Somatic Symptom + Related Disorders
Somatic symptom = physical symptom/reactions
Somatic Symptom Disorder - somatic symptoms present, creating high anxiety
Illness Anxiety Disorder - preoccupation with having or acquiring a serious illness. Somatic Symptoms are not present, or are just mild. (Hypochondriasis would now fit here)
Somatic Symptom Disorder (more rare than Ill. Anx.) Criteria
Presence of one or more somatic symptoms
Symptoms often medically unexplained
Excessive thoughts, feelings, and behaviors related to the symptoms (eg. excessive thoughts about seriousness of symptoms, frequent complaints and request for help, health-related anxiety, excessive research)
Substantial impairment in social or occupational functioning
Stats
Relatively rare condition
Onset usually in adolescence
Unfinish**
Illness Anxiety Disorder
Very similar to DSM 5 hypochondriasis
Clinical description:
Severe anxiety about the possibility of having or acquiring a serious disease
Actual symptoms are either very mild or absent
Strong disease conviction
Medical reassurance does not seem to help
Affects app. 1-7% of the general population
Affects all ages approximately equal
Often comorbid with anxiety + mood disorders
Culturally Specific Disorders
Dhat = Symptoms (eg. dizziness, fatigue) attributed to semen loss in some Indian cultures
Kyol goeu or Kyhal - “Wind overload” among Khmer people of Cambodia
Fear wind cannot circulate effectively through the body
Dizziness, weakness, fatigue, and trembling = sign
Etiology
Consistent overreaction to physical signs and sensation
Cause is unlikely to be found in isolated biological or psychological factors → not just one smoking gun
Genetic component present
May have learned from family to focus anxiety on physical sensations (conditions, not faking)
Other factors: Illness in family during childhood, stressful life events, benefits of illness
Conversion Disorder - something neurophysiological manifests
Functional Neurological Symptom Disorder (involving brain)
Evolving disorder, now more unexplained
One or more Symptoms of altered voluntary motor or sensory function
Symptoms don’t match established medical condition
Not better explained by another mental/medical disorder
Causes significant impairment or distress
Factitious Disorders
Malingering vs. Factitious Disorders
Malingering has external motivation (not psych disorder)
Factition - no clear external motivation
Munchausen Syndrome (by proxy is most common) - person physically creates the symptoms in someone else themselves
Book highlights - other doc
Dissociative Identity Disorder
Dissociation is normal
Not schizophrenia
Example: United Stats of Tara, The Crowded Room
Etiology: severe childhood trauma – the “scab” metaphor
Perhaps an extreme version of PTSD?
Dif identities are called “alters” - host alter → takes responsibility
False Memory Syndrome - by no means saying victims faked
Memories can be planted
Source Monitoring Error → remember piece but get source wrong
Memory is a fragile thing → very suggestable
Every time we remember, we create new memories of remembering
Other Dissociative Disorders
Depersonalization - Derealization Disorder
Dissociative amnesia
Dissociative fugue now a subtype of dissociative amnesia
Schizophrenia
Psychotic = Delusions (beliefs out of touch with reality)/Hallucination → sensory
Very specific + severe
Patterns of this is only when word “psychotic” is used
DSM Criteria (p.489) Positive Symptoms
Positive = Presence (not good)
Delusions: grandeur (ruler), persecution (paranoia), capgras (loved one replaced by a double), Cotard’s
Hallucination (auditory most common)
Negative symptoms (absence of something that should be there)
Avolition
Apathy
Alogia – absence of speech
Anhedonia – absence of pleasure
Affective flattening
Disorganized Symptoms (not working correctly)
Disorganized speech
Cognitive slippage - slipping away
Tangentiality - really extremely hard to follow tangents
Loose associations - thinking things are connected that aren’t
Inappropriate affect - ex: laughing when something bad happens
Catatonia
Waxy rigidity
Prodromal Stage - psychotic break
First time someone has really broken with reality
Tend to happen early 20s, late teens → in schizophrenia
Finding from SPECT studies
Neuroimaging chows that the part of the brain most active during auditory hallucinations is Broca's areas
Involved in speech production (not comprehension)
Hallucinations not coming from stimuli
Instead maybe processing own thoughts that I would be speaking as being spoken
Probably being generated by thoughts in brain rather than external stimulus
Onset and prevalence of schizophrenia worldwide
About 0.2% to 1.5% (or about 1% of population)
Often develops in early adulthood
Can emerge at any time; childhood cases are extremely rare but no unheard of
Important Points
Schizophrenia covers a WIDE range of symptoms two different people might have very different behaviors
In fact, new research into genetic markers may indicate eight distinct disorders
Medication treatment needed for psychotic symptoms, but side effects can be problematic (Bonior personally thinks its needed for psychotic symptoms)
Homelessness is common - more likely to be victims of violence rather than perpetrators
Risk of violence is very exaggerated in media
Schizophrenia is generally chronic
Most suffer with moderate-to-severe lifetime impairment
