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