Section 3 Abnormal Psychology

Dissociative Disorders

Dissociative Disorders

A group of disorders characterized by symptoms of disruption in consciousness, memory, identity, emotion, perception, motor control, or behavior
-Usually follows a significant stressor or years of ongoing stress

The three main types of Dissociative Disorders

1. -Dissociative Identity Disorder

2. -Dissociative Amnesia

3. -Depersonalization/Derealization
   Disorder

Signs of Dissociation

1. Memory loss

2. Feelings of depersonalization

3. Feeling lightheaded

4. Not feeling pain

5. Loss of self-identity

Dissociative Identity Disorder
(DID)

To be diagnosed with DID, there must be at least two distinct personality states or expressions which have their own tone of voice, physical gestures, behaviors, etc.

-Aka multiple personality disorder

-There must also be a gap in recall of events, information, and/or trauma due to the switching of
personalities

-

Dissociative Amnesia Disorder

Identified by the inability to recall important autobiographical information although the information is
successfully stored in the individual’s memory

Localized amnesia

the most common type where one is unable to recall events during a specific period

Selective amnesia

a component of localized amnesia in that the individual can recall some, but not all, the details during a specific time period

Generalized amnesia

a rare condition where there is a complete loss of memory of their entire life history, including their own identity; individuals experience deficits in semantic and procedural knowledge (i.e., common knowledge and learned skills)

Dissociative fugue

the most extreme type of dissociative amnesia where not only does an individual forget personal information, but they also flee to a different location; can last hours to years, after which it goes away suddenly

Depersonalization/Derealization
Disorder

Categorized by recurrent
episodes of depersonalization
and/or derealization which can
last hours to months

-Triggered by intense stress or
trauma

Depersonalization

a feeling of unreality or detachment from oneself; can feel like an outer body experience; a lack of speech, motor control deficits, and distortions of one’s physical body are also possible

Derealization

includes feelings of unreality or detachment from the world, including individuals, objects, or their surroundings; can include sensory changes and distortions in time, distance, and size/shape of objects

Dissociative Disorder Comorbidity

-There is a high comorbidity between most
dissociative disorders and PTSD
-Depressive disorders are also often found
in combination with dissociative disorders

Dependent, obsessive-compulsive, avoidant, and borderline personality traits/disorders are comorbid for…

dissociative identity disorder

Dissociative amnesia there is evidence of comorbidity with…

substance-related and feeding and eating disorders

Anxiety disorders (and unipolar depressive) are common for…

depersonalization/derealization disorder

Biological (DD)

the heritability rates for
dissociation range from 50-60% but it is really the combination of genetic and environmental factors that
develop dissociative disorders

Cognitive(DD)

memory retrieval deficit
(or the combination of psychological
stress and various other
biopsychosocial predispositions
affects the frontal lobe’s executive
system’s ability to retrieve
autobiographical memories);
hippocampus activation is
implicated in DID

Sociocultural (DD)

Lilienfeld and
colleagues argue that mass media
and its publications of dissociative
disorders provide a model for
individuals to not only learn about
the disorders, but to engage in
similar behaviors; mass media can
also affect how clinicians gather
data about their patients

Psychodynamic (DD)

assumes that the
dissociative disorders are caused by
and individual’s repressed thoughts
and feelings related to an
unpleasant or traumatic event; DID
might result from repeated exposure
to trauma because the personalities
serve as an escape from reality

Dissociative Identity Disorder Treatment

Integration of subpersonalities to a point of final fusion
◦ Requires psychoeducation so that the individual understands the disorder and can better
acknowledge their subpersonalities
◦ The latter can be especially hard because of the one-way amnesia that this disorder can create
Steps
◦ The clinician must build a strong rapport with the primary personality
◦ Then, they can encourage gradual communication and coordination between the subpersonalities
◦ Focus switches to fusion which occurs when two or more alternate identities join
◦ Final fusion is reached when the individual identifies themselves as one unified self
◦ However, final fusion is not everyone’s goal, although not achieving this puts the
individual at risk for relapse

Treatment for dissacociative disorders

1. Many individuals
   recover on their own
   without intervention

2. Rarity of these
   disorders limits the
   opportunities for
   research and treatment
   development

Dissociative Amnesia Treatment

-Hypnosis

-Barbiturates, or “truth serums” can also help relax the individual and free their
inhibitions

Hypnosis

allows the individual to contain, modulate, and reduce the intensity of the amnesia symptoms, thus allowing them to process the traumatic or unpleasant events underlying the amnesia episode; then, the clinician helps walk them through the events during the amnesic time to reorient the individual

Depersonalization/
Derealization
Disorder Treatment

-The diagnosis alone can
effectively reduce symptom
intensity because it can
relieve the anxiety
surrounding the baffling
nature of the symptoms
-Goal of treatment is often
alleviating the anxiety and
depression that is comorbid
with this disorder
-SSRIs can be effective in
improving mood, but
medications work best when
paired with psychological
treatments (i.e., CBT)

What’s included in the Schizophrenia Spectrum?

