several ways to develop a phobia

    1. Direct experience
      choking phobia, claustrophobia
    2. Observing someone else experience
       severe phobia. (vicarious experience)
    3. Being told about the danger
    4. Panic experience in a specific situation
        (false alarm)
   Anticipatory anxiety   about   certain
    danger -> phobia

    “preparedness”, that is, inherited
    tendency to fear situations that have
    been dangerous to human race, such
    as being threatened by wild animals or
    trapped in small places.

   Cultural factors
     male -> phobic feeling not accepted
3. Treatment

    structured and consistent exposure
    under the supervision
    Individuals who attempts to carry out
    the exercises alone attempts to do too
    much, too soon and ends up escaping
    the situation, which strengthens the
    phobia.
    When treating blood-injury-injection
     phobia must offer exposure with muscle
     tension
    -> because the patient might faint.

     therapist offer exposure spending most
     of the day together with the patient
    -> later the patient can do alone
    -> being checked by the therapist
          4. Social Phobia
< clinical description >

   Marked and persistent fear of one or more
    social or performance situations that involve
    exposure to unfamiliar people or possible
    scrutiny by others, with the fear that one
    will be embarrassed or humiliated.

    Performance anxiety
    public speaking, eating in a restaurant,
    signing a paper in front of a clerk, urinating
    in a public rest room etc.
   Social phobia generalized type or social
    anxiety disorder => individuals who are
    extremely and painfully shy in almost all
    social situations.

   Exposure to the feared situation
    almost always provokes anxiety,
    sometimes as a panic attack
   Recognition (in adult) that the fear is
    excessive and unreasonable
   The feared social or performance
    situation is avoided or endured with
    intense anxiety or distress
   The avoidance, anxious anticipation,
    or distress interferes significantly with
    the person‟s life and healthy
    functioning
1.   Statistics

     prevalence rate 13.3%
     most common psychological disorder
     currently
     the sex ratio favors women a little
     (1.4:1)
     sex ratio of social phobics appearing
      at clinics is 50 : 50
      => males seek help more frequently,
           because of career related issues
   Onset mostly in adolescence (15yrs old)
    more among young, undereducated, single,
    and low socio-economic class
   Relatively equally distributed among different
    ethnic groups.


    2. Cause

   Heredity; some infants are born with a trait of
    inhibition that is evident as early as 4 moths
    of age
   Anticipatory anxiety after unexpected
    experience of panic attack against
    similar situation
   Trauma experience in childhood
   vicarious learning of fear through
    parents
   prepared fear of social blame, assault,
    rejection etc

   We learn more quickly to fear angry
    expression than other facial expressions,
    and this fear diminishes much more
    slowly than other types of learning
    social phobics remembered critical
    expressions more, whereas normals
    remembered the accepting expressions.

3. Treatment

   Rehearsal in front of patient group
   The rest play a supporter role observing the
    performance
    Therapist helps the patient to find and
    correct his or her automatic perceptions.

   According to research, behavioral rehearsals
    are more effective than cognitive therapy part.
   Tricyclic antidepressant MAO inhibitor is
    effective, but high probability of relapse when
    stopping
      5. Posttraumatic Stress Disorder;
                       PTSD
< clinical description >

    Enduring, distressing emotional disorder that
     follows exposure to a severe helpless
    - or fear inducing threat such as rape, violence,
     traffic accidents, natural disaster,
     sudden death of family members or friend etc.

   Reexperiences extreme fear, helplessness
    that the patient experienced at the time of
    traumatic event through memories and
     nightmares.

   flash back => when memories are suddenly
    and the victims find themselves reliving the
    event

   Victims avoid anything that reminds them of
    the trauma
   They display a characteristic restriction or
    numbing of emotional responsiveness.
   They repress emotion, sometimes unable to
    remember certain aspects of the event

   Chronically over-aroused, easily startled, and
    quick to anger
   First diagnosed in DSM-III
   But history goes long back

   Insomnia, continuous memory of the event
   Apathy and stupor
    = > dissociation
   Can‟t remember part or all of the event
   feeling of unreality or de-realization
   Acute PTSD -> 1 month after the
    event
   Chronic PTSD -> after 3 months
    more prominent avoidance behaviors
     usually comorbid with social phobia

   Delayed PTSD -> shows few
    symptoms after trauma, but later
    develop full-blown PTSD. Often years
    afterwards.

