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Abnormal Psychology
V.M. Durand & D.H. Barlow
Sungshin Women’s University
Jungkyu Kim Ph.D
Table of contents
1.
Classification and diagnosis of
abnormal behaviors
I. Anxiety Disorders
1. Generalized Anxiety Disorder
2. Panic Disorder with (without)
Agoraphobia
3. Specific Phobia
4. Social Phobia
5. Post Traumatic Stress
disorder (PTSD)
6. Obsessive Compulsive
Disorder
II. Somatoform Disorder and
Dissociative Disorder
1. Somatoform Disorder
1. Hypochondria
2. Somatization Disorder
3. Conversion Disorder
4. Pain disorder
5. Body Dysmorhic disorder
2. Dissociative Disorder
1. Depersonalization Disorder
2. Dissociative Amnesia
3. Dissociative Fugue
4. Dissociative Trance Disorder
5. Dissociative Identity Disorder
III. Developmental and Cognitive
Disorder
1. Developmental Disorder
1. Attention Deficit and Hyperactivity
Disorder
2. Learning Disability
3. Communication and related Disorder
4. Autism
5. Mental Retardation
2. Cognitive Disorder
1. Delirium
2. Dementia
3. Amnestic Disorder
IV. Mood Disorders
1. Depression
2. Bipolar Disorder
V. Schizophrenia and related
Psychotic Disorders
Positive Symptoms
Negative Symptoms
Disorganized Symptoms
I. Classification and diagnosis of abnormal
behaviors

Reliability => If the same results come out
shown to multiple doctors. If the results
remain the same over the time.

Validity => If the test measures what the
test promises to
concurrent validity, predictive validity

Standardization => To make a norm
against which to compare the individual
score and interpret the meaning of it
The procedures of making a
Diagnosis
1.
Clinical Interview
A. Appearance and Behavior
Clothing, Posture, Facial expression,
Movement, Voice etc.
B. Thought Process
Speed of Speech, Consistency,
Cohesion, Fluency, Delusion,
Hallucination
C. Mood State
Appropriateness of mood,
Depression, Elation, Blunt, Flat
D. Intellectual Functioning
Comprehension, Use of Language,
Memory
E. Perception of Environment
Date, Space, Perception of Self
2. Behavioral Assessment



Direct assessment by means of
behavioral observation
Patient’s statements are often not
enough or distorted
So, this is the most direct and
effective way to get accurate
informations
II. Classifications

Causes of psychopathology are complex
For example, psychological, environmental,
and physiological
-> classical categorical approach is
inappropriate

Dimensional approach
-> assessing various dimensions
for example cognition, emotion,
behavior
-> this is not complete either, because
there are no agreed on dimensions
among the assessors

Prototypical approach
=> integration of the categorical
approach and dimensional approach
Used most often recently
-> used in DSM-IV
DSM-IV




Reorganized together with ICD-10
The most salient difference between DSM-IV
and its previous versions => eliminating the
distinction between organically based
disorders and psychologically based
disorders
Axis I : various psychopathologies, pervasive
developmental disorders, learning disorders,
motor skills disorders, communication
disorders
Axis II : Personality disorders, mental
retardation




Axis III : Medical conditions
Axis IV : Psychological and
environmental problems that might have
an impact on the disorder
Axis V: current level of adjustment
From 0 to 100 scale (100 indicating
superior functioning in a variety
of situations)
Other optional Axes: Defense mechanisms,
coping styles, social and occupational
functioning, and relational functioning
< Criticisms of DSM-IV>





There are many overlaps among the
categories
Too much emphasis on the reliability
-> ignoring the validity
Tendency to stick to the traditional
categories
Needs to classify on the basis of more
researches in the future
The problem of the labeling
< New diagnostic categories >


Mixed anxiety-depression ; currently
being studied
It belongs neither to Anxiety disorder
nor to Depression, but shows symptoms
of both
I. Anxiety Disorders






Characteristics of anxiety
negative emotion, bodily tension, worrying
over the future
Knows that he or she doesn’t need to
worry so much
Related closely to depression
Positive aspect of anxiety => protection,
improve achievement
Increase of heart rate, blood pressure,
dilation of pupil, muscle tension etc.
Autonomous Nerve system => flight or fight
< Cause >
-





Physiological aspects
Multiple genes are interrelated
GABA-benzodiazepine sytem of brain
Shortage of the neurotransmitter GABA
(Gamma-Aminobutyric Acid) -> anxiety
The noradrenergic system and serotonergic
system are involved also
The brain region which is most closely
related to anxiety -> lymbic system

Lymbic system mediates between brain stem
which is in charge of body functioning and cortex
which is responsible for cognitive processes
-
Psychological aspects

Feeling of uncontrollability
Initially caused by external stimulus
-> associated with various internal and
external situations

-
Social aspects

Social pressures, marriage, divorce, occupation,
death of close person
Integrative model
Anxiety cannot be explained by genetic
factors alone
 The thought of uncontrollability causes
anxiety
 Social and environmental pressures
 Once
the anxiety become chronic, it
doesn’t go away even if the external
factors disappear
-> it becomes automatic

1. Generalized Anxiety
Disorder(GAD)






Overly concerned and worrying
Worries about every thing in the life
Difficulties in making decision
Future oriented
At least persisted more than 6 months
Days of feeling uncontrollable
exceeds those of controllable

Tension, irritability, easily tired,
nervous, insomnia, difficult to
concentrate

Worry about minor things such as
family members, health,
appointments etc.
In case of the children =>
academic, athletic, or social
performance and physical injuries.
1. statistics






