ABNORMAL PSYCHOLOGY -It protects us by activating a massive response from the autonomic nervous

system (increased heart rate and blood pressure, for example), which, along
Lesson 2: Anxiety Disorder & other related disorders with our subjective sense of terror, motivates us to escape (flee) or, possibly,
to attach (fight).
What is Anxiety?

-It refers to a negative mood state characterized by bodily symptoms of

physical tension and apprehension about the future. Panic Attack

- It is characterized by intense fear, anxiety, and related behavioral -It is defined as an abrupt experience of intense fear or acute discomfort,
disturbances. accompanied by physical symptoms that usually include heart palpitations,
chest pain, shortness of breath, and, possibly, dizziness
-For a person with an anxiety disorder, the anxiety does not go away and can
get worse over time

-The feelings can interfere with daily activities such as job performance, Types of Panic attack
schoolwork, and relationships
•Situationally bound (cued) panic attack
-People who suffer from anxiety dx would be more likely to experience a panic
attack - The panic is bound to a specific stimulus

- Ex. If you know you are afraid of high places or of driving over long bridges,
you might have a panic attack in these situations but not anywhere else
Gretchen…Attacked by Panic

-was 25 when I had my first attack. It was a few weeks after I come had my
out. The surgery had gone well, and I wasn’t in any danger, which is why I don’t •Unexpected (uncued) panic attacks
understand what happened. But one night I went to sleep and I woke up a few
- No stimulus can determine the panic attack
hours later-I’m not sure how long-but I woke up with this vague feeling of
apprehension. Mostly I remember how my heart started pounding. And my -Ex. If you don’t have a clue when or where the next attack will occur
chest hurt; it felt like I was dying-that I was having a heart attack. And I felt
kind of queer, as if I were detached from the experience. It seemed like my
bed- room was covered with a haze. I ran to my sister’s room, but I felt like I
was a puppet or a robot who was under the con- trol of somebody else while I •Situationally predisposed panic attack
was running. I think I scared her almost as much as I was frightened myself.
She called an ambulance (Barlow, 2002).. - Between cued and uncued types. You are more likely to, but will not
inevitably, have an attack where you have had one before

- Most panic attacks end within 20 – 30 minutes and they rarely last more than
“Too much of a good thing can be harmful” an hour

Diagnostic Criteria for Panic Attack: Anxiety

-An abrupt surge of intense fear or intense discomfort that reaches a peak -It is a future-oriented mood state, characterized by apprehension because
within minutes, and during which time four (or more) of the following we cannot predict or control upcoming events.
symptoms occur.
-(fear in the future) hindi mo alam ang mangyayari in the future
1. Palpitations, pounding heart, or accelerated heart rate

2. Sweating
Fear
3. Trembling of shaking
-an immediate emotional reaction to current danger characterized by strong
4. Sensations of shortness of breath or smothering escapist action tendencies and, often, a surge in the sympathetic branch of
the autonomic nervous system.
5. Feeling of choking
- (kapag alam mo na ang mangyayari in the future)
6. Chest pain or discomfort

7. Nausea or abdominal distress

Panic
8. Feeling dizzy, unsteady, lightheaded, or faint
-Sudden overwhelming reaction
9. Chills or heat sensations
Panic Attack
10. Paresthesias (numbness or tingling sensations)
-An abrupt experience of intense fear or acute discomfort, accompanied by
11. Derealization (feelings of unreality) or depersonalization (being detached physical symptoms that usually include heart palpitations, chest pain,
from oneself) shortness of breath, and, possibly, dizziness.

12. Fear of losing control or going crazy -( results of anxiety )

13. Fear of dying

Causes of Anxiety Disorder

Difference between Fear and Anxiety? •Biological Contributions

-It refers to the immediate alarm reaction •Psychological Contributions

-Fear can be good for us: •Social Contributions

 -The various disorders differ only in what triggers the anxiety and, perhaps, the
patterning of panic attacks
1. Biological Contributions

-We inherit a tendency to be tense, uptight, and anxious. The tendency to

panic also seems to run in families and probably has a genetic component Comorbidity with Major depression
that differs somewhat from genetic contributions to anxiety.
-It is the most common additional diagnosis for all anxiety disorders.
- Contributions from collections of genes in several areas on chromosomes
make us vulnerable when the right psychological and social factors are in -Which occurred in 50% of the cases over the course of the patient’s life,
place. probably due to the shared vulnerabilities between depression and anxiety
disorders in addition to the disorder-specific vulnerability.
- Furthermore, a genetic vulnerability does not cause anxiety and/or panic
directly. -Additional diagnoses of depression or alcohol or drug abuse make it less
likely that you will recover from an anxiety disorder and more likely that you
-Anxiety is also associated with specific brain circuits and neurotransmitter will relapse if you do recover.
systems.