Schizophrenia, Schizophreniform disorder, Schizoaffective disorder, Delusional
disorder

What are hallmark symptoms in the Schizophrenia Spectrum?

Delusions, hallucinations, disorganized thinking (speech), disorganized or abnormal motor behavior, and negative symptoms

Psychosis

A loss of contact with reality where it becomes difficult for individuals to perceive and respond to environmental stimuli, which causes a significant disturbance in everyday functioning

Delusions

Fixed beliefs that are not amenable to change considering
conflicting evidence

What are the different types of delusions?

Of Grandeur, Of Control, Of Thought Control, Of Persecution, Of Reference, Of Thought Withdrawal

Of grandeur – belief that they have exceptional abilities, wealth, or fame; belief
they are God or another religious savior

Of grandeur – belief that they have exceptional abilities, wealth, or fame; belief
they are God or another religious savior

Of control

belief that their thoughts/feelings/actions are controlled by others
• Of thought broadcasting – belief that one’s thoughts are transparent, and everyone
knows what they are thinking

Of persecution

belief they are going to be harmed, harassed, plotted or
discriminated against by either an individual or an institution ***most common

Of reference

belief that specific gestures, comments, or even larger
environmental cues are directed directly to them

Of thought withdrawal

belief that one’s thoughts have been removed by another
source

Disorganized Thinking

Thoughts and speech patterns may appear to be circumstantial or tangential (e.g., they give unnecessary details, or they may never reach the point)

Retardation

another cognitive symptom where the individual may take a long period of time before answering a question

Derailment

the illogical connection in a chain of thoughts

Illogicality

the tendency to provide bizarre explanations for things

Psychomotor symptoms

include awkward movements
or even ritualistic/repetitive behaviors that are often
unpredictable and overwhelming

Catatonic Behavior

• The decrease or even lack of reactivity to the environment
• Includes: negativism (resistance to instruction), mutism or
stupor (complete lack of verbal and motor responses), rigidity
(maintaining a rigid or upright posture while resisting efforts to
being moved), posturing (holding odd, awkward postured for
long periods of time) and catatonic excitement (hyperactivity of
motor behavior

Negative symptoms are defined as

the
inability or decreased ability to initiate
actions, speech, expressed emotion, or to
feel pleasure

SCHIZOPHRENIA criteria

Requires the presentation of at least two of the following for at least one month: delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, and/or negative symptoms
Also requires the presence of symptoms for a minimum of 6 months

SCHIZOPHRENIFORM
DISORDER

1. Considered an
   “intermediate disorder”
   because the symptoms are
   present for at least one
   month but no longer than 6
   months
   2. About 2/3 of individuals go
   on to develop schizophrenia
   3. Impaired functioning is not
   essential for diagnosis
   4. Any major mood episodes
   present concurrently must
   only be present for a small
   period of time (otherwise,
   the individual may be
   diagnosed with
   schizoaffective disorder)

negativism

resistance to instruction

mutism or
stupor

complete lack of verbal and motor responses

rigidity

maintaining a rigid or upright posture while resisting efforts to
being moved

posturing

holding odd, awkward postured for
long periods of time

catatonic excitement

hyperactivity of
motor behavio

Examples of Negative symptoms

• Affective flattening – reduction in emotional
expression; reduced display of emotional expression
• Alogia – poverty of speech or speech content
• Anhedonia – inability to experience pleasure
• Apathy – general lack of interest
• Asociality – lack of interest in social relationships
• Avolition – lack of motivation of goal-directed behavior

Alogia

poverty of speech or speech content

Anhedonia

inability to experience pleasure

Apathy

general lack of interest

Asociality

lack of interest in social relationships

Avolition

lack of motivation of goal-directed behavior

prodromal symptoms

early signs of of a disease that can evolve over time

residual symptoms

symptoms that persist or appear after the main condition has been treated or resolved