   Acute stress disorder -> until a month
    after event
     40% of the acute stress disorder
       => keep PTSD
     Acute stress disorder was diagnosed first in
     DSM-IV to help these people get insurance
     coverage


1.   Statistics

     Rachman(1991): only few who endured air
     raid during the world war II, fire, earth
     quakes, floods etc. developed later PTSD
1.   Kilpatrick(1985): 2,000 women    who
     experienced rape, molesting, robbery,
     violence

     32% of rape victims -> PTSD
     19.2% -> attempted suicide
     44% -> suicidal ideation

     Resnick의 연구(1993);
     17.9% of American women -> PTSD
     7.8% of the whole American -> PTSD
   Male -> mostly due to war experience
   15-20% of those involved in car accidents ->
    PTSD

2. Cause

   Interaction of biological, psychological
    and sociological factors
   Vulnerability according to genetic disposition
   Monozygotic twin concordance rate
    -> .28-.41
   Dizygotic twin -> .11-.24
   Excessive secretion of corticotropin releasing
    factor ( CRF; a neurotransmitter of olivo-
    cerebellar climbing fiber system)
    and cortisol (stress hormon)

    -> damage to hippocampus


   Prepared -> torture victims in turkey
    -> political vs non political groups
          with a support group after a trauma
     -> low rate of PTSD
   High rate of PTSD for the veterans of the
    Vietnam war
    -> lack of social support and acceptance

3. Treatment

   Facing the trauma situation
   Systematic re-experiencing with guidance of
    a therapist
    Behavior therapy with a child bitten by a dog

    -> first the brother models the treatment
        lying on an examination table
    -> Marcie tried each one in turn
    -> the therapist took instant photographs
      so that she kept it after completing the
      procedure

->she was asked to draw pictures of the
  situations -> supports of the family
  members

    SSRI (Prozac, Paxil) -> reducing anxiety
    6. Obsessive-Compulsive Disorder; OCD


< Clinical description >

   Most severe form of anxiety disorder
   High comorbidity with GAD, Panic disorder,
    Major depression

   Objects of avoidance
    Other anxiety disorder -> external situation,
    animal, traumatic event etc
    OCD -> his or her own thought, image,
    impulse
   Obsession => thought, image, impulse that
    come to consciousness against one’s will

   The contents of Intrusive and persistent
    thoughts and impulses -> sex, aggression,
    religious contents

   Compulsion => thoughts or behaviors that
    are used to suppress the obsession such
    as repetitive checking, washing, ordering
    and arranging, magical ritual, counting
    numbers, praying, which helps reduce
    stress and prevents imagined disaster.
< Obsession >

   Jenike, Baer and Minichiello(1986);
    most common obsession -> contamination
    (55%), aggressive impulse(50%), sexual
    content (32%), somatic concerns (35%),
    need for symmetry (37%)

    60% of patients showed multiple symptoms
   Need for symmetry refers to keeping things in
    perfect order
   Careful not to step on cracks in the sidewalk
   Impulse to yell out a swear word in church
   A woman was afraid to ride a bus for fear
    that if a man sat down beside her she
    would grab his crotch.
< Compulsion >

   The most common ritual => checking,
    ordering and arranging, washing and cleaning
   Most of OCD patients show washing and
    cleaning or checking rituals.
   Washing or cleaning -> gives patients a
    sense of safety and control
   checking rituals -> prevents imagined disaster
    or catastrophe
   Certain kinds of obsession are strongly
    associated with certain kinds of rituals
   Aggression and sexual obsession lead to
    checking rituals.

