NEUROTIC DISORDERS.pptx

Neurotic Disorders
Neurosis:
- unsatisfactory term.
- Refers to mental disorders that are generally less severe than psychosis.
- Symptoms are closer to normal experience.
• Neurotic disorders are common and a substantial proportion of these disorders are
associated with psychological causation.
• Mixtures of symptoms, especially anxiety and depressive ones are common in these
disorders.
• About one fourth of the population in developed countries will suffer from neurotic
disorders during its lifetime course.
• With the exception of social phobia their frequency is higher in women than in men.

Neurotic disorders
• Anxiety disorders.
• Obsessive-compulsive and related disorders.
• Trauma and stressor related disorders.
• Dissociative disorders.
• Somatic symptom and related disorders.
• Other neurotic disorders.

ANXIETY VS FEAR
• Anxiety is “a diffuse, unpleasant, vague sense of apprehension…”
• It is a response to an imprecise or unknown threat.
• For example, imagine you’re walking down a dark street. You may feel
a little uneasy and perhaps you have a few butterflies in your
stomach. These sensations are caused by anxiety that is related to
the possibility that a stranger may jump out from behind a bush, or
approach you in some other way, and harm you.
• This anxiety is not the result of a known or specific threat. Rather it
comes from your mind’s vision of the possible dangers that may result
in the situation.

WHEN DOES ANXIETY BECOME A DISORDER?
• Anxiety is a normal human response to objects, situations or events
that are threatening.
• Anxiety is different from fear due to its cognitive component (i.e. fear
of the future).
• Anxiety can be helpful and adaptive (e.g. anxiety about giving doing
exams!)
• Anxiety becomes a disorder when out of proportion or when it
significantly interferes with life.

ANXIETY DISORDERS
• Highly treatable yet also resistant to extinction
• Often begins early in life
• Reported more by women than men
• Often comorbid both with other anxiety diagnoses and with other
disorder groups (e.g. Mood disorders, psychoses)

ANXIETY DISORDERS
• The anxiety disorders differ from one another in the types of
objects or situations that induce fear, anxiety, or avoidance
behavior, and the associated cognitive ideation.
• Thus, while the anxiety disorders tend to be highly comorbid
with each other, they can be differentiated by close
examination of the types of situations that are feared or
avoided and the content of the associated thoughts or
beliefs.

ANXIETY DISORDERS
• Anxiety disorders differ from developmentally normative fear or
anxiety by being excessive or persisting beyond developmentally
appropriate periods.
• They differ from transient fear or anxiety, often stress-induced, by
being persistent (e.g., typically lasting 6 months or more), although
the criterion for duration is intended as a general guide with
allowance for some degree of flexibility and is sometimes of shorter
duration in children (as in separation anxiety disorder and selective
mutism).

ANXIETY DISORDERS
• Since individuals with anxiety disorders typically overestimate the
danger in situations they fear or avoid, the primary determination of
whether the fear or anxiety is excessive or out of proportion is made
by the clinician, taking cultural contextual factors into account.
• Each anxiety disorder is diagnosed only when the symptoms are not
attributable to the physiological effects of a substance/medication or
to another medical condition or are not better explained by another
mental disorder.

CAUSES OF ANXIETY DISORDERS
• There is no one cause for anxiety disorders. Several factors can play a role
– Genetics
– Brain biochemistry
– Overactive "fight or flight" response
• Can be caused by too much stress
– Life circumstances
– Personality
• People who have low self-esteem and poor coping skills may be more prone
• Certain drugs, both recreational and medicinal, can lead to symptoms of anxiety
due to either side effects or withdrawal from the drug.
• In very rare cases, a tumor of the adrenal gland (pheochromocytoma) may be
the cause of anxiety

SEPERATION ANXIETY DISORDER
• Fear or anxiety about separation from attachment figures to a degree
that is developmentally inappropriate.
• There is persistent fear or anxiety about harm coming to attachment
figures and events that could lead to loss of or separation from
attachment figures and reluctance to go away from attachment
figures, as well as nightmares and physical symptoms of distress.
• Although the symptoms often develop in childhood, they can be
expressed throughout adulthood as well.
• The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in
children and adolescents and typically 6 months or more in adults.

SELECTIVE MUTISM
• Characterized by a consistent failure to speak in social situations in which there is
an expectation to speak (e.g., school) even though the individual speaks in other
situations.
• The failure to speak has significant consequences on achievement in academic or
occupational settings or otherwise interferes with normal social communication.
• The failure to speak is not attributable to a lack of knowledge of, or comfort with,
the spoken language required in the social situation.
• The disturbance is not better explained by a communication disorder (e.g.,
childhood onset fluency disorder) and does not occur exclusively during the
course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

PHOBIAS
• Disruptive fear of a particular object or situation
• Fear out of proportion to actual threat (exaggerated fear).
• Awareness that fear is excessive
• Must be severe enough to cause distress or interfere with job or social life
• Avoidance
• How do common fears differ from phobias?
• More intense and persistent fear
• Greater desire to avoid feared object or situation
• Distress that interferes with functioning

WHAT CAUSES PHOBIAS?
• Process of stimulus generalization: Responses to one
stimulus are also elicited by similar stimuli
• Can develop through modeling.
• Maintained through avoidance.