Life expectancy is slightly less than average
Increased risk for suicide
Increased risk for accidents
Self care may be poorer
Schizophrenia was previously divided into subtypes based on content of psychosis
This is no longer the case in DSM-5, but outdated terms are still in partial use
Included paranoid, catatonic, residual (minor symptoms persists after past episode), disorganized (many disorganized symptoms) and undifferentiated
Schizophreniform Disorder
Psychotic symptoms lasting between 106 months (>/= 6 months = schizophrenia)
Associated with relatively good functioning
Most patients resume normal lives
Lifetime prevalence: approximately 0.2%
Schizoaffective Disorder
Symptoms of schizophrenia + additional experience of a major mood episode (depressive or manic)
Psychotic symptoms must also occur outside the mood disturbance
Prognosis is similar for people with schizophrenia
Such persons do not tend to get better on their own
Medications
Acute and permanent side effects are common with first-generation medications
Parkinson’s-like side effects
Tardive dyskinesia
Compliance with medication is often a problem
Aversion to side effects
Financial cost
Poor relationship with doctors - hard to have with someone out of touch with reality
New directions
Avatars - patients interact with a digital embodiment of their auditory hallucination, represented by a computer-generated face, with a personalized series of dialogues
Patients can customize how the face looks and sounds
Therapists helps the process… slides
Psychosocial treatment of Schizophrenia (Bonior argues you need both medication and this)
Illness management and recovery
Engages patient as an active participant in care
Continuous goal setting and tracking
Modeles include: social skills training, stress management, substance use issues addressed
Mood Disorders
Depression
Persistent negative mood in affect
Withdrawal, avoidance, isolation
Hopelessness and helplessness
Worthlessness
Most of the day nearly every day: (DSM collapsed)
At least two weeks (probably shortest for any disorder)
Cognitive symptoms - difficulty concentrating, negative thoughts, guilt
Disturbed physical function
Emotional symptoms – Anhedonia
Depressive Episode
Can be a building block for other disorders
Not just emotional but physical response → change is important?
Most of the day nearly everyday
At least two weeks
Cognitive Symptoms
Disturbed physical function
Emotional symptoms - Anhedonia → loss of pleasure, irritability, emptiness, detachment
Mania - Building block
Opposite pull compared to depression
Arousal/nerve system on overdrive
Signs:
Hyperactivity
Grandiose plans
Rapid speech, flight of ideas, jumping between topics
Impulsivity → huge + key and makes mania dangerous
Irritability → period where energy is coming down (end of episode)
Manic episode only has to last one week (can be less if hospitalized)
Very observable
Very biologically drive (nervous system arousal)
Not reactive to something in your life
Very common:
Difficulty sleeping
Complaining others are slow
Surges of energy
Increased substance use
Bad decisions
Taking too much responsibilities
Increased sexual activity
Increased appetite (or opposite)
Hypomania - Another building block
Low level mania
Doe not cause marked impairment in function
Does not meet mania criteria
Energized not problem but combined with other things can be a problem
Bipolar + Unipolar Disorders
Unipolar vs. Bipolar
Bipolar I: full mania and full depression (alternating)
Bipolar II: hypomania and full depression (less severe)
Cyclothymia - chronic cycles of hypomania and mild depression; few periods of euthymia (normal moods) (2 years of this)
Dysthymia (Persistent Depressive Disorder) - chronic milk depression, 2 years or longer (unipolar version of cyclothymia)
Double depression - major depressive episode on top of a baseline Persistent Depressive Disorder (risk of suicide)
Kids: DMDD (Disruptive Mood Dysregulation Disorder) (vs. Bipolar)
Pediatric diagnosis
Lots of kids misdiagnosed with bipolar disorder in 2000s but it was wrong and had consequences (diagnosis didn’t hold)
Something is off, kids have hard time regulating their emotions
Premenstrual Dysphoric Disorder (new to DSM) (part of PMS→ just mood part)
Significant depressive symptoms occurring prior to menses during the majority of cycles, leading ot distress or impairment
Controversial diagnosis
Advantage: Legitimizes the difficulties some people face when symptoms are very severe
Disadvantage: Pathologized an experience many consider normal
Mood Disorders across US subcultures
Similar prevalence among U.S. subcultures, but experience symptoms may vary
Eg. some cultures more likely to express depression as somatic concern
Higher prevalence among Native Americans: 4 times the rate of the general population
Prevalence among men + women pretty equal with bipolar but more in women for depression
Genetic contributions to mood disorders
Twin studies
Concordance rates are high in identical twins
2-3 times more likely to present with mood disorders than a fraternal twin of a depressed co-twin
Severe mood disorders have a strong genetic contribution
Heritability rates are higher for females compared to males
Some genetic factors condor risk for both anxiety and depression (not totally separate, could be more mixed)
Neurobiological influences
Neurotransmitter systems
Serotonin and its relation to other neurotransmitters
Serotonin regulates norepinephrine and dopamine
Mood disorders are related to low levels of serotonin
Permissive hypothesis: low serotonin “permits” other neurotransmitters to vary more widely, increasing vulnerability to depression (not just serotonin, most implicated but not alone)
More neurobio influences
The endocrine system (talking about anxiety but strong correlation to depression)
Elevated cortisol (over time)
Stress hormones decrease neurogenesis in the hippocampus, making it less able to make new neurons (not repairing well which means they wont develop new pathways + behavior and thought processes)
Sleep disturbance
Hallmark of most mood disorders
Depressed patients have more intense REM sleep and go into it more quickly (less restful)
Sleep deprivation may temporarily improve depressive symptoms in bipolar patients (temporary risk to go in mania) (maybe something different in their brain)
Psychological Etiology of Depression
Stress, trauma, Context of memories: Pessimism (how you understand what has happened)
Reciprocal gene environment model (genetic + environment)
Cognitive errors (Aaron Beck) - overgeneralized, arbitrary inference (before depression, prone to think this way)
Depressed thoughts becoming “sticky” (sticking to thoughts)
Learned Helplessness (Martin Seligman)
Looked at dogs in bad conditions and their learned helplessness
Even when they could control their environment, they didn’t believe they could
Found in humans and is risk factor for depression
People can be accused of this when there are really systematic barriers keeping them from taking control
Careful we don’t use it as a weapon
Precursor + symptoms of depression
Martin Seligman’s “Depressed Attributional Style”
Learned Optimism → good book
Research is important
Precursors + Symptoms common in Depression and Components of distorted thinking
Internal → tend to blame yourself (distortion begins when this is over and over again)
Global → overgeneralizing (specific makes whole bad) (made bigger than it is)\
Stable → don’t think things will change (hopelessness → suicide risk)
The role of attention (in depression too, also anxiety)
Might pay attention to environments differently
Keep looking for stuff that reinforces world as bad place
Attuning to things that fit distortion
Tune into things that fit their biases
Negativity rather than threat (threat is in anxiety)
Social/Cultural Etiology of Depression
Gender imbalances - genetic, environmental, or both?
Social support - protective factor
Marital satisfaction - particularly in men (protective)
Societal stressors - job loss example
Integrative Theory of etiology
Biological and psychological vulnerabilities interact with stressful life events to cause depression
Biological vulnerability: eg. overactive neurobiological response to stress
Psychological vulnerability: eg. depressive cognitive style
Not everyone has the same risk and cause for depression
Reciprocal Gene-environment model (Gene-env. correlation)
Treatment for Depression
Therapy!!! → it can alter neurobiology
Medication alone does not have as well affect
Risk of doing Medication Only
The “Band-Aid Effect”
Higher risk of relapse
No one monitoring side effects
Not giving sense of autonomy that you can get through it on your own
Not changing the thoughts and behaviors that need changed
Common Types of Therapy - *Therapies depend on interpersonal experiences and relationship with the therapist
Cognitive-Behavioral Therapy (CBT) - Most preferred - challenging automatic thoughts
Psychodynamic Psychotherapy - underlying roots focused
Interpersonal Psychotherapy (IPT) - relationship
Existential Therapy - connection to meaning
Adlerian Therapy - self sabotage (Alfred Adler focuses)
Gestalt Therapy - relationship of person to various aspects of their life
New Directions branching off of CBT
Acceptance and Commitment Therapy (ACT): mindfulness and accepting and moving on from thoughts rather than fighting them → learning to be gentle observer (separate thoughts rather than diffuse effect of them or added onto that)
“The Happiness Trap” is a great primer on this
Antidepressant Medication (older categories)
Tricyclics (risk of overdose)
MAOIS (MAO Inhibitors) - lifestyle annoyances/side effects
SSRIS - Selective Serotonin Reuptake Inhibitors
Zoloft
Paxil
Prozac
Celexa
Lexapro
SNRI/mixed reuptake inhibitors act on norepinephrine/dopamine as well
Sometimes taken with SSRIs or because they weren’t working
Wellbutrin (Zyban)
Pristiq
Effexor
TMR (Transcranial Magnetic Stimulation)
Usually not tried till someone tried medication and therapy
Side effects: headaches, pressure, fogginess (temporary)
Applying electrodes outside of skull (non invasive)
Typically multiple times a week over multiple weeks
Newer Directions
Esketamine (nasal-administered ketamine) and also ketamine infusions
Psychedelics including psilocybin, MDMA (LCD) (whole other area and hard to have placebos)
Gut bacteria
Modified ECT (electric compulsive therapy)
Deep brain stimulation (invasive)
Treatment for Bipolar Disorder: evening the mood (medication is key difference compared to depressive disorder)
Lithium (patent)
Other mood stabilizers
Mediation (usually Lithium) is first line of defense
Psychotherapy helpful managing the problems (eg. interpersonal, occupational) that accompany bipolar disorder (not the most effective)
Family therapy can be helpful