SCHIZOAFFECTIVE
DISORDER

Involves the psychotic symptoms of
schizophrenia and a concurrent,
uninterrupted period of a major mood
episode that occurs for the majority
or total duration of the disorder

Psychotic symptoms should continue
for at least 2 weeks in the absence of
a major mood disorder

This separates schizoaffective
disorder and major depressive
disorder with psychotic features

Delusional Disorder

Requires the presence of
at least one delusion that
lasts for at least one
month in duration and
that individuals must not
have experienced
hallucinations,
disorganized speech,
disorganized or catatonic
behavior, or negative
symptoms to be
diagnosed with
delusional disorder

5 MAIN SUBTYPES OF
DELUSIONAL DISORDER

Erotomanic
Grandiose
Jealous
Persecutory
Somatic

Erotomanic delusion

occurs when an individual reports a delusion of another person being in love
with them (usually a person of higher status)

Grandiose delusion

involves the conviction of having a great talent or insight; these may take on a religious affiliation

Jealous Delusion

revolve around the conviction that one’s spouse or partner is/has been
unfaithful; this is much more extensive than common questions of infidelity and is generally based
on incorrect inferences

Persecutory delusion

involves the individual believing that they are being conspired against,
spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in pursuit
of their long-term goals; individuals with these delusions are most at risk of becoming aggressive
or hostile

Somatic delusion

involves delusions regarding bodily functions or sensations (e.g., that they emit
a foul odor or that there are insect in/on them)

Schizophrenia is often
found with

obsessive-
compulsive disorder
and panic disorder

High comorbidity rate
between schizophrenia
and…

substance abuse

identical twin develops
schizophrenia, there is a
48% chance that the
other…

will also develop
the disorder; similar
brain abnormalities
between schizophrenic
individuals and their
relative

Neurobiological –
neuroimaging has
found...

enlargement as well as
volume reductions in the
medial temporal lobe
(amygdala – emotion
regulation; hippocampus
– memory); neocortical
surface – auditory
information process

A significant reduction in
overall and specific brain
regions volumes, as well
as tissue density of
individuals with
schizophrenia

A reduction in the
orbitofrontal regions of
the brain (responsible for
inhibition)

Stress Cascade

the HPA axis (which mediates
stress) doesn’t function
properly due to an influx
of glucocorticoids

Like the diathesis-stress
model, cognitive model
proposes that

premorbid neurocognitive impairment
places individuals at risk for aversive
work/academic/interpersonal experiences which, in
return, lead to dysfunctional beliefs and cognitive appraisals, ultimately leading to maladaptive behaviors such as delusions/hallucinations

Sociocultural etiology of schizophrenia spectrum

1. Expressed emotion
   (hostility, criticality,
   overinvolvement) –
   patients in this kind
   of home environment
   are twice as likely to
   relapse

2. Family dysfunction –
   i.e., conflict, difficulty
   with communication,
   overall disruption; all
   of which do not
   support the patient’s
   progress

Although more recent advancements
in treatment for schizophrenia appear
promising, the disease itself is
continued to be viewed as one that

requires lifelong treatment and care

Possible treatments of schizophrenia spectrum

a combination of
psychopharmacological, psychological,
and family interventions is the most
effective treatment in managing
schizophrenia symptoms

PSYCHOPHARMACOLOGICAL
TREATMENT for schizophrenia spectrum

1. Conventional antipsychotics (e.g., Thorazine, Chlorpromazine) –
   successfully calm agitated patients by acting on dopamine receptors, but
   come with awful side effects (e.g., muscle tremors; involuntary
   movements; muscle rigidity; and tardive dyskinesia which includes
   involuntary movements of the tongue, mouth, and face) which increase the
   longer an individual takes the medication
   2. Second generation/Atypical antipsychotics (e.g., Clozapine, Risperidone,
   Aripiprazole) – acts on dopamine and serotonin receptors and manages
   both positive and negative symptoms; side effects are less likely but still
   possible
   3. Patients often discontinue medications, which makes it important to
   incorporate psychological treatment and additional support

TX

Cognitive Behavioral Therapy in regards to schizophrenia spectrum(CBT)

Goal: to identify negative biases and attributions
that affect one’s interpretation of events, thoughts,
and behaviors
 Focuses on the maladaptive emotional and
behavioral responses to psychotic experiences
 Does NOT try to reduce symptoms, but rather to
improve self-understanding through
psychoeducation, challenging and replacing
negativity, learning positive coping strategies, etc.
 Hopes to let patients live independently, secure
employment, and improve social relationships and
does so effectively