-The area of the brain most often associated with anxiety is the limbic system
which acts as a mediator between the brain stem and the cortex. Comorbidity with Physical Disorders

-The more primitive brain stem monitors and senses change in bodily -The presence of any anxiety disorder was uniquely and significantly
functions and relay these potential danger signals to higher cortical associated with thyroid disease, respiratory disease, gastrointestinal disease,
processes through the limbic system. arthritis, migraine headaches, and allergic conditions.

-As with almost all emotional traits and psychological disorders, no single -People with these physical conditions are likely to have an anxiety disorder
gene seems to cause anxiety or panic, or any other psychiatric disorder but are not any more likely to have another psychological disorder.

-Instead, contributions from collections of genes in several areas on

chromosomes make us vulnerable when the right psychological and social
factors are in place Comorbidity Suicide

-20% of patients with panic disorder had attempted suicide based on

epidemiological data.
2. Psychological Contributions
-They concluded that such attempts were associated with panic disorder.
-Childhood, we may acquire an awareness that events are not always in our
control. -They also concluded that the risk of someone with panic disorder attempting
suicide is comparable to that for individuals with major depression.
-The continuum of this perception may range from total confidence in our
control of all aspects of our lives to deep uncertainty about ourselves and our - astigators also found out that even patients with panic attack who did not
ability to deal with upcoming events. have accompanying depression were at risk suicide.

-A general “sense of uncontrollability” may develop early as a function of - Having anxiety or a related disorder, not just panic disorder uniquely
upbringing and other disruptive or traumatic environmental factors increases the chances of having thoughts about suicide or making suicidal
attempts, but the relationship is strongest with panic disorder and
-The actions of parents in early childhood seem to do a lot to foster this sense posttraumatic stress disorder
of control or uncontrollability.
-People with generalized anxiety disorder and social anxiety disorder who
-Parents who interact in a positive and predictable way with their children by engaged in deliberate self-harm were especially more likely to engage in this
responding to their needs, particularly when the child communicates the behavior multiple times, and at lest one of those times was a suicide attempt.
need for attention, food, relief from pain, and so on, perform an important
function.

-Freud thought anxiety was a psychic reaction to the danger surrounding the Anxiety Disorders
reactivation of an infantile fearful situation
•Generalized anxiety disorder

•Panic disorder
3. Social Contributions
•Agoraphobia
-Stressful life events trigger our biological and psychological vulnerabilities to
•Specific phobia
anxiety.
•Social anxiety disorder
-Stressors
•Separation anxiety disorder
-marriage, divorce, difficulties at work, death of a loved Pone, pressures to
excel in school, and so on. •Selective mutism
-These stressors can trigger physical reactions, such as headaches or •These specific anxiety disorders are complicated by panic attacks or other
hypertension, and emotional reactions, such as panic attack. features that are the focus of the anxiety

Comorbidity Generalized Anxiety Disorder

-It refers to the co-occurrence of two or more disorders in a single individual -It is excessive anxiety and worry, occurring more days than not for at least 6
months, about a number of events or activities (such as work or school
-They also share the same vulnerabilities – biological and psychological – to
performance)
develop anxiety and panic
-The individual finds it difficult to control the worry and has difficulty
concentrating or their mind going blank
-They worry about their everyday routine life, such as job responsibilities, Treatment
health, and finances, the health of family members, or minor matters
- GAD is quite common, and available treatments, both drug and
-Although they experience no episodes of acute panic, these patients feel psychological, are reasonably effective.
tense or anxious much of the time and worry about many different issues
-Benzodiazepines are most often prescribed for generalized anxiety, and the
evidence indicates that they give some relief, at least in the short term.

Symptoms -Meditational and mindfulness-based approaches help teach the patient to

be more tolerant of these feelings.
-Relatively unfocused

-The nervousness is low-key and chronic

Panic Disorder and Agoraphobia
-There are no panic attacks
• Panic Disorder
- Muscle tension
-Individuals experience severe, unexpected panic attacks; they may think
-Mental agitation they’re dying or otherwise losing control.

-Some irritability •Agoraphobia

-Difficulty in sleeping -This is fear and avoidance of situations in which a person feels unsafe or
unable to escape to get home or to a hospital in the event of a developing
-The worry of GAD often starts of its own accord, seemingly without cause panic, panic-like symptoms, or other physical symptoms, such as loss of
bladder control.
-People with GAD mostly worry about minor, everyday life events, a
characteristic that distinguishes GAD from other anxiety disorders.

