mental health - post midterm content

somatic disorders - generally

physical symptoms with no obvious cause

- hard for people to recognize it may be psychological

- stressful and frustrating for docs and patients

physical symptoms

85-95% of people have at least one physical symptoms every 2-4 weeks

- common complaints include chest pain, abdominal pain, dizziness, headache, back pain, fatigue

- an organic cause is only found 10% of the time

somatic symptoms and related disorders

group of disorders characterized by excessive thoughts, feelings, and behaviours, related to somatic symptoms

- experience REAL physical symptoms, but their pain cannot be explained by a medical condition

somatic symptom disorder

presence of physical symptoms and preoccupation of physical symptoms

- continuously feeling weak/ill, or pain (can be severe), or gastrointestinal distress, or even psychogenic seizures

- lots of dysfunction (due to symptoms and preoccupation)

people with somatic symptom disorder are very _____ to physical sensations

hypervigilant

somatic symptom disorder tends to affect who the most

single, earlier 20s, low SES women

- maybe due to smaller support, instability, etc.

- not an anxiety disorder, but does involve high feelings of anxiety

state of being symptomatic must be present for

usually more than 6 months

- doesn't need any one symptoms to be present for that long, but just the state of being symptomatic for that long

- looks diff for everyone

illness anxiety disorder

physical symptoms are absent or super mild

preoccupation is 'idea' of being sick

- often elicit negative reactions from physicians (ask for testing that gets rejected, feels physician is dismissive, etc.)

- repetitive beh similar to OCD rituals (reassurance seeking, self-monitoring, avoidance of feared situations)

- used to be called hypochondriasis (was split into somatic symptom disorder and this)

problems with constant reassurance seeking

can strain relationships, decreased support, which thereby increases mental health disorders

examples of maladaptive avoidance in illness anxiety disorders

avoiding doctors appts - germs, mistrust, fear of negative results

somatic symptom and illness anxiety disorder (SS & IAD) stats

1-5%

- in illness anxiety, it is more common in unmarried women and lower SES

- same as SSD

understanding of SS & IAD is

poor

- we only have some correlational data

psychological factors: etiology of SS & IAD

- children and adults who report more aches and pains have more negative emotions

- poor self-awareness of the presence of these emotions and are less able to regulate their emotions (mislabeling stress as stomach illness)

- lack of understanding of emotional stress and its relation to physical functioning

behavioural principles: etiology of SS & IAD

modelling and reinforcement

- maybe learned that ppl who are sick get lots of attention

environmental stressors: etiology of SS & IAD

stress, childhood abuse, family separation, family conflict

cognitive factors: etiology of SS & IAD

distorted cognitions (somatic amplification, similar to hypervigilance)

- inaccurate beliefs about 1. the presence and contagiousness of illnesses, 2. meaning of bodily symptoms, and 3. course of treatment for illnesses

treatments of SS & IAD

- really difficult; may resent and resist ppl trying to help

- CBT: works to reduce stress, minimize help-seeking beh (helps social relationships), and helps relate to others

conversion disorder (functional neurological symptom disorder)

- motor symptoms or deficits that seem neurological

- globus (lump in throat)

- sensory abnormalities

la belle indifference: substantial emotional indifference to the presence of dramatic symptoms (not always a symptom)

how to help differentiate FNSD from a physical disorder?

- symptoms of FNSD typically don't follow correct neurological patterns of human body

ex. ppl may lose feeling in entire hand, but not arm at all, but doesn't make sense with the nerves there

FNSD stats

- rare in mental health settings (bc they go to medical docs)

- prevalence in neurological setting in 30%

- primarily in women

FNDS triggered by stress - theory

- theory that mind becomes hypervigilant to stress, so it shuts down body to 'restart'

- but, not all the time

potential causes of FNDS

- unconscious repression of stress/anxiety

- so, when anxiety becomes conscious, person converts it to physical symptoms (like an extreme version of a stomach ache from stress

- person gets attention (positive reinforcement)

interpersonal and social/cultural factors of FNDS

interpersonal - substantial stress from abuse, parental divorce, etc.

social and cultural factors - less educated, lower SES (less educated on disease and medical info, which makes sense in numb hand ex)

treatment of FNSD

- identify source of stress, then remove/reduce it

- minimize help-seeking beh

- CBT

CBT thought records - FNSD

1. situation

2. physical sensation

3. automatic thought

4. emotions

5. evidence for/against

6. alternative thought

7. outcome

CBT for somatic symptoms disorders

its not just the symptoms that causes distress, its how the symptoms are interpreted and responded too

trigger (bodily sensation) -> thought ('something is wrong') -> emotion (anxiety) -> behaviour (doc visit)

malingering

faking for personal benefit

- not a medical disorder since it has an easily identifiable reason

factitious disorder

physical or psychological symptoms are intentionally produced in what appears to be a desire to assume a sick role

behaviours of people with factitious disorder imposed on self

- deceptive practices to produce signs of illness (red candy in urine, mouthwash in wound, hurting self)

- go to emergency room during evenings and weekend to see inexperienced staff

- invent false demographic info

- may fake psychological illness

behaviours of ppl with factitious disorder imposed on another

- deceptive practices to produce signs of illness on someone else

- often a mother produces symptoms in a child, often infants to teenagers

- child abuse!!

- sometimes seen in nursing homes

potential cause for factitious disorder imposed on another

- get lots of sympathy if somebody close to you is ill

- feeling like a caretaker/you are needed

how factitious disorder imposed on another differs from typical child abuse

- sings not obvious (usually) from physical examination

- perpetrator presents symptoms to healthcare workers (while abusers tend to hide victims' bruising)

- children serve as the vector in gaining attention

- not typically obvious that abuse is happening

functional impairment of somatic symptom disorders

issues with employment, physical disability, overuse of health services, economic costs

dissociative disorders

characterized by severe maladaptive behaviour or alterations of identity, memory, and consciousness that are experienced as beyond one's control

dissociation

lack of normal integration of thoughts, feelings, and experiences in consciousness and memory

normal dissociations

- driving and just ending up home on autopilot

- reading a book for hours

* but, could snap out of it if needed

* control is biggest diff

dissociative disorders: 3

- dissociative amnesia & fugue

- depersonalization/derealization disorder

- dissociative identity disorder (formally known as multiple identities disorder)

dissociative amnesia

- commonly triggered by traumatic events

- not due to a brain injury (would be a TBI if that)

- hypothesis that brain is trying to protect us

dissociative amnesia types

generalized: inability to remember anything, including identity

localized: inability to remember specific events (usually traumatic)

localized dissociative amnesia - example

woman hit a moose and kept driving to work (20+) min, and didn't even realize she had been in a crash

- she already had injuries

dissociative fugue

subtype of dissociative amnesia

- loss of memory of past and personal identity (usually generalized type), ALSO travel suddenly

- commonly experience trauma, then suddenly/abruptly travel (end of trip is abrupt too)

dissociative fugue - once in new place

don't have memories but arrive in new place

- some assume a new identity, others wonder around until 'claimed'

- typically go to hospitals or police stations, so we don't have a lot of data

- potentially some genetic diathesis, but stress more significant here

kids and amnesia

not always bad if they forget traumatic events

depersonalization-derealization disorder

severe feelings of detachment (outside observer of own body or mind)

- significant distress or impairment (emotion, perception)

- comorbid panic disorder (comes second)

- rare, onset usually follows traumatic events

* don't need both for diagnosis

depersonalization

lose sense of own reality

- 3rd person watcher of own self

derealization

lose sense of reality of external events

- can be many diff things; seeing ppl as 2D, thinking not in real version of the world, seeing things as bigger or smaller

how can depersonalization/derealization be triggered

sometimes by hallucinogens/stimulants (if they have the genetic vulnerability)

- can be lifelong, commonly leads to suicidal thoughts

symptoms of depersonalization-derealization disorder

cognitive and perceptual deficits occur - prob bc of distress abt disorder

tunnel vision and mind emptiness

deficits in emotion regulation - inhibition of emotional responding

dysregulation in the HPA axis (fight or flight) - we don't know about the directionality

* some have it constantly, others on and off

epidemiology of dissociative disorders

depersonalization - 0.8%

dissociative amnesia - 1.8%

dissociative identity disorder - 1.5%

stats of dissociative disorders

commonly comorbid with depression (comes 2nd usually), PTSD (at same time bc both triggered by trauma)

both men and women affected equally

average age of onset of depersonalization: 11.9-22.8

why is it hard to study dissociative disorders?

- few data bc it is so rare

- the presence of comorbid disorders doesn't allow for an estimate of impairment (for ex, we don't know what impairment is due to what)

dissociative amnesia treatment

usually resolves without treatment

derealization treatments

no controlled trials for derealization have been conducted, but some think antidepressants may be helpful

CBT may be helpful, but unsure how

depersonalization treatments

CBT has been shows to be effective

- cognitive restructuring helpful when feeling like outside of own body

dissociative identity disorder

several identities co-exist simultaneously (15 on avg)

- prob rly related to PTSD

- childhood onset

- often suffer from other disorders

DID and western culture

more common in Western societies

- could be due to many different reasons, such as differing manifestations or expressions of symptoms (others may believe they are being taken over by a spirit, so not seen as problematic)

host identity

asks for treatment - usually the og identity, not always though

alters

the different identities or personalities

switch

instantaneous transition from one personality

- 37% report changes in handedness to another (going from left to right handedness, for ex)

- we even see diff allergies sometimes

what causes most of the distress in dissociative identity disorder

gaps in memory

etiology of DID

posttraumatic model - childhood abuse:

- result of severe trauma

- take on different identities as escape is not possible (type of dissociation, so only the alter lives thru the abuse)

- escape sought from physical and emotional pain

criticism: CSA increases risk of adult psychopathology in general, but not the development of any specific disorder

suggestibility of DID

- dissociation as coping

- autohypnotic model: suggestible people may use dissociation as a defense against trauma

- less suggestible people may develop PTSD

* results of studies inconclusive

* treated as PTSD

can therapy cause DID?

- increasing prevalence of DID when it corresponds to bools and movies

- 80-100% of patients are unaware of alters prior to therapy; as they continue therapy, the number of alters increases

- the more the therapist believes in diagnosis, the more likely ppl are given the diagnosis

- consider leading questions and suggestions in therapy

false claims and memories

therapists guide questions and accidentally plant false memories

- the memories still feel real!!

- suggestible patients may agree with therapist due to social desirability

biological factors of DID

- roles of heredity and env debated we don't rly know with both (we do know that many experience trauma, but not all traumatized ppl get did)

- temporal lobe seizures associated with dissociated symptoms

- sleep deprivation (symptoms worsen when person is tired)

* most research is case studies, so hard to know fs)

treatment of DID

long-term psychotherapy

- reintegrate separate personalities

- 22% success rate

treatment of associated trauma similar to PTSD (lots of exposure, cog restructuring, etc.)

mood disorders

- involve big deviations in mood

major depressive episode - general

- a state you can be in

- most commonly diagnosed and most severe

- anhedonia (inability to experience pleasure, especially in things that used to be pleasurable)

mania

extreme pleasure in every activity, excessive euphoria (opposite deviation in mood from anhedonia)

hypomaniac episode

less severe version of manic episode

unipolar mood disorder

either just depression or just mania (just mania is rare)

bipolar mood disorder

alternate between depression and mania

- a fluctuation

mixed features - mood disorders

experiencing both mania and depression

- for ex, being manic but feel somewhat depressed at he the same time

major depressive disorder

depressed mood for most of the day, for most days for 2 weeks

- physical and cognitive symptoms (disruptions in sleep, appetite, libido, feelings of worthlessness, guilt)

- if untreated, avg first ep is 9 months

single ep vs recurrent MDD

can happen just once, but 85% who have one get another in next 20 years

- to be considered recurrent, needs to be 2 or more separated by at least 2 months

* rarely ever fully goes away

chronic course of MDD

- median number of episodes is 4-7

- median duration of recurrent episodes is 4-5 months

do major depressive episodes look the same for everyone?

no

- only 5/9 symptoms needed it

- not just being sad all the time

Persistent Depressive Disorder (Dysthymia)

- chronic state of depression (20-30)

- symptoms are same as MDD, but less severe

- needs to last for 2+ years, never 2 months without symptoms

persistent depressive disorder - details

persistence of symptoms -> more severe outcomes

- higher rates of comorbidity than MDD

- less responsive to treatment than MDD

double depression

individuals who suffer with both major depression episodes and persistent depression disorder

- even more severe psychopathology and problematic course

depressive disorders - first specific in diagnosis

first: mild, moderate, or severe

depressive disorders - specifiers

1. with psychotic features

2. with anxious distress (not enough for an anxiety disorder)

3. with mixed features (depression needs to still always be there)

4. with melancholic features

5. with atypical features

6. with catatonic features (catalepsy; muscles become rigid and waxy)

7. with peripartum onset (post partum depression)

8. with seasonal pattern (seasonal affective disorder)

seasonal affective disorder

- tend to be gloomy when dark in fall and winter

- not fixed until spring weather again (or opposite!)

- light therapy works!

specifier - melancholic features

lack of mood reactivity, and 3 of:

1. muscle retardation

2. loss of appetite/weight

3. early morning waking

4. guilt

5. worse mood in morning

6. depression

7. anhedonia

MDD with peripartum onset

80% of mothers get baby blues, usually subsides after two weeks (normal!)

- 6.5-12.9% prevalence of the disorder, peaks at 2-6 months after birth

- mothers functional impairments: temperamental, social, emotional, cognitive, beh difficulties, etc.

- can also occur with non-birthing parent (hormones shift, lack of routine

MDD with peripartum onset - causes and risks

likely a genetic vulnerability that could be passed on

- higher risk if this happened with first child

- higher vulnerability with lack of resources

rare version of MDD with peripartum onset

postpartum mood episodes with psychotic features (hallucinations, delusions, OCD, intrusive thoughts, etc.)

depressive disorders - epidemiology

mean age of 25 - but may be decreasing

- seems to be increases in adolescence

- may be more willing to talk about it, easier to point out

- social media -> leads to self diagnosing, normalizing/romanticizing it, misinfo, overgeneralization, etc.

subtypes of PDD

adult

adolescent - lasts longer, poorer prognosis, worse response to treatment, and strong chance it runs in families

- a time where personality and identity are being developed, so this + PDD leads to high comorbidity with personality disorders

women and depressive disorders

- twice as likely in women, especially those with lower SES, who have less education, or are unemployed

- reproductive events are risks for mood disturbances (changes in estrogen may trigger those who have the vulnerability)

integrated grief

- eventually learn to live with it

- grief integrated into relatively normal life

complicated grief

- when grief surpasses 'normal' amount of grief

- can't adjust

- clinician takes into account a lot of details

* in DSM section for areas needing future studies

premenstrual dysphoric disorder (PMDD)

severe emotional reactions pre-period (not normal or average)

- some argue it shouldn't be a disorder -> reinforces stereotypes

* it pathologizes emotional experiences

disruptive mood dysregulation disorder

children and adolescents with recurrent temper outbursts (out of proportion and lasting into adolescence 6-14)

- occurs frequently

bipolar disorders

experiencing both sides on emotional continuum (depressed and mania)

manic episode criteria

a period of abnormally and persistently elevated, expansive, or irritable mood and increased goal-directed activity or energy, lasting 1 week

involving 3 or more specific symptoms

causes impairment

* can be presented really differently for different people

* no need for distress!!

bipolar I disorder

major depressive episodes and full manic episodes

- previously known as manic depression

Bipolar II Disorder

major depressive episodes and hypomaniac episodes (less severe than manic episodes)

- needs to have never been a manic episode in history of patient

- greater chronicity, longer depression periods, more seasonal variation

hypomaniac episode criteria

minimum duration 4 days

change in functioning, but not severe enough for marked social or occupational impairment/hospitalization

no psychotic features (hallucinations, delusions, etc.)

cyclothymic disorder

chronic alteration of mood elevation and depression that does not meet severity or manic or major depressive episodes

- chronic; at least 2 years