Exam 2 (Part 2)

Lecture 13, 14, 15

somatoform (definition)

• excessive thoughts, feelings, and behaviors about a bodily sensation

• disproportionate & persistent thoughts about the seriousness of symptom(s)

• excessive time & energy devoted to symptom(s)

• aberrant physical fixations that one overexaggerates

somatoform assessment

MMPI or MSPQ

• MSPQ : uses pain free somatoform items

• clients high in somatoform endorse many different types of symptoms

somatoform (& HiTOP)

• somatoform is the outlier → normal personality measures do not reveal this measure of psychopathology

• negative affectivity (neuroticism) is STRONGLY associated with internalizing

*considered the most tentative spectra

• emotional dysfunction superspectrum connects small shared variance between somatofrom and internalizing

pain vs. somatoform

pain — subjective physical suffering

somatoform — experience of physical sensations that are disproportionate to, or unexplained by, a physical cause

somatoform (with pain)

• patient with fibromyalgia whose symptoms aren’t responding to/managed by typical intervention

• disproportionate & persistent thoughts about seriousness of pain symptoms

• excessive time & energy devoted to pain symptoms

somatic symptom disorder (criteria)

• one ore more somatic symptoms that are distressing or result in significant disruption of daily life

• excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated with health concerns as manifested by at least one of the following

  • disproportionate and persistent thoughts about the seriousness of one’s symptoms

  • persistently high level of anxiety about health or symptoms

  • excessive time and energy devoted to these symptoms or health concerns

• state of symptomatic is persistent (typically more than 6 months)

somatic symptom disorder (contributory causes)

• past experiences with illness in self, family, or media that create dysfunctional assumptions about symptoms

• negative affect (especially when paired with suggestion and difficulty naming emotions)

• secondary reinforcement : illness may bring comfort, attention, or release from responsibilities

somatic symptom disorder (risk factors)

• comorbidity with depression and anxiety

• more likely to be diagnosed in women

illness anxiety disorder / hypochondria (criteria)

• preoccupation with having or acquiring a serious illness

• somatic symptoms are not present, or, if present, are only mild in intensity. if another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate

• there is a high level of anxiety about health, and the individual is easily alarmed about personal health status

• illness preoccupation has been present for at least 6 months

• the illness related to preoccupation is not better explained by another disorder

somatic symptom disorder + health anxiety (interventions)

• CBT : challenge illness beliefs, reinterpret bodily sensations, reduce checking/reassurance seeking

• pain-focuses : relaxation, activity scheduling, cognitive restructuring, reinforcement of “no-pain” behaviors

• antidepressants may reduce pain intensity/mood effects

• medical management

functional neurological symptom disorder / conversion disorder (definition)

applied to patients who present neurobiological symptoms (numbness, blindness, paralysis, or fits) which are not consistent with a well-established organic cause

functional neurological symptom disorder (symptoms)

sensory

• blindness or tunnel vision

• deafness

• anesthesia, including “glove anesthesia”

motor

• paralysis or selective loss of function

• aphonia (whispering without true laryngeal paralysis)

• globus : feel of a lump in the throat

seizure-like symptoms

• episodes resembling seizures

• no matching EEG changes

• often more thrashing and less injury than true seizures

functional neurological symptom disorder (causes)

psychodynamic

• symptoms linked to unconscious conflict

behavioral

• symptoms may provide negative reinforcement or positive reinforcement

neuroimaging

• affected body parts are stimulated/moved → expected sensory/motor areas may show reduced activation while emotion regions (anterior cingulate, insula, orbitofrontal cortex) become more active

*emotion-processing networks can override normal sensory or motor processing

functional neurological symptom disorder (treatment)

• stress-management approaches

• behavior rehab for motor symptoms

• CBT for seizures

• hypnosis

factitious disorder / munchausen (definition)

a condition in which a person, without a malingering motive, acts as if they have an illness by deliberately producing feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patients role

factitious disorder imposed on another

a condition in which a person deliberately produces, feigns, or exaggerates the symptoms of someone in their care

dissociation disorder

disruptions in normally integrated functions of consciousness, memory, identity, or perception

*50-74% of people experience mild depersonalization/derealization at least once

what makes dissociation pathology?