- Children with GAD most often worry about competence in academic, Clinical Description
athletic, or social performance, as well as family issues
•Panic Disorder
-Adults typically focus on possible misfortune to their children, family health,
job responsibilities, and more minor things such as household chores or -To meet the criteria for panic disorder, a person must experience an
being on time for appointments. unexpected panic attack and develop substantial anxiety over the possibility
of having another attack or about the implications of the attack or its
-Older adults tend to focus, understandably, on health; they also have consequences.
difficulty sleeping, which seems to make the anxiety worse
•Agoraphobia

-Most agoraphobic avoidance behavior is simply a complication of a severe,

unexpected panic attack

-Even if agoraphobic behavior is closely tied to the occasions of panic initially,

it can become relatively independent of panic attacks

- Most patients with panic disorder and agoraphobic avoidance also display
another cluster of avoidant behaviors that we call interoceptive avoidance or
avoidance of internal physical sensations

- These behaviors involve removing oneself from situations or activities that

might produce the physiological arousal that somehow resembles the
beginnings of a panic attack.

Causes

- Strong evidence indicates that agoraphobia often develops after a person

has unexpected panic attacks (or panic-like sensations), but whether
agoraphobia develops and how severe it becomes seem to be socially and
culturally

Characteristics of People with Agoraphobia

-Using public transportation (e.g., automobiles, buses, trains, ships, planes).

-Being in open spaces (e.g., parking lots, marketplaces, bridges).

-Being in enclosed places (e.g., shops, theaters, cinemas). Standing in line or

being in a crowd.
 - Many of these situations have some danger associated with them and,
therefore, mild to moderate fear can be adaptive. These phobias have a peak
age of onset of about 7 years. They are not phobias if they are only

Passing fears

-They have to be persistent (lasting at least 6 months) and interfere

substantially with the person’s functioning and leading to avoidance.

Animal Phobia

- Fears of animals and insects.

- These fears are common but become phobic only if severe interference with
functioning occurs.

- The age of onset for these phobias, like that of natural environment phobias,
peaks around 7 years.

Other types:

• Arachnophobia (Fear of spiders)

• Triskaidekaphobia (Fear of the number 13)

• Thalassophobia
Specific Phobia
-It is an intense and persistent fear of the sea or of sea travel
• It is an irrational fear of a specific object or situation that markedly interferes
with an individual’s ability to function. The very commonness of fears, even -It can include fear of being in large bodies of water, fear of the vast emptiness
severe fears, often causes people to trivialize the more serious psychological of the sea, and fear of distance from land
disorder.
-It can also include fear of the unknown, of what lurks beneath
• People with specific phobias, or strong irrational fear reactions, work hard to
avoid common places, situations, or objects even though they know there’s
no threat or danger. The fear may not make any sense, but they feel powerless
Causes
to stop it
•Direct experience
•Four major types: Situational Type, Blood-injection-injury type, natural e
ronment type, and animal type. -It is where real danger or pain results in an alarm response (a true alarm). It
can be developed through Experiencing a false alarm (panic attack) in a
specific situation
Blood-injection-injury Phobia
•Observing
• The phobia develops over the possibility of having this response and the
-Someone else experiencing severe fear (vicarious experience), or, under the
average age of onset for this phobia is approximately 9 years
right conditions, being told about danger.
• It runs in families more strongly than any phobic disorder we know.

• This is probably because people with this phobia inherit a strong vasovagal
•Information transmission
response to blood, injury, or the possibility of injection, all of which cause a
drop in blood pressure and a tendency to faint. -Fear can be acquired through vicarious learning even after watching a brief
film clip

-Sometimes just being warned repeatedly about a potential danger is

Situational Phobia
sufficient for someone to develop a phobia.
-Phobias are characterized by fear of public transportation or enclosed
-Terrifying experiences alone do not create phobias
places.
-A true phobia also requires anxiety over the possibility of another extremely
-Situational phobia, as well as panic disorder and agoraphobia, tends to
traumatic event or a false alarm, and we are likely to avoid situations in which
emerge from the midteens to mid-20s
that terrible thing might occur.
-The main difference between situational phobia and panic disorder is that
people with situational phobia never experience panic attacks outside the
context of their phobic object or situation. _______________________________________________________________________

Social Anxiety Disorder

Natural Environment Phobia -SAD is more than exaggerated shyness.
-Sometimes very young people develop fears of situations or events occurring • It is a fear of appearing clumsy, silly, or shameful.
in nature.
-People with SAD usually have no difficulty with social interaction, but when
- The major examples are heights, storms, and water. they must do something specific in front of people, anxiety takes over and
they focus on the possibility that they will embarrass themselves.
- These fears also seem to cluster together.
• The most common type of performance anxiety, to which most people can
relate, is public speaking.

•Other situations that commonly provoke performance anxiety are eating in a

restaurant or signing a paper or checking in front of a person or people who
are watching. Anxiety-provoking physical reactions include blushing,
sweating, trembling, or, for males, urinating in a public restroom (“bashful
bladder” or paruresis).