    Obsessions with symmetry leads to ordering
    and arranging or repeating rituals.
    Obsession with contamination lead to
    washing rituals.

    some people compulsively hoard things,
    fearing that if they throw something away,
    even a 10-year old newspaper, they then
    might need it.
1. statistics

    lifelong prevalence 2.6%(Karno &
    Golding, 1991).
    Frost et al(1986); 10-15% of “normal”
    students engaged in checking behavior
    To experience occasional intrusive or
    strange thought is regarded normal.
    many people experience bizarre sexual
    or aggressive thought when bored.
   For example, impulse to jump out of
    a high window
   Idea of jumping in front of a car
   Impulse to push someone in front of
    a train
   Thoughts of catching a disease from
    public pools
   Wishing a person would die
   While holding a baby thought of
    dropping the baby
    Idea of swearing or yelling at my
    boss
   Thought of unnatural sexual acts
   Thought that I‟ve left the heater and
    stove on
   Idea that I‟ve left the car unlocked
    when I know I‟ve locked it.
   Most people let these thought pass by
   Certain individuals are horrified by such
    thoughts, considering them as “bad thought,
    bad and evil” and try to defend against them

    More females (55-60%) are inflicted by OCD
    than male
   In case of children, more boys suffer than
    girls.
   Maybe because male‟s onset begins earlier.
   In adolescence the sex ratio equalize
   Average age of onset ranges from early
    adolescence to mid-20s, but typically peaks
    earlier in males(13 to 15) than in females(20
    to 24)
   Once OCD develops, it tends to become
    chronic

   Contents of obsession and that of compulsion
    differ from culture to culture. Nevertheless,
    OCD looks remarkably similar across cultures.
    Showing similar types and proportions.
   In Arabic countries, obsessions are primarily
    related to religious practices, specifically the
    Muslim emphasis on cleanliness.
   Contamination themes are also highly prevalent
    in India

2. Causes

   Many people experience intrusive thoughts or
    impulses. But don‟t develop OCD.
   We must develop anxiety focused on the
    possibility of having additional intrusive
    thoughts.
   OCD needs fear of fear as in GAD or
    Panic disorder
   However, why do OCD patients develop
    fear of intrusive thoughts rather than of
    panic attack or other external situation ?

   Because they have learned that some
    thoughts    are     dangerous     and
    unacceptable.
   They bestow special meaning on their
    thoughts and regard them as equivalent
    to reality.
   Similar to fundamental religious dogma
   Thinking of abortion is the same as
    doing abortion
   Thinking of homosexuality is the same
    as doing the action
   Try to suppress the frightening
    thoughts or impulses -> distraction,
    praying, or checking
   Biological, psychological vulnerability
    and environmental stress interact
    together -> OCD

3. Treatment

    SSRIs have effect on 60% of patients

   The average treatment gain is moderate at
    best and relapse occurs when drug is
    discontinued.

   Most effective method ->
    exposure and ritual prevention (ERP)
-   The rituals are actively prevented and
    patients    are     systematically and
    gradually     exposed to the feared
    thoughts or situations.

   Washing and checking behaviors are
    prevented

   Therapist watch over patient behavior
   Seeing the feared result not ensuing ->
    emotional learning
   Medication     and      psychotherapy
    combined together -> better effect

   Severest patients => psychosurgery
    (surgical lesion to the cingulate bundle)
    -> 30% of patients benefited
       < Two pathways related to
              memory >

   Papez circuit :
    cingulate gyrus/retrosplenial cortex -
    --
    cingulate bundle ---
    subiculum / entorhinal cortex ---
    hippocampus --- fornix --- septal
    area / mamillary body ---
    mamillothalamic tract ---
    anterior n. of the thalamus ---
    cingulate gyrus
   The lateral limbic circuit:
    anterior temporal cortex --- amygdala
    --- dorsomedial n. of the thalamus---
    posterior orbitofrontal cortex

     II. Somatoform and Dissociative
                    Disorders

   Excessive concern about physical health or
    appearance

   Somatoform disorders
    pathological concerns of individuals with the
    appearance or functioning of their bodies,
    usually in absence of any identifiable medical
    condition
   Dissociative disorders

    Disorders, in which individuals feel detached
    from themselves or their surroundings, and
    reality, experience, and identity disintegrate.

   Historically two disorders have been
    studied together.

   Two disorders show many commonalities and
    in the past had been called under the same
    name “hysterical neurosis”
   Hysteria -> wandering uterus (Greek,
    Egyptian)

   The term „hysterical‟ came to refer more
    generally to physical symptoms without
    known organic cause or to dramatic or
    “histrionic” behavior thought to be
    characteristic of women.
   Freud suggested that in a condition called
    conversion hysteria unexplained physical
    symptoms indicated the conversion of
    unconscious emotional conflicts into a
    more acceptable form.

