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`Chapter 9: dissociative disorders and somatic symptom disorders: Dissociative Disorders

Somatic Symptom Disorders/ Somatoform disorder

● Dissociation can be common (spacing out), it is seen as a normal response to traumatic or difficult situations- it involves involuntary disruption of consciousness that tends to recur and is often short-lived ● Reported more often in females than males and is not particularly tied to hypnosis 1)Depersonalization-derealization disorder 2) Dissociative Amnesia 3)Dissociative Identity Disorder (DID)

● Disorders where the person feels there is something wrong with them and shows unnecessary anxiety over it as well as seeking medical attention 1) Somatic Symptom Disorder 2) Illness Anxiety Disorder 3) Conversion Disorder 4) Factitious Disorder ● Treatment: education, CBT and antidepressants- treatment research is limited in this area

Dissociative Disorders: Depersonalization ● The experience of not experiencing the reality of one’s self- can include feeling detached, or observing oneself as if you were an outside observer ● Individuals with depersonalization disorder may show inhibitory responses to negative emotional info ● Lower activity in sensory areas and less cortical thickness is found in those with personalization disorder Derealization ● The experience that the external world is not solid- can include a sense of detachment as if in a fog or dream - Depersonalization and derealization are normal reactions to acute stress Dissociative Amnesia ● Inability to recall important autobiographical info, involves first person memory loss not global memory loss and may last for only days, or for years (appears more often in peoples 30’s and 40’s) ↳now includes dissociative fugue- dissociative amnesia along with traveling away from home or workplace Dissociative Identity Disorder/ Multiple Personality Disorder ● A complex disorder related trauma occurring before age 6 characterized by a poorly integrated sense of self, different “personalities” at different times, has a 1-3% prevalence ● Involves disruption of memory, loss of ability to do learned skills, finding things done the person doesn't remember doing

● The host personality is sometimes replaced by the “alters” and the “alters” may even argue with each other in the person's mind ● SCID-D is a screening test for DID developed by Marlene Steinberg ● Patients show a smaller hippocampus and amygdala- show similar patterns to PTSD patients Somatic symptom disorders: Somatic Symptom Disorder: ● Can cause a person distress and disruption without an actual medical disorder, symptoms (lasting more than 6 months) include persistent thoughts about the seriousness of symptoms, high levels or anxiety about health, spending excessive time and energy on health ● The prevalence is 5-7% Illness Anxiety Disorder/ Hypochondriasis: ● Preoccupation with the possibility of having a serious illness but MAY experience A FEW symptoms, see bodily symptoms are incompatible with good health, see their symptoms are worse when compared to another person Conversion Disorder/ Functional neurological symptom disorder ● History: originally attributed to a “wandering uterus,” Freud invented the term “conversion reaction” because he thought psychic energy was converted into physical symptoms ● Research: suppression may be occurring below cortex and mirror neurons may not create an internal map of movement when we see others move the way they do in normal people ● Sensory or motor symptoms such as not being able to hear, see or feel pain or move a part of the body ● Show “la belle indifference” ● Symptoms are involuntary and unconscious and do not follow known physiological or neurological patterns ↳Things that are NOT conversion disorder: Malingering and Factitious disorder Malingering: ● A person is faking the illness consciously for gain Factitious disorder/ Munchausen syndrome: ● A person engages in deliberate sabotage in order to seek medical treatment ● Symptoms are created by tampering or sabotage ● Attempts to manipulate health care system by seeking extra medical tests or procedures and when they do not receive the attention they seek they become angry and claim mistreatment ● Factitious disorder imposed on another is called Munchausen syndrome by proxy Chapter 10: Eating disorders Feeding disorders:

● ● 1) 2) 3) ●

Refusal or avoidance of particular foods that causes adverse health effects in the future There are THREE types of feeding disorders: Pica Rumination Avoidant/restrictive food intake disorder Pica: eating items that are not food; can lead vitamin deficiency, poisoning and other health problems (ex: eating chalk) ● Rumination: regurgitating food then re-chewing, re-swallowing or spitting it out ● Avoidant/restrictive food intake disorder: person (by choice not aversion) does not eat a particular food leading to health and nutritional problems) Obesity: ● The thrifty gene hypothesis suggests scarce food sources shaped our genetic makeupfood abundance, environments discouraging activity and food choices are also factors ● Obesity involves disruption in dopamine pathways in the brain, food intake involves large numbers of mechanism such as digestive organs, hypothalamus signals and cognition about energy needs ● Obese adolescent girls show less activation of reward circuits when consuming food but show more activation of somatosensory area when anticipating eating food- combination of more cravings but less enjoyable food may contribute to overeating ● Obesity world-wide had double since 1980 with 39% of people now overweight and 13% obese- the USA obesity rate is the highest ● Females overestimate their wights and males underestimate theirs Anorexia Nervosa: ● Serious restriction of food, below normal body weight, fear of gaining weight, distorted body perception and lack of recognition of the seriousness of their weight loss ● Patients show remarkably consistent symptoms between people: 1) Restricting 2) Binge eating/ purging ● Consists of perceptual, affective and cognitive distortions ● There are differences in the precuneus and inferior parietal lobe in anorectics (area responsible for perception) and differences in the prefrontal cortex, insula and amygdala (area responsible for sense of self) ● Binding potential of serotonin (5-HT) receptor is increased, dopamine system doesn't get same satisfaction from thinking about food or reward from other activities ● Consequences: problems with lack of nutrition, lower estrogen, higher cortisol levels, decreased bone density, couples with increasing risk for fractures, cardiovascular problems, reduced motility of GI tract and much higher likelihood of death

● Causes: some genetic connection, reductions in brain volume and in brain metabolism in frontal, cingulate, temporal and parietal areas, anorexia rate higher in countries with more developed economies, gut bacteria may play a role ● Treatment: highly resistant to treatment since most don't want to be treated, CBT in adults attacks irrational thoughts and conclusions ↳Maudsley approach (adolescence): 1) Phase 1: weight restoration through encouraging the person to eat during family meals 2) Phase 2: having the person take control over his or her eating problems 3) Phase 3: developing a healthy adolescent identity as well as personal autonomy Bulimia Nervosa: ● Periods of binge eating followed by purging (binging usually occurs when person in alone late at night), occur more commonly in women, associated with trying to “better” appearance, weight and body image. ● 3 aspects of disorder: binging, purging and self-worth being tied to body weight and image ● Can cause dental erosions, electrolyte imbalances and menstrual disturbances ● No specific genetics link to the cause of this disorder ● Treatment: CBT (food log, diary of thoughts) and SSRI’s (fluoxetine/prozac) Binge Eating Disorder: ● Consuming huge amounts (up to 10,000 calories worth) of food without purging, seen most commonly in overweight people but not tied directly to obesity, may run in families ● Must meet ⅗ criteria from DSM: 1) Eating more rapidly than normal 2) Eating until you're uncomfortably full 3) Eating large amounts of food when not hungry 4) Eating alone and being embarrassed about the amount of food consumed 5) Feeling disgusted, guilty or depressed after eating ● Treatment: diet and exercise, antidepressants and CBT (to reduce negative emotions) Chapter 12: substance-related and addictive disorders: Drug use in the USA ● Use went from casual tolerance in the 1800s to prohibition and control in the early 1900’s and war on drugs begun in the late 1960’s- 51% of americans regularly use alcohol, 18% use tobacco, 22.3% of those under 21 use alcohol and 4.9% use tobacco, 27M americans aged 12 or over used an illicit drug in the last month, marijuana is the most common illicit drug used by 8.4% of population- has increased since the 80’s but cocaine and amphetamines have decreased Addiction

● Tied to dependence- desire to seek and take substance, ability to avoid or limit taking the substance and the experience of negative emotional states when the substance is not available ● Those who start drinking before 15 are 4x more likely to become addicted Intoxication: impairment to psychological processes and behavioral abilities Withdrawal: symptoms when the substances is reduced or no longer used Disordered use: use of substances causes the person to experience significant impairment or distress ● The reward of drugs comes from release of dopamine in the mesolimbic dopamine system- those with low dopamine levels show compulsive behaviors, hypersexuality and gambling when dopamine is used ● The “high” from a drug affected by a speed of entering the brain- dysfunction in the prefrontal cortex is associated with drug addicted Alcohol ● Use is historic, widely used for celebratory occurrences due to mild euphoria and increased social interactions, wide cultural variations, moves directly into blood, food in stomach slows absorption and CO2 increases it Cannabis ● Main psychoactive ingredient is THC- affects receptors in hippocampus, cerebellum, basal ganglia and neocortex ● May increase risk of psychosis ● Is being pushed for legalization Hallucinogens ● Alter perceptual experiences ● Include mescaline, psilocybin, LSD, MDMA, MDA and PCP ● Have three major effects: 1) Oceanic boundlessness 2) Anxious ego dissolution 3) Visionary reconstructuralization ● Don't directly affect dopamine, produce dependence or cause withdrawal but can cause fearful or anxious experiences- tend to be similar to serotonin in chemical structure Opioids ● Substances derived from opium poppy and artificial drugs, goes back 1000s of years to control pain and bring euphoria, highly addictive, affects the opioid receptors in the brain and body that respond to endorphins (ex: heroin, opium, morphine, methadone and oxycodone) Cocaine:

● Naturally derived from coca plant, cocaine interferes with normal dopamine reuptake and is a powerful stimulant and euphoric effects, affects nucleus accumbens and parts of prefrontal cortex in new users ● The striatum, amygdala, hippocampus becomes involved with long-term use, and change in the amygdala reduce info available from prefrontal cortex Amphetamines: ● Stimulant effects similar cocaine but laboratory-produced, used medically since the 1930’s ● Long term effects:compulsive patterns of use, negative changes consistent with brain injury, changes in cognitive functioning- brain problems with methamphetamine Tobacco (nicotine): ● Originated with native populations, was first associated with cancer, stroke and heart disease in the 1950’s, less than 19% adults 25 and over are smokers, smoking tied to level of education ● Nicotine increases dopamine levels, altered inhibitory effects of GABA, has combination of stimulant and depressant effects Gambling: ● Impulse control disorder, 2.3% lifetime prevalence, comorbid with substance abuse disorders but show substance tolerance Treatment of addiction: ● Remove drugs from person’s body, psychosocial treatment helps one understand addiction and develop a plan of action and help person gain control over substance use ● Behavioral therapies, medication, counseling and medically assisted detoxification, 12 step programs ● Does not have to be voluntary to be effective Chapter 13: Schizophrenia: Schizophrenia: ● Part of psychotic disorders, involves loss of touch with reality, delusions, hallucinations, disorganized thinking and speech, abnormal motor behaviors and negative symptoms ● Affects ability to express ideas clearly, have close social relationships, express positive emotions and make future plans ● Affects 1% of population, males show earlier onset than females- its survival may be due to a creativity, cognitive ability, or language ● Symptoms may spontaneously remit- symptom variation suggest were dealing with multiple similar illnesses ● Phases of schizophrenia: 1) Premorbid phase- cognitive motor or social deficits 2) Prodromal Phase: brief/ attenuated positive symptoms and/or functional decline; marks the first psychotic episode

3) Psychotic phase- florid positive symptoms 4) Stable phase- negative symptoms, cognitive/ social deficits and functional decline Positive symptoms:

Negative symptoms:

-Hallucinations -Delusions -Disorganized thinking and behavior

-Avolition (lack of motivation or will) -Alogia (lack of interest in talking) -Anhedonia (inability to feel pleasure)

● Symptoms: delusions, hallucinations, disorganized speech, catatonia, avolition, alogia and anhedonia ● Functioning: reductions in ability to work, relate to other, take care of self ● Duration: symptoms present at least 6 months ● Elimination: ruling out other causes 4 SUBTYPES: 1) Paranoid 2) Disorganized 3) Catatonic 4) Residual Genetic Factors: ● More likely to be concordant between people who share genes, many genes are involved by interact in different combinations to make it more likely to occur, impaired elimination of synapses during adolescence, white matter connection abnormalities and loss of gray matter also found, DNA deletions and duplications ● Minor physical abnormalities, physiological abnormalities, neuropsychological measures, neuromotor abnormalities, sensory processing and event related potentials ● Lower levels of gray matter in frontal, temporal and parietal lobes, the hippocampus, and striatum portion of the basal ganglia- gray matter reductions tied to neurons being closely packed, white matter reduction in the cortex also found ● Schizophrenics have larger ventricles ● Less depression of default networks ● Dopamine and glutamate play a big role in this disorder ● Individuals with this disorder show cognitive function deficits, working memory and episodic memory Treatments: ● Until 1960’s people were warehoused in mental hospitals with little treatment other than controlling them now it is controlled with medication ● Chlorpromazine and other first generation antipsychotics address positive symptoms but not negative ones, may causes tardive dyskinesia ● Second-generation antipsychotics can address some negative symptoms- operate differently on dopamine receptors