Selective Mutism

• It is a rare childhood disorder characterized by a lack of speech in one or

more settings in which speaking is socially expected.

• As such, it seems clearly driven by social anxiety since the failure to speak is
not because of a lack of knowledge of speech or any physical difficulties, nor
is it due to another disorder in which speaking is rare or can be impaired such
as autism spectrum disorder.
Obsessions
• The disturbance interferes with educational or occupational achievement or
with social communication -Repetitive and persistent thoughts, images or urges It’s not pleasurable or
experienced as voluntary They are unwanted and cause distress and anxiety
• The disorder typically begins during preschool years (ages 2-4), after normal The individual tries to ignore these obsessions by doing or performing a
speech has developed. compulsion

Obsessive-Compulsive Disorder & other related Disorders Compulsion

Obsessive-compulsive Disorder • These are repetitive behaviors or mental acts that the individual feels driven
to perform in response to an obsession or according to rules that must be
• Recurrent and persistent thoughts, urges, or images that are experienced as
applied rigidly Most individuals with OCD have both obsessions and
intrusive and inappropriate and that in most individuals cause marked anxiety
compulsions
or distress
• The aim is to reduce the distress triggered by obsessions or to prevent a
• Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts
feared event
(Praying, counting, repeating words silently)
• However, these compulsions either are not connected in a realistic way to
• Obsession and compulsion are time-consuming 1 hour per day
the feared event

• These are repetitive behaviors that a person with OCD feels the urge to do in
response to an obsessive thought • Excessive cleaning and/or hand washing

• Ordering and arranging things in a particular, precise way Repeatedly

checking on things, such as repeatedly checking to see if the door is locked or
that the oven is off

• Compulsive counting

• They can’t control their thoughts and 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
 Hoarding Disorder

• Persistent difficulty discarding or parting with possessions, regardless of

their actual value

• This difficulty is due to a perceived need to save the items and to distress
associated with discarding them

• They have strong sentimental attachment to the possessions

• They feel distress at the thought of discarding the items

Trichotillomania (Hair pulling)

• It is the persistent urge to pull out one’s own hair from anywhere on the
body, including the scalp, eyebrows, and arms

• Hair pulling lead to hair loss

• It may accompanied by various emotional states and it may be triggered by

anxiety, boredom or pleasure

Body Dysmorphic Disorder

Excoriation (Skin picking)
• It is a preoccupation with some imagined defect in appearance by someone
who actually looks reasonably normal • Characterized by repetitive and compulsive picking of the skin leading to
tissue damage
• The individual has performed repetitive behaviors or mental acts in
response to the appearance concerns • The most commonly picked sites are the face, arms, and hands, but many
individuals pick from multiple body sites Skin rubbing, squeezing, lancing,
and biting
” I didn’t want to talk to anybody….I was afraid because what I saw on my face • It happens several hours per day
they saw…. If I could see it, they could see it. And I thought there was like an
arrow pointing at it. And I was very self- conscious. And I felt like the only time • It may be triggered by feelings of anxiety, boredom or tension
I felt comfortable was at night, because it was dark time

Treatments
Diagnostic Criteria for Body Dysmorphic Disorder
•Medication

•Psychotherapy
A. Preoccupation with one or more defects or flaws in physical
appearance that are not observable or appear slight to others. •Exercise
B. At some point during the course of the disorder the individual has
performed repetitive behaviors (eg, mirror checking, excessive
grooming, skin picking, reassurance seeking) or mental acts (eg.
Comparing his or her appearance with that of others) in response Somatic Symptom and Related Disorders: An Overview
to the appearance concerns
C. The preoccupation causes clinically significant distress of -This category refers to conditions that involve physical symptoms combined
impairment in social occupational or other important areas of with abnormal thoughts, feelings, and behaviors in response to those
functioning symptoms (American Psychiatric Association [APA], 2013
D. The appearance preoccupation is not better explained by con-
-Soma means “body.” People with somatic symptom disorders experience
cerns with body fat or weight in an individual whose symptoms
bodily symptoms that cause them significant psychological distress and
meet diagnostic criteria for an eating disorder.
impairment.
Specify if:

•With good or fair insight: The individual recognizes that the body
Ex. I Know Something Is Wrong:
•Dysmorphic disorder beliefs are definitely or probably not true or that
-Richard is a 46-year-old software engineer who reports a long his- tory of
•They may or may not be true. With poor insight: The individual thinks that the many somatic complaints. His problems began in high school when he
body dysmorphic disorder beliefs are probably true. started to have headaches and pain in his chest. As time has progressed he
has developed a broad range of symptoms all over his body including back
•With absent insight/delusional beliefs: the individual is completely pain, abdominal pain and discomfort, joint pain, feelings of dizziness, and a
convinced that the body dysmorphic disorder beliefs are true. general sense of weakness and fatigue. During the past 20 years, Richard has
seen many doc- tors and received numerous medical examinations. Although
he has received several descriptive diagnoses that do little more than
describe his symptoms, no medical explanation for his problems has been
•With muscle dysmorphia: The individual is preoccupied with the idea that found. Richard worries constantly that something is being missed and that,
his or her body build is too small or insufficiently muscular This specifier is on the days the tests were done, the underlying problem was somehow
used even if the individual is preoccupied with other body areas, which is unable to be detected. Richard subscribes to several health newsletters and
often the case frequently uses the internet to learn more about the possible causes of his
symptoms. He realizes his current doctor is getting annoyed with his frequent
visits, but he continues to worry constantly about his health.
•Studies conducted throughout the world show that somewhere between 20 Illness Anxiety Disorder
and 50 percent of the physical symptoms that cause people to seek medical
care are medically unexplained. In other words, no medical cause can be •Illness anxiety disorder, sometimes called hypochondriasis or health anxiety,
found (Kroenke, 2003). is worrying excessively that you are or may become seriously ill. You may have
no physical symptoms. Or you may believe that normal body sensations or
•For many people that is the end of it. They are satisfied when told that all the minor symptoms are signs of severe illness, even though a thorough medical
tests that they have had are negative. But a subset of patients (like Richard) exam doesn’t reveal a serious medical condition.
will continue to be very worried that something is seriously wrong-that they
have a not-yet-diagnosed disease.

DSM-5 Criteria for…Illness Anxiety Disorder

The four most important disorders in the Somatic Symptom and Related A. Preoccupation with having or acquiring a serious illness.
Disorders category : B. Somatic symptoms are not present or, if present, are only mild in
intensity. If another medical condition is present or there is a high
•Somatic Symptom Disorder risk for developing a medical condition is strong family history is
present, the preoccupation is clearly excessive or disproportionate
-Somatic symptom disorder is diagnosed when a person has a significant C. There is a high level of anxiety about health, and the individual is
focus on physical symptoms, such as pain, weakness or shortness of breath, easily alarmed about personal health status.
to a level that results in major distress and/or problems functioning. The D. The individual performs excessive health-related behaviors leg,
physical symptoms may or may not be associated with a diagnosed medical mpeatedly checks his or her body for signs of itnesst or exhibits
condition, but the person is experiencing symptoms and believes they are sic maladaptive avoidance (e.g., avoids doctor appointments and
hospitalist
DSM-5 Criteria for…Somatic Symptom Disorder E. Illness preoccupation has been present for at least 6 months, but
the specific illness that is feared may change over that period of
A.One or more somatic symptoms that are distressing or result in significant
time
disruption of daily life.
F. The illness-related preoccupation is not better explained by
B.Excessive thoughts, feelings, or behaviors related to the somatic symptoms another mental disorder, such as somatic symptom disorder, panic
or associated health concerns as man feshed by at least one of the following: disorder, generalized ankety disorder, body dys morphic disorder
obsessive-compulsive disorder, or deksional deorder, somatic type
1. Disproportionate and persistent thoughts about the seriousness of one’s
symptoms.

2. Persistently high level of anvety about health or symptoms

Conversion Disorder
3. Excessive time and energy devoted to these symptoms or health concerns.
(Functional Neurological Symptom Disorder)
C.Although any one somatic symptom may not be continuously present, the
state of being symptomatic is persistent (typically more than 6 months •It is characterized by the presence of neurological symptoms in the absence
of a neurological diagnosis. In other words, the patient has symptoms or
deficits affecting the senses or motor behavior that strongly suggest a
medical or neurological condition. However, the pattern of symptoms or
Cause of Somatic Symptom Disorder deficits is not consistent with any neurological disease or medical problem
-It was long thought that symptoms developed as a defense mechanism •A few typical examples include partial paralysis, blindness, deafness,
against unresolved or unacceptable unconscious conflicts. Rather than being muteness, and episodes of limb shaking accompanied by impairment or loss
expressed directly, psychic energy was instead channeled into more of consciousness that resemble seizures.
acceptable physical problems.