   The historical term conversion remains
    with us ; however, the prejudicial and
    stigmatizing term hysterical is no longer
    used.
   The term neurosis was eliminated from the
    diagnostic system in 1980, because it was
    too vague and applying to almost all non-
    psychotic disorders, and because it
    implied a specific but unproved cause for
    these disorders.
    1. Somatoform Disorders

   Five basic somatoform disorders are listed in
    DSM-IV : hypochondriasis, somatization
    disorder, conversion disorder, pain disorder,
    and body dysmorphic disorder.

   In each individuals are pathologically
    concerned with the appearance or functioning
    of their bodies.
1. Hypochondriasis

< clinical description >

   Characterized by anxiety or fear that
    one has a serious disease.
   The essential problem is anxiety but its
    expression is different from that of the
    other anxiety disorders.
   The individual is preoccupied with bodily
    symptoms, misinterpreting them as
    indicative of illness or disease.
   Normal bodily functions such as heart
    rate or perspiration or cough etc are
    considered to be indicative of serious
    illness.
   Assurances from doctors that all is well
    and the individual is healthy don‟t help.
   Overly concerned in response to slight
    uncomfortableness in body

   Respond very sensitively to physical
    sensation in body
   Don‟t drink and exercise for fear of becoming
    ill

   Some people even don‟t laugh and cannot fall
    asleep for fear of stopping breathing.
   Similar to panic disorder
   Frequently co-morbid with panic disorder
    60% of illness phobia went on later to
    develop hypochondriasis and panic
    disorder.
   Illness phobia => individuals who have
    marked fear of developing a disease

   Hypochondriasis => individuals who
    mistakenly believe they have a disease.
   Core feature of hypochondriasis is the
    disease    conviction. They misinterpret
    physical symptoms.

   The latter has a later onset

   Panic disorder have immediate expectation of
    catastrophe, whereas hypochondriasis have
    relatively delayed expectation of catastrophe.

   The number and art of feared body symptoms
    are more and diverse in hypochondriasis than
    in panic disorder.
   Panic disorder => focused on about 10
    symptoms of sympathetic nervous system

    1. statistics

   prevalence 3 % ; sex ratio 50 : 50
   spread fairly evenly across various phases
    of adulthood

   cultural specific syndromes => koro ;
    Chinese have severe anxiety that the
    genitals are retracting into the abdomen.
    Guilty   about     excessive     masturbation,
    unsatisfactory intercourse, or promiscuity
   Hot sensations in the head or senation
    of something crawling in the head,
    specific to African patients.

   Sensations of burning in the hands and
    feet in Pakistani or Indian patients.

    2. Causes

   Misinterpretation of body sensations of
    signals
   A disorder of cognition or perception
    with strong emotional contribution

   Excessive focusing on body
    -> increase of body symptom
    -> misinterpret
    -> excitement
    -> excessive focusing
    -> increase of body symptom
   Similar to process found in panic
    disorder
    Genetic and psychological
    vulnerability
    learned behavior => family members
    often show the same symptoms

   Related to stress events
   Reinforced through patient role in family
    history -> exempt from responsibility
    and getting attention and affection
    3. Treatment

   Identifying and challenging illness - related
    misinterpretations of physical sensations and
    on showing patients how to create “symptoms”
    by focusing attention on certain body areas.

   Bringing on their own symptoms persuaded
    many patients that such events were under
    their control.
   Caring in support group is helpful.
   Some people are helped by physician‟s
    reassurance. However, doctors don‟t
    usually find enough time to offer
    reassurance.
      2. Somatization disorder
   < Clinical description >

   French physician Pierre Briquet gave first the
    name in 1859 “Briquet's syndrome”
   In 1980 it was changed into somatization
    disorder
   Complain innumerable number of body
    symptoms
   Suffer chronic pain
   Disease make up one‟s identity
   Visits clinic again and again with similar list of
    symptoms
   Different from hypochondriasis, they are not
    so afraid that they have a disease.
   They are concerned with the symptoms
    themselves, not with what they might mean
   They do not feel the urgency to take action
    but continually feel weak and ill, and they
    avoid exercising, thinking it will make them
    worse.