● CBT can help clients understand psychotic experience, cope and reduce stress Chapter 12: sexuality disorders and gender dysphoria: History: ● Sex has been depicted in art for thousands of years, masturbation was once considered to lead to insanity, study of sex began with Darwin’s focus on sexual selection, Ellie’s research on human sexual behavior and Kinsey’s surveys of sexual activity Sex: ● In the male brain, there are area differences when watching sports videos vs watching erotic videos Phases of male sexual response in humans following desire: 1) 2) 3) 4)

Excitement Plateau Orgasm Resolution

Phases of female sexual response in humans following desire: 5) 6) 7) 8)

Excitement Plateau Orgasm Resolution

Sexual dysfunctions: ● Problems with sexual functioning that last 6 or more months, causes significant distress or impairment, can be physiological or psychological, fairly common, becoming even more common with age 1) Problems with desire 2) Problems with arousal 3) Problems with orgasm 4) Sexual pain problems Erectile disorder: ● Male has problems in either obtaining an erection, maintaining and erection or decreased rigidity of erection that interferes with completing sexual activity ( 2.3% in 30-39 y/o and 64-76% in 80 y/o) Female orgasmic disorder: ● Does not experience orgasm or has reduced intensity of organsm and suffered significant distress as a result; this is difficult to quantify but the females usually experience orgasm some years after puberty rather than at puberty like males do but females are more likely to orgasm to masturbation than intercourse Delayed Ejaculation: ● Males experience significant delay in ejaculation/ lack of that causes significant distress; occurs during 75% of sexual encounters or more and last 6 months or more Early Ejaculation:

● Male ejaculates within first minute of sexual activity causing significant distress and last 6 or more months; reported by 30% of men with 90% of those reporting problems ejaculating within 1 minute and 40% within 15 seconds ● Ejaculation can be delayed with SSRI’s Female sexual interest/ arousal disorder: ● Significant distress or impairment caused by at least THREE symptoms: 1) Reduction or absence of interest in sexual activity 2) Reduction or absence of interest in sexual fantasies 3) Reduction or absence of excitement or pleasure during sex 4) Reduction or absence of interest in internal or external sexual cues or situations Male Hypoactive sexual desire disorder: ● Male has little desire for sexual activity or eroti thoughts lasting 6 or more months, this lack causes significant distress Genito-pelvic Pain/penetration disorder: ● Involves pain that makes intercourse impossible ● Dyspareunia: pain during intercourse ● Vaginismus: spasm of pelvic floor muscles or vaginal muscles resulting in pain when any penetration is attempted Sexual therapy: ● Masters and Johnson’s Sensate Focus- pleasuring (kissing, touching with no genital contact) then teasing body and genital stimulation (no orgasm attempt) then full on sexual contact ● Early ejaculation can be treated with delay practice and the squeeze technique, sexual pain can be addressed by working on vaginal muscle control then practicing insertion beginning with fingers ● Lubricants and estrogen creams can be used for painful sex and erectile problems 50% can be fixed by cialis, viagra, levitra and drugs that increase genital blood flow Paraphilic Disorders(8): ● Exhibitionistic disorder: arousal exposing genitals to an unsuspecting person, rare in females, make up 1 to ⅔ of all sex offenders, very high recidivism rates, treated with CBT to teach empathy and realistic assessments, SSRI’s ● Frotteuristic disorder: becoming aroused by touching or rubbing against a non-consenting person, individuals seek crowded situations, observed only in males ● Fetishistic disorder: erotic fixation on objects or body parts that are not secual in nature, focus on the object, last 6 or more months ● Pedophillic disorder: persistent sexual interest in prepubescent or early pubescent children, person gains arousal around children and have distressing urges, last more than 6 months, develops in adolescence and reduction in the right amygdala decrease in gray matter

● Sexual masochism disorder: deriving sexual arousal from being humiliated, beaten, bound or made to suffer, last 6 months or more, desire for asphyxiation during sex may also be involved ● Sexual sadism disorder: deriving sexual pleasure from inflicting pain or humiliation on others, person must act on impulses with a non-consenting person, last 6 months or more, often comorbid with impulse control disorders, antisocial personality disorder and borderline personality disorder ● Transvestic disorder: person experiences intense sexual arousal from cross-dressing in fantasies, urges or behaviors lasting 6 or more months- transsexualism means the person feels they are opposite sex and dresses as...