FAMILY INTERVENTIONS

Goal is to reduce the stress on the individual that is likely to elicit onset of symptoms
Majority of programs focus on psychoeducation, problem-solving skills, and CBT
Social skills training

Inpatient hospitalization

helpful during stabilization of patients
 Can be short-term (a few weeks), long-term (months, years), or partial (during the day)
 So, patients learn how to interact with others (e.g., establish eye contact, engage in reciprocal
conversation, etc.) through group therapy and role play

Inpatient hospitalization

helpful during stabilization of patients
 Can be short-term (a few weeks), long-term (months, years), or partial (during the day)

tardive dyskinesia

a disorder that results in involuntary repetitive body movements, which may include grimacing, sticking out the tongue or smacking the lips. Additionally, there may be chorea or slow writhing movements. In about 20% of people with TD, the disorder interferes with daily functioning.

Personality Disorder

when personality traits are
inflexible and maladaptive and cause significant functional
impairment or subjective distress

Personality Trait

enduring patterns of perceiving, relating
to, and thinking about the environment and oneself that are
exhibited in a wide range of social and personal contexts

Four defining features of personality disorder

1. Distorted thinking
patterns
2. Problematic
emotional responses
3. Over- or under-
regulated impulse
control
4. Interpersonal
difficulties

Personality Disorder criteria

Per the DSM 5 TR, for a personality disorder to be
diagnosed in an individual younger than 18 years, the features must have been present for at
least 1 year (with the exception of Antisocial Personality Disorder)

-Must display these behaviors in adulthood

-Kids can have this, have to have these symptoms for one year

Cluster A

“Odd/eccentric”
• Paranoid PD
• Schizoid PD
• Schizotypal PD

Cluster B

“Dramatic,
emotional,
erratic”
• Antisocial PD
• Borderline PD
• Histrionic PD
• Narcissistic PD

Cluster C

“Anxious/fearful”
• Avoidant PD
• Dependent PD
• Obsessive-
Compulsive PD

Schizotypal Personality Disorder

• Cluster A

• Characterized by a range
  of impairment in social and
  interpersonal relationships
  due to discomfort in
  relationships, along with
  odd cognitive and/or
  perceptual distortions and
  eccentric behaviors

• Individuals seek isolation
  and have few established
  relationship

• Can have auditory
  hallucinations, as well as
  unusual speech patterns of
  derailment or incoherence

• Display inappropriate or
  restricted affect;
  significant social anxiety

Ideas of references

the
belief that unrelated
events pertain to them in
an unusual way; can lead
to superstitious behaviors
or preoccupation with
paranormal activities (e.g.,
they may believe they
have special powers

Differentiating Schizotypal
Personality From Schizophrenia

1.Shyness and eccentricities gain traction from childhood through adulthood
and remain constant, however...
2.There are no past or present well-formed delusions, gross disorganization,
hallucinatory activity, or catatonia.
3.The presentation is not episodic and there is no ebbing and flowing of
symptoms.
4.Psychotic disorders tend to develop in the 20s to early 30s, whereas
Schizotypal Personality “is the way the person has always been.”

Paranoid Personality Disorder

-Marked distrust or
suspicion of others, and
therefore doubt
relationships
-Often feel as though
they have been deeply
and irreversibly hurt by
others even though
there lacks evidence to
support this
-Hesitant to share with or
confide in others for fear
the information will be
used against them
-Benign remarks or
events are often
interpreted as
demeaning or
threatening
-Quick to hold grudges
and unwilling to forgive
insults or injuries –
whether intentional or
not
-Quick to angrily
counterattack either
verbally or physically
when they feel insulted

Schizoid Personality Disorder

-Display a persistent
pattern of avoidance
from social relationships
along with a limited
range of emotion among
social relationships
-Do not have many close
relationships because
they lack the desire to
engage with others
-Lack of desire for
establishing social
relationships also
extends to sexual
behaviors
-Often indifferent to
criticisms or praises of
others and appear to not
be affected by what
others think of them
-Described as having a
“bland” exterior in that
they rarely reciprocate
facial expressions or
gestures (e.g., smiles,
nods)
-Limited need for
attention or acceptance

Epidemiology of Cluster A
PDs

Prevalence rate around 3-4%
◦ Paranoid PD – 4.4% (no reported gender
discrepancy)
◦ Schizoid PD – 3.1% (more commonly diagnosed in
males)
◦ Schizotypal PD – 3.9% (more commonly diagnosed
in males)