    1. statistics

    prevalence rate : 4.4%
    onset in adolescence
   More female, single, low socio-
    economic class
    proportion of female : 68%
    accompanies anxiety, depression
   Suicidal attempt to manipulate others
   Mostly chronic, continues through old
    age
   In some cultures sex ratio is
    equivalent or even higher prevalence
    among male.
2. causes

   A history of family illness
   Related with Anti social personality disorder

   Both begin early in life, typically run a chronic
    course, predominant among lower socio-
    economic classes, are difficult to treat, and
    are associated with marital discord, drug and
    alcohol abuse, and suicide attempts.

   Both group are common in their tendency to
    seek short term gratification, and impulsivity.
   Temporary attention, care
     => isolation in long term
   Genetic common factors
   Differences in identification of sex roles
   Antisocial personality disorder
    -> masculine, aggressivity
   Somatization disorder
    -> feminine, non-aggressivity
    3. Treatment

    Very difficult
    Reassuring, caring
    Reducing stress
    Decreasing dependency
    Allowing visiting clinics after consulting
    „gate keeper‟ doctor
    Frustrating reinforcement through
    showing symptoms
    Encouraging independency
     => getting job
        3. Conversion disorder
    < clinical description >

   Disorder of bodily malfunction such as
    paralysis, blindness, aphonia, loss of the sense
    of touch, seizure etc. without physical
    pathology.

   Feel weak and can‟t walk
   Another relatively common symptom is globus,
    the sensation of a lump in the throat that
    makes it difficult to swallow, eat or sometimes
    talk.
    < closely related disorders >

   Indifference to the symptoms. But not always.
   Sometimes       real   patients  show     also
    indifference.

 Usually precipitated by marked stress.
 therefore must check, if the symptoms
  appear without any preceding stress.
 => real physical problem
   Although people with conversion
    symptoms can usually function normally,
    they seem unaware of sensory input.
    -> people with symptom of blind or
       paralysis of leg
    -> normal function in emergency

   Sometimes misdiagnosis of physical
    disorder as a conversion
   Difficult to distinguish malingering       and
    conversion disorder
   Malingering
    aware of their own motivation
     => economic interest
   factitious disorder
    -> just to draw other people‟s attention    ->
    sometimes making their children sick
        (factitious disorder by proxy)
< Unconscious processes related to
  conversion disorder >

   Anna. O nursed her father for a long time.

   visual hallucination of a black snake
    crawling up father‟s bed
     => at the moment of catching the snake,
        the arm was paralyzed

    While praying, English came out of her mouth
    instead of German, which was her mother
    tongue
   Gradually right part of her body paralyzed
    and then spread to the other parts of body

    Dr. Breuer hypnotized her and let her re-
     experience the trauma
    -> recovered her sensation and could speak
     German again. Dr. Breuer called this
     =>„catharsis‟ treatment.

   according to recent research, we can
    process various informations (visual and
    auditory) without being aware of it.
    1. statistics

   Comorbid with other disorders,
    especially with somatization disorder
   Prevalence rate range from 1% to 30%
   More females are inflicted
   Males can also be attacked when
    stressed extremely
   Onset mostly in adolescence
   Often found in specific religious group
    2. Cause

   Freud explained in 4 steps

 1) experience of a trauma
 2) repress it, because it is unacceptable
 3) increase of anxiety and conflict ->
   converted into body symptom
 -> reduction of anxiety -> primary gain
4) Attention and sympathy from the
  environment + exempt from difficult work
  and responsibility -> secondary gain
 Indifferent attitude of patients
 -> because of primary gain
 Not supported by research data

 Could be only preoccupation of the
  therapist
 Socio-cultural influences

   => low education and
       low economic class
 Familial influence => imitation of family
  member‟s real diseases
   Recently low prevalence => change of social
    situation resulting in decrease of secondary
    gain
   Interpersonal problems, psychological factors
   Inter-related with other somatoform
    disoders