Prevalence rate 4%
Among the elderly; 17-21.5%
Visit clinics less often than panic disorder
or social phobia patients.
Female patients outnumbers
male patients with 55 - 65%
Develops slowly and become chronic
in most cases
Benzodiazepine, a sedative that is
prescribed often to old people =>
risk of hip injury
2. Cause (integrative model)

Heredity
research
proved
by
monozygotic
twin

A heredity of a general anxiety proneness
rather than that of GAD

Increase of EEG beta activity in frontal lobe
observed in recent research
=> a strong information processing in this
region


Worrying helps defend negative affects
and images, but it prevents adaptation
to them
multiple causes => physiological factors,
stress, habit of worrying, incompetence of
problem solving
3. Treatment

Most often used drug is Benzodiazepine
questionable in its long term effects
risk factors => impairment in cognitive,
motor functioning => driving, falling down

Dependency; psychologically, physiologically
helpful in crisis intervention

There is reports that anti-depressant are
effective.
psychotherapies are more effective on
long term based

Patients have tendency to avoid negative
affects and images => confronting them
and relaxation at the same time ; Borkovec
and Costello(1993)

Inducing and then confronting the worry
process in CBT + various coping strategies
and cognitive therapy (Craske and Barlow )

Combined with family therapy -> very
effective in children

PRO meditation (Gregory Kramer)
2. Panic Disorder with and without
Agoraphobia




Normal in relationship with people
Avoid unsafe situations for fear of not
being
able to escape in case of panic
=> stay at home
Not all panic experience leads to panic
disorder
Unexpected experience of panic
=> extreme fear of re-experiencing
the panic




Feeling of dying in panic attack
Avoid such places as shopping mall,
bus, train, subway, open street, tunnel,
restaurants, theater etc agoraphobia
can appear later independent of panic
experience
Arise according to patients’ thoughts
or expectations rather than by their
actual experiences
Endures the feared place or situations
if necessary



Avoid not only specific place or
situation, but particular physical
experiences
For example, ascending stairs,
walking around under hot weather,
dancing, making love, watching horror
movies, having a quarrel, taking hot
sauna, climbing mountains
This is called intero-ceptive
avoidance (cf. intero-ceptive
exposure)
1. statistics




Prevalence 3.5%
female outnumbers 3:2
Onset : from middle of 10~40
mostly after puberty
In case of severe agora phobia
proportion of the female 89%
Men mostly tend to develop alcohol
abuse => the problem become worse





Prevalence stay constant throughout
various cultures
Similar prevalence rate among various
ethnic groups in the States
Black people show hypertension
together
60% of the patients experience panic
attack at night
Early morning between 1:00 and 1:30
AM

Night panic takes place during delta
wave of EEG
=> deepist phase of sleep

Extreme fear of death
Different from night mare, which takes
place during the REM phase and it
comes much later.
Also different from the sleep apnea,
which puts the person to sleep again


2. Cause


After unexpected panic experience
Mediated by social and cultural factors

Affected by physiological and
psychological components

Physiological responsiveness to stress
inherited
=> it associates specific environmental
and internal stimuli to panic attack


Misinterpretation of a neutral stimulus
as dangerous
=> anxiety of reexperiencing
panic attack
8-12% of people experience
intermittently panic
-> in most cases don’t develop panic
disorder
-> attribute to conflicts with friends,
ingested foods, by chance etc


Only 3% of people leads to panic
disorder
These people have cognitive
vulnerability
-> misinterpret a normal bodily
reaction as dangerous
=> sympathic nervous system
aroused
=> perceived as dangerous
=> vicious circle
3. treatment

Imipramine, a tricyclic antidepressant
-> influences on serotonin and
noradrenalin
-> has effect on panic disorder
-> but not on GAD

Benzodiazepine decreases anxiety
-> but not panic disorder
=> So, anxiety and panic disorder are
two independent illnesses
(Donald Klein, 1964).

But in follow up benzodiazepine had a
similar effect as Imipramin or SSRI
(Serotonic specific reuptake inhibitors;
Prozac, Paxil), if the dose is enhanced.

Imipramin has such side effects as
dizziness, dry mouth, sometimes low sexual
functioning,
which causes patients to refuse medication.

Good effects, if there is no complications





SSRI is used widely because of low side
effects
But it lowers sexual functioning
Alprazolam (Xanax) is high density
Benzodiazepine
=> Good effect, but high dependency
Benzodiazepine affects cognitive and motor
functioning => difficulties in learning and
driving
It can decrease 60 % of panic attack during
medication, but relapse rate of 20-50% if stop

Psychological treatment is also effective
mainly exposure therapy
- Systematic exposures on the hierarchic
tasks
-> visiting shopping malls 30 minutes
-> walking 5 blocks alone from home
-> driving 5 miles on the high way
-> eating in a restaurant alone
-> going to the cinema alone

Barlow & Crask’s Panic control treatment
(PCT)
-> deals with panic disorder directly

Direct exposure to the stimuli that patients
are afraid of
Going up and down the step in the office
Turning around on the chair




Blood
pressure
increasing,
dizziness -> habituation
Combining cognitive therapy,
training and breathing exercise
inducing
relaxation
< Comparison of effectiveness of drug
and psychotherapy >

Barlow(1998)’s NIMH research
304 panic disorder patients
PCT alone, imipramine alone, PCT +
imipramine, PCT+ placebo, placebo alone
=> PCT + imipramine and PCT+ placebo
showed most effective
However, the two showed no differences
=> drug has no additional merits
3. Specific Phobia
< clinical descriptions >
Irrational fear of specific object or
situations that impairs daily
functioning of the individual
 It was called in the past as “simple
phobia”
 At a closer look, it is not that simple
 Many people suffer from it
 Give up work or move out


Objects of fear are innumerable
- Insects, darkness, heights, wind,
wide space, streets, sharp objects,
cars, pains, dusts, injury, men,
women, society, flood, infinity,
physical contact, thunder, lightening,
chaos, ruins, aurora, being alone etc.