DSM-5 Criteria for…Conversion Disorder

Treatments for Somatic Symptom Disorder
A. One or more symptoms of altered voluntary motor or sensory function.
•Cognitive-Behavioral Therapy (CBT) is a widely used and effective
treatment for somatic symptom disorders. It focuses on addressing the B. Clinical findings provide evidence of incompatibility between the symptom
cognitive and behavioral components that contribute to these disorders. By and recognized neurological or medical conditions.
modifying faulty beliefs about illness and teaching patients to manage bodily
sensations, CBT can reduce physical symptoms, anxiety, and depression. C. The symptom or deficit is not better explained by another medical or
mental disorder.
•For somatic symptom disorders involving pain, CBT programs often include
relaxation techniques, support, activity scheduling, cognitive restructuring, D. The symptom or deficit causes clinically significant distress or impairment
and reinforcement of “no-pain” behavior in social, occupational, or other important areas of functioning or warrants
medical evaluation.

Range of Conversion Disorder Symptoms

1. Sensory Symptoms or Deficits

- People with conversion disorder often experience problems with their

senses, like vision, hearing, or feeling. For example, they might report being
blind or deaf, but they can still do things that suggest they can see or hear.
They might also lose feeling in parts of their body, like their hands.

2. Motor Symptoms or Deficits

- People with conversion disorder can also have problems with their
movement. For example, they might lose the ability to use a limb, like an arm
or leg, but they can still use the same muscles for other things. They might
also have trouble speaking or feel like they have a lump in their throat.
 Factitious Disorder

3. Seizures • Factitious Disorder involves deliberately faking or exaggerating physical or

psychological symptoms without obvious external incentives (like financial
- People with conversion disorder might also have seizures, but they are gain), often to assume a “sick role.”
different from real seizures. They don’t cause changes in brain activity or
memory problems. They also look different, with more thrashing and writhing. • Unlike malingering, where external benefits are sought (such as avoiding
And people with conversion seizures rarely hurt themselves or lose control of work),individuals with Factitious Disorder are motivated by an internal desire
their bladder or bowels to be seen as ill.

• Factitious Disorder can also involve “imposed on another” (formerly called

Munchausen syndrome by proxy), where the individual fabricates symptoms
Important Issues in Diagnosing Conversion Disorder in someone else, often a child.

• The frequent failure of the dysfunction to conform clearly to the symptoms

of the particular disease or disorder simulated. For example, little or no
wasting away or atrophy of a “paralyzed” limb occurs in conversion paralyses, Distinguishing Between Different Types of Somatic Symptom and Related
except in rare and long-standing cases. Disorders

•The nature of the dysfunction is highly selective. As already noted, in

conversion blindness the affected individual does not usually bump into
people or objects, and “paralyzed” muscles can be used for some activities • Somatic Symptom Disorder: Characterized by excessive focus on physical
but not others. symptoms, which can lead to significant distress and impairment. These
symptoms may or may not have a medical explanation.
• Under hypnosis or narcosis (a sleeplike state induced by drugs), the
symptoms can usually be removed, shifted, or reinduced at the suggestion of • Conversion Disorder (Functional Neurological Symptom Disorder):
the therapist. Similarly, a person abruptly awakened from a sound sleep may Involves neurological symptoms (e.g., paralysis, seizures) without a medical
suddenly be able to use a “paralyzed” limb. explanation.

Prevalence and Demographic Characteristics • Illness Anxiety Disorder. Excessive worry about having or developing a
serious illness, despite little or no medical evidence supporting the concem.
• Conversion disorder is relatively rare. Estimates suggest that it occurs in
0.005% of the general population, though it may be underdiagnosed.

• More common in women than in men, especially in rural or lower • Factitious Disorder: As mentioned earlier, involves deliberately faking
socioeconomic areas. symptoms with no obvious external gain.

• Tends to emerge in adolescence or early adulthood, but can appear at any

age.
• Malingering: Often distinguished from these disorders because it involves
• Historically, it was more common, but changes in diagnostic criteria and faking symptoms for external rewards, like avoiding military service or gaining
healthcare financial compensation.

Systems have influenced how often it is diagnosed today.

Dissociative Disorder: An Overview

• Psychodynamic theory: Historically, Freud suggested that conversion • Dissociative disorders are a group of conditions involving disruptions in a
disorder results from repressed emotional conflicts manifesting as physical person’s normally integrated functions of consciousness, memory, identity, or
symptoms. perception (APA, 2013; Spiegel et al., 2013). Included here are some of the
more dramatic phenomena in the entire domain of psychopathology: people
• Behavioral factors: Reinforcement plays a role – patients may receive who cannot recall who they are or where they may have come from, and
attention or escape from stressful situations because of their symptoms. people who have two or more distinct identities or personality states that
alternately take control of the individual’s behavior
• Cognitive factors: Some researchers believe that conversion disorder may
stem from an individual’s heightened awareness of bodily sensations and
misinterpretation of these sensations.
Understanding Dissociative Disorders
• Neurobiological aspects: Research is increasingly investigating the role of
brain dysfunction in the manifestation of conversion disorder, particularly in • Dissociative disorders often involve an involuntary escape from reality,
areas related to sensory and motor functions. leading to disconnection between thoughts, memories, identity,
consciousness, and surroundings. Individuals may experience memory loss,
• Cognitive-Behavioral Therapy (CBT): CBT is often employed to help a fragmented sense of self, emotional numbness, and a perception of
patients recognize and change the thoughts and behaviors contributing to unreality.
their physical symptoms.