Treatment for Cluster A PDs

◦ Patients don’t often seek help, and those who do go to
treatment, do not enter it willingly
◦ Patients struggle to trust the clinician because they’re
suspicious of the clinician’s intentions or are emotional
distant with a lack of desire to engage in treatment
◦ High drop-out rates
◦ CBT is used to reduce anxiety-related symptoms,
address the misinterpretations of others’ words and
actions, experience more positive emotions and
engage in more satisfying social experiences, and/or
evaluate unusual thoughts
◦ Sometimes includes social skills training

Borderline Personality Disorder

I-ndividuals are often
uncomfortable in
social settings
unless they are the
center of attention
Often very lively and
dramatic which can
be initially charming,
but will eventually
wear down the
audience
-May make-up stories
and/or cause
dramatic scenes
-May engage in
sexually seductive
or provocative ways
and/or spend
significant time on
their physical
appearance
-Easily suggestable Over-exaggerate
relationships

Histrionic Personality Disorder

-Individuals display a
pattern of grandiosity
along with a lack of
empathy for others
Over-evaluate their
abilities and
accomplishments and
come across as
boastful and
pretentious
-Need excessive
admiration from
others; and their self-
esteem is extremely
inflated but fragile
Often have difficulty
(or choose not to)
recognizing the
desires or needs of
others
-Exploit interpersonal
relationships
Envious of others who
achieve greater
success or
possessions and
believe that everyone
should be envious of
them

-More of a female diagnosis

Epidemiolog
y of Cluster B
PDs

Prevalence
◦ Antisocial PD – 3.3% (more commonly diagnosed in
males, especially those with substance abuse
disorders and those from disadvantaged
socioeconomic settings)
◦ Borderline PD – 5.9% (women make up 75% of the
diagnoses)
◦ Histrionic PD – 1.84% (diagnosis rate is equal
between genders)
◦ Narcissistic PD – 6.2% (men make of 75% of the
diagnoses)

Treatment for Cluster
B PDs

Antisocial PD – options are limited and generally not effective;
patients are often forced to participate in treatment where they try to
address the lack of moral conscious and encourage patients to think
about the needs of others
Borderline PD – treated with Dialectical Behavioral Therapy (DBT)
which tries to reduce suicidal behavior, reduce therapy interfering
behavior, improve quality of life, and reduce post-traumatic stress
symptoms
Histrionic PD – more likely to seek treatment that other PD patients,
but still difficult to treat because the individuals use their demands
and seductiveness in the treatment setting; goal of treatment is to
identify dependency and change helpless beliefs
Narcissistic PD – more difficult to treat because individuals only seek
out help for secondary issues (e.g., depression); treatment addresses
grandiose, self-centered thinking, and how to empathize with others
More about DBT:
- Skills training (mindfulness,
distress tolerance,
interpersonal effectiveness,
emotion regulation)
- Enhancing motivation
- Telephone and in vivo coaching
– not uncommon to have phone
number of the clinician
- Case management – patients
become their own case
managers
- Consultation team – provides
support to the providers
- Drop out rates are extremely
low

Cluster C
Personality
Disorders

Display a pervasive pattern of social anxiety due to feelings
of inadequacy and increased sensitivity to negative
evaluations
Driven by their fear of being rejected
Reluctant to engage in social situations, and thus it is
difficult to maintain employment
Have very few if any friends, despite their desire to
establish social relationships
Often exaggerate the potential negative consequences and
embarrassment that may occur if they take up new
activities or relationships
Do not typically suffer from social skills deficits, but rather
from misattributions of their own behaviors
APD differs from SAD mainly in the depth of belief in the level of inferiority
and at times self hatred.

SAD Vs APD

-avoidant personality disorder have more severe
anxiety and lower self-esteem, making them more likely to completely avoid others and self-isolate than those
with social anxiety

-
individuals with AVPD are less likely to make
an effort.3, 5 While those with social anxiety might only avoid certain types of social situations, people with AVPD
are more likely to avoid all social settings, making them more likely to become isolated and have fewer close
relationships

-
these issues are more severe in individuals with AVPD. Someone with AVPD is more
likely to believe that they are completely socially inept, unworthy, or unable to have normal interactions

-While a person with social anxiety may struggle with these same insecurities, it will be to a lesser extent. They
are more likely to feel slightly insecure or self-conscious rather than entirely inadequate or inferior.