Defining Mental Health Issues PDF

Defining Mental Health Issues Statistical Infrequency People exhibiting unusual behavior (talking to themselves in the street) may have a mental illness.​ Issues are that:​ Unusual behavior may not necessarily be due to mental illness, could be rehearsing a script for an audition.​ This suggests th...

Defining Mental Health Issues Statistical Infrequency People exhibiting unusual behavior (talking to themselves in the street) may have a mental illness.​ Issues are that:​ Unusual behavior may not necessarily be due to mental illness, could be rehearsing a script for an audition.​ This suggests that mental health issues are rare which isn’t necessarily the case (Is this true?). ​ World Health Organisation (WHO) – 2019 – 1 in 8 or 970 million people live with a mental health disorder (anxiety/depression most common). ​ Anxiety disorder: 301 mil, 58 mil children and adolescents. ​ Depression: 280 million ic 23 mil children and adolescents. NHS mental health of children and young people survey (2022) In young people 17-19 rates of probable mental health disorders rose from 10.1% 2017 to 18% 2010 to 26% 2022. Violation of Social Norms: Breaking of social conventions.​ Someone talking to themselves breaks social norms.​ Issues are that:​ May be deliberately rehearsing lines for an acting audition in front of people to practice, this is perfectly logical.​ To what extent do mental health issues depend on time and place? EXAMPLE : bertha pappenheim Attempts to understand Bertha Pappenheim’s mental health issues formed the very beginning of Psychoanalysis: Partial paralysis of her legs, arms, and neck muscles, which made it difficult, and at times impossible, to rotate her head or use her limbs. No physical bases for these symptoms could be found, instead they were thought to be due to the psychological stress from limited opportunities for women at the time: “She was markedly intelligent,.. great poetic and imaginative gifts,.. was bubbling over with intellectual vitality, which led an extremely monotonous existence in her puritanically-minded family.” “As was typical at that time, the brilliant Bertha was denied the higher education she clearly needed, while her brother was encouraged to pursue a professional career.” Berger (2009, p.32) Personal Distress Someone crying in the street displays personal distress, is this caused by a mental illness?​ Issues are:​ May have had some bad news/grieving, which is a very common natural reaction.​ Some forms of mental illness may not appear to be distressing. Dysfunction Mental state gets in the way of someone’s daily life.​ Someone crying in the street may be distressed because they have trypophobia and just saw someone with really big pores on their nose shocking them and causing them to vomit.​ Issues with this:​ Not all MHI are outwardly disabling e.g. bulimia.​ Most dysfunctional issues/disabilities don’t constitute mental issues. Historical Perspectives on Mental Health Prehistory: Biological-Supernatural Approaches TREPANATION STONE AGE: Holes drilled into the skull (stone age) some large 3-4 inches, some small. Some died from procedure some healed. Technique suggested to alleviate mental disorder, possibly by releasing evil spirits e.g. selling 1940. ​ 40% survival rate jumped to 80% later on, evidence of healing over of the skull Hippocrates and the Greeks Hippocrates born on Kos.​ Studied medicine in the Asklepion of Kos.​ Hippocratic medicine focus is that medicine should be practiced as a science, preventing disea se as well as treating.​ Holistic health care model: Science informed drug therapy, diet, physical and mental exercise.​ Physical and mental health interlinked.​ Sports and gymnastics essential part of all treatment.​ Music and theatre in treatment of mental illnesses strongly encouraged. Healing soul through music healed the body, specific musical application for certain diseases (Kleisiatis 2014).​ Optimise functional harmony between mind and body 'healthy body healthy mind'.​ Classical antiquity: Naturalistic approaches. Theories of Mental Illness Hippocrates (460-377 B.C.) – mental illness may have natural causes than supernatural.​ Mental health illness is caused in part by internal physical problems rather than trouble with bad spirits.​ Four fluids flow through body (yellow bile, black bile, blood and phlegm). Imbalance between these humours leads to physical brain pathology. e.g. an excess of black bile causes depression. Contributions of Marcus Aurelius and Galen Emperor Marcus Aurelius (161-180 AD) Followed stoicism.​ Kept notebook (MEDITATIONS) to cope with stresses of running Roman empire for positive thoughts and ideas.​ 'If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.'​ 'Very little is needed to make a happy life; it is all within yourself in your way of thinking.'​ These ideas Marcus took from Stoic philosophy remain the cornerstones of the most widely tested and used therapy today, CBT. Galen: Physician to gladiators of the high priest of Asia Distinguished between purely physical causes of mental distress and and emotional distressors Wrote passions of errors from the soul: directions for talk therapy We see the faults of others but not of ourselves western Roman empire broke up after his son took power Middle Ages: Shift in Focus MIDDLE AGES: (568 AD – 14th century) end of western Roman empire.​ Greco Roman positive approaches put on hold, Europe decided to focus on the supernatural for some reason. Example: Bethlehem Hospital EXAMPLE: Bethlehem Hospital:​ Priory housing for poor and sick.​ Built in 1247 (Henry III times). Pronounced bedlem by local people High society went for amusement Dr Johnston and bedlam’s entertainment: famous English man wrote dictionary. He visite bedlam also Historical Context of Mental Health Treatment Early Views and Entertainment Thomas More (1522): “…thou shalt in Bedleem see one laugh at the knocking of his head against a post” = wealthy went there to be entertained by those with mental illnesses or disabilities (one of London’s greatest tourist attraction)​ Dr Johnson and bedlams entertainment Gutenberg (1440)​ Printing press allowed for dissemination of knowledge on new mass scale​ Renewed interest in classical antiquity (greco-roman techniques) Leading to…. Scientific Renaissance Scientific renaissance start:​ Galileo (1610)​ Found moons orbiting Jupiter with new telescope​ Contradicted the geocentric model of Ptolemy, which was backed and accepted by the Roman Catholic Church (cue inquisition)​ Scientific renaissance end:​ Newton's Principia Mathematica (1687)​ Laws of motion to explain this orbiting​ No inquisition Power of reason more useful for understanding world The Enlightenment Era The enlightenment: (17th-18th cent)​ Power of reason to understand the world and improve the human condition Resurgence I’m ideas of classical antiquity Reforms in Mental Health Treatment York Retreat REFORMS: York Retreat​ Hannah Mills: Quaker​ Young widow from Leeds​ Admitted to York asylum for melancholy (clinical depression)​ Relatives requested York Quakers visit her but they were denied permission​ She died there 29th April 1790​ Shocked Quakers Wanted to honour her to do something better​ William Tuke enlisted to develop more humane alternatives​ New York Retreat opened 1796 – model for progressive practices worldwide Bethlem Reforms REFORMS: Bethlem​ Edward Wakefield (1814): Quaker​ During inspection for parliamentary report on madhouses​ Was appalled by Bethlem​ Focused on JAMES NORRIS: restrained for 12 years​ Apparatus severely restricted his movement​ “.. a stout iron ring was riveted about his neck, from which a short chain passed to a ring made to slide upwards and downwards on an upright massive iron bar”​ “. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection, which being fashioned to and enclosing each of his arms, pinioned them close to his sides” Massive scandal in parliament​ Wakefield’s findings led to House of Commons Select Committee Report on Madhouses (1815) and subsequent reforms. Sarah gardner: 26 year old servant admitted from stress and thought of self harm after talk in her neighbourhood of her working for a single man and the stigma and had been deserted by fiancé. was admitted to bethlem and discharged two months later. john Payne: charged with ruffuanism and homocide. And killed another inmate dies to delirium, was transferred to bethlem. viscious tendancies Acquitted for reasons of insanity.​ Then transferred to broadmoore acquired triads and gave up alcohol, then Ended up being discharged into sisters care. Got better. Treatment Options in Historical Context Early Treatments TREATMENT OPTIONS:​ THE SWING: 1772​ Belief that madness was caused by inflammation of the brain​ BENJAMIN RUSH (1772) designed two devices to reduce inflammation by reducing sensory input:gyrator/swing which spun patients to presumably reduce attention to outside world​ “I have the pleasure of knowing that he continues well, and I am confident owes his life and reason to the swing.” – Dr Joseph Mason Cox (1811).​ WET PACKS: early 20th century​ Treatment for schizo​ Wrap in wet sheets (packs) and lay in neat rows WATER BATHS: early 20th century​ Treatment for schizo + others​ Duration: hrs to days​ Arms allowed out at mealtimes​ Water temp:​ Warm (Relaxing)​ Cold (reduce agitation) Lobotomy FULL FRONTAL LOBOTOMY: 1935​ MONIZ​ Entered brain through top of skull​ Severed connections between thalamus (emotions) and frontal lobes (thoughts) in a single patient​ Supposedly they improved​ Won Nobel Prize for medicine in 1949​ FREEMAN AND WATTS (1942)​ ‘improved’ this technique using transorbital techniques​ Entered brain via eye sockets after shock to head and used ice picks​ Went on tour through US performing thousands 150 1945 5000 1949 many willing patients moved away to where he could perform on regular people used on housewives who were bored or depressed, on hyperactive children 19 Evaluation:​ Moser (1969)​ On average patients worse than before​ Variety of new psychological deficits including:​ Apathy​ Lack of initiative​ Learning deficits​ 10-20% death rate​ Incidence rates of lobotomies declined rapidly following the introduction of neuroleptics, and is now used very rarely indeed - and not in the treatment of schizophrenia. Classification of Mental Disorders Historical Classification CLASSIFICATION OF MENTAL DISORDERS:​ HIPPOCRATES: list of different mental disorders​ Mania, Melancholy, Phrenitis, Insanity, Disobedience, Paranoia, Panic, Epilepsy and Hysteria.