Psych Test #3

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


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