    3. Treatment

    Very similar to somatization disorder
    => similar treatment
   Let a patient talk about trauma event
    => encouraged to re-experience
       the trauma
    => catharsis
   Remove the secondary gain
   Often conspiracy with the family members
   Without collaboration of the family
    => relapses after treatment

   Elois who can‟t walk -> expectation of the
    mother who was busy with her store
            4. Pain disorder

    < clinical description >

   Somatoform disorder featuring true pain but
    for which psychological factors play an
    important role in onset, severity
    or maintenance

   Overlaps with physical illness
     therefore was considered        seriously   to
    remove from DSM-IV
   Three subtypes
    1) pure psychological origin
    2) psychological and physical factors
       combined
    3) pure physical origin

   In all three psychological factors
    involved
   Pain is real and very hurts, regardless
    whatever causes it was initiated
   Abdomen, head, muscle pain
   Temporary or chronic pain
   Psychological treatment combined with a
    physical treatment
   Relaxation training, group therapy, meditation
   Increased interest in health psychology

   5-12% of the population meets the criteria for
    pain disorder (Grabe et al., 2003)
     5. Body dysmorphic disorder

< Clinical description >

   Disruptive preoccupation with some imagined
    defect in appearance (“imagined ugliness”)
   Hair, nose, skin, eyes, head, face, bone
    structure, lips, chin, stomach, waist, teeth,
    legs, knees, breast, ears, cheeks, buttocks,
    penis, arms, wrist, neck, forehead, facial
    muscle, shoulders, hips
   Relative normal looking people imagine
    they are so ugly that they cannot interact with
     others
    An attractive young man feared to go out,
     because he imagined his head was square
     formed.

   Checks frequently mirror to see if there is a
    change in appearance
   In other cases avoids mirror
   often suicidal attempts
   Ideas of reference (in BDD related with
    appearance)
   In the past regarded as a psychotic delusional
    state
   50% of patients -> think their belief as
    real
    => in such cases an additional
    diagnosis of Delusional disorder:
    somatic type will be given

1. statistics

   Prevalence now well known
   But widely spread than known
   No spontaneous remission when not treated
   Similar distribution in both sex
   In a Japanese research 62% were male
   Onset age ranges from early adolescence to
    twenties
    usually don‟t visit clinic
    according to Veale et al(1996) suicidal rate
    up to 24%
    influenced by social and cultural
    standards
   In some cultures, prolonged or enlarged face
    are regarded beautiful
   In other cultures long neck or flat nose is
    seen as beautiful
   Small feet in china, also in European fairy tale
    (Cinderella)

2. Cause and treatment

   Not very well known
   No research results as to genetic and
    psychological cause

   Psychoanalytic theory assumes repressed
    conflict displaced into bodily concern
   Comorbid often with OCD
   Checking behavior related
    with appearance
   Similar onset and process

   Clomipramine(Anafranil)      and   Fluoxetine
    (Prozac) are effective to some patients,
    which are also effective to OCD
   Like in OCD, exposure and response
    prevention are effective
    cultural influences => in Japan and Korea, it
    could be diagnosed as social phobia
 2% of plastic surgery patients are BDD
 According to recent research higher proportion

 Nose, chin, eyebrow surgery

 no satisfaction after surgery
  => resurgery or surgery of other parts

- Of the 25 patients who received the surgery
  only 2 showed relief and in more than 20
  cases, the severity of the disorder increased
  (Philip et al., 1993)
        2. Dissociative Disorders

   Feels detached from oneself or one‟s
    surroundings, as if they are dreaming or living
    in slow motion
   The sense of things and the external reality is
    lost
   Loses sense of one‟s own reality
   Depersonalization => feels change in one‟s
    identity
   Derealization => the individual loses his or
    her sense of the reality of the external world
   The latter being followed by the former
    1. Depersonalization disorder
   Sense of severe unreality
   Making an individual unable to carry out
    normal daily life
   makes him or her frightening
   as if one observe oneself from outside
   main symptom being depersonalization and
    derealization
   According to Simeon(1997), average onset
    16.1 age
   Mostly become chronic
   50% of the patient additionally diagnosed with
    anxiety disorder and mood disorder