​ Mental illness viewed as effect of nature on man​ Treated like other diseases​ Believed more effective treatment if handled in a similar manner to physical ailments​ Argued that the brain is responsible for mental illness​ Sensitivity reach the brain through mouth by breathing (Kleisiaris et al 2014) DSM and ICD DSM:​ Diagnostic and statistical manual of mental disorders​ First published in 1952 by American Psychiatric Association​ 106 disorders​ Linnaeus (1707-1778) father of modern taxonomy: mental disorders classified/”pigeonholed” grey area needs to be recognised DSM-5 2013. Minor revision in 2022 (DSM-5TR):​ Approx 400 disorders​ More dimensional approach than earlier editions​ Disorders seen as more continuums rather than black or white MEZZICH (2002): DSM-IV most valued for research​ However very expensive​ Motions for criteria controversial Dsm: Medicalisation of mental state: Dexedrine (anphetamine) SMITH KLINE AND FRENCH​ Contained d-amphetamine – psychomotor stimulant​ Promoted to housewives who were feeling in a state of “mental and emotional fatigue” from being crushed by dull workload COSGROVE et al (2006):​ Major financial ties between DSM-5 panel members and drug industry across nearly all committees. Connections most strong (100%) when drugs are the first line of treatment​ e.g. mood disorders and schizophrenia​ Capitalism plays a big role in classifica of disorders Critiques of Classification Systems IC"D:​ Originally only for physical ailments​ WHO (world health organisatio) took task of maintaining ICD in 1949​ Added a section on mental issues​ 88 disorders​ ICD-11 (2022)​ Latest version​ Section on mental behavioural and neurodevelopmental disorders includes hundreds of conditions​ Simple general descriptions of conditions clinicians find easy to use​ FREE​ However more qualitative descriptions of conditions than DSM​ More emphasis on general descriptions​ Mezzich (2002): “comparing the two most visible diagnostic systems… DSM 5 more valued for research​ ICD lagged on intro of new conditions Body Dysmorphic Disorder Body Dysmorphic Disorder​ First introduced by DSM-III in 1980​ Called Atypical somatoform disorder​ Term body dysmorphic disorder introduced in DSM-III-R in 1987​ Hypochondriacal disorder mentioned symptoms of BDD​ Basic symptoms of BDD first mentioned briefly in ICD-10 (2010)​ BDD not introduced as distinct condition until 2022 in the latest version the ICD-11 General Criticisms of Manuals General criticisms of the manuals of mental health issues:​ BRITISH PSYCHOLOGICAL SOCIETY (2011):​ Disorders categorised as ‘not otherwise specified” run at 30% of all disorders​ Some categories still very wide ranging e.g. anxiety disorders run from generalized anxiety to 100s of specific phobias and agoraphobia to panic attacks and selective mutism: or OC disorders from OCD to hoarding disorders to body dysmorphic disorders​ Diagnosis from this have problems of reliability and consequent validity​ Too many criteria based on social norms and cultural dependence with symptoms relying on subjective judgments Reliability and Cultural issues Reliability Issues Reliability issues with manuals of mental health issues:​ STUDY: Freedman et al. (2013)​ Major study examining reliability of using the DSM-5​ Measured extent of agreement between psychiatrists on diagnosis of certain disorders​ Very low levels of agreement on the most common disorders such as generalized anxiety and depression Cultural Dependence CULTURAL DEPENDENCE:​ DSM-II published in 1968 classified same sex orientation as a mental disorder​ Revised in 1970, not removed entirely until DSM-IV in 1994​ Obesity still not feeding and eating disorder in the DSM-5 (much debate on this) Section 1: Rise and Fall of DID in Popular Culture Fall of DID Loss of credibility: DID's credibility was questioned due to overdiagnosis, media sensationalism, and cases where therapists induced symptoms through iatrogenic factors (leading questions, suggestion, and false memory implantation). DSM-5 Criteria for DID Criterion A: ​ Disruption of identity involving two or more distinct personality states. In some cultures, these may be described as possession. ​ Marked discontinuity in self and sense of agency, accompanied by alterations in behavior, memory, perception, cognition, and sensory-motor functioning.​ Criterion B: ​ Recurrent gaps in the recall of everyday events, important personal information, or traumatic events that go beyond ordinary forgetting. Key Case Studies Jeanne Fery (1584-1585): Van der Haft et al (1996) ​ Context: Jeanne Fery was a Dominican nun in 16th-century France who exhibited behaviors now seen as consistent with DID. ​ Symptoms: Jeanne claimed to be possessed by multiple internal devils, each representing aspects of trauma or sinful behavior: ○​ Mary Magdalene: Acted as an internal helper, appearing during crises. ○​ Belial: Represented the seven deadly sins, with 50 devils in total. ○​ Other entities included Cornau (disturbed eating behaviors), Sanguinaire (demanded self-harm), and Garga (responsible for her body-banging and self-strangulation). ​ Treatment: Over a 21-month period, Jeanne underwent exorcism and extensive care from her fellow nuns and priests. The process was well-documented. 1584-November,  ​ Outcome: Jeanne reported a severe struggle between her personalities, which resulted in the devils 'leaving' her body after a dramatic conflict. Mary reportedly told her to publish all her secrets leading to the fight between her ‘devils’. Anneliese Michel (1952-1976): ​ Context: A German woman from a religious family who began showing signs of epilepsy and depression in her youth. ​ Symptoms: First seizure in 1968 depression and psychiatric care. By 1973, Anneliese started showing signs of possession, becoming intolerant to religious symbols and hearing voices. ​ She claimed to be possessed by six demons: Lucifer, Judas Iscariot, Nero, Cain, Hitler, and Fleischmann. ​ Exorcisms: Between 1975 and 1976, she underwent 1-2 exorcisms per week. ​ Outcome: Anneliese died of malnutrition and dehydration on July 1, 1976, after refusing medical treatment in favor of exorcisms. ​ Her death sparked legal battles and ethical questions about the nature of her treatment. The Sybil Case (Shirley Mason) Background: ​ Shirley Mason (known as Sybil) was the subject of a famous case of Multiple Personality Disorder (now Dissociative Identity Disorder - DID). ​ Dr. Cornelia Wilbur, a psychoanalyst, treated Shirley over many years and documented the case in the 1973 book Sybil, written by Flora Rheta Schreiber. Personality Alters: ​ 16 distinct personalities were reportedly identified during Shirley Mason's psychoanalysis. Examples include: ○​ Sybil Isabel Dorsett: The main personality. ○​ Victoria Antoinette Scharleau ('Vicky'): A self-assured, sophisticated French girl. ○​ Peggy Lou Baldwin: Assertive, enthusiastic, and often angry. ○​ Marcia Lynn Dorsett: An extremely emotional writer and painter. ​ Most of the 'alters' had limited or no knowledge of each other, which is a common feature of DID. ​ The psychoanalysis reportedly ended with the integration of the personalities into a new self, called 'The Blonde.'​ Controversy and Criticism: RISE of DID Historical precedence: Early accounts of DID-like symptoms can be seen in cases such as Jeanne Fery (1584-5).​ 1980s explosion: DID diagnoses increased significantly, influenced by the popularity of cases like Sybil and increased media attention. 1981: dr bennett braun Richard Luft and Putnam joined dam advisory committee 1983: founded international society for the study of multiple personality disorder 300 members in first conference 1984-1987: 3 new members had discovered over 800 new cases 1987: DID placed 1 in the DSM-III-R after previously being much further down previously. 'recent reports suggest that this disorder is not nearly so rare as it has commonly be thought to be Nathan (2011): Sybil Exposed: ○​ No evidence of alters prior to Shirley's extensive psychoanalysis. ○​ Shirley was coached and encouraged by Dr. Wilbur to produce these multiple personalities through: ○​ Leading questions during therapy. ○​ Techniques that heightened her suggestibility and fantasy proneness. ​ Unethical Therapeutic Methods: ○​ Dr. Wilbur regularly injected Shirley with sodium pentothal (truth serum) during sessions. ○​ Shirley was prescribed high doses of powerful drugs, including: ○​ Daprisal, Demerol, Dexamyl, Edrisal, Equanil, Seconal, and Serpatilin (tranquilizer + Ritalin). ○​ Thorazine, a potent antipsychotic known for severe side effects (restlessness, confusion, blackouts). ○​ Wilbur also conducted electroconvulsive therapy (ECT) on Shirley, clamping paddles to her temples, which caused violent convulsions after climbing into bed with her. ​ 1958 Confession: ○​ In 1958, Shirley Mason confessed that she did not have multiple personalities:​ 'I do not have any multiple personalities... I do not even have a double... I have been essentially lying.' ​ Despite this confession, her story continued to be propagated and became the basis for the famous book and film. Cultural Impact and Legacy ​ The Sybil case became a cultural phenomenon, contributing significantly to the rise in Multiple Personality Disorder (DID) diagnoses in the 1980s and 1990s. ​ Nathan’s investigation in Sybil Exposed revealed that the case was largely fabricated through suggestive and unethical therapy, turning it into a cautionary tale about mass cultural delusion.  ​ The case raises questions about the validity of some mental health diagnoses that may be influenced by cultural trends or therapeutic practices, such as modern phenomena like 'TikTok Tics.'​ Key Takeaways: ​ Sybil's personalities were likely a product of suggestive therapy and medication rather than genuine DID. ​ The case illustrates the dangers of unethical therapy, where the therapist’s influence can create false narratives. ​ It serves as a warning to critically examine voguish diagnoses that may not be based on solid evidence but are instead influenced by cultural trends and suggestibility. Section 2: Fall and Rise of DID in Scientific Research Key Case Study: Patricia Burgus Patricia Burgus (1986): ​ Dr. Braun linked devil worshipping cults with DID 'widespread' (lying). ​ 'Satanic cults were transgenerational family traditions that have been going on in secret for at least 2000 years.' ​ 1986: she was treated by him for 6 years. ​ Initially believed to have 20 personalities but was given sodium amytal (truth serum) and hypnotized. By end of therapy had 300 personalities. ​ After this began to remember early experiences of satanic cult and cannibalism even sending off meat from burgers they had made to be tested, they were negative. ​ However, Dr. Braun claimed the results were inconclusive. ​ He used her as a showpiece for his theory. Sybil's Case and Controversy Initial Diagnosis and Treatment Initially believed to have 20 personalities but was given sodium amytal (truth serum) and hypnotised.​ After this began to remember early experiences of satanic cult and cannibalism even sending off meat from burgers they had made to be tested, they were negative.​ However Dr. Braun claimed the results were inconclusive.​ He used her as a showpiece for his theory.​ Results: By the end of the therapy she had 300 personalities and cut ties with family (own children also).​ In Braun for malpractice and in 1997 won $10.6 mil settlement. Criticism and Ethical Concerns Nathan (2011): Sybil Exposed: No evidence of alters prior to Shirley's extensive psychoanalysis.