SPECIFIC PHOBIA
• Individuals with specific phobia are fearful or anxious about or avoidant of
circumscribed objects or situations.
• You feel intense fear of a specific object or situation, such as heights or
flying. The fear goes beyond what’s appropriate and may cause you to
avoid ordinary situations.
• The fear, anxiety, or avoidance is almost always immediately induced by the
phobic situation, to a degree that is persistent and out of proportion to the
actual risk posed.
• There are various types of specific phobias:
animal; natural environment; blood-injection-injury;
situational; and other situations.

TYPES OF SPECIFIC PHOBIAS

SPECIFIC PHOBIAS
• Acrophobia --- Fear of heights
• Xenophobia – Fear of Strangers
• Zoophobia – Fear of animals
• Algophobia – Fear of pain
• Arachnophobia – Fear of spiders and other arachnids such as
scorpions.
• Claustrophobia – Fear of closed places
• Ailurophobia – Fear of cats
Among many others

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
• The individual is fearful or anxious about or avoidant of social
interactions and situations that involve the possibility of being
scrutinized.
• These include social interactions such as meeting unfamiliar people,
situations in which the individual may be observed eating or drinking,
and situations in which the individual performs in front of others.
• The cognitive ideation is of being negatively evaluated by others, by
being embarrassed, humiliated, or rejected, or offending others.

PANIC DISORDER
• Characterized by recurrent unexpected panic attacks and persistent
concern or worry about having more panic attacks or change of
behavior in maladaptive ways because of the panic attacks (e.g.,
avoidance of exercise or of unfamiliar locations).
• Panic attacks are abrupt surges of intense fear or intense discomfort
that reach a peak within minutes, accompanied by physical and/or
cognitive symptoms.

SYMPTOMS OF PANIC ATTACK
• Somatic: shortness of breath, accelerated heart rate, chest pain,
choking sensations, dizziness, tingling or numbing sensations, hot or
cold flashes, sweating, trembling, and nausea.
• Cognitive: fear of dying, going crazy, or losing control.
• Places that often trigger an attack are crowded malls, theaters,
auditoriums, restaurants, and schools.

• Panic attacks may be expected, such as in response to a typically
feared object or situation, or unexpected, meaning that the panic
attack occurs for no apparent reason.
• Panic attacks function as a marker and prognostic factor for severity
of diagnosis, course, and comorbidity across an array of disorders,
including, but not limited to, the anxiety disorders (e.g., substance
use, depressive and psychotic disorders).
• Panic attack may therefore be used as a descriptive specifier for any
anxiety disorder as well as other mental disorders.

AGORAPHOBIA
• is a type of anxiety disorder in which you fear and avoid places or
situations that might cause you to panic and make you feel trapped,
helpless or embarrassed.
• Individuals with agoraphobia are fearful and anxious about two or more of
the following situations: using public transportation; being in open spaces;
being in enclosed places; standing in line or being in a crowd; or being
outside of the home alone in other situations.
• The individual fears these situations because of thoughts that escape might
be difficult or help might not be available in the event of developing panic-
like symptoms or other incapacitating or embarrassing symptoms.
• These situations almost always induce fear or anxiety and are often
avoided and require the presence of a companion.

AGORAPHOBIA
• Afraid of being in situations where escape might be difficult, should
they experience panic or become incapacitated
• Avoid crowded places, driving, and public transportation
• Many experience panic attacks & may receive a second diagnosis of
panic disorder

GENERALIZED ANXIETY DISORDER (GAD)
• Persistent and excessive anxiety and worry about various domains,
including work and school performance, that the individual finds
difficult to control. Other worries may be relationship, health,
finances etc.
• In addition, the individual experiences physical symptoms, including
restlessness or feeling keyed up or on edge; being easily fatigued;
difficulty concentrating or mind going blank; irritability; muscle
tension; and sleep disturbance.
• You feel excessive, unrealistic worry and tension with little or no
reason.

MANAGEMENT OF ANXIETY DISORDERS
Psychosocial and psychopharmacological treatments are
available.
Cognitive behavioral therapy.
Anti-anxiety medications are used as well as antidepressants and heart
medications to control irregular heartbeats.