2. Dissociative Amnesia

   General amnesia => forgets totally who one
    is
   Localized amnesia => a failure to recall
    specific events, usually traumatic, that
    occurred during a specific period
   In most cases occur after severe traumatic
    events
   Sometimes remembers the even itself, but
    not the emotion related to it.
   More prevalent than general memory
    disorder
       3. dissociative Fugue
   Fugue means escape or flight
   Move from a place associated with trauma to
    a different environment
   Can‟t remember how he or she came to the
    place
   Often gets a new identity
   Usually begins at an adult age
   Found in various cultures with different
    names
    4. dissociative Trance Disorder
   Dissociation experienced with ecstasy
   Sudden changes in personality
   In some cultures -> believed to be mediated
    by spirit => Possession
   Like in other dissociative disorder, related to
    current stress or trauma rather than past
    trauma
   More often in female
   Regarded as normal in certain religion
   Common in India, Thailand, Africa, American
    Indian, in South America
    5. Dissociative Identity Disorder

    < Clinical description >

   Former multiple personality disorder
   Certain aspects of a person‟s identity
    are dissociated.
   A person‟s identity is fragmented
    =>     many      identity    can    exist
    simultaneously in a person
   Separate identities with characteristic
    behaviors, voices, gestures
   Sometimes with only partial characteristics
   Mostly develops after experiencing violence
    or other traumatic events

   A man changed identity every time he had a
    head ache

    - He became aggressive and violent.
      Afterwards he did not remember the incident
    - A third identity who was promiscuitous
      Each identity except host personality don‟t
      know about each other
   Host personality is rational and calm
    It is also host who seeks help.
    Host     tries   to    integrate   other
    personalities. But it fails and will be
    overwhelmed.
   Host is usually not the original
    personality, but develops later.
   Some times a DID patient shows male
    and female identity at the same time.
   Facial expression, voice, body posture or
    even optical function changed, when another
    identity appears.

   According to Putnam et al.(1986) 37% of the
    patients showed changes of the handedness

   The Hillside Strangler, Kenneth Bianchi raped
    and murdered 10 young woman in 1970s in
    Los Angeles and left their body naked in full
    view in various hills.
   Despite overwhelming evidence he denied
    the criminal act.
    some professionals raised the question he
     might have a DID.

    - his lawyer brought in a clinical psychologist,
     who hypnotized him and asked whether there
     were another part of Ken with whom he could
     speak.

    Then somebody called Steve answered and
    said he had done all the killing. Steve also
    said that Ken knew nothing about the
    murders. With this evidence, the lawyer
    entered a plea of not guilty by reason of
    insanity.
- The defense called on the late Marti Orne, a
  distinguished clinical psychologist and
  psychiatrist who was a leading experts on
  hypnosis and dissociative disorders.

 - Orne gave him psychological tests to find no
 significant differences among the
 personalities. By interviewing Bianchi‟s
 friends and relatives, Orne couldn‟t find any
 independent corroboration of different
 personalities before his arrest.
   And several psychopathology text books
    were found in Bianchi‟s room, which suggests
    he studied the subject and faked DID. On the
    basis of Orne‟s testimony, Bianchi was found
    guilty and sentenced to life in prison.

   DID patients usually have high suggestibility
    to hypnosis.
    by experimental research it is found that
    people can fake the symptoms.
   Faking subjects remembered far less than
    those who were hypnotized.
   Various identities (alter) showed different
    physiological responses (GSR, EEG)
1. statistics

   mostly case studies
   in average 15 identities
   onset : early childhood (before age 9)
   sex ratio 1 : 9 in favor of female
   prevalence in clinical group 3-6%
   in general group 0.5-1 %
   Show high comorbidity with other disorders
    such    as drug addiction, depression,
    somatization disorder, borderline PD, panic
    disorder, eating disorder etc.

 Complex disorder due to childhood taumatic
  experiences
 Similar to borderline PD
 self destructive, suicidal impulse, emotional
  instability
 Frequent hallucination
=> often misdiagnosed as a psychosis.
 But different from the psychosis they hear the
  voice from inside.

