Some Mental Disorders

Shulin Chen, MD & PhD

Zhejiang UniversityHangzhou 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 Disorder1. 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 symptoms2) 2 gastrointestinal symptoms3) 1 sexual symptom4) 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 factsD. 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

symptomsb) 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 statesB. 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