• Physical therapy: For patients with motor-related symptoms, physical

rehabilitation can be beneficial alongside psychological treatment. Depersonalization/Derealization Disorder

• Hypnosis: Sometimes used to address underlying psychological issues. • This disorder is characterized by persistent or recurrent feelings of
detachment from one’s self (depersonalization) or the environment
• Addressing stress or trauma: Since stress or past trauma often underlie (derealization). Individuals may feel as though they are observing themselves
the condition, psychological therapy focusing on these areas can be helpful. from outside their body or that their surroundings are unreal or dream like
DSM-5 Criteria for…Depersonalization/Derealization Disorder DSM-5 Criteria for…Dissociative Amnesia

A.The presence of persistent or recurrent experiences of deper- sonalization, A. An inability to recall important autobiographical information
derealization, or both usually of a traumatic or stressful nature that is inconsistent with
ordinary forgetting
1. Depersonalization: Experiences of unreality, detach- ment, or being an
outside observer with respect to one’s thoughts, feelings, sensations, body, or Note: Dissociative as most often consists of localized or selective amnesia
actions (e.g.. perceptual alterations, distorted sense of time, unreal or absent boor a specific avent or avents or gen enakzed amnesia for identity and the ter
self, emotional and/or physical numbing).
B. The symptoms cause clinicaly significant distress or impar ment in
2. Derealization: Experiences of unreality or detachment with respect to social, occupational, or other important areas of functioning
surroundings (e.g., individuals or objects are experienced as unreal, C. The disturbance is not atributable to the physiological effects of a
dreamlike, foggy, lifeless, or visually distorted). substance jeg alcohol or other drug of abuse a medication or a
neurological or other medical condition (eg, partial complex
B.During the depersonalization or derealization experiences. Reality testing seizures, transient global amnesia, sequelae of a closed head
remains intact. injury traumatic brain injury. Other neurological condition)
D. The disturbance is not better explained by dissociative identity
C.The symptoms cause clinically significant distress or impair ment in social, disorder, posttraumatic stress disorder, acute stress disorder,
occupational, or other important areas of functioning. somatic symptom disorder, or major or mild neurocognitive
disorder.
D.The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, medication) or another medical condition
(e.g., seizures).
The Role of Trauma in Dissociative Disorders
E. The disturbance is not better explained by another mental dis order, such
as schizophrenia, panic disorder, major depressive disorder, acute stress -Dissociative disorders typically develop as a response to traumatic events.
disorder, posttraumatic stress disorder. Or another dissociative disorder. Children, in particular, are at a heightened risk of developing these disorders
when exposed to prolonged abuse or severe neglect. Natural disasters, war,
and other traumatic incidents can also trigger dissociative responses.

2.2 Dissociative Amnesia Dissociative Identity Disorder (DID)

•Dissociative amnesia is primarily characterized by an inability to recall • formerly known as multiple personality disorder, DID is a mental health
important personal information, usually related to traumatic or stressful condition characterized by: a the presence of two or more distinct personality
experiences. This memory loss is more severe than typical forgetfulness and states or an experience of possession
cannot be attributed to a medical condition
•Firecurrent episodes of dissociative amnesia

•The fragmentations of identity may vary across cultural contexts le.g

3 Types of Dissociative Amnesia possession-form presentations) and with circumstance. Thus, individuals
may expertence discontinuities in identity and memory that may not he
-People with dissociative amnesia are often unaware or only partially aware of
immediately evident to others or are obscured by attempts to hide
their gaps in memory. No permanent damage occurs, it is reversible.
dysftinction
•Localized Amnesia:

- Failure to recall events during a spefic period of time.

Important terms to remember:
•Selective Amnesia
•System a term used to refer to individuals with dissociative identity (disorder
- Some, but not all, events can be recalled during a period of time (DID).
Only part of a traumatic event may be remembered.
•Fronting a term used to refer to the act of taking control of the body and the
•Generalized Amnesia conscious part of the mind.

-complete amnesia for one’s life history. May forget their identity and sudden •Alters-is a dissociated self state. Most if not all alters can take recurrent
onset executive control of the body in which they reside.

Dissociative Amnesia Symptoms Host – the alter that most commonly uses the body. Host alters collectively
fall under the category of fronters.
• Confusion
•Other types of alters are: protectors, persecutors, introjects, memory
• Depressive symptoms holders, gatekeepers, internal self-helpers, fragments, etc.