​ Shirley was coached and encouraged by Dr. Wilbur to produce these multiple personalities through: ​ Leading questions during therapy. ​ Techniques that heightened her suggestibility and fantasy proneness.​ Unethical Therapeutic Methods: ​ Dr. Wilbur regularly injected Shirley with sodium pentothal (truth serum) during sessions. ​ Shirley was prescribed high doses of powerful drugs, including: Daprisal, Demerol, Dexamyl, Edrisal, Equanil, Seconal, and Serpatilin (tranquilizer + Ritalin). ​ Thorazine, a potent antipsychotic known for severe side effects (restlessness, confusion, blackouts). ​ Wilbur also conducted electroconvulsive therapy (ECT) on Shirley, clamping paddles to her temples, which caused violent convulsions. Confession and Cultural Impact 1958 Confession: In 1958, Shirley Mason confessed that she did not have multiple personalities: ​ "I do not have any multiple personalities... I do not even have a double... I have been essentially lying."​ Despite this confession, her story continued to be propagated and became the basis for the famous book and film.​ Cultural Impact and Legacy: The Sybil case became a cultural phenomenon, contributing significantly to the rise in Multiple Personality Disorder (DID) diagnoses in the 1980s and 1990s.​ Nathan’s investigation in Sybil Exposed revealed that the case was largely fabricated through suggestive and unethical therapy, turning it into a cautionary tale about mass cultural delusion. FALL of Dissociative Identity Disorder (DID) Membership and Publication Changes Fall of DID: 1993-1998 ISSMP&D lost nearly half its members (Piper & Merskey 2004).​ 1998: main journal for dissociative disorders stopped publishing. DSM Changes and Interpretations DSM-IV 1994 dropped DID back to 3 in dissociative disorders chapter.​ “The sharp rise in reported cases of Dissociative Identity Disorder in the United States in recent years has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestible.” p.486 Critical Reviews and Perspectives: Important reviews argued that DID is a fantasy/suggestibility phenomenon: ​ Piper & Merskey (2004a,b) “The Persistence of Folly” – Parts 1 and 2. ​ “DID is best understood as a culture-bound and often iatrogenic (caused by a therapist’s leading questions) condition.” ​ Piper & Merskey (2004b): “Is Iatrogenesis the Royal Road to DID?” p.681. ​ Giesbrecht et al. (2008): major review: ​ “... it is associated with an enhanced propensity toward pseudo-memories, possibly mediated by heightened levels of interrogative suggestibility…[and]…fantasy proneness…” Fantasy/Sociocognitive Model of DID Fantasy-Proneness and False Memories Dalenberg et al. (2012): ‘Fantasy’ model - fantasy-proneness and related factors are intrinsic characteristics of some individuals, which with inappropriate forms of therapy may lead to false memories and related phenomena said by some to be the main features of DID. Suggestibility: implantation of false episodic memory: ​ Loftus and Pickrell (1995): ​ “14-year-old boy named Chris was supplied with descriptions of 3 true events that supposedly happened in Chris' childhood and one fake event being lost in a shopping mall. ​ Instructed to write about all four events every day for 5 days. Chris remembered more and more about getting lost. He remembered being scared that he would never see his family again. He remembered his mother scolding him. Gave it the second highest rating out of all the memories. ​ Didn't believe then when they told him it was false Repeated Studies on Suggestibility A few weeks later, Chris was reinterviewed. For the false shopping mall memory, he assigned his second-highest rating: 8. …provided rich details about the toy store where he got lost and his thoughts at the time ("Uh-oh. I'm in trouble now.").​ Chris was told that one of the memories was false and to identify. …He selected one of the real memories! When told that the memory of being lost was the false one, he had trouble believing it. “ p. 721​ Repeated this with 24 participants: ​ 4 events ​ 1 false event arranged by family members ​ Initial booklet, then 2 follow-up interviews. ​ Firstly about a third of the participants recalled the first memory. ​ Secondly the false memory’s subjective clarity increased between interviews, the more they thought about it! Suggestibility culture dependency? Historical Context and Modern Cases Changing Character of DID: Over the past century, Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder (MPD), has drastically changed in presentation.​ These changes may be influenced by demand characteristics, where societal or clinical expectations shape how patients present symptoms. Historical Examples Spanos (1994): ​ In the 19th and early 20th centuries, MPD patients typically exhibited only two or three alters. ​ Switches between alters were often associated with transitional sleep, where patients had periods of unconsciousness or seizures before transitioning into a different alter. Sauvage (1768): ​ Describes a young woman who experienced a seizure in the morning, followed by a period of liveliness (a “live fit”), during which she behaved animatedly but had no memory of her actions when she returned to her normal state. Spanos 1994: ​ Modern DID patients often present with 15 or more alters, with some cases reporting over 100 alters (Ross, Norton, & Fraser, 1989). ​ This exponential growth in the number of dissociated memory systems suggests that cultural and therapeutic factors may play a role in how the disorder is expressed. ​ Differences in amnesia and memory recall patterns over time indicate that DID patients may alter their behavior based on expectations in therapeutic settings. The procedures used to diagnose DID may create rather than discover multiplicity in  personalities, suggesting that suggestibility and therapist influence contribute significantly to the disorder’s presentation. Sociocognitive/Fantasy Model This model proposes that therapy acts as a kind of "Shopping Mall Experiment," where patients are encouraged to "select" personalities or behaviors based on suggestions from therapists or cultural influences.​ DID is seen as a culturally-dependent phenomenon, where the disorder is shaped by social norms, media portrayal, and therapeutic practices. Key Takeaways Suggestibility and cultural expectations play a major role in shaping the presentation of DID over time, leading to a dramatic increase in the number of alters reported in modern cases. Understanding DID Cultural Influences on DID DID is seen as a culturally-dependent phenomenon, where the disorder is shaped by social norms, media portrayal, and therapeutic practices.​ Suggestibility and cultural expectations play a major role in shaping the presentation of DID over time, leading to a dramatic increase in the number of alters reported in modern cases.​ The sociocognitive/fantasy model argues that DID is a culturally constructed disorder, often influenced by therapeutic practices, rather than a purely spontaneous condition. Trauma Model of DID Dalenberg and Carlson (2012): a variety of traumatic events may be at least partially responsible for DID, and the extent to which defence mechanisms such as dissociation or fantasy proneness are employed may determine whether PTSD or true DID is the outcome. Defense Mechanisms in DID Dissociation Marmar et al (1994): Vietnam veterans reported many peri-traumatic dissociative experiences. Freud's Perspective Freud: The splitting of consciousness … is so striking in the well known classical cases under the form of ‘double conscience’ i.e. the distressing antithetic idea, which seems to be inhibited, continues to exist as a disconnected or dissociated idea, often unconsciously to the patient himself. Avoidance Techniques Dalenberg and Carlson (2012): Avoidance techniques: derealization, depersonalization or gaps in awareness reflect efforts to reduce distress through distancing. The relief provided by intentional or unconscious efforts to avoid reminders of trauma tends to reinforce the efforts and they increase on frequency. reStudies on Trauma and Dissociation Homeless Veterans Study Mamar et al 1994: vietnam veterans reported many peri-traumatic dissociative experiences. Carlson et al (2012): examined the relationship between severity of PTSD and those of self-reported dissociation in several groups. Childhood Trauma Study Allen et al (2002): higher mean score of childhood trauma associated with a higher probability of dissociative tendencies in adulthood. Fantasy Proneness and Dissociation Research on Fantasy Proneness Merckelback et al (2022): Researchers believe that the genesis of fantasy proneness is accredited to adverse childhood experiences and trauma-related psychopathology. Fantasy proneness is fuelled by a need to escape adverse childhood experiences and functions as an automised habitual defensive reaction. Overlap with Dissociative Symptoms Kluemper and Dalenberg (2014): Fantasy proneness and dissociative symptomology overlap because both originate from a traumatic history and both involve absorption. (i.e. a state of strong attentional focus) which could be construes as a mental flight from adverse memories. PTSD and DID Van Heuten et al (2014): both participants with PTSD and DID showed much higher levels of dissociative tendencies and fantasy proneness. Not features specific or sufficient enough to cause DID as per the fantasy model then but defence mechanisms to the experience of trauma. Sociocognitive/Fantasy Model Characteristics of Individuals Dalenberg (2012): fantasy proneness and related factors are intrinsic characteristics of some individuals, which with inappropriate forms of therapy may lead to false memories and related phenomena being the main features of DID. Research Findings Vassia et al. (2016): Four groups of participants: 1.​ Participants with DID, tested in two identity states: ​ DID-G (NIS) Neutral identity state (no/limited access to traumatic events) ​ DID-G (TIS) Trauma-related identity state, fixated on traumatic memories and Corry on defensive actions when feel threatened 2.​ Participants who simulated DID: spent weeks training pro actors to dev their own neutral and trauma identity states DID-S (NIS) and DID-S (TIS). There were pages of instructions, videos and movies to watch. 3.​ Participants with PTSD. 4.