Before publication of DSM-IV in 1994, there
was no meaningful classification of specific
phobias existed

Currently 4 major subtypes of specific
phobia identified
1) animal type 2) natural environmental type
3) blood-injury- injection type
4) situational type
< Animal phobia >





Fear of animal and insects
It restricts the individual’s activity
severely
Cannot read magazines for fear of
unexpectedly coming across a snake
or mouse
Cannot take a trip
Early onset around 7 years old
< Natural environmental
phobia >




Fear of heights, thunder, water
Temporary fear is excluded
Persistent and severe restrictions of
daily life
Early onset around 7 years old
< Blood – injury – injection phobia >


Fears of losing control and going to faint,
if exposed to a feared situation
But this doesn’t happen, because the
blood pressure and pulse rate goes up

By the way, blood-injury-injection phobia
patients can really faint, if they are confronted
with the feared situations, because their
blood pressure and pulse rate drop

Genetic influences
Onset around 9 years old

< situational phobia >





Fears of being trapped in public
transportations or in a closed space
Used to be thought as similar to Panic
Disorder with Agoraphobia (PDA)
On the closer look, it shows quite different
modality
Situational phobia shows phobic reaction
in reaction to the specific situations
PDA shows panic reaction in unexpected
situations
< Other phobias >




Overly cautious behaviors against becoming
infected or getting sick
Extreme restriction of activities in fear of
getting contaminated from AIDS
Avoiding public restrooms, restaurants
Choking phobia ;
avoiding intake of foods
-> marked decrease of weights
degeneration of teeth and the gums
< separation anxiety >




Unique anxiety occurring during childhood
Unrealistic and persistent worry that
something might happen to their parents or
themselves that will separate them from their
parents
Refuse going to school
Not because they dislike the school, but
because they fear the separation




Refuse to sleep alone, night mare,
physical symptoms, anxiety symtoms
Must make sure, if the anxiety is
abnormally strong
To be differentiated from school
phobia, which is related to concrete
situations in the school.
They can go to the places alone other
than schools
1.Statistics





Relatively easy to see. prevalence 11 %
More female than men (4:1)
snake phobia and heights phobia is
most common
Persists lifelong
To be differentiated from temporary phobia
in childhood such as fear of new face,
fear of darkness, fear of ghost etc.


Hispanics develops twice as often as
whites
Chinese show “fear of the cold”
=> Pa-leng
They have morbid fear of losing balance
between yin and yang.
They ruminate over loss of body heat
and may wear layers of clothing even
on a hot day.
2. Cause

In the past, it was thought to be influenced
by trauma experience. Not proved yet.
There are several ways to develop a phobia
1. Direct experience
choking phobia, claustrophobia
2. Observing someone else experience
severe phobia. (vicarious experience)
3. Being told about the danger
4. Panic experience in a specific situation
(false alarm)

Anticipatory anxiety
danger -> phobia
about
certain

“preparedness”, that is, inherited
tendency to fear situations that have
been dangerous to human race, such
as being threatened by wild animals or
trapped in small places.

Cultural factors
male -> phobic feeling not accepted
3. Treatment



structured and consistent exposure
under the supervision
Individuals who attempts to carry
out the exercises alone attempts to
do too much, too soon and ends up
escaping the situation, which
strengthens the phobia.

When treating blood-injury-injection
phobia must offer exposure with muscle
tension
-> because the patient might faint.

therapist offer exposure spending
most of the day together with the
patient
-> later the patient can do alone
-> being checked by the therapist
4. Social Phobia
< clinical description >

Marked and persistent fear of one or more
social or performance situations that involve
exposure to unfamiliar people or possible
scrutiny by others, with the fear that one
will be embarrassed or humiliated.

Performance anxiety
public speaking, eating in a restaurant,
signing a paper in front of a clerk, urinating
in a public rest room etc.

Social phobia generalized type or social
anxiety disorder => individuals who are
extremely and painfully shy in almost all
social situations.

Exposure to the feared situation
almost always provokes anxiety,
sometimes as a panic attack



Recognition (in adult) that the fear is
excessive and unreasonable
The feared social or performance
situation is avoided or endured with
intense anxiety or distress
The avoidance, anxious anticipation,
or distress interferes significantly with
the person’s life and healthy
functioning
1.
Statistics

prevalence rate 13.3%
most common psychological disorder
currently
the sex ratio favors women a little
(1.4:1)
sex ratio of social phobics appearing
at clinics is 50 : 50
=> males seek help more frequently,
because of career related issues





Onset mostly in adolescence (15yrs old)
more among young, undereducated, single,
and low socio-economic class
Relatively equally distributed among different
ethnic groups.
2. Cause

Heredity; some infants are born with a trait
of inhibition that is evident as early as 4
moths of age





Anticipatory anxiety after unexpected
experience of panic attack against
similar situation
Trauma experience in childhood
vicarious learning of fear through
parents
prepared fear of social blame, assault,
rejection etc


We learn more quickly to fear angry
expression than other facial expressions,
and this fear diminishes much more
slowly than other types of learning
social phobics remembered critical
expressions more, whereas normals
remembered the accepting expressions.
3. Treatment

Rehearsal in front of patient group




The rest play a supporter role observing the
performance
Therapist helps the patient to find and
correct his or her automatic perceptions.
According
to
research,
behavioral
rehearsals are more effective than cognitive
therapy part.
Tricyclic antidepressant MAO inhibitor is
effective, but high probability of relapse
when stopping
5. Posttraumatic Stress Disorder;
PTSD
< clinical description >

Enduring, distressing emotional disorder
that follows exposure to a severe helpless
- or fear inducing threat such as rape,
violence, traffic accidents, natural disaster,
sudden death of family members or friend etc.

