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Some Mental Disorders Shulin Chen, MD & PhD Zhejiang University Hangzhou Mental Health Center Outline • Stress • Anxiety and OCD • Somatoform and Dissociative disorders Stress-Related Disorders Categories of Stressors • Frustrations • Conflicts – Approach-avoidance – Double approach – Double avoidance • Pressures – internal and external Factors Predisposing a Person to Stress - Stressor characteristics • Duration (acute versus chronic) • Number of stressors • Severity (“size” of the stressor) Psychological Moderators of Stress • Self-efficacy • Psychological hardiness – commitment; high in challenge • Sense of humor • Predictability and controllability • Social support • Task oriented versus defense oriented coping Effects of Stress • Physical effects • Physiological effects – General Adaptation Syndrome • Alarm stage • Resistance stage • Exhaustion state Stress-Related Disorders: Adjustment Disorders • Adjustment Disorders – Mild – A maladaptive reaction to an identifiable psychosocial stressor – Typical sources of stress: • unemployment • relocation Disaster Syndrome • Characterizes the initial reactions of many victims to catastrophes • Stages: – Shock – Suggestible – Recovery Acute Stress Disorder and Post Traumatic Stress Disorder • Similar symptoms, but “time-frame” of symptoms differ. • Both occur in reaction to traumatic events (e.g., natural disasters, rape, assault, war, etc). • Acute stress disorder, if it lasts past one month, will turn into a diagnosis of PTSD. PTSD: General Categories of Symptoms • Reexperiencing of the traumatic event • Avoidance of stimuli associated with the event. • Numbing of general responsiveness • Increased arousal PTSD: Vulnerability Factors • Premorbid personality – pre-existing psychological problems, low self-esteem, social skill deficits, external locus of control. • Severity of trauma • Conditioned fear • Childhood factors – Poverty, early divorce or separation, family history of mental disorders, history of sexual/physical abuse • Social support PTSD- Types of Trauma • Rape – Anticipatory phase, impact phase, posttraumatic recoil phase, and reconstitution phase • Military combat Treatment • Immediate treatment (if possible) • Stress innoculation training – provide information about the stressful situation – rehearse adaptive self-statements – practice self-statements while expose to various stressors • Exposure Anxiety Disorders and OCD Who is afraid of ? • small insect • animal, reptile • speaking to a large audience • speaking in front of a small group of familiar people • meeting new people • attending social gatherings Anxiety as a Normal and an Abnormal Response • Some amount of anxiety is “normal” and is associated with optimal levels of functioning. • Only when anxiety begins to interfere with social or occupational functioning is it considered “abnormal.” Bell Curve The Fear and Anxiety Response Patterns • • • • Fear Panic Anxiety Anxiety Disorder Phobia Disorders • Phobias – Specific phobias – Social phobia – Agoraphobia Specific Phobias Specific Phobias • Psychosocial causal factors • Genetic and temperamental causal factors • Preparedness and the nonrandom distribution of fears and phobias • Treating specific phobias Social Phobia • General characteristics Fear of being in social situations in which one will be embarrassed or humiliated Social Phobia • Interaction of psychosocial and biological causal factors – Social phobias as learned behavior – Social fears and phobias in an evolutionary context – Preparedness and social phobia Social Phobia • Interaction of psychosocial and biological causal factors – Genetic and temperamental factors – Perceptions of uncontrollability – Cognitive variables Panic Disorder With and Without Agoraphobia • • • • Panic disorder Panic versus anxiety Agoraphobia Agoraphobia without panic Panic Disorder • • • • Prevalence and age of onset Comorbidity with other disorders Biological causal factors The role of Norepinephrine and Serotonin Panic and the Brain Panic Disorder • Genetic factors • Cognitive and behavioral causal factors • Interoceptive fears Panic Disorder: The Cognitive Theory of Panic Panic Disorder: The Cognitive Theory of Panic • Perceived control and safety • Anxiety sensitivity as a vulnerability factor for panic • Safety behaviors and the persistence of panic • Cognitive biases and the maintenance of panic Treating Panic Disorder and Agoraphobia • Medications • Behavioral and cognitive-behavioral treatments Generalized Anxiety Disorder • General characteristics • Prevalence and age of onset • Comorbidity with other disorders Generalized Anxiety Disorder: Psychosocial Causal Factors • The psychoanalytic viewpoint • Classical conditioning to many stimuli • The role of unpredictable and uncontrollable events • A sense of mastery: immunizing against anxiety Generalized Anxiety Disorder: Biological Causal Factors • Genetic factors • A functional deficiency of GABA • Neurobiological differences between anxiety and panic Obsessive-Compulsive Disorder • Obsessions- repetitive unwanted ideas that the person recognizes are irrational • Compulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions Obsessive-Compulsive Disorder • • • • Prevalence and age of onset Characteristics of OCD Types of compulsions Comorbidity with other disorders Obsessive-Compulsive Disorder: Psychosocial Causal Factors • • • • Psychoanalytic viewpoint Behavioral viewpoint The role of memory Attempting to suppress obsessive thoughts Obsessive-Compulsive Disorder: Biological Causal Factors • Genetic influences • Abnormalities in brain function • The role of serotonin