​ Controls, no training or prior issues. LEADING QUESTIONS: Used Gudjonsson suggestibility scale: Participants read a passage and were later interviewed with leading questions. Results: Vissia et al. (2016): People with DID were not more vulnerable to the ‘Leading Questions Test’, in fact when in their TIS they were inclined to be the least suggestible group! FALSE MEMORIES: Used Deese–Roediger–McDermott Scale: Given list of words told needed to recall later e.g. “…table, sit, legs, seat…” Later asked how confident that a newly presented, but closely associated ‘critical lure’ target word had been in the original list, e.g. “Chair”. Results: Vissia et al. (2016): again, people with DID were clearly not more influenced by ‘critical lure’ keywords into thinking they’d previously seen a word when they hadn’t: if anything when in their TIS there were a little less suggestible! NIS vs TIS – Enhanced Trauma Response: Compared DID’s (NIS and TIS) with high fantasy-prone non-DID controls. If DID findings are due to high fantasy-proneness, DID’s should look like high-fantasy-prone controls. Reinders et al (2012): DID patients showed a larger response to traumatic stimuli when in TIS vs NIS compared with high fantasy, healthy controls. Differences not due to high fantasy proneness. Neurological basis: Baseline differences: sar et al 2007: baseline regional cerebral blood flow measurements decreased blood flow in DID participants in orbitofrontal regions of host personality states. But is this due to DID directly or due to fantasy proneness? DSM-TR Criteria for DID: ​ Criterion A. Disruption of identity characterized by:​ two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. ​ Criterion B. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting. To assess gaps in recall, did Working memory: ​ Vissia et al. (2022): used n-back test for working memory. with DID-S, DID-G and Controls, in NIS and TIS’s. Controls in TIS were diagnosed with PTSD. ​ 1-back (1 possession back), 2-back (2 positions back), 3-back, all get progressively harder over time ​ Results: Controls and DID-S participants performed similarly on the n-back test of working memory to each other, whether in NIS or TIS states. However, DID-G participants were uniquely poor when in their TIS. Treatment of DID Diagnosis via Pattern Recognition Reinders et al (2019): used a pattern recognition technology to identify people with DID to an accuracy level of around 74%. " This level of accuracy is comparable to what has been demonstrated for most psychiatric disorders…” “…We found widespread grey and white matter spatially dependent patterns of abnormal brain morphology in individuals with DID as compared with healthy controls.” Treatment Stages Brand et al (2012): surveyed 36 international experts on treatment for DID, identifying key features of each stage. Treatment Outcomes Brand and Loewenstein (2014): about 298 therapists and DID patients somewhat reduced symptoms of DID following long-term therapy. Treatment 2: Brand et al 2012: 1.​ Most clinicians use a variety of techniques aimed at establishing a feeling of safety and building an alliance between patient and clinician 2.​ Builds on stage 1, with maybe some CBT where we change distorted cognitions 3.​ Still building on safety and alliance from 1 and 2, but contains more direct trauma based work e.g. recall of earlier traumatic events, CBT more likely to occur at this stage and distorted, trauma related cognitions may be challenged and reconsidered. 4.​ 4-5 Increasing daily functioning skills and relationally focussed work/ emotion regulation are priorities. Direct trauma focuses work less important. Overview of Substance-Related and Addictive Disorders Substance-Related Disorders Substance-related disorders: Alcohol, Caffeine, Cannabis, Hallucinogen, Inhalant, Opioid, Sedative/hypnotic/anxiolytic, stimulant, tobacco… Non-Substance Related Disorders Non-substance related disorders: Gambling disorder (only one it has) DSM-5 (2013) Insights ‘Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as 'sex addiction', 'exercise addiction', or 'shopping addiction', are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.’ (p.481) Social Networking and Addiction Facebook Addiction Disorder Kuss 2011: From a clinical psychologist’s perspective, it may be plausible to speak specifically of ‘Facebook Addiction Disorder’ (or more generally ‘SNS Addiction Disorder’ [Social Networking Sites]), because addiction criteria, such as neglect of personal life, mental preoccupation, escapism, mood modifying experiences, tolerance, and concealing the addictive behavior, appear to be present in some people who use SNSs excessively… Social Networking and Reward Farari et al: Participants in fMRI working to win rewards in card game. Played together with a computer, an unknown person or a friend. The same rewards were rated as most exciting when won with a friend. Measured mesolimbic dopamine system at same time Ventral Tegmental Area (VTA):​ Function: Origin of dopaminergic neurons that project to various brain areas.​ Role: Releases dopamine in response to rewarding stimuli. ​ In this study excitement increases from comp to confederate to friend (Ferrari et al) Nucleus Accumbens (NAc):​ Function: Receives dopamine from the VTA.​ Role: Processes reward and reinforces pleasurable behaviors. ​ Looked at Facebook and neural response to likes and response to self likes. Responded more in this area when likes for self than for others. Medial Prefrontal Cortex (mPFC):​ Function: Involved in decision-making and impulse control.​ Role: Modulates the VTA and NAc, regulating responses to rewards. How They Work Together When you encounter something rewarding, the VTA releases dopamine to the nucleus accumbens, creating pleasure.​ The mPFC helps regulate this by evaluating the situation and controlling impulsive responses.​ This system is essential for learning, emotional regulation, and goal-directed behavior. Social Networking and Brain Activity Reward-Related Brain Activity Activity in the ventral striatum tracked individuals' subjective excitement during rewards.​ The ventral striatum, a key region in the brain's reward system, was most activated when participants received rewards while sharing the experience with a friend. Neural Response to Likes on Facebook The nucleus accumbens of participants responded more strongly when they received Likes on their Facebook posts compared to when they observed others receiving Likes.​ The study also revealed that the heaviest Facebook users exhibited the largest brain response, indicating a stronger reward reaction to social validation in those more engaged with the platform. TikTok and VTA Activation Participants viewed TikTok-style images that were either rather general in nature (GV), or tailored specifically to themselves (PV) as per TikTok’s selection algorithms used to drive engagement.​ Selected PV images increased VTA activity much more than GV viewing. (su et al) Increase activity in nucleus suc and mPFC Impact of Social Media on Brain Structure Grey Matter Loss and Facebook Use Increased time spent on Facebook was associated with reduced grey matter volume in the nucleus accumbens, a brain region involved in reward processing.​ This suggests that heavy Facebook use may negatively impact brain structure related to reward and motivation. (Montag et al 2017) Internet Addiction and Dopamine D2 Receptor Availability Found widespread drop-offs in dopamine D2 receptor availability in internet addicts throughout dopaminergic regions, including the nucleus accumbens.​ Increased time spent on Facebook is associated with reduced grey matter volume in the nucleus accumbens – a key brain region involved in reward and pleasure.​ This suggests that excessive social media use may impact brain structure, potentially influencing addictive behaviors and motivation. Specific Case Studies World of Warcraft World of Warcraft (WOW) images specifically activated the medial frontal cortex and nucleus accumbens—brain areas linked to reward and decision-making. Similar reaction to induce craving in substance dependance. ​ Activity in MPC ​ Activity in nucleus accumbent Online Gaming Addiction World of Warcraft (2009) found that World of Warcraft (WOW) images specifically activated the ​ medial frontal cortex and ​ nucleus accumbens—brain areas linked to reward and decision-making. ​ The study suggested that the neural substrate of online gaming addiction resembles the patterns of cue-induced craving seen in substance dependence, highlighting similar brain responses in both types of addiction. League of Legends Dong et al. (2017): League of Legends addicts self-reported extreme levels of craving before and after an LoL session, with hugely increased lateral, prefrontal and striatal activity.​ Dong et al. (2017) found that individuals addicted to League of Legends reported intense cravings before and after gaming sessions.​ This was accompanied by significantly increased activity in the ​ lateral prefrontal cortex and ​ striatum, brain regions involved in reward, decision-making, and impulse control, suggesting strong neural responses similar to addiction-related patterns. Grey Matter Reduction Yuan et al. (2011) found that individuals addicted to internet gaming (playing 10 hours/day for 3 years) showed reduced grey matter volume in several brain regions.​ The extent of grey matter reduction correlated with the duration of addiction, suggesting prolonged gaming may negatively impact brain structure over time. Dopamine D2 Receptors Tian et al. (2014) found that League of Legends addicts had reduced D2 striatal receptors (dopamine receptors), particularly in the nucleus accumbens.​ This reduction in dopamine receptors is linked to the brain's reward system, suggesting altered reward processing in individuals with gaming addiction. Reward/Punishment Sensitivity Dong et al 2011: Guessing task while in fMRI scanner: which of 2 cards is red (or black). Internet addicts showed ​ enhanced frontal activity during gains, ​ reduced anterior cingulate during losses. Hypersensitive to reward and subsensitive to punishing events (not put off)​ Dong et al. (2011) conducted a guessing task in an fMRI scanner, where participants had to choose between two cards (red or black).​ Internet addicts showed enhanced frontal activity during gains, but reduced anterior cingulate activity during losses.​ This pattern suggests increased reward sensitivity and decreased loss sensitivity in internet addicts, indicating altered decision-making and emotional responses. Treatment for Gaming Addiction Han et al 2010: Starcraft addicts (>7h/day) showed higher brain activation in dorsolateral prefrontal cortex with game cues.​ After 6 weeks Bupropion (also used to help people stop smoking), craving for game play and cue-induced brain activity in dorsolateral prefrontal cortex decreased.​ Game play time down > third. Gambling Addiction Neuropsychological Effects Potenza et al 2003b: first fMRI study of pathological gamblers – normal response to happy or sad videos, but increased activity to gambling videos in regions associated with reward reactivity (orange: nucleus accumbens).​ This suggests that gambling triggers heightened reward reactivity in individuals with gambling addiction. Craving and Brain Activity Crockford et al. (2005) presented sections of nature scenes (baseline) or gambling scenes to both controls and pathological gamblers.​ Pathological gamblers self-reported high levels of craving when viewing gambling-related images.​ Additionally, they exhibited enhanced frontal cortex activity, suggesting that gambling cues trigger strong craving and heightened brain responses in individuals with gambling addiction. Dopamine Release Joutsa et al. (2012) measured striatal dopamine release in pathological gamblers while they performed either a control task or a slot-machine task that accurately mimicked a typical real-world slot machine.