Treatment of Phobia
• Mainly behavioural or cognitive behavioural techniques are used
Systematic Desensitisation (Gradual exposure therapy) (with or without relaxation
training)
Flooding (with or without relaxation training)
Modelling
Cognitive restructuring, skills training, gradual exposure
[Relaxation not recommended for blood phobia where fainting is a risk]
•Hypnosis
•Medication (mainly social phobia)
 MOAIs
 SSRIs

How Are Specific Phobias Treated?
 Systematic desensitization
 Teach relaxation skills
 Create fear hierarchy
 Pair relaxation with feared objects or situations
 Since relaxation is incompatible with fear, relaxation
response is thought to substitute for fear response
 Several types:
 In vivo desensitization (live)
 Covert desensitization (imaginal)

How Is Agoraphobia Treated?
• Situational Exposure

Treatments for Social Anxiety Disorder
• Address fears behaviorally with exposure (group therapy
helpful)
• Lack of social skills
• Social skills and assertiveness trainings have proved
helpful

Treatments for Social Anxiety Disorder
• Antidepressants
• Psychotherapy: less likely to relapse than people treated with
drugs alone

Panic Disorder Treatments
• Biological treatments include use of antidepressant and anxiolytic
drugs
• Require long-term use, symptoms return upon drug cessation; risk of
addiction to anxiolytics
• Psychological treatments emphasize exposure to stimuli that
accompany panic
• Barlow’s therapy includes a combination of breathing re-training, cognitive
interventions, and exposure to the internal cues that elicit panic

Psychological Treatment of GAD
• Relaxation training
• Cognitive behavioral methods
• Challenge and modify negative thoughts
• Increase ability to tolerate uncertainty
• Worry only during “scheduled” times
• Focus on present moment

Medications
• Anxiolytics: drugs that reduce anxiety
• Benzodiazepenes
• Valium
• Xanax
• Antidepressants
• Tricyclics
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Side effects can be problematic with continuing medication
• D-cycloserine (DCS)
• Enhances learning and can bolstered treatment effectiveness

Obsessive-Compulsive and Related
Disorder

Obsessive-compulsive and related
disorders
 Obsessions are recurrent and persistent thoughts, urges, or
images that are experienced as intrusive and unwanted.
 Compulsions are repetitive behaviors or mental acts that an
individual feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.
 Preoccupation; extreme or excessive concern with
something. An idea or subject that someone thinks about
most of the time.

Obsessive-Compulsive and Related
Disorders
 Obsessive-
Compulsive Disorder
 Body Dysmorphic
Disorder
 Hoarding Disorder
 Trichotillomania
 Excoriation Disorder
 Kleptomania

Obsessive-Compulsive Disorder (OCD)
 Obsessional thought are ideas, images or impulses that enter
the individual’s mind again and again in a stereotyped form.
 They are recognized as the individual’s own thoughts, even
though they are involuntary and often repugnant. Common
obsessions include fears of contamination, of harming other
persons or sinning against God.
 Compulsions are repetitive, purposeful, and intentional
behaviours or mental acts performed in response to
obsessions or according to certain rule that must be applied
rigidly. Compulsions are meant to neutralize or reduce
discomfort or to prevent a dreaded event or situation.

Obsessive-Compulsive Disorder (OCD)
 Obsessive-compulsive disorder (OCD) is characterized by
repetitive, unwanted, intrusive thoughts (obsessions) and
irrational, excessive urges to do certain actions (compulsions).
Although people with OCD may know that their thoughts and
behavior don't make sense, they are often unable to stop them.
 In simple terms, Obsessive-Compulsive Disorder (OCD) is a
common, chronic and long-lasting disorder in which a person has
uncontrollable, reoccurring thoughts (obsessions) and behaviors
(compulsions) that he or she feels the urge to repeat over and
over.

Signs and Symptoms
 People with OCD may have symptoms of obsessions,
compulsions, or both. These symptoms can interfere with
all aspects of life, such as work, school, and personal
relationships.
 The signs and symptoms of the disorder can be classified
as obsessions or compulsions.

Signs and Symptoms
 Examples of obsessions include:
 Doubts about having done something right, like turning off the stove or locking
a door.
 Unpleasant sexual images.
 Having things symmetrical or in a perfect order
 Aggressive thoughts towards others or self
 Fears of saying or shouting inappropriate things in public.
 Examples of compulsions include:
 Hand washing due to a fear of germs
 Counting and recounting money because a person can't be sure they added
correctly.
 Checking to see if a door is locked or the stove is off
 "Mental checking" that goes with intrusive thoughts is also a form of
compulsion. © 2017 Thomas Owondo. All rights reserved.

Signs and Symptoms
 Not all rituals or habits are compulsions. Everyone double
checks things sometimes. But a person with OCD
generally:
 Can't control his or her thoughts or behaviors, even when those
thoughts or behaviors are recognized as excessive
 Spends at least 1 hour a day on these thoughts or behaviors
 Doesn’t get pleasure when performing the behaviors or rituals,
but may feel brief relief from the anxiety the thoughts cause
 Experiences significant problems in their daily life due to these
thoughts or behaviors

FACTS ABOUT OCD
 Autonomic anxiety symptoms are often present.
 There is very frequent comorbidity with depression (about
80%) - suicidal thoughts. Obsessive-compulsory
symptoms may appear in early stages of schizophrenia.
 The life time prevalence: 2 - 3%. Equally common in men
and women. The course is variable and more likely to be
chronic.