Reexperiences extreme fear, helplessness
that the patient experienced at the time of
traumatic event through memories and
nightmares.

flash back => when memories are suddenly
and the victims find themselves reliving the
event

Victims avoid anything that reminds them of
the trauma
They display a characteristic restriction or
numbing of emotional responsiveness.


They repress emotion, sometimes unable
to remember certain aspects of the event

Chronically over-aroused, easily startled,
and quick to anger
First diagnosed in DSM-III
But history goes long back






Insomnia, continuous memory of the event
Apathy and stupor
= > dissociation
Can’t remember part or all of the event
feeling of unreality or de-realization


Acute PTSD -> 1 month after the
event
Chronic PTSD -> after 3 months
more prominent avoidance behaviors
usually comorbid with social phobia

Delayed PTSD -> shows few
symptoms after trauma, but later
develop full-blown PTSD. Often years
afterwards.

Acute stress disorder -> until a month
after event
40% of the acute stress disorder
=> keep PTSD
Acute stress disorder was diagnosed first
in DSM-IV to help these people get
insurance coverage
1.

Statistics
Rachman(1991): only few who endured
air raid during the world war II, fire, earth
quakes, floods etc. developed later PTSD
1.
Kilpatrick(1985):
2,000
women
who
experienced rape, molesting, robbery,
violence
32% of rape victims -> PTSD
19.2% -> attempted suicide
44% -> suicidal ideation

Resnick의 연구(1993);
17.9% of American women -> PTSD
7.8% of the whole American -> PTSD


Male -> mostly due to war experience
15-20% of those involved in car accidents ->
PTSD
2. Cause




Interaction of biological, psychological
and sociological factors
Vulnerability according to genetic disposition
Monozygotic twin concordance rate
-> .28-.41
Dizygotic twin -> .11-.24

Excessive secretion of corticotropin releasing
factor ( CRF; a neurotransmitter of olivocerebellar climbing fiber system)
and cortisol (stress hormon)
-> damage to hippocampus

Prepared -> torture victims in turkey
-> political vs non political groups
with a support group after a trauma
-> low rate of PTSD

High rate of PTSD for the veterans of the
Vietnam war
-> lack of social support and acceptance
3. Treatment


Facing the trauma situation
Systematic re-experiencing with guidance of
a therapist

Behavior therapy with a child bitten by a dog
-> first the brother models the treatment
lying on an examination table
-> Marcie tried each one in turn
-> the therapist took instant photographs
so that she kept it after completing the
procedure
->she was asked to draw pictures of the
situations -> supports of the family
members

SSRI (Prozac, Paxil) -> reducing anxiety
6. Obsessive-Compulsive Disorder; OCD
< Clinical description >



Most severe form of anxiety disorder
High comorbidity with GAD, Panic disorder,
Major depression
Objects of avoidance
Other anxiety disorder -> external situation,
animal, traumatic event etc
OCD -> his or her own thought, image,
impulse

Obsession => thought, image, impulse that
come to consciousness against one’s will

The contents of Intrusive and persistent
thoughts and impulses -> sex, aggression,
religious contents

Compulsion => thoughts or behaviors that
are used to suppress the obsession such
as repetitive checking, washing, ordering
and arranging, magical ritual, counting
numbers, praying, which helps reduce
stress and prevents imagined disaster.
< Obsession >

Jenike, Baer and Minichiello(1986);
most common obsession -> contamination
(55%), aggressive impulse(50%), sexual
content (32%), somatic concerns (35%),
need for symmetry (37%)
60% of patients showed multiple symptoms




Need for symmetry refers to keeping things
in perfect order
Careful not to step on cracks in the
sidewalk
Impulse to yell out a swear word in church
A woman was afraid to ride a bus for fear
that if a man sat down beside her she
would grab his crotch.
< Compulsion >





The most common ritual => checking,
ordering and arranging, washing and cleaning
Most of OCD patients show washing and
cleaning or checking rituals.
Washing or cleaning -> gives patients a
sense of safety and control
checking rituals -> prevents imagined
disaster or catastrophe
Certain kinds of obsession are strongly
associated with certain kinds of rituals

Aggression and sexual obsession lead to
checking rituals.
Obsessions with symmetry leads to ordering
and arranging or repeating rituals.
Obsession with contamination lead to
washing rituals.
some people compulsively hoard things,
fearing that if they throw something away,
even a 10-year old newspaper, they then
might need it.
1. statistics




lifelong prevalence 2.6%(Karno &
Golding, 1991).
Frost et al(1986); 10-15% of “normal”
students engaged in checking behavior
To experience occasional intrusive or
strange thought is regarded normal.
many people experience bizarre sexual
or aggressive thought when bored.