​ The study found that dopamine release was significantly higher during the slot-machine task, suggesting that gambling cues, like those found in actual slot machines, trigger strong reward responses in the brains of pathological gamblers. Dopamine Release Correlation Joutsa et al 2012: increased accumbens dopamine release on a gambling vs. control task in pathological gamblers, and positive correlation between severity of gambling issues and size of dopamine release.​ This suggests that more intense gambling problems are associated with stronger reward responses. Higher level of gambling SOGS, higher dopamine release (pathological correlation) Shopping Addiction Decision-Making in Compulsive Shoppers Raab et al (2011): compulsive shoppers shown product pictures and decided whether they wanted each product or not once they were shown the price.​ The study explored how compulsive shoppers make decisions, particularly focusing on the impact of price on their purchasing behavior. Nucleus Accumbens Response Raab et al. (2011) found that compulsive shoppers exhibited a much stronger nucleus accumbens response during the initial presentation of items they later purchased.​ This heightened response indicates that the brain’s reward system is strongly activated when these shoppers first encounter products they are likely to buy.​ This suggests that reward-related brain activity may play a significant role in impulsive shopping decisions. Overview of Substance-Related and Addictive Disorders Types of Disorders Alcohol, caffeine, cannabis, hallucinogen, opioid, sedative/hypnotic/anxiolytic, stimulant, tobacco, inhalant …-related disorders!​ Non-substance related disorders: Gambling disorder Behavioral Addictions Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear.​ Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as "sex addiction," "exercise addiction," or "shopping addiction," are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders. (p.481) Alcohol-Related Disorders Alcohol Use Disorder Criteria Criterion A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 2.​ There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3.​ A great deal of time is spent in activities necessary to obtain alcohol, … or recover from its effects. 4.​ Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 5.​ Tolerance: need more for same effect. 6.​ Withdrawal symptoms: e.g. ‘cold turkey’ from heroin use. Historical Cases of Addiction Scythians and Substance Use Scythians: 9th-1st cent. BC West Eurasian Steppe Nomads.​ Herodotus (450BC): describes Scythian funeral rites:​ “…they make a booth by fixing in the ground three sticks inclined towards one another, and stretching around them woolen felts, which they arrange so as to fit as close as possible: creeping under the felt coverings, inside the booth a dish is placed upon the ground, into which they place red hot stones and then add some hemp seed. Immediately it smokes, and produces such a steam, that no Grecian vapour surpass it. The Scythians, delighted by the vapour, shout for joy.”​ Belinski (2016): unearthed rare Scythian goldware. Asked criminologists in nearby Stavropol to analyze a black residue found inside the vessels. The results came back positive for opium and cannabis. Emperor Marcus Aurelius Emperor Marcus Aurelius (161-180 A.D.): took the precaution of a daily dose of theriac, a concoction based on 'mithridatum' originally developed by 'The Poison King' Mithridates VI of Pontus (120-63BC) to offset the effects of poisoning attempts.​ Theriac contained opium, for anti-anxiety purposes according to Galen. “Very little is needed to make a happy life; it is all within yourself in your way of thinking.” Increasing Dosages of Theriac Marcus took heavier and heavier dosages of theriac during a campaign on the Danube, to combat the weather and strain of winter warfare.​ Cassius Dio (155-235AD): "He [Marcus] could not stand the cold or even address the assembled troops and ate very little and only at night. During the day he took nothing but some of the drug called theriac which he used, not because he was afraid [of poison], but in order to ease his stomach and his chest. They say that this habit made it possible for him to endure this and other things."​ Took a concoction mixing small amounts of different poisons to make him intolerant. However contained opium. He couldn’t get out of bed to address troops without this concoction. Showed DSM-5 criteria for addiction. Withdrawal Symptoms and Recourse to Poppy-Juice When he found himself getting drowsy at his duties, he had the poppy-juice removed from the compound, but then he was unable to sleep at night. Withdrawal symptoms.​ Galen explains that this was because his dry Humor was predominant:​ “So he was obliged to have recourse again to the compound which contained poppy-juice, since this was now habitual to him.”​ Africa (1961): What Galen ascribes to dry humours, a modern physician will recognize as the severe disturbance of opium withdrawal:​ “The mind of Marcus dwelt in the mountains because part of him cried from the depths.” Neurobiology of Addiction Mesolimbic Dopamine System: The mesolimbic dopamine system plays a central role in reward, motivation, and reinforcement. It involves several key areas: ​ Ventral Tegmental Area (VTA): The origin of dopaminergic neurons, crucial for detecting rewards and initiating dopamine release.  ​ Medial Prefrontal Cortex (mPFC): Part of the mesocortical dopamine projection. It regulates decision-making, impulse control, and goal-directed behavior, receiving dopamine from the VTA. ​ Nucleus Accumbens (NAc): Part of the mesoaccumbens dopamine projection. It processes rewards and reinforces motivated behavior, also receiving dopamine from the VTA.​ In summary, the VTA sends dopamine to the mPFC (influencing cognition) and the NAc (influencing reward and motivation), driving behaviors related to pleasure and goal pursuit. Electrical Brain Stimulation Research Olds & Milner (1954): investigating whether electrical stimulation of the reticular formation increased arousal and facilitated learning. Rats.​ In checking whether this stimulation might unfortunately be aversive, in one animal they observed a unique phenomenon:​ “I applied a brief train of 60-cycle sine-wave electrical current whenever the animal entered one corner of the enclosure. The animal did not stay away from the corner, but rather came back quickly after a brief sortie which followed the first stimulation, and came back even more quickly after a briefer sortie which followed the second stimulation. By the time the third electrical stimulus had been applied the animal seemed indubitably to be “coming back for more”. ​ Stimulation was small/equivalent to what the neurons were producing themselves (mimicked stimulation from drugs). Discovery of Intra-Cranial Self-Stimulation Mispositioned electrode (too high) was probably located in the region of the hypothalamus, through which passes the medial forebrain bundle (mfb).​ The mfb is a major highway from ascending and descending neural tracts, including the mesoaccumbens dopamine projection from the VTA to the nucleus accumbens. Reinforcement of ICSS Subsequent studies allowed rats to induce electrical current in the region of the mfb themselves - hence ‘intra-cranial self-stimulation’, or ICSS.​ As we’ll see in the next study by Olds (1958), ICSS in the mfb is EXTREMELY reinforcing. Human Studies on ICSS Bishop et al. (1963) studied intracranial self-stimulation (ICSS), where humans could stimulate their brain’s reward centers.​ They found that ICSS could be so reinforcing that participants would ignore basic needs, such as food.​ In one experiment, after being without food for 7 hours, a participant ignored an attractive food tray placed nearby and continued responding for ICSS.​ Although they repeatedly glanced at the food, they didn’t stop to eat, later stating they knew they could have, but chose not to. This shows how powerful reward stimulation can be, overriding even hunger and essential needs. Mesoaccumbens Dopamine and Reward THC and Dopamine Release Bossong et al. (2008) found that Δ9-tetrahydrocannabinol (Δ9-THC), the main psychoactive compound in cannabis, increases dopamine release in the ==striatum,== a brain region involved in reward and motivation.​ Using PET scans, they showed that THC activates the brain's reward system, similar to other addictive substances. This explains why cannabis use can lead to feelings of euphoria and reinforce use. Methylphenidate and Dopaminergic Activation Kalivas & Volkow (2007) found that dopaminergic activation in the striatum (where nucleus accumbens is found) was correlated with self-reported feelings of a 'high' after using methylphenidate, a stimulant commonly prescribed for ADHD. Psychomotor stimulant Dopaminergic Mechanisms in Addiction Mesoaccumbens Dopamine and Reward Kalivas & Volkow (2007) found that dopaminergic activation in the striatum was correlated with self-reported feelings of a 'high' after using methylphenidate, a stimulant commonly prescribed for ADHD. Their study showed that as dopamine levels increased in the striatum, participants reported stronger sensations of euphoria, linking dopamine release to the pleasurable effects of the drug. This suggests that the dopamine system plays a key role in the subjective experience of reward from stimulant use. Breiter et al. (1997) found that cocaine activates the nucleus accumbens in humans, a key brain region involved in reward processing. ​ Activation was strongest when participants were craving cocaine, suggesting that the nucleus accumbens plays a critical role in craving and the reinforcing effects of cocaine. ​ When addicts were shown videos of people using cocaine, they experienced increased activation in this area, further linking dopamine release with the psychomotor stimulant effects of cocaine. This highlights how cocaine triggers dopamine release and reinforces the craving and reward cycle in addicted individuals. Chronic Drug Use and Its Effects Dalley et al. (2011) used PET scans to observe ​ reduced dopamine receptors in the striatum of individuals and animals with a history of drug use. ​ They found that recently abstinent human cocaine addicts, a rhesus monkey after 3 months of intravenous cocaine self-administration, and a rat after extended exposure to amphetamines all showed lower dopamine receptor levels. This reduction suggests that chronic drug use, whether cocaine or amphetamines, can lead to long-term changes in the brain's reward system, potentially contributing to addiction and relapse vulnerability. Wiers et al. (2017) studied dopamine function in the nucleus accumbens of smokers. ​ They found that ==smoking led to a **reduction in the number of ==D2** dopamine receptors in this brain region. ​ Additionally, **methylphenidate-induced dopamine release was also diminished, suggesting that **smoking alters the brain's reward system by decreasing dopamine receptor availability and impairing