Etiology of OCD
 The neurobiological model has received widespread support in the past
decade. OCD occurs more often in persons who have various neurological
disorders, including cases of head trauma, epilepsy, Sydenham’s and
Huntington’s chorea. OCD has also been linked to birth injury, abnormal EEG
findings, abnormal auditory evoked potentials, growth delays, and
abnormalities in neuropsychological test results. Recently, a type of OCD has
been identified in children after a group A beta-streptococcal infection.
 The most widely studied biochemical model has focused on the
neurotransmitter serotonin because SRIs are effective in treating patients
with OCD.
 Brain imaging studies have provided some evidence of basal ganglia
involvement in persons with OCD.

OTHER RELATED DISORDERS

BODY DYSMORPHIC DISORDER
 Characterized by preoccupation with one or more perceived defects
or flaws in physical appearance that are not observable or appear
only slight to others, and by repetitive behaviors (e.g., mirror
checking, excessive grooming, skin picking, or reassurance seeking)
or mental acts (e.g., comparing one's appearance with that of other
people) in response to the appearance concerns.
 The appearance preoccupations are not better explained by
concerns with body fat or weight in an individual with an eating
disorder.
 Muscle dysmophia is a form of body dysmorphic disorder that is
characterized by the belief that one's body build is too small or is
insufficiently muscular.

HOARDING DISORDER
 Characterized by persistent difficulty discarding or parting with
possessions, regardless of their actual value, as a result of a strong
perceived need to save the items and to distress associated with
discarding them.
 Hoarding disorder differs from normal collecting. For example,
symptoms of hoarding disorder result in the accumulation of a large
number of possessions that congest and clutter active living areas to
the extent that their intended use is substantially compromised.
 The excessive acquisition form of hoarding disorder, which
characterizes most but not all individuals with hoarding disorder,
consists of excessive collecting, buying, or stealing of items that are
not needed or for which there is no available space.

TRICHOTILLOMANIA (HAIR-PULLING
DISORDER)
 Characterized by recurrent pulling out of one's hair
resulting in hair loss, and repeated attempts to decrease
or stop hair pulling.

EXCORIATION (SKIN-PICKING) DISORDER
 Characterized by recurrent picking of one's skin resulting in skin lesions and
repeated attempts to decrease or stop skin picking. The body focused repetitive
behaviors that characterize these two disorders are not triggered by obsessions or
preoccupations; however, they may be preceded or accompanied by various
emotional states, such as feelings of anxiety or boredom.
 They may also be preceded by an increasing sense of tension or may lead to
gratification, pleasure, or a sense of relief when the hair is pulled out or the skin is
picked.
 Individuals with these disorders may have varying degrees of conscious awareness
of the behavior while engaging in it, with some individuals displaying more focused
attention on the behavior (with preceding tension and subsequent relief) and other
individuals displaying more automatic behavior (with the behaviors seeming to
occur without full awareness).

KLEPTOMANIA
 Its an impulse control disorder characterized by a recurrent failure
to resist stealing.
 People with this disorder have an overwhelming urge to steal and
get a thrill from doing so.
 The recurrent act of stealing may be restricted to specific objects
and settings, but the affected person may or may not describe
these special preferences.
 People with this disorder usually exhibit guilt after the theft.
 Repeated theft of objects that are unnecessary for either personal
use or monetary value.

DIFFERENTIAL DIAGNOSES OR
COMORBIDITIES
 More than 90 percent of patients with OCD met the
criteria for at least one of the other mental disorders in
their lifetime.
 The most common comorbid diagnosis is major
depressive disorder, which affects two thirds of persons
with OCD at some point in life.
 Panic disorder, social phobia, specific phobias, and
substance abuse are also common.

MANAGEMENT
 The treatment of OCD has traditionally been viewed as difficult and
unsatisfactory. Recent developments have changed this picture substantially.
 Evidence-based medical and behavioral therapies are available to reduce the
severity and frequency of obsessions and compulsions. However, it may take
weeks to months for these therapies to become effective. Physicians should
inform patients about this delay in treatment response, provide support, and
encourage adherence during the early phase of treatment.