For example, impulse to jump out of
a high window
Idea of jumping in front of a car
Impulse to push someone in front of
a train
Thoughts of catching a disease from
public pools
Wishing a person would die
While holding a baby thought of
dropping the baby





Idea of swearing or yelling at my
boss
Thought of unnatural sexual acts
Thought that I’ve left the heater and
stove on
Idea that I’ve left the car unlocked
when I know I’ve locked it.
Most people let these thought pass
by

Certain individuals are horrified by such
thoughts, considering them as “bad
thought, bad and evil” and try to defend
against them

More females (55-60%) are inflicted by OCD
than male
In case of children, more boys suffer than
girls.
Maybe because male’s onset begins earlier.
In adolescence the sex ratio equalize






Average age of onset ranges from early
adolescence to mid-20s, but typically
peaks earlier in males(13 to 15) than in
females(20 to 24)
Once OCD develops, it tends to become
chronic
Contents of obsession and that of compulsion
differ from culture to culture. Nevertheless,
OCD looks remarkably similar across cultures.
Showing similar types and proportions.


In Arabic countries, obsessions are primarily
related to religious practices, specifically the
Muslim emphasis on cleanliness.
Contamination themes are also highly
prevalent in India
2. Causes


Many people experience intrusive thoughts or
impulses. But don’t develop OCD.
We must develop anxiety focused on the
possibility of having additional intrusive
thoughts.




OCD needs fear of fear as in GAD or
Panic disorder
However, why do OCD patients
develop fear of intrusive thoughts rather
than of panic attack or other external
situation ?
Because they have learned that some
thoughts
are
dangerous
and
unacceptable.
They bestow special meaning on their
thoughts and regard them as equivalent
to reality.




Similar to fundamental religious
dogma
Thinking of abortion is the same as
doing abortion
Thinking of homosexuality is the same
as doing the action
Try to suppress the frightening
thoughts or impulses -> distraction,
praying, or checking

Biological, psychological vulnerability
and environmental stress interact
together -> OCD
3. Treatment

SSRIs have effect on 60% of patients

The average treatment gain is moderate at
best and relapse occurs when drug is
discontinued.

Most effective method ->
exposure and ritual prevention (ERP)
-
The rituals are actively prevented and
patients are systematically and
gradually
exposed to the feared
thoughts or situations.

Washing and checking behaviors are
prevented

Therapist watch over patient behavior
Seeing the feared result not ensuing ->
emotional learning


Medication
and
psychotherapy
combined together -> better effect

Severest patients => psychosurgery
(surgical lesion to the cingulate bundle)
-> 30% of patients benefited
< Two pathways related to
memory >

Papez circuit :
cingulate gyrus/retrosplenial cortex -cingulate bundle --subiculum / entorhinal cortex --hippocampus --- fornix --- septal
area / mamillary body --mamillothalamic tract --anterior n. of the thalamus --cingulate gyrus

The lateral limbic circuit:
anterior temporal cortex --- amygdala
--- dorsomedial n. of the thalamus--posterior orbitofrontal cortex

II. Somatoform and Dissociative
Disorders


Excessive concern about physical health or
appearance
Somatoform disorders
pathological concerns of individuals with the
appearance or functioning of their bodies,
usually in absence of any identifiable medical
condition

Dissociative disorders
Disorders, in which individuals feel detached
from themselves or their surroundings, and
reality, experience, and identity disintegrate.

Historically two disorders have been
studied together.

Two disorders show many commonalities and
in the past had been called under the same
name “hysterical neurosis”

Hysteria -> wandering uterus (Greek,
Egyptian)

The term ‘hysterical’ came to refer
more generally to physical symptoms
without known organic cause or to
dramatic or “histrionic” behavior
thought to be characteristic of
women.

Freud suggested that in a condition called
conversion hysteria unexplained physical
symptoms indicated the conversion of
unconscious emotional conflicts into a
more acceptable form.

The historical term conversion remains
with us ; however, the prejudicial and
stigmatizing term hysterical is no longer
used.

The term neurosis was eliminated from
the diagnostic system in 1980, because
it was too vague and applying to almost
all
non-psychotic
disorders,
and
because it implied a specific but
unproved cause for these disorders.
1. Somatoform Disorders

Five basic somatoform disorders are listed in
DSM-IV : hypochondriasis, somatization
disorder, conversion disorder, pain disorder,
and body dysmorphic disorder.

In each individuals are pathologically
concerned with the appearance or functioning
of their bodies.
1. Hypochondriasis
< clinical description >


Characterized by anxiety or fear that
one has a serious disease.
The essential problem is anxiety but
its expression is different from that of
the other anxiety disorders.



The individual is preoccupied with
bodily symptoms, misinterpreting
them as indicative of illness or
disease.
Normal bodily functions such as heart
rate or perspiration or cough etc are
considered to be indicative of serious
illness.
Assurances from doctors that all is
well and the individual is healthy don’t
help.

Overly concerned in response to slight
uncomfortableness in body

Respond very sensitively to physical
sensation in body
Don’t drink and exercise for fear of
becoming ill




Some people even don’t laugh and cannot
fall asleep for fear of stopping breathing.
Similar to panic disorder
Frequently co-morbid with panic disorder



60% of illness phobia went on later to
develop hypochondriasis and panic
disorder.
Illness phobia => individuals who have
marked fear of developing a disease
Hypochondriasis => individuals who
mistakenly believe they have a disease.

Core feature of hypochondriasis is the
disease conviction. They misinterpret
physical symptoms.

The latter has a later onset

Panic disorder have immediate expectation
of catastrophe, whereas hypochondriasis
have relatively delayed expectation of
catastrophe.

The number and art of feared body
symptoms are more and diverse in
hypochondriasis than in panic disorder.

Panic disorder => focused on about 10
symptoms of sympathetic nervous system
1. statistics



prevalence 3 % ; sex ratio 50 : 50
spread fairly evenly across various
phases of adulthood
cultural specific syndromes => koro ;
Chinese have severe anxiety that the
genitals are retracting into the abdomen.
Guilty about excessive masturbation,
unsatisfactory intercourse, or promiscuity

Hot sensations in the head or
senation of something crawling in the
head, specific to African patients.

Sensations of burning in the hands
and feet in Pakistani or Indian
patients.
2. Causes

Misinterpretation of body sensations of
signals

A disorder of cognition or perception
with strong emotional contribution

Excessive focusing on body
-> increase of body symptom
-> misinterpret
-> excitement
-> excessive focusing
-> increase of body symptom




Similar to process found in panic
disorder
Genetic and psychological
vulnerability
learned behavior => family members
often show the same symptoms
Related to stress events
Reinforced through patient role in
family history -> exempt from
responsibility and getting attention
and affection
3. Treatment

Identifying and challenging illness - related
misinterpretations of physical sensations
and on showing patients how to create
“symptoms” by focusing attention on
certain body areas.

Bringing
on
their
own
symptoms
persuaded many patients that such events
were under their control.


Caring in support group is helpful.
Some people are helped by physician’s
reassurance. However, doctors don’t
usually find enough time to offer
reassurance.
2. Somatization disorder







< Clinical description >
French physician Pierre Briquet gave first
the name in 1859 “Briquet's syndrome”
In 1980 it was changed into somatization
disorder
Complain innumerable number of body
symptoms
Suffer chronic pain
Disease make up one’s identity
Visits clinic again and again with similar list
of symptoms



Different from hypochondriasis, they are
not so afraid that they have a disease.
They are concerned with the symptoms
themselves, not with what they might mean
They do not feel the urgency to take action
but continually feel weak and ill, and they
avoid exercising, thinking it will make them
worse.
1. statistics


prevalence rate : 4.4%
onset in adolescence






More female, single, low socioeconomic class
proportion of female : 68%
accompanies anxiety, depression
Suicidal attempt to manipulate others
Mostly chronic, continues through old
age
In some cultures sex ratio is
equivalent or even higher prevalence
among male.
2. causes


A history of family illness
Related with Anti social personality disorder

Both begin early in life, typically run a chronic
course, predominant among lower socioeconomic classes, are difficult to treat, and
are associated with marital discord, drug and
alcohol abuse, and suicide attempts.

Both group are common in their tendency to
seek short term gratification, and impulsivity.





Temporary attention, care
=> isolation in long term
Genetic common factors
Differences in identification of sex
roles
Antisocial personality disorder
-> masculine, aggressivity
Somatization disorder
-> feminine, non-aggressivity
3. Treatment







Very difficult
Reassuring, caring
Reducing stress
Decreasing dependency
Allowing visiting clinics after consulting
‘gate keeper’ doctor
Frustrating reinforcement through
showing symptoms
Encouraging independency
=> getting job
3. Conversion disorder
< clinical description >

Disorder of bodily malfunction such as
paralysis, blindness, aphonia, loss of the
sense of touch, seizure etc. without physical
pathology.

Feel weak and can’t walk
Another relatively common symptom is
globus, the sensation of a lump in the throat
that makes it difficult to swallow, eat or
sometimes talk.

< closely related disorders >


Indifference to the symptoms. But not always.
Sometimes real patients show also
indifference.
Usually precipitated by marked stress.
 therefore must check, if the symptoms
appear without any preceding stress.
=> real physical problem


Although people with conversion
symptoms can usually function
normally, they seem
unaware of
sensory input.
-> people with symptom of blind or
paralysis of leg
-> normal function in emergency

Sometimes misdiagnosis of physical
disorder as a conversion



Difficult to distinguish malingering and
conversion disorder
Malingering
aware of their own motivation
=> economic interest
factitious disorder
-> just to draw other people’s attention
-> sometimes making their children sick
(factitious disorder by proxy)
< Unconscious processes related to
conversion disorder >

Anna. O nursed her father for a long time.

visual hallucination of a black snake
crawling up father’s bed
=> at the moment of catching the snake,
the arm was paralyzed

While praying, English came out of her mouth
instead of German, which was her mother
tongue

Gradually right part of her body paralyzed
and then spread to the other parts of body

Dr. Breuer hypnotized her and let her reexperience the trauma
-> recovered her sensation and could
speak German again. Dr. Breuer called this
=>‘catharsis’ treatment.

according to recent research, we can
process various informations (visual and
auditory) without being aware of it.
1. statistics






Comorbid with other disorders,
especially with somatization disorder
Prevalence rate range from 1% to 30%
More females are inflicted
Males can also be attacked when
stressed extremely
Onset mostly in adolescence
Often found in specific religious
group
2. Cause

Freud explained in 4 steps
1) experience of a trauma
2) repress it, because it is unacceptable
3) increase of anxiety and conflict ->
converted into body symptom
-> reduction of anxiety -> primary gain
4) Attention and sympathy from the
environment + exempt from difficult work
and responsibility -> secondary gain
Indifferent attitude of patients
-> because of primary gain
 Not supported by research data
 Could be only preoccupation of the
therapist
 Socio-cultural influences
=> low education and
low economic class
 Familial influence => imitation of family
member’s real diseases




Recently low prevalence => change of social
situation resulting in decrease of secondary
gain
Interpersonal
problems,
psychological
factors
Inter-related with other somatoform
disoders
3. Treatment
Very similar to somatization disorder
=> similar treatment





Let a patient talk about trauma event
=> encouraged to re-experience
the trauma
=> catharsis
Remove the secondary gain
Often conspiracy with the family members
Without collaboration of the family
=> relapses after treatment
Elois who can’t walk -> expectation of the
mother who was busy with her store
4. Pain disorder
< clinical description >

Somatoform disorder featuring true pain but
for which psychological factors play an
important role in onset, severity
or maintenance

Overlaps with physical illness
therefore was considered
remove from DSM-IV
seriously
to

Three subtypes
1) pure psychological origin
2) psychological and physical factors
combined
3) pure physical origin

In all three psychological factors
involved

Pain is real and very hurts, regardless
whatever causes it was initiated






Abdomen, head, muscle pain
Temporary or chronic pain
Psychological treatment combined with a
physical treatment
Relaxation
training,
group
therapy,
meditation
Increased interest in health psychology
5-12% of the population meets the criteria
for pain disorder (Grabe et al., 2003)
5. Body dysmorphic disorder
< Clinical description >



Disruptive
preoccupation
with
some
imagined defect in appearance (“imagined
ugliness”)
Hair, nose, skin, eyes, head, face, bone
structure, lips, chin, stomach, waist, teeth,
legs, knees, breast, ears, cheeks, buttocks,
penis, arms, wrist, neck, forehead, facial
muscle, shoulders, hips
Relative normal looking people imagine






they are so ugly that they cannot interact
with others
An attractive young man feared to go out,
because he imagined his head was square
formed.
Checks frequently mirror to see if there is a
change in appearance
In other cases avoids mirror
often suicidal attempts
Ideas of reference (in BDD related with
appearance)
In the past regarded as a psychotic
delusional state

50% of patients -> think their belief as
real
=> in such cases an additional
diagnosis of Delusional disorder:
somatic type will be given
1. statistics





Prevalence now well known
But widely spread than known
No spontaneous remission when not treated
Similar distribution in both sex
In a Japanese research 62% were male






Onset age ranges from early adolescence to
twenties
usually don’t visit clinic
according to Veale et al(1996) suicidal rate
up to 24%
influenced by social and cultural
standards
In some cultures, prolonged or enlarged face
are regarded beautiful
In other cultures long neck or flat nose is
seen as beautiful

Small feet in china, also in European fairy
tale (Cinderella)
2. Cause and treatment




Not very well known
No research results as to genetic and
psychological cause
Psychoanalytic theory assumes repressed
conflict displaced into bodily concern
Comorbid often with OCD





Checking behavior related
with appearance
Similar onset and process
Clomipramine(Anafranil)
and
Fluoxetine
(Prozac) are effective to some patients,
which are also effective to OCD
Like in OCD, exposure and response
prevention are effective
cultural influences => in Japan and Korea,
it could be diagnosed as social phobia
2% of plastic surgery patients are BDD
 According
to recent research higher
proportion
 Nose, chin, eyebrow surgery
no satisfaction after surgery
=> resurgery or surgery of other parts

- Of the 25 patients who received the
surgery only 2 showed relief and in more
than 20 cases, the severity of the disorder
increased (Philip et al., 1993)
2. Dissociative Disorders






Feels detached from oneself or one’s
surroundings, as if they are dreaming or living
in slow motion
The sense of things and the external reality
is lost
Loses sense of one’s own reality
Depersonalization => feels change in one’s
identity
Derealization => the individual loses his or
her sense of the reality of the external world
The latter being followed by the former
1. Depersonalization disorder







Sense of severe unreality
Making an individual unable to carry out
normal daily life
makes him or her frightening
as if one observe oneself from outside
main symptom being depersonalization and
derealization
According to Simeon(1997), average onset
16.1 age
Mostly become chronic

50% of the patient additionally diagnosed
with anxiety disorder and mood disorder
2. Dissociative Amnesia





General amnesia => forgets totally who one
is
Localized amnesia => a failure to recall
specific events, usually traumatic, that
occurred during a specific period
In most cases occur after severe traumatic
events
Sometimes remembers the even itself, but
not the emotion related to it.
More prevalent than general memory
disorder
3. dissociative Fugue






Fugue means escape or flight
Move from a place associated with trauma
to a different environment
Can’t remember how he or she came to
the place
Often gets a new identity
Usually begins at an adult age
Found in various cultures with different
names
4. dissociative Trance Disorder







Dissociation experienced with ecstasy
Sudden changes in personality
In some cultures -> believed to be
mediated by spirit => Possession
Like in other dissociative disorder, related
to current stress or trauma rather than past
trauma
More often in female
Regarded as normal in certain religion
Common in India, Thailand, Africa,
American Indian, in South America
5. Dissociative Identity Disorder
< Clinical description >




Former multiple personality disorder
Certain aspects of a person’s identity
are dissociated.
A person’s identity is fragmented
=>
many
identity
can
exist
simultaneously in a person
Separate identities with characteristic
behaviors, voices, gestures



Sometimes with only partial characteristics
Mostly
develops
after
experiencing
violence or other traumatic events
A man changed identity every time he had a
head ache
- He became aggressive and violent.
Afterwards he did not remember the incident
- A third identity who was promiscuitous
Each identity except host personality don’t
know about each other




Host personality is rational and calm
It is also host who seeks help.
Host
tries
to
integrate
other
personalities. But it fails and will be
overwhelmed.
Host is usually not the original
personality, but develops later.
Some times a DID patient shows male
and female identity at the same time.

Facial expression, voice, body posture or
even optical function changed, when
another identity appears.