the release of dopamine in response to stimulants. This highlights how smoking can affect dopamine function and may contribute to addictive behaviors. Franklin et al. (2002) found that crack cocaine addicts had reduced frontal grey matter volume (which contains neural cell bodies) compared to control participants. On average, the addicts had been using cocaine for 13 years, suggesting that long-term cocaine use can lead to structural changes in the brain, particularly in areas involved in decision-making, impulse control, and other cognitive functions. Thompson et al. (2004) found that methamphetamine addicts exhibited reduced grey matter volume across large areas of the brain, including regions such as the ​ cingulate gyrus, ​ subgenual cortex, and ​ paralimbic belts, which surround the corpus callosum. These reductions in grey matter, which contains neural cell bodies, suggest that long-term methamphetamine use can lead to widespread structural changes in the brain, particularly in areas involved in emotion, cognition, and sensory processing. Conditioning and Craving Pavlovian Conditioning and Dopamine The mesoaccumbens dopamine projection appears to modulate the efficacy of conditioned stimuli, rather than the impact of unconditioned stimuli. Zweynert et al. (2011) examined dopaminergic activation in the ventral striatum/nucleus accumbens following repeated presentations of reward cues (conditioned stimuli) in a specific situation. Participants were shown complex scenes (either indoors or outdoors), which were either paired with monetary rewards (reward cues) or not paired (control cues). The study found that dopaminergic activation in the ventral striatum/nucleus accumbens was stronger when the scenes were paired with reward cues, highlighting how conditioned stimuli associated with rewards can activate brain regions involved in motivation and reinforcement. Volkow et al. (2006) found that cocaine addicts, when shown videos of people using cocaine, exhibited a dopaminergic response in brain regions associated with reward, such as the nucleus accumbens. This response was not observed when the participants watched neutral videos. Importantly, the intensity of the dopaminergic response was correlated with self-reported cravings, suggesting that the brain's reward system is closely tied to craving and may play a role in the reinforcement of addictive behaviors. Conditioned Drug Effects Robinson & Berridge (1993, 2000); Berridge, Robinson, Aldridge (2012): drugs are addictive because they activate the mesoaccumbens dopamine projection, causing drug-associated stimuli to acquire potent conditioned properties (consequences from that).​ Re-exposure to drug-associated stimuli at a later date - perhaps months after the drug was last taken - activates memories of the drug experience itself, and hence craving for the drug. Craving for the drug may lead to relapse into drug-taking itself. Pharmacological and Psychological Treatments Pharmacological Treatments ​ Nicotine: nicotine patches/gum, ameliorate withdrawal symptoms and craving. ​ Opiates: (morphine, heroin) - methadone, mild non-high inducing version of heroin. Prevents onset of withdrawal symptoms, and also craving. ​ Alcohol: ‘Antabuse’ (Disulfiram), inert until alcohol consumed, then induces nausea, dizziness etc. Disulfiram is a medication primarily used to support the treatment of alcohol use disorder. It works by interfering with the metabolism of alcohol. When someone takes disulfiram and consumes alcohol, it causes unpleasant effects such as ​ nausea, ​ vomiting, ​ headache, ​ flushing. These reactions occur because disulfiram inhibits the enzyme aldehyde dehydrogenase, which is responsible for breaking down acetaldehyde, a toxic byproduct of alcohol metabolism. The accumulation of acetaldehyde causes the unpleasant symptoms, creating a deterrent for alcohol consumption. Disulfiram is used as part of a comprehensive treatment plan for alcohol dependence, often combined with therapy and support. It is not a cure for alcohol use disorder but serves as a tool to help individuals maintain sobriety by discouraging alcohol consumption. Extinction Therapy As long as the conditions don’t change, repeated presentations of Pavlovian conditioned stimuli will eliminate the conditioned response. Extinction therapy involves repeatedly presenting Pavlovian conditioned stimuli without the associated unconditioned stimulus (e.g., a reward or substance). Over time, this eliminates the conditioned response (e.g., craving or urges). It is used in addiction treatment to break the link between cues and addictive behaviors. However, the conditions must remain consistent to prevent spontaneous recovery of the conditioned response. Innovative Treatments Martell et al. (2005) tested a cocaine-specific vaccine (TA-CD) on cocaine addicts. The vaccine works by causing the immune system to recognize cocaine molecules and break them down more quickly, reducing their effects on the brain. The study found that addicts who received the vaccine showed a dose-dependent reduction in relapse rates, suggesting that the vaccine could be a promising approach to help prevent cocaine relapse by blocking the drug's effects. Xue et al. (2012) studied heroin addicts and found that cue exposure followed by extinction therapy effectively erased the craving response to drug cues. By repeatedly presenting drug-related cues without the drug, the study showed that craving could be reduced, demonstrating the potential of extinction therapy in treating addiction. ​ These results were very context speicfic and when they got home the cravings resumed, only worked within the laboratory Overview of Narcissistic Personality Disorder Learning Objectives Discuss the main features of NPD: grandiosity, need for admiration and a lack of empathy.​ Appreciate that grandiosity and related features may be seen as attempts to compensate for a deficit in sense of self, and self-esteem.​ Have some awareness of the neurobiological aspects of NPD, particularly in relation to a lack of empathy and a self-awareness. Historical Context and Definitions Mythological Roots Narcissistic personality disorder has its earliest roots in ancient Greek mythology. Many versions of the myth, but in all, Narcissus was a handsome and overly proud young man. Upon seeing his reflection on the water, he became so enamored that he could not stop gazing at his own image. He remained at the water's edge until he eventually wasted to death. Psychoanalytic Descriptions Otto Rank (1911): earliest psychoanalytic description narcissism, defined it as 'the being in love with oneself'.​ Sigmund Freud (1914): 'An Introduction to Narcissism'. Following on from Rank, described Narcissism in adults as a developmental issue in which the self-love or primary narcissism of the infant fails to become directed outwards towards others. DSM-5 Criteria for Narcissistic Personality Disorder Main Symptoms ​ Grandiose sense of self-importance: Routinely overestimate their abilities and inflate their accomplishments, often appearing boastful and pretentious. ​ Excessive need for admiration: Unrealistic sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). ​ Lack of empathy: unwilling to recognize or identify with the feelings and needs of others. Behavioral Correlations and Research Findings Selfie Behavior and Narcissism Selfie Frequency​ Selfie Attractiveness​ Correlation: 0.5​ Singh et al. (2018): Narcissistic personality traits corresponded well with a variety of social networking behaviours, of which the grandiosity subscale correlated most strongly of all. Narcissism and Depression Correlation: 0.5​ Watson et al. (2002): various depression measures all positively correlated with severity of narcissistic personality disorder, i.e. the more severe the symptoms of NPD the more likely the person was also to show symptoms of depression. Very unlike psychopathy then. Neurobiological Aspects of NPD Brain Structure and Empathy Schulze et al 2013: participants with narcissistic personality disorder had smaller/less developed regions associated in part with empathy, e.g. rostral anterior cingulate, medial prefrontal cortex and median cingulate cortex.​ Schulze et al 2013: participants with narcissistic personality also had less developed anterior insula, a region closely associated with empathy – or awareness of the thoughts and feelings of others. Treatment and Awareness Awareness of Symptoms Cooper et al. (2012): the more narcissistic participants were (raw score), the less aware they were of their narcissism, compared with others around them. Treatment Options Dimaggio et al., (2014): describe a single case study of apparently successful treatment for NPD.​ King et al., (2020): 'Evidence-based treatment for NPD is limited. …. No randomised control trials have been conducted.' Overview of Anxiety Disorders DSM-5 Anxiety Disorders ​ Separation anxiety disorder ​ Selective mutism ​ Generalized anxiety disorder: disproportionate worry over everyday things. (SELF GENERATED ANX) ​ Specific phobia: fear of specific object or situation. (EXTERNALLY TRIGGERED ANX) ​ Panic disorder: recurring panic attacks. (INTERNALLY TRIGGERED ANX) ​ Agoraphobia: fear of particular environments. ​ Social anxiety disorder (social phobia): intense fear of social situations. ​ Substance/medication-induced anxiety disorder Limbic System and Anxiety Role of the Amygdala Amygdala heavily involved in anxiety disorders. Anterior cingulate cortex PFC Ventromedial (orbitofrontal) cortex​ Interaction between these areas also have an influence. Interview with SM (lost amygdala) case study: Feinstein et al. (2011): ‘SM’ has Urbach-Wiethe Disease, meaning her amygdalae are destroyed through calcification. ​ She does not feel fear/anxiety in response to external (normally) fear-provoking stimuli. ​ SM was in early 20s and Amygdala was calcified and had no fear, has to stop from playing with snakes. ​ Emotionally blind to fear e.g. loud shock noises. ​ Open to even those who mean her harm. ​ Held at knifepoint and gunpoint twice, exposes her more to dangerous situations. Genetic and Environmental Influences on Anxiety Genetic Factors Hettema et al. (2005): laid out the many genetic and environmental influences on anxiety disorders, both common and unique sources.​ A1 A2 genetic factor common to all disorder to a varying degree.​ Also very specific genetic component to each one. Environmental Factors ONE ENVIRONMENTAL FACTOR: LOCUS OF CONTROL:​ Hudson & Rapee (2001): the more controlling the mother’s style of parenting, the more anxious the children.​ More clear than previous studies.​ Looking at children upbringing and level of control over their lives.​ Focused on the mothers, didn’t check fathers.​ Looked at parenting style.