Psychological mgt
 Cognitive behavior therapy (CBT) is the method of
psychotherapy most often used.
 Exposure and response prevention is a key element of
CBT that has been proven effective in the treatment of
OCD.
 Patients are taught to confront situations that create fear
related to their obsessions, and to avoid performing
compulsive behaviors in response.
 The feared situations may be confronted directly (e.g.,
touching objects in a public restroom), or through

Pharmacotherapy.
 Antidepressants.
 OCD exhibits a highly selective response to serotonergic
medications. Clomipramine, a tricyclic antidepressant with a
strong serotonergic effect, was historically the first-line
pharmacologic treatment for OCD. However, because of
concerns about the safety and adverse effects of tricyclic
agents, SSRIs have become first-line pharmacologic
treatments for OCD. Fluoxetine (Prozac), and sertraline
(Zoloft) are used.
NOTE: Higher doses of the drugs are required to treat OCD
than depression, and response is often delayed.

Trauma- and Stressor-
Related Disorders

Trauma- and Stressor- Related Disorders
This chapter includes disorders in which exposure to a traumatic or
stressful event is listed explicitly as a diagnostic criterion.
These include:
 Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other specified Trauma- and Stressor-Related Disorder
Unspecified Trauma- and Stressor-Related Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
 = we will mainly be talking about these three disorders tonight

Post Traumatic Stress Disorder

Posttraumatic Stress Disorder
 Exposure to actual or threatened death, serious injury or
sexual violence in one or more of the following ways:
 Direct experiencing of traumatic event(s)
 Witnessed in person the events as it occurred to others
 Learning that the traumatic events occurred to person close to
them
 Experiencing repeated or extreme exposure to aversive details
of trauma. (e.g., first responders collecting human remains:
police officers repeatedly exposed to details of child abuse).
Note: Last criterion does not apply to exposure through electronic
media, television, movies, or pictures, unless this exposure is
work related. © 2017 Thomas Owondo. All rights reserved.

THOSE AT-RISK INCLUDE:
People who have been in a natural disaster, such as a tidal wave,
earthquake, tornado or tsunami.
Anyone who have been raped or physically or sexually abused.
Anyone who have witnessed or been a part of a life-threatening event.
Anyone with military combat experience or even civilians who have
been injured in war.
NB: Risk increases with “dose” of trauma, lack of social support,
pre-existing psychiatric disorder

SYMPTOMS OF PTSD
 Recurrent, involuntary and intrusive
memories of event
 Recurrent trauma-related
nightmares
 Dissociative reactions (e.g.,
flashbacks) in which the individual
feels or acts as if the traumatic
event(s) were recurring.
 Intense physiologic distress at cue
exposure
 Marked physiological reactivity at
cue exposure
 Avoidance of distressing
memories, thoughts or
feelings of the event(s)
 Avoidance of external
reminders of that arouse
memories of event(s) e.g.
people, places, activities
1.Intrusive
symptoms 2. Avoidance
symptoms

3. Negative alterations in cognitions and mood
symptoms
 Inability to remember an important aspect of the traumatic event(s) (typically
due to dissociative amnesia and not to other factors such as head injury,
alcohol, or drugs).
 Persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is
completely dangerous,” “My whole nervous system is permanently ruined”).
 Persistent distorted cognitions about cause or consequence of event that
lead to blame of self or others
 Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
 Marked diminished interest
 Feeling detached from others
 Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).

4. Arousal and reactivity symptoms
 Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
 Reckless or self-destructive behavior
 Hypervigilance
 Exaggerated startle response
 Problems with concentration
 Sleep disturbance (e.g., difficulty falling or staying asleep
or restless sleep).

Diagnosing PTSD
 Duration of disturbance is more than one month AND
causes significant impairment in function
 Specifiers:
 With dissociative sx (derealization or depersonalization)
 With delayed expression (don’t meet criteria until >6 months
after event)

Comorbidities
 Depression
 Other anxiety disorders
 Substance use disorders
 Somatization
 Dissociative disorders

Acute Stress Disorder
 Similar exposure as in PTSD
 Presence of >9 of 5 categories of intrusion, negative
mood, dissociation, avoidance, and arousal related to the
trauma.
 Duration of disturbance is 3 days to 1 month after trauma
 Causes significant impairment

Clinical Management
 Pharmacological approach:
 antidepressant medication
 short-term benzodiazepines trials
 mood stabilizers (carbamazepine, valproate)
 antipsychotics
 Psychotherapy is also of importance - CBT using education and
exposure techniques
 Group therapy, family therapy and self-help groups are widely
recommended.

Adjustment Disorders
 Adjustment disorder comprises states of subjective distress and emotional
disturbance arising in the period of adaptation to a significant life change or
to the consequences of a stressful life event, such as serious physical illness,
bereavement or separation, migration or refugee status.
 The clinical picture: depressed mood, anxiety, worry, a feeling of inability to
cope, plan ahead, or continue in the present situation, and some degress of
disability in the performance of daily routine.
 Onset - within 1 month; duration - below 6 months.
 More frequently women, unmarried and young persons.
 Psychotherapy is the first line treatment of this disorder. Symptomatic
treatment may comprise short trial of hypnotics or benzodiazepines.