symptoms become disruptive, create loss of needed information, or profduce jarring discontinuities in experience and sense of self

depersonalization (definition)

a feeling of detachment or estrangement from one’s self; feeling as if you are onlooking of your own body

depersonalization (symptoms)

• detachment from the world and one’s self

• embodiment, denoting unusual or changing experiences of the body

• identity changes, a lack of congruence between one’s felt self and one’s words and action

derealization (definition)

an alteration in the perception of one’s surroundings so that a sense of reality of the external world is lot; the world you are experiencing does not seem real

derealization (symptoms)

• sense of “fog”

• see-through wall or veil separating you from surroundings

• world appears lifeless, muted, or fake

• objects/people look “wrong”

• sounds are distorted

• time speeds up or stands still

depersonalization/derealization (prevalence)

• 1-2% lifetime prevalence

• mean onset of age 16

• ~80% chronic course

• sex distribution about equal

depersonalization/derealization (associated clincial features)

• mood and anxiety disorders commonly co-occur

• avoidant, borderline, and obsessive-compulsive personality disorders are elevated (all marked by severe interpersonal distress)

• episodes can feel frightening and may create fear of mental collapse

depersonalization/derealization (treatments)

• no clearly effective medication/psychotherapy

• clinical help for managing stressors and reducing anxiety

dissociative amnesia (definition)

an inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting

*gaps often follow intolerably stressful circumstances such as combat, catastrophic events, suicide attempts, or other trauma

retrograde amnesia

when dissociative amnesia affects finding old memories

anterograde amnesia

when dissociative amnesia blocks the formation/storage of new memories

*very rare, typically reserved for neurological injuries/diseases

dissociative amnesia (case research)

• primary deficit is episodic or autobiographical memory

• implicit memory often remains available (explicit is impaired)

dissociative fugue (flight + amnesia)

subtype of dissociative amnesia

• person not only becomes amnesic for parts of the past but also leaves home and may assume a new identity

• when fugue remits, original amnesia often clears but is replaced by amnesia fro the fugue period

dissociative amnesia (treatment)

• place person in a safe environment (memory may return when threat is removed)

• hypnosis and certain sedating drugs

identity confusion

struggling with sense of self

identity alteration

shifts in identities, behaviors, and/or personas

• manifestations of alters (or alternative identities) containing and expressing differing opinions, perceptions, and sense of self

• individuals may notice a shift in a sense of how old they are, gender identity, preferences, skills, and memories

  • vocal pitch, body language, and physical reactivity to stress

identity confusion/alteration (criteria)

• disruption of identity characterized by 2+ distinct personality states or possession-like states

• recurrent gaps in recall for everyday events, important personal information, and/or traumatic events

• disruption can be observed by others or self-reported by the patient

• symptoms must not be better explained

alters

• most frequently encountered identity is often called the host identity

• switches can be rapid or gradual

• amnesia across identities is often present, but may not be perfectly symmetrical

identity confusion/alteration (trauma theory)

• DID begins in early repeated trauma and reflects an attempt to cope with helplessness and powerlessness

• child may dissociate, fantasize, or imagine the abuse is happening to someone else

• fantasy proneness and hypnotizability may function as vulnerability facts in a diathesis-stress model

*95% of DID patients report severe childhood abuse by some estimates

identity confusion/alteration (sociocognitive theory)

• DID develops when a highly suggestible person learns to adopt and enact multiple identities

• clinician suggestion, hypnosis, media portrayal, and cultural scripts may help shape the disorder

• role enactment is not assumed to be consciously faked

• number of alters sometimes increases with time in therapy

identity confusion/alteration (treatment)

• trauma-based origin, aiming for integration of alters

• psychodynamic insight-oriented (hypnosis)

eating disorders (definition)

persistent disturbances in eating behavior that impair health and daily functioning

maintained by…

• distorted beliefs about weight/shape

• emotional processes

• powerful reinforcement loops

who is most affected by eating disorders?

anorexia nervosa

• age onset : 16-20

• U.S. lifetime prevalence : 0.9% women, 0.3% men

bulimia nervosa

• age onset : 20-24

• worldwide prevalence : 1%

• U.S. : 1.5% women, 0.5% men

binge-eating disorder

• age onset : 30-50

• worldwide prevalence : 2%

• U.S. : 3.5% women, 2% men

eating disorder (gender statistics)