• Flashbacks •Different systems have different needs, and systems may or may not have
one or more alters for each of the above jobs. In smaller systems particularly,
• Difficulty in relationships due to memory loss alters might hold multiple roles.

• Suicidal thoughts, when memory is suddenly recovered and overwhelming •Each identity may appear to have a different personal history.sell image, and
to the individual name, although there may be some identities that are only partially distinct
and independent from other identities. In most cases, the one identity that is
most frequently encountered and carries the real person’s real name is the
host identity.

• The alter identities may differ in striking ways involving gender, age,
handedness, handwriting, sexual orientation, prescription for eyeglasses,
predominant affect, foreign languages spoken, and general knowledge.
•Alter identities take control at different points in time, and the switches
typically occur very quickly (in a matter of seconds), although more gradual
switches can also occur. When switches occur in people with DID, it is often •Structural Dissociation Theory states that all humans are born asia
easy to observe the gaps in memories for things that have happened – often collection of unintegrated self states that naturally integrate over unless this
for things that have happened to other identities. process is disrupted by trauma.

•In sum, DID is a condition in which normal integrated aspects of memory,

identity, and consciousness are no longer integrated
Treatment and Management Strategies

•While dissociative disorders can be challenging to treat, effective

•Add Honal symptoms of DID include depression, self-injurious behavior therapeutic approaches typically include psychotherapy, wherein individuals
frequent suicidal ideation and attempts, erratic behavior, headaches learn to process traumatic memories and develop coping skills. Common
hallucinations, posttraumatic symptoms, and other amnesic and tugue therapeutic modalities include cognitive behavioral therapy (CBT), dialectical
symptoms (APA, 2013: Maldonado et. Al., 2002). behavior therapy (DBT), and eye movement desensitization and reprocessing
(EMDR).

•Depressive disorders. PTSD, substance use disorders, and borderline

personality disorder are the most common comorbid diagnoses (Maldonado Treatment and Outcomes in Dissociative Disorders
& Spiegel, 2007).
•Treatment Challenges: Effective treatments are still being researched;
hypnosis and psychotherapy are common. Treatment approaches typically
include psychotherapy and medication, and effectiveness can vary widely
based on individual circumstances and the specific disorder.

Diagnostic Criteria for DID according to the DSM-5-TR:

A. Disruption of identity characterized by two or more distinct Therapeutic Approaches:

personality states, which may be described in some cultures as an
experience of possession. The disruption in identity involves •Psychotherapy: Cognitive Behavioral Therapy (CBT) and Dialectical
marked discontinuity in sense of self and sense of agency, Behavior Therapy (DBT) are commonly used to help patients discuss
accompanied by related alterations in affect, behavior, traumatic memories and develop healthier coping mechanisms. In therapy,
consciousness, memory. Perception, cognition, and/or sensory- individuals can work toward integrating aspects of their identity
motor functioning. These sigus and symptoms may be observed by
others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important persimal

information, and/or traumatic events that are unconsistent with Cognitive Behavioral Therapy (CBT)
urdinary forgetting.
-helps individuals identify and change negative thought patterns that affect
their emotions and behaviors. By focusing on specific problems, CBT
encourages clients to practice new coping strategies to improve their mental
health.
C. The symptoms cause clinically significant distress or impairmentin
social, occupational, or other important areas of functioning

Dialectical Behavior Therapy (DBT)

D. The disturbance is not a normal part of a broadly accepted cultural -Is designed for individuals with intense emotions and focuses on building
an religious practice. Note: In children, the symptoms are not skills in areas like mindfulness, emotional regulation, distress tolerance, and
better explained by imaginary playmates or other fantasy play interpersonal effectiveness.

Importance of Support Systems

E. The symptoms are not attributable to the physiological effects
substance (e.g., blackouts or chaotic behavior during alcohol •Effective management of dissociative disorders often requires the support of
Intoxication) or other medical condition (e.ge complex parital family, friends, and mental health professionals. A strong support network
seizures (American Psychiatric Association, 2022). can provide encouragement and understanding, which is crucial for
individuals navigating their dissociative experiences

Ethical Considerations in Treatment

How does DID develop?
•When recovering memories, particularly through techniques like hypnosis,
•Posttraumatic Theory states that DID starts from the child’s attempt to cope ethical considerations are paramount. The risk of creating false memories is a
with an overwhelming sense of hopelessness and powerlessness in the face significant concern in therapy.
of repeated traumatic abuse.

•Sociocognitive Theory states that DID develops when a highly suggestible

person learns to adopt and enact the roles of multiple identities, mostly
because clinicians have inadvertently suggested, legitimized, and reinforced
them and because these different identuues are geared to the individual’s
own personal goals.