Take home points
 Anxiety, Obsessive-Compulsive and Related, and Trauma and
Stressor-related disorders are common, common, common!
 There are significant comorbid psychiatric conditions associated
with anxiety disorders!
 Screening questions can help identify or rule out diagnoses
 There are many effective treatments including psychotherapy and
psychopharmacology
 There is a huge amount of suffering associated with these
disorders!

Dissociative Disorders

Dissociative Disorders
• A category of psychological disorders in which extreme and frequent
disruptions of awareness, memory, and personal identity impair the
ability to function
• What is dissociation?
– literally a dis-association of memory
– person suddenly becomes unaware of some
aspect of their identity or history
– unable to recall except under special circumstances (e.g., hypnosis)
• It is a psychological state in which certain emotions, thoughts, memories, or
sensations are separated from the rest of the body.
• Unconscious defense mechanism involving the segregation of any group of
mental or behavioral processes from the rest of the person's psychic activity;
may entail the separation of an idea from its accompanying emotional tone.
• It is a disconnection between a person’s thoughts, memories, feelings,
actions or sense of who he or she is.

Causes of Dissociative Disorders
• Dissociative disorders usually develop as a way to cope with trauma.
• The disorders most often form in children subjected to long-term
physical, sexual or emotional abuse or, less often, a home
environment that's frightening or highly unpredictable.
• The stress of war or natural disasters also can bring on dissociative
disorders.
• However, many abused people do not develop DID
• It is important to keep in mind that dissociation is an adaptive
response to an abnormal situation.

Signs and symptoms
Signs and symptoms depend on the type of dissociative disorders you
have, but may include:
• Memory loss (amnesia) of certain time periods, events, people and
personal information
• A sense of being detached from yourself and your emotions
• A perception of the people and things around you as distorted and unreal
• A blurred sense of identity
• Inability to cope well with emotional or professional stress
• Mental health problems, such as depression, anxiety, and suicidal
thoughts and behaviors.

DISSOCIATIVE DISORDERS
• Dissociative Amnesia.
• Dissociative Fugue.
• Dissociative Identity Disorder
• Depersonalization & derealization disorder.

Dissociative Amnesia
• The main symptom is memory loss that's more severe than normal
forgetfulness and that can't be explained by a medical condition.
• You can't recall information about yourself or events and people in
your life, especially from a traumatic time.
• Can be specific to events in a certain time, such as intense
combat, or more rarely, can involve complete loss of memory about
yourself.
• It may sometimes involve travel or confused wandering away from
your life (dissociative fugue).
• An episode of amnesia usually occurs suddenly and may last
minutes, hours, or rarely, months or years

Dissociative Amnesia
Example
Barbra and her brother were recently victims of a
robbery. Barbra was not injured, but her brother was
killed when he resisted the robbers. Barbra was unable
to recall any details from the time of the accident until
four days later.

Dissociative Fugue
• Also known as psychogenic fugue
• Global amnesia with identity replacement
– One leaves home
– develops a new identity
– apparently no recollection of former life called a ‘fugue state’
• If fugue wears off, old identity recovers and the new identity is
totally forgotten.

Dissociative Fugue
Example
• Pedson, a high school physics teacher in Mukono High
School, disappeared three days after his wife unexpectedly
left him for another man. Six months later, he was
discovered tending bar in Kisoro. Calling himself Martin,
he claimed to have no recollection of his past life and
insisted that he had never been married.

Depersonalization disorder
• This involves an ongoing or episodic sense of detachment or
being outside yourself - observing your actions, feelings,
thoughts and self from a distance as though watching a movie
(depersonalization).
• Here, the sufferers feel disconnected from one's physicality or
body, feeling detached from one's own thoughts or emotions,
feeling as if one is disconnected from reality and a sense of
feeling as if one is dreaming or in a dreamlike state.
• Sensation of unreality concerning oneself, parts of oneself that
occurs under extreme stress or fatigue.

Derealization disorder
• Other people and things around you may feel detached and
foggy or dreamlike, time may be slowed down or sped up,
and the world may seem unreal (derealization).
• Derealization is an alteration in the perception or experience
of the external world so that it seems unreal.
• It also occurs under extreme stress or fatigue.
• You may experience depersonalization, derealization or
both. Symptoms, which can be profoundly distressing, may
last only a few moments or come and go over many years.

Dissociative Identity Disorder
• Formerly known as multiple personality disorder, this disorder is
characterized by "switching" to alternate identities.
• You may feel the presence of two or more people talking or living
inside your head, and you may feel as though you're possessed by
other identities.
• Each identity may have a unique name, personal history and
characteristics, including obvious differences in voice, gender,
mannerisms and even such physical qualities as the need for
eyeglasses.
• There also are differences in how familiar each identity is with the
others. People with dissociative identity disorder typically also have
dissociative amnesia and often have dissociative fugue.

Dissociative Identity Disorder (DID)
Example
Harriet has frequent memory gaps and cannot account for her
whereabouts during certain periods of time. While being interviewed
by a clinical psychologist, she began speaking in a childlike voice.
She claimed that her name was Dorothy and that she was only six
years old. Moments later, she seemed to revert to her adult voice and
had no recollection of speaking in a childlike voice or claiming that
her name was Dorothy.

DID Facts
• Alternate personalities, often called alters, may be of widely varying ages
and of different genders.
• Alters are not really separate people; rather, they constitute a “system of
mind.” At different times, different alters take over. Person’s primary
personality often not aware of the alters.
• Some researchers report physiological differences among the different
personalities within a single individual
• Symptoms of amnesia and memory problems are almost always
present. People with DID typically have numerous other psychiatric and
physical problems along with a chaotic personal history.

• Pattern typically starts prior to age 10 (childhood)
• Most people with disorder are women
• Most report recall of torture or sexual abuse as
children and show symptoms of PTSD

MANAGEMENT OF DISSOCIATIVE
DISORDERS
• Generally, dissociative disorders are treated with
psychotherapy (talk therapy).
• Rarely do we use drugs in the management.

• Treat co-morbid disorders
• Intense insight-oriented psychotherapy-attempt to integrate split
personalities into one whole
• Help pt understand that original reasons for dissociation
(overwhelming rage, fear & confusion secondary to abuse) no longer
exist
• & affect states can be expressed by one whole person without the
self being destroyed

Dissociative amnesia
• Spontaneous recovery
• Hypnosis

Dissociative fugue
• Spontaneous recovery
• Hypnosis
• Drug assisted interviews
• Psychotherapy (expressive supportive psychodynamic
therapy for healthy adjustment to stressor)

Depersonalisation- derealization disorder
• Treat anxiety
• With anxiolytic’s, supportive and insight oriented therapy
• As anxiety is reduced, episodes of depersonalization
decrease

SOMATIC SYMPTOM AND RELATED
DISORDERS

Definition
• These are mental health disorders characterized by an intense focus
on physical (somatic) symptoms, which cause significant distress
and/or interfere with daily functioning.
• Most mental health disorders are characterized by mental
symptoms. That is, people have unusual or disturbing thoughts,
moods, and/or behaviors. However, in somatic symptom disorders,
mental factors are expressed as physical symptoms—a process
called somatization—and the person's main concern is with physical
(somatic—from soma, the Greek word for body) symptoms, such as
pain, weakness, fatigue, nausea, or other bodily sensations.
• The person may or may not have a medical disorder that causes or
contributes to the symptoms. However, when a medical disorder is
present, the person responds to it excessively.

• Everyone reacts on an emotional level when they have physical
symptoms. However, people with a somatic symptom disorder have
exceptionally intense thoughts, feelings, and behaviors in response
to their symptoms.
• To distinguish a disorder from a normal reaction to feeling ill, the
responses must be intense enough to cause significant distress to
the person (and sometimes to others) and/or make it difficult for the
person to function in daily life.
• The different responses people have define the specific disorder
they have.

SOMATIC SYMPTOM AND RELATED
DISORDERS
• Somatic symptom disorder (Somatization)
• Conversion disorder.
• Illness anxiety disorder (hypochondriasis).
• Factitious disorder.
• Psychological factors affecting other medical
conditions.

SOMATIC SYMPTOM DISORDER
(SOMATIZATION DISORDER)
• Involves having a significant focus on physical symptoms e.g. pain or
fatigue to the point that it causes major emotional distress and
problems functioning. One may or may not have another diagnosed
medical condition associated with these symptoms.
• Excessive thoughts, feelings and behaviors in response to physical
symptoms may lead to frequent doctor visits.
• You often think the worst about your symptoms and continue to
search for an explanation, even when other serious conditions have
been excluded.
• Health concerns may become such a central focus of your life that
it's hard to function, sometimes leading to disability.

CAUSES
• The exact cause of somatic symptom disorder isn't clear, but any of
these factors may play a role:
• Genetic and biological factors, such as an increased sensitivity to
pain
• Family influence, which may be genetic or environmental, or both
• Personality trait of negativity, which can impact how you identify and
perceive illness and bodily symptoms
• Decreased awareness of or problems processing
emotions, causing physical symptoms to become the focus rather than
the emotional issues
• Learned behavior — for example, the attention or other benefits
gained from having an illness; or "pain behaviors" in response to
symptoms, such as excessive avoidance of activity, which can increase
your level of disability © 2017 Thomas Owondo. All rights reserved.

CONVERSION DISORDER
• Also called functional neurological symptom disorder, is a condition
in which mental factors (psychological stresses) are expressed as
physical symptoms.
• Conversion disorder is thought to be caused by mental factors, such
as stress and conflict, which people with this disorder experience as
(convert into) physical symptoms.
• In conversion disorder, physical symptoms that resemble those of a
nervous system (neurologic) disorder develop.

Symptoms
They include the loss of one or more bodily functions, such as:
• Blindness
• Inability to speak
• Numbness
• Paralysis
The symptoms such as paralysis of an arm or leg or loss of sensation in a
part of the body suggest nervous system dysfunction. Other symptoms may
resemble a seizure or involve problems with thinking, difficulty swallowing, or
loss of one of the special senses, such as vision or hearing.
Often, symptoms begin after some distressing social or psychological event.
Symptoms are not consciously produced. That is, people are not faking their
symptoms. Symptoms are severe enough to cause substantial distress and
to interfere with functioning.
People may have only one episode in their lifetime or episodes that occur
sporadically. Usually, the episodes are brief.

Signs and symptoms that affect movement function may include:
• Weakness or paralysis
• Abnormal movement, such as tremors or difficulty walking
• Loss of balance
• Difficulty swallowing or "a lump in the throat"
• Seizures or convulsions
• Episode of unresponsiveness
Signs and symptoms that affect the senses may include:
• Numbness or loss of the touch sensation
• Speech problems, such as inability to speak or slurred speech
• Vision problems, such as double vision or blindness
• Hearing problems or deafness

ILLNESS ANXIETY DISORDER
(HYPOCHONDRIASIS)
• The disorder is characterized by a persistent preoccupation and a
fear of developing or having one or more serious and progressive
physical disorders.
• Patients persistently complain of physical problems or are
persistently preoccupied with their physical appearance.
• The fear is based on the misinterpretation of physical signs and
sensations.
• Physician physical examination does not reveal any physical
disorder, but the fear and convictions persist despite the
reassurance.

mgt
Psychotherapy especially cognitive behavioural therapy.
Cognitive behavioral therapy can help:
• Examine and adapt beliefs and expectations about health and physical
symptoms.
• Learn how to reduce stress.
• Learn how to cope with physical symptoms.
• Reduce preoccupation with symptoms
Antidepressant.

FACTITIOUS DISORDER
• Factitious disorder is a serious mental disorder in which someone
deceives others by appearing sick, by purposely getting sick or by
self-injury.
• It also can happen when family members or caregivers falsely
present others, such as children, as being ill, injured or impaired.
• Factitious disorder symptoms can range from mild (slight
exaggeration of symptoms) to severe (previously called
Munchausen syndrome).
• The person may make up symptoms or even tamper with medical
tests to convince others that treatment, such as high-risk surgery, is
needed.

• Factitious disorder is not the same as inventing medical problems
for practical benefit, such as getting out of work or winning a lawsuit.
• Although people with factitious disorder know they are causing their
symptoms or illnesses, they may not understand the reasons for
their behaviors or recognize themselves as having a problem.
NOTE: Factitious disorder ≠ Malingering

• In factitious disorders, the clients simulate, induce, or aggravate
illness, often inflicting painful, deforming, or even life-threatening
injury on themselves or those under their care. Unlike malingerers
who have material goals, such as monetary gain or avoidance of
duties, patients with factitious disorder undertake these tribulations
primarily to gain the emotional care and attention that comes with
playing the role of the patient.

CAUSES
• The cause is unknown, but stress and a severe personality disorder,
most often borderline personality, may be involved.
• People may have an early history of emotional and physical abuse.
• They may have experienced a severe illness during childhood or
had a seriously ill relative.

PSYCHOLOGICAL FACTORS AFFECTING
OTHER MEDICAL CONDITIONS
• It is diagnosed when attitudes or behaviors have a negative effect
on a medical disorder that the person has.
• People's attitudes or behavior can negatively affect any disorder
(such as diabetes mellitus, heart disease, or migraines) or symptom
(such as pain).
• Attitudes and behavior can make a disorder or symptoms worse,
sometimes resulting in hospitalization or a visit to an emergency
department. For example, severe stress can temporarily weaken the
heart, or chronic work-related stress can increase the risk of high
blood pressure. The risk of suffering, death, or disability due to the
disorder can be increased.

Factors that can worsen a medical condition include the following:
• Denying the significance or severity of symptoms
• Denying the need for treatment
• Not following the prescribed treatment plan
• Not getting the recommended tests
Treatment involves
• Teaching people about the effects of psychological factors or behavior
• Psychotherapy

mgt
• For many people, symptoms of conversion disorder get better without
treatment, especially after reassurance from the doctor that their
symptoms aren't caused by a serious underlying problem, and after
referral to a mental health professional.
• One may benefit from treatment if the signs and symptoms keep coming
back, or has severe symptoms, or has other mental or physical health
conditions.
Treatment will depend on your particular signs and symptoms and may
include:
o Psychotherapy
o Identifying any related physical condition or stress.

ANY
QUESTIONS

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