    Knowing that the voices are hallucination,
    they don‟t respond to them.
    In some cultures, they are thought to be
    possessed
   Distributed in various cultures

2. causes

    In most cases, they experienced severe
    childhood abuse
    Escape into a fantasy world, if pain is
    unbearable and they can do nothing to stop it.
    Our mind has the ability to create a new
    identity

    Putnam et al.(1986): of 100 DID patients, 97
    had experience of sexual abuse or physical
    abuse.
   68% had incest sexual abuse experience
   Some children had witnessed their parents
    blown to bits in a minefield.
   Familial support consitutes an important
    variance.
   Psychological vulnerability plays also an
    important role.

   Recently researchers tend to see DID
    as an extreme subtype of PTSD
   The difference is that greater emphasis
    in on the process of dissociation rather
    than on symptoms of anxiety, although
    both are present in each disorder.

   After around 9 years of age, DID is
    unlikely to develop, although severe
    PTSD might.
   Heredity is not yet proven
   Seizure disorder patients experience
    many dissociative symptoms

   About 50% of temporal lobe epilepsy
    displayed some kinds of dissociative
    symptoms
    => related to brain physiology

   Dissociative symptoms of epilepsy
    patientsare not related to trauma
    experience.
    < Suggestibility >

   Dissociation and suggestibility in
    hypnosis are similar phenomenon
   People in trance tend to be focused on
    aspect of their world, and they become
    vulnerable to suggestions by the
    hypnotist.
   People with high suggestibility can use
    dissociation as a defense against
    anxiety.
   50% of DID reports of imaginary
    playmates in childhood (Beautiful
    Mind)

   When        the  trauma    becomes
    unbearable, the person’s identity
    splits    into  multiple dissociated
    identities.

    As the ability of the children to
    distinguish fantasy from reality
    increases, around 9 years old, the
    developmental window closes for DID
   People with low suggestibility develop
    PTSD ?
< Real memory and false >
 Accuracy of trauma memory is very
  controversial
 Suggestions by therapists ?



   In case of real trauma, it is important to
    re-experience the trauma
   False Memory Syndrome Foundation
    => to help innocent victims
   Loftus et al.(1996): an imaginary event was
    told to a 14 years old boy that he was lost at
    the age of 5 and then rescued by an old man.
    Several days after receiving this suggestion,
    the boy reported remembering the event and
    even that he felt frightened when he was lost.

   Bruck et al.(1995): of the 35 three years old
    girls of experimental group who received
    medical examination, 60% did not remember
    examination of sexual organ.
    Whereas of the control group, 60% reported
    on examination of sexual organ, although
    they didn‟t receive the examination.

    Ceci et al.(1995, 2003): preschool children
    were asked to actively imagine both a real
    event and a fictitious event during 10
    consecutive weeks.

=> another researcher interviewed them.
 58% of children described the fictitious event
 as if it had happened.

    27% of the children claimed that they
    remembered the event, even after they were
    told their memory were false.
-On the other hand, there are many cases
 where    childhood   abuse   cannot  be
 remembered.

Williams(1994): 129 real childhood victims of
abuse were interviewed.
 =>
 38% did not remember the abuse event

 The younger the child was at the time of
 abuse and in case of knowing the abuser, the
 more likely was that the event was not
 remembered.
    3. Treatment

   Dissociative amnesia, dissociative fugue =>
    usually spontaneous recovery
    the episodes are clearly related to current life
    stress
   Removal of stress, strengthening personal
    coping strategies
   Recalling what happened during the amnesic
    or fugue states
   In case of DID, long term psychotherapy is
    needed
   Only about 20% accomplished full integration
    of their identities.
   Methods that were developed in PTSD
    treatment could be applied also to DID
    treatment.
   Cues or triggers that provoke memories of
    trauma are identified and then neutralized.
   Confront and relive the early trauma and gain
    control over the horrible events

   Help the patient visualize and relive aspects
    of the trauma until it is simply a terrible
    memory instead of a current event.
   Hypnosis could be utilized to help patients
    to access unconscious memories
   Process of hypnosis is similar to that of
    dissociation
   As trauma memory reemerge, it can trigger
    further dissociation
   The trust in therapy process is very important
   Some times medication is combined with
    therapy, but there is little indication that it
    helps.
   Antidepressant helps to some patients