According to Putnam et al.(1986) 37% of
the patients showed changes of the
handedness

The Hillside Strangler, Kenneth Bianchi raped
and murdered 10 young woman in 1970s in
Los Angeles and left their body naked in full
view in various hills.
Despite overwhelming evidence he denied
the criminal act.


some professionals raised the question he
might have a DID.
- his lawyer brought in a clinical
psychologist, who hypnotized him and
asked whether there were another part of
Ken with whom he could speak.
Then somebody called Steve answered
and said he had done all the killing. Steve
also said that Ken knew nothing about the
murders. With this evidence, the lawyer
entered a plea of not guilty by reason of
insanity.
- The defense called on the late Marti Orne,
a distinguished clinical psychologist and
psychiatrist who was a leading experts on
hypnosis and dissociative disorders.
- Orne gave him psychological tests to
find no significant differences among the
personalities. By interviewing Bianchi’s
friends and relatives, Orne couldn’t find
any independent corroboration of different
personalities before his arrest.

And several psychopathology text books
were found in Bianchi’s room, which
suggests he studied the subject and faked
DID. On the basis of Orne’s testimony,
Bianchi was found guilty and sentenced to
life in prison.

DID patients usually have high
suggestibility to hypnosis.
by experimental research it is found that
people can fake the symptoms.
Faking subjects remembered far less than
those who were hypnotized.
Various identities (alter) showed different
physiological responses (GSR, EEG)



1. statistics






mostly case studies
in average 15 identities
onset : early childhood (before age 9)
sex ratio 1 : 9 in favor of female
prevalence in clinical group 3-6%
in general group 0.5-1 %

Show high comorbidity with other disorders
such as drug addiction, depression,
somatization disorder, borderline PD, panic
disorder, eating disorder etc.
Complex disorder due to childhood taumatic
experiences
 Similar to borderline PD
self destructive, suicidal impulse, emotional
instability

Frequent hallucination
=> often misdiagnosed as a psychosis.
But different from the psychosis they hear
the voice from inside.




Knowing that the voices are hallucination,
they don’t respond to them.
In some cultures, they are thought to be
possessed
Distributed in various cultures
2. causes

In most cases, they experienced severe
childhood abuse

Escape into a fantasy world, if pain is
unbearable and they can do nothing to stop
it. Our mind has the ability to create a new
identity

Putnam et al.(1986): of 100 DID patients, 97
had experience of sexual abuse or physical
abuse.
68% had incest sexual abuse experience
Some children had witnessed their parents
blown to bits in a minefield.
Familial support consitutes an important
variance.




Psychological vulnerability plays also
an important role.

Recently researchers tend to see DID
as an extreme subtype of PTSD
The difference is that greater emphasis
in on the process of dissociation rather
than on symptoms of anxiety, although
both are present in each disorder.


After around 9 years of age, DID is
unlikely to develop, although severe
PTSD might.


Heredity is not yet proven
Seizure disorder patients experience
many dissociative symptoms

About 50% of temporal lobe epilepsy
displayed some kinds of dissociative
symptoms
=> related to brain physiology

Dissociative symptoms of epilepsy
patientsare not related to trauma
experience.
< Suggestibility >



Dissociation and suggestibility in
hypnosis are similar phenomenon
People in trance tend to be focused
on aspect of their world, and they
become vulnerable to suggestions by
the hypnotist.
People with high suggestibility can
use dissociation as a defense against
anxiety.

50% of DID reports of imaginary
playmates in childhood (Beautiful
Mind)

When
the
trauma
becomes
unbearable, the person’s identity
splits
into
multiple
dissociated
identities.

As the ability of the children to
distinguish fantasy from reality
increases, around 9 years old, the
developmental window closes for DID
People with low suggestibility develop
PTSD ?

< Real memory and false >
 Accuracy of trauma memory is very
controversial
 Suggestions by therapists ?


In case of real trauma, it is important
to re-experience the trauma
False Memory Syndrome Foundation
=> to help innocent victims

Loftus et al.(1996): an imaginary event was
told to a 14 years old boy that he was lost at
the age of 5 and then rescued by an old man.
Several
days
after
receiving
this
suggestion, the boy reported remembering
the event and even that he felt frightened
when he was lost.

Bruck et al.(1995): of the 35 three years old
girls of experimental group who received
medical examination, 60% did not remember
examination of sexual organ.

Whereas of the control group, 60%
reported on examination of sexual organ,
although they didn’t receive the examination.

Ceci et al.(1995, 2003): preschool children
were asked to actively imagine both a real
event and a fictitious event during 10
consecutive weeks.
=> another researcher interviewed them.
58% of children described the fictitious event
as if it had happened.
27% of the children claimed that they
remembered the event, even after they were
told their memory were false.
-On the other hand, there are many cases
where childhood abuse cannot be
remembered.
Williams(1994): 129 real childhood victims of
abuse were interviewed.
=>
38% did not remember the abuse event
The younger the child was at the time of
abuse and in case of knowing the abuser,
the more likely was that the event was not
remembered.
3. Treatment





Dissociative amnesia, dissociative fugue
=> usually spontaneous recovery
the episodes are clearly related to current
life stress
Removal of stress, strengthening personal
coping strategies
Recalling what happened during the
amnesic or fugue states
In case of DID, long term psychotherapy is
needed
Only about 20% accomplished full
integration of their identities.




Methods that were developed in PTSD
treatment could be applied also to DID
treatment.
Cues or triggers that provoke memories of
trauma are identified and then neutralized.
Confront and relive the early trauma and
gain control over the horrible events
Help the patient visualize and relive
aspects of the trauma until it is simply a
terrible memory instead of a current event.






Hypnosis could be utilized to help patients
to access unconscious memories
Process of hypnosis is similar to that of
dissociation
As trauma memory reemerge, it can trigger
further dissociation
The trust in therapy process is very important
Some times medication is combined with
therapy, but there is little indication that it
helps.
Antidepressant helps to some patients