Somatoform and Dissociative Disorders I. Somatoform Disorders A. Sick Role • Have you ever “played sick” in order to get out of something? How did that work out (did you get what you wanted)? • Sick attention (friends, family, medical) = secondary gains • Likely link between secondary gains and somatoform disorders • Some medical condition may actually exist B. Somatization Disorder 1. Historical perspective • • • • In the medical/clinical nomenclature since the mid-1600’s Known as “Hysteria,” “hypochondriasis,” and “melancholia” until 1800’s when mental disorders were differentiated Briquet’s syndrome, named for the French physician who initially defined it in 1859 Term “somatization disorder” was first used in DSM-III (1980) B. Somatization (cont.) 2. DSM-IV criteria (p. 174) A. History of many physical complaints beginning before age 30 occurring over several years resulting in treatment being sought or significant impairment in functioning 2. DSM-IV criteria (cont.) B. Each of the following met at some point during disorder: 1) 4 pain symptoms 2) 2 gastrointestinal symptoms 3) 1 sexual symptom 4) 1 pseudoneurological symptom 2. DSM-IV criteria (cont.) C. Either: 1) symptoms in Criterion B cannot be fully explained by a known GMC or 2) when a GMC does exist, the symptoms in Criterion B are in excess of what would be expected based on medical facts D. Symptoms not intentionally feigned or produced B. Somatization (cont.) 3. Additional descriptive information • • • Report of symptoms usually colorful or exaggerated; factual info usually lacking Lab findings do not support somatic complaints Treatment sought from several doctors at once hazardous mix of treatments 3. Additional info (cont.) • Primary relationships are with doctors; personal relationships usually have problems • Often seem indifferent about what symptoms represent – Concerned with individual symptoms, not what symptoms might indicate in terms of a disease • Physical symptoms become part of their identity (ego syntonic) B. Somatization (cont.) 4. Statistics and course – Lifetime prevalence: • • • 0.2 – 2% in women less than 0.2% in men Rates affected by rater, method of assessment, and demographic variables: – Non-physicians diagnose it less frequently – In primary medical care settings, rate is 4.4 – 20% – Typical demographic is lower SES unmarried woman 4. Statistics and course (cont.) • Onset is usually before 25 (must have symptoms before 30) • Course is chronic and rarely remits completely B. Somatization (cont.) 5. Causes a) familial/genetic • • Clear link between somatization and antisocial personality disorder Genetic influence (30-50%) on somatization symptoms b) Social learning • • Parents may reinforce somatic complaints in children gain attention (sick role) Research shows somatization features and help seeking for illness in parents of somatizing children 5. Causes (cont.) c) Cultural – Cultural differences in type of symptoms – Different rates across cultures – Possible differences in the use of somatic references in communication (not a disorder, just differences in communication?) d) Societal – More acceptance of medical vs. psychological problems B. Somatization (cont.) 6. Treatment – No treatment shown to be effective – Behavioral approach limit doctor visits • Use a gatekeeper physician – Train patient to relate to others without using physical complaints Somatoform and Dissociative Disorders II. Dissociative Disorders Overview • Disorders are marked by disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment • What are some “normal” dissociative experiences that people have sometimes? A. Common Features of Dissociative Disorders 1. Depersonalization = distortion in perception such that a sense of reality is lost 2. Derealization = losing a sense of the external world • e.g., things change size or shape B. Dissociative Identity Disorder (DID) • Formerly known as multiple personality disorder 1. DSM-IV criteria (p.192) A. presence of 2 or more distinct identities or personality states B. At least 2 identities/personalities recurrently take control of the person’s behavior 1. DSM-IV criteria (cont.) C. Inability to recall important personal information (goes beyond ordinary forgetfulness) D. Not due to effects of a substance or GMC; in children, symptoms not attributable to imaginary playmates or fantasy play Additional descriptive info • Alter = identity or personality in DID – Many have at least 1 impulsive alter – Alters of the opposite gender are common • Host = identity that seeks treatment and tries to keep other identities integrated • Switch = transition to another identity B. DID (cont.) 2. Course and statistics - 3-9 times more common among women - ratio may be more even in children - number of identities varies: - women average about 15 - men average about 8 - course is chronic; dissociation can be spurred by stress B. DID (cont.) 3. Causes - almost every DID case has history of severe sexual or physical abuse dissociation seems to be a defense - may be extreme form of PTSD - biological influences not clear - very few twin studies suggest environment is more influential than genes 3. Causes (cont.) • Most are highly suggestible; easily hypnotized B. DID (cont.) 4. Treatment - similar to treatment of PTSD - exposure to traumatic memories; goal is desensitization and prevention of response (dissociation) Summary • Somatoform disorders involve a focus on physical symptoms that are either not real or are exaggerated • Dissociative disorders involve a disturbance in normally integrated functions (memory, identity, etc.) • Course is usually chronic • Causes for most are unknown Thanks and Question Welcome