• approximately 3:1 ratio

• high risk male subgroups : gay/bisexual men, wrestlers, jocks

*men often missed because concerns may focus on masculinity and overexercising rather than thinness

anorexia nervosa (definition, criteria)

definition

relentless pursuit of thinness leading to a significantly low body weight

criteria

• restriction of energy intake resulting in a significant low body weight

• intense fear of gaining weight or becoming fat

• disturbance in weight / shape perception

anorexia nervosa (symptoms)

• significant weight loss

• dry, brittle hair and nails

• feeling cold all the time

• dizziness, fatigue, low energy

• counting calories and/or dieting

• saying they’re fat

• exercising a lot

• using laxatives and diuretics

anorexia nervosa (subtypes)

restricting type — extreme limitation of food intake

• tight caloric control, slow eating, cutting food into tiny pieces, hiding/disposing food

binge-eating/purging type — in addition to restriction, includes bingeing and/or purging behaviors

• purging includes vomiting, laxatives, diuretics, and enemas

• compensatory exercise and fasting

anorexia nervosa (clinical presentation)

• deny serious problem; fulfillment rather than alarm

• thinness concealed

• weight shape over-evaluation can persist even when body is severely compromised

anorexia nervosa (treatment)

• re-feeding/weight restoration (can require hospitalization, intensive nutritional control, intravenous feeding)

• family therapy for adolescence (Maudsley Model) works through phases of re-feeding→negotiation of new relationships→termination

antidepressants do NOT work

Maudsley Model

bulimia nervosa (definition, critera)

definition

• recurrent episodes of binge eating (usually an unusually large amount of food in a short time with a loss of control)

• inappropriate compensatory behavior (self induced vomiting, misuse of laxatives, fasting, or excessive exercise)

• occurs at least once a week over 3 months

bulimia nervosa (clinical presentation)

• typically normal weight range or slightly overweight

• accompanied by feelings of shame and guilt

bulimia nervosa (risk factors)

• thinness-focused settings (ballet, gymnastic, figure skating)

• incredibly culturally bound

  • thin-ideal exposure, abundant food, private purging

  • greater exposure to Western media

bulimia nervosa (treatment)

CBT is the leading treatment involved in bulimia nervosa

CBT

• meal planning

• nutritional education

• regularizing eating to disrupt bing/purge cycle

CBT

• challenge all-or-nothing thinking

• challenge “good/bad food” rules

• challenge hot thoughts

*antidepressants can only reduce binge frequency

binge eating disorder (criteria)

A : recurrent episodes of binge eating characterized by BOTH of the following

• eating, in a discrete period of time, an amount of food that is larger than whet most people would in a similar period of time under similar circumstances

• a sense of lack of control over eating during the episode

B. the binge eating episodes are associated with 3+ of the following

• eating much more rapidly than normal

• eating until feeling uncomfortably full

• eating large amounts of food when not feeling physically hungry

• eating alone because of feeling embarrassed by how much one is eating

• feeling disgusted with oneself, depressed, or very guilty afterward

C. marked distress regarding binge eating

D. occurs at least once a week for 3 months

*not associated with compensatory behavior

binge eating disorder (comorbidity)

• Depression

  • 68% anorexia nervosa

  • 63% bulimia nervosa

• OCD : common

• Personality Disorders

  • 58% of woemn

• Substance abuse : frequently co-occurs in binge eating/purging subtypes

binge eating disorder (socio-cultural factors)

media and culture

• exposure to western media, media in general (attitudes toward thinness)

internalization of thin idea

• belief that thinness equals beauty and success

• social comparison and peer evaluation

family influence

• families exhibit rigid attitudes, high expectations, an focus on dieting

• parental preoccupation with appearance

binge eating disorder (biological factors)

genetics

• relatives of people with anorexia nervosa show 11.4x risk

• relatives of people with bulimia show 3.7x risk

• twin studies indicate anorexia and bulimia as heritable

serotonin

• EDs may relate to serotonergic disruption

  • serotonin helps regulate mood, appetite, impulsivity, feeding behavior

reward sensitivity

• food restriction may make anoretic cues more rewarding

• patients with anorexia nervosa show greater reward-area activity to thin models

set points

• body resists weight change through physiological “set point” pressures

binge eating disorder (risk factors)

• perfectionism portrayed

• bodily dissatisfaction

• negative emotionality

• being female and internalizing the thin ideal

restrict-binge cycle