​ Non-anxious control children had more control; clinically anxious control had less control. Further evidence from Harry Harlow and he used Monkeys. ​ Uses scary robot designed to scare monkey ​ See reaction from baby monkey ​ Baby monkey runs to cloth monkey to drive away his fear ​ Changes personality Minkeka (1986): master monkey (more control) obtained food and water by pressing lever, delivered at same time time as yoked monkeys (less control). Later in life, yoked monkeys generally more anxious e.g. to fearful stimulus. Master monkeys closer to front of cage and yoked monkeys stayed near mother. Generalised anxiety disorder: DSM-5 Two main criteria: ​ Criterion A. Excessive anxiety and worry (apprehensive expectation), occurring​ more days than not for at least 6 months. ​ Criterion B. The anxiety and worry are associated with three (or more) of the following six​ symptoms: Restlessness or feeling keyed up or on edge; Being easily fatigued; Difficulty​ concentrating or mind going blank; Irritability; Muscle tension; Sleep disturbance. Wittchen et al. (2002): GAD is most common form of anxiety; around 22% cases in primary care. 1.​ Self-generated anxieties Most common form Amygdala: Nitsche et al. (2009): large response of multiple regions of the amygdala in GAD participants in​ response to BOTH aversive and neutral pictures. Neural basis: Paulescu et al. (2010): exposed GAD participants to worry-inducing sentences e.g. “Mull over what worries you about your future”. Selectively activated dorsomedial prefrontal cortex and anterior cingulate – during post-stimulus ‘rest’ period. Treatment: Wetherell et al. (2013): SSRI effective in reducing worry symptoms of generalised anxiety disorder,​ adding in CBT helped even more. Specific phobias: externally triggered anxieties DSM-5: ​ Criterion A. Marked fear or anxiety about a specific object or situation (e.g. flying,​ heights, animals, receiving an injection, seeing blood). ​ Criterion B. The phobic object or situation almost always provokes immediate fear or anxiety.​ Specific phobias: there are almost as many specific phobias as there things to be phobic about​ (over 500 in any standard list), e.g. Xanthophobia - Fear of the color or the word yellow;​ Xerophobia - fear of bald people; Ailurophobia – fear of cats(!); Pteronophobia - Fear of being​ tickled by feathers; Omphalophobia - Fear of belly buttons; Macrophobia - Fear of long waits;​ Geniophobia - Fear of chins;​ …and Phobophobia - fear of phobias! 2.​ Externally-triggered anxieties Learning Theories of Phobias Conditioning and Phobias John B. Watson & Rosalie Raynor (1920): Conditioning: ‘…white rat suddenly taken from the basket and presented to Albert. He began to reach for rat with left hand. Just as his hand touched the animal the bar was struck immediately behind his head. The infant jumped violently and fell forward, burying his face in the mattress.’​ Little ALBERT!!​ Presented with fire, a monkey, a dog, a rabbit, and a white rat, all things Albert liked.​ Loud bar was struck when reaching for rat, leading to fear when reaching for rat, then presented with other furry things, a dog, seal fur coat and he showed fear response. Evaluation of Learning Theories Watson used his children as study subjects, but later publicly regretted much of his child-rearing advice, e.g. physical affection was taboo.​ In 1930, Rosalie Rayner Watson wrote an article for Parents' Magazine expressing her mixed feelings about behaviorism and its impact on her children.​ Both sons suffered from extreme depression. Conditioning of emotional reactions is predisposed towards some stimuli more than others: certain stimuli may not be able to be conditioned:​ Ohman et al (1976): potentially phobic stimuli, e.g. snakes or spiders more ‘conditionable’ to shock than non-emotive stimuli e.g flowers and mushrooms. Treatment of Phobias Behavioral Therapies: ​ Modelling: therapist based, patient doesn’t have to do much; therapist performs the behaviors on the patient’s hierarchical list while the patient watches. ​ **Flooding: full exposure** to the stimulus from the outset; low take-up rates but effective, however needs top-ups over time. ​ **Systematic Desensitization: patient first learns some **basic relaxation techniques, e.g. controlled breathing; patient then draws up a list of fears in rank order, and is then exposed to them starting with the least feared scenario. Panic Disorder DSM-5 Panic Disorder Criterion A. Recurrent unexpected panic attacks…an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: ​ Palpitations, ​ pounding heart, or accelerated heart rate; ​ Sweating; Trembling or shaking; ​ Sensations of shortness of breath or smothering; ​ Feelings of choking; ​ Chest pain or discomfort; ​ Nausea or abdominal distress; ​ Feeling dizzy, unsteady, light-headed, or faint; ​ Chills or heat sensations; ​ Derealization (feelings of unreality) or depersonalization (being detached from one-self); ​ Fear of losing control or 'going crazy'; ​ Fear of dying. Internally triggered anxieties Interoceptive Cues Small internal event will trigger state of panic (internal). Domschke et al 2008: presented fearful vs non-fearful images to induce panic disorder participants hyperactivity in ​ Amygdala ​ Orbitofrontal cortex Ehlers and Breuer (1992): Given questionarres for state and trait levels of anxiety in controls, simple phobics and panic disorder. ​ Firstly, people with simple phobias or panic disorder showed similarly high levels of both trait (how you feeling generally) and state (how you feeling rn) anxiety ​ Secondly, by contrast people with panic disorder were specifically much more accurate in monitoring their own heart rate, even compared with people with simple phobias Treatment of Panic Disorder Effective Treatments Sanchez-Meca et al. (2010): meta-analysis of 42 studies, concluded exposure (desensitization) training coupled with relaxation/breathing training most effective treatment. Virtual treatment through interceptive cues: Botella et al. (2007): systematic desensitization to internal cues including heart rate response to​ virtual reality exposure worked at least as well as actual exposure to the real situations: and much​ easier to carry out. Very effective in reducing panic severity in PD direct and virtual, this was maintained in follow up too. Overview of Disorders DSM-5 Disorders ​ Obsessive-compulsive disorder: intrusive thoughts/behaviours ​ Hoarding disorder: persistent difficulty in discarding or parting with possessions. ​ Body dysmorphic disorder: excessive concern over perceived defect in body part. ​ Trichotillomania (hair-pulling disorder): compulsion to pull hair. ​ Excoriation (skin-picking) disorder: compulsive skin-picking not co-occurring with other conditions e.g. obsessive-compulsive disorder. Obsessive Compulsive Disorder (OCD) Main Criterion Criterion A. Presence of obsessions, compulsions, or both:​ Obsessions: Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted, and cause marked anxiety or distress.​ Compulsions: Repetitive behaviors (e.g., hand washing, ordering, repetitive checking) or mental acts (e.g., praying, counting, repeating words silently) aimed at preventing or reducing anxiety or distress. 1.​ Some stimulus internal or external activates 2.​ Distress, anxiety, obsession 3.​ Reinforcement of behaviour through ritualised behaviour (compulsions) providing temporary relief from distress/anxiety. Neurological Activation OCD: Excess frontal striatal activation ​ Caudate (motor output) ​ Anterior cingulate ​ Orbitofrontal cortex Maltby et al. (2005): Participants responded as quickly as possible to the letter ‘K’ (Go Stimulus) but not to the letter ‘X’ (No-go Stimulus). Proportion of Go to No Go stimuli was 5:1 causing strong response conflict when X’s appeared. OCD participants reacted fairly typically when they mistakenly responded to an ‘X’ as above, but…​ OCD: Excess frontal-striatal activation when correct. Maltby et al. (2005): Participants with OCD clearly showed excess activity in particular during correct rejections in ​ anterior cingulate cortex (action monitoring) and ​ orbitofrontal cortex, ​ caudate ​ thalamus. Suggested that compulsive behaviors are accompanied by overresponsive anterior cingulate and a feeling that things are 'just not right' even when following correct completion of a task (e.g., hand washing). Serotonin and Love OCD: Serotonin, obsessions and love​ Marazitt et al (1999): Participants who had recently fallen in love scored highly on an OCD scale, and also showed comparably low levels of serotonin as patients diagnosed with OCD. People suddenly experienced OCD symptoms in people in love OCD+In love both have low levels of serotonin in the brain Treatment OCDs respond quite well to certain drug treatments, e.g. Zohar et al. (1988): clomipramine reduced symptoms of OCD; more recently various serotonin-selective reuptake inhibitors (SSRIs).​ Cognitive-behavioural therapy has a good success rate: ​ Behavioral - Patients receive exposure to the focus of their obsession whilst at the same time using relaxation techniques and prevention of the compulsive response. This allows anxiety to extinguish. Such exposure does not, of course, have to be direct - imagining the situation seems to work just as well. ​ Cognitive - This focuses on cognitive restructuring, breaking down the irrational belief system that has built up around the obsession, and using self-report techniques to control anxiety. Simpson at al (2013): CBT greatly enhanced impact of SSRis on OCD symptoms Neurological Changes with Treatment Nakao et al. (2005): Symptom provocation task: stimuli were identified for each patient, such as contamination, pathological doubt, and violence. All OCD patients treated with fluoxetine (boosting serotonin levels in brain) and behaviour therapy showed reduced orbitofrontal and anterior cingulate activation to the symptom provocation task after treatment. Nabeyama et al. (2008): even cognitive behaviour therapy alone (12 weeks, symptoms reduced by​ 60%) reduced the frontal response to a symptom provocation test (Stroop: orbitofrontal and​ frontal/fusiform gyri). Hoarding Disorder DSM-5 Criteria ​ Criterion A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. ​ Criterion B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. Historical Context Hoarding is first mentioned by DSM-IV in 1994, though not as its own category yet:​ Hoarding Disorder was first introduced as a specific condition by DSM-5 in 2013. ICD Classification There is no entry for hoarding in ICD even up to ICD-10 (2010)​ Hoarding Disorder was not introduced until the very latest edition of ICD, ICD-11 (2022) Cognitive-Behavioral Model From Grisham and Baldwin (2015), highlight Cognitive-behavioral model of Steketee & Frost (2006) – 3 components: 1.​ Positive emotions become associated with belongings; 2.​ Growing reluctance to discard belongings due to resulting distress: avoidance behavior as removal (or thought of removal) punishing; 3.​ Cognitive issues e.g. memory, attention. Attentional Issues Grisham et al. (2007): Assessed ADHD-like symptoms, and a specific attentional task to keep watching for a specific letter presentation and to quickly respond. Participants with high hoarding tendencies scored highly for ADHD, and performed less well on the sustained attentional task in a number of respects, for example errors of commission (impulsively responding to the wrong letter). Hoarding vs OCD An et al. (2009): OCD patients with hoarding symptoms shown objects likely to hoard: high anxiety and big response in ventromedial prefrontal cortex, but a smaller response in anterior cingulate cortex. The significance is difficult to interpret.​ Tolin et al. (2014): Go/no-go task. OCDs big orbitofrontal cortex response to ‘correct rejects’ (successful response inhibition). Hoarders did not: large precentral gyrus response instead. The significance of this activity is not immediately clear. Psychological Treatment Muroff et al. (2014): Assessed CBT therapy for hoarding in 29 participants, with 12 months’ follow-up interval. Most patients showed either no improvement, or very modest improvements over this interval. Pharmacological Treatment Grassi et al (2016): Treated participants with hoarding disorder with anti-ADHD drug atomoxetine for 12 weeks, the majority showed large improvements in hoarding severity. Body Dysmorphic Disorder (BDD) Historical Background Enrico Morselli (1886): Italian doctor, described a condition called 'dysmorphophobia'.​ Morselli E. (1886) Dismorfofobia e Sulla Tafefobia. Bolletinno della R Accademia di Genova 6, p.110-119. Case Study: The Wolf Man Freud initially treated a Russian aristocrat called Sergei Pankejeff (1886-1979) for nightmares, including a recurring one about wolves, hence the case became known as Freud and the Wolf Man.​ Sergei was later treated by Ruth Brunswick (1926+), by which time he’d developed an obsession with his nose: 'He neglected his daily life and work because he was engrossed, to the exclusion of all else, in the state of his nose...' Suicidal Ideation Phillips (2007): The mean annual suicide attempt rate of 2.6% in this study is an estimated 3–12 times higher than in the US population as a whole, within range for clinical depression and higher than generalized anxiety disorder, panic disorder or agoraphobia. Neurological Findings Feusner et al. (2010): Presented participants’ own faces to BDD subjects: highly aversive to BDD participants and increased activity in orbitofrontal cortex and head of caudate, akin to classic symptoms of OCD.​ Feusner et al. (2010): BUT BDD participants also showed decreased activity in occipital (visual) cortex, suggested to indicate suppression of visual (face) information and not seen in OCD. The Thatcher Illusion Thompson (1980): Discovered the so-called ‘Thatcher Illusion’, which demonstrates we typically see faces ‘as a whole’ and so don’t attend to the details of a face. Face Matching and BDD Feussner et al 2010: Target faces presented, then two faces to choose from: one the same, the other distorted. All participants quick to match target face when upright, but controls much slower when faces upside down. BDD participants less affected by inversion, thought to be because they tended to see the details of faces more than controls, who saw faces ‘as a whole’ re. Thatcher Illusion. Corpus Callosum Findings Buchanan et al. (2013): Measured white matter density and found reduced levels particularly in corpus callosum. Suggested might lead to impaired integration of detail (left hemisphere) with more global features (right hemisphere). Treatment Crerand et al. 2005: Cosmetic surgery was no help in almost all cases, and in some actually made things worse.​ Phillips et al. (2013): Long-term follow up study over 4 years: vast majority of participants had a mix of SSRI/psychotherapy (around 12 sessions). High relapse rates. DSM-5 Overview Characterization of Disorders All characterised by focus on physical concerns:​ Conversion Disorder (Functional Neurological Symptom Disorder)​ Factitious Disorder (imposed on Self or Another) ​ also known as Munchhausen’s Syndrome (/by proxy)​ Somatic Symptom Disorder: physical symptoms (e.g. pain or fatigue) causing real distress but without 'evident medical explanation'. p.311​ ~75% previously diagnosed with hypochondriasis.​ Illness Anxiety Disorder: great anxiety over health issues, with minimal current physical symptoms. ~25% previously diagnosed with hypochondriasis. Conversion Disorder DSM-5 Criteria Two main criteria:​ Criterion A. One or more symptoms of altered voluntary motor or sensory function.​ Criterion B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. Difficulties in Diagnosis Andersen et al (2005): around 10% neurologic diagnoses of psychogenic origin, around 10% of psychogenic diagnoses may actually have organic origin. Neurological Evidence Ghaffar et al (2006): 3 people with conversion disorder: stimulation of affected limb did not activate contralateral primary somatosensory region, stimulation of unaffected limb – or bilateral stimulation - did.​ '…bilateral stimulation acts as a distractor which overcomes the inhibition that occurs with unilateral stimulation.' p.2037 Psychogenic Seizures Freudian Hysteria: The Case of Anna O:​ Anna O. (Bertha Pappenheim, 1859–1936) was a patient of Sigmund Freud and Josef Breuer.​ Treated for paralysis on right side of her body, with disturbances of sensation including vision and hearing.​ Freud diagnosed hysteria (conversion disorder), meaning he felt Anna’s physical symptoms were actually manifestations of her psychological issues, specifically trauma over her father’s fatal illness.​ His treatment of Anna O. seen as the beginning of psychoanalysis. Repression of Memories Anderson & Green (2001): think/no-think procedure - participants were trained with word pairs, then presented with one word from each pair and asked either to recall the associated word, or to suppress all conscious memory of it.​ Anderson et al. (2004): think/no-think procedure again: during suppression trials, found increased activity in dorsolateral prefrontal cortex, together with decreased activity in hippocampus. Suggested cortex suppressing hippocampal memory ‘function’.​ ![Here's a concise alt text/caption for the image: Evidence for Memory Suppression Aybek et al. (2014): read distressing accounts to participants with conversion disorder. Increased activity in dorsolateral prefrontal cortex, with decreased activity in hippocampus taken as evidence for suppression of traumatic memories.​ Aybek et al. (2014): Increased activity in both the supplementary motor area and temporoparietal junction taken as evidence for highly abnormal mental representations of body parts affected by the disorder. Out of Body Experiences Case Studies Blanke et al. (2004): reported the cases of 6 patients with epilepsy associated with out of body experiences, and found in each case the focus of their seizures centred in or near to the RTPJ.​ Blanke et al. (2004): 'Patient 1 felt as if she would be elevated vertically and effortlessly from her actual position associated with vertigo and fear. She saw herself (entire body as lying on the ground, facing up) and some unknown people (some were standing around her body, others were moving around) below. Initially, she felt as being 'above her real body', but that she was rapidly rising higher. She felt as if her elevated body was in the horizontal position, but did not see any part of it. The visual scene always took place outdoors and was described as 'a green meadow or hill'. The sensation of elevation continued and, quickly, she saw everything from so far away that she could not distinguish details anymore stating that she saw 'something like a map of some country as you find in geography books'. Here, the elevation stopped and she fell back 'to earth'. Stimulation Studies Blanke et al. (2002): stimulated a wide area, but found only the yellow/spot / temporoparietal junction elicited out of body experiences. The stronger the current, the more complete the experience. Treatment of Conversion Disorder Psychodynamic Psychotherapy Hinson et al. (2006): patients with conversion disorder given psychodynamic psychotherapy (1h/wk/12 weeks), focusing on early life experiences, parenting dynamics and links between these and current life experiences and emotional and behavioural issues. All measures improved. Factitious Disorder DSM-5 Criteria Factitious Disorder Imposed on Self or Another:​ Criterion A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease…[in another] Historical Context Richard Asher (1951): 'Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly the syndrome is respectfully dedicated to the baron, and named after him.' p.339​ Munchausen’s Syndrome: marked by frequent hospitalisations and pathological lying Biography of Baron Munchhausen Baron Karl Friedrich Hieronymus von Munchhausen (1720-97) was well-known amongst his friends for his tall, after-dinner tales of his earlier adventures with the Russian cavalry during the Russo-Turkish war.​ Raspe 'The Surprising Adventures of Baron Munchausen' (1781): written anonymously while in Cornwall while earning a living pretending to discover precious ores on the land of his mineralogist benefactor. Ran away just before exposed.​ Raspe remained a somewhat shadowy figure in the main, and book translated into German by the poet Burger (1786).​ Baron Munchhausen (the real one) became an overnight sensation: extreme fans/stalkers were frequently found on his estate and needed chasing off by his groundskeepers.​ First wife died and he became more and more withdrawn. When aged 74, married again to local 17yr old noblewoman. Many scandals and debts: ended in divorce.​ Interviewed shortly before his death in 1797: just as bitter and resentful of his ‘fame’ as previously. Munchausen’s Syndrome Profile Treatment Depression/anxiety can be treated through appropriate medication and talk therapy, e.g. CBT, which may also be helpful in tackling directly the thought processes leading to the behaviour.​ Treatment can be complex though, recommendations include associated medical staff too:​ Huffman & Stern (2003): "The most important role of the psychiatrist in the treatment of Munchausen’s syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. …physicians typically react intensely to such patients. The patient’s demands and ability to shame the physician can lead the physician to order unnecessary procedures, to dispense addictive or dangerous treatments, or to make errors …in medical care. The team should only perform those diagnostic procedures that are indicated by objective signs or data, especially if the procedure involves risk to the patient." Munchausen’s Syndrome by Proxy Overview Sir Roy Meadow (1977): presented two cases: "Although in each case the end result for the child was non-accidental injury, the long-running saga of hospital care was reminiscient of the Munchausen syndrome, in these cases by proxy…" Attachment & Loss Adshead & Buglass (2005): mothers showing Munchausen’s by Proxy behaviour also reported very disturbed attachments to their own mothers and early life. "…insecure mental representations of caregiving and care-eliciting relationships, and that unresolved psychological distress in response to previous childhood illness or loss is common in factitious illness by proxy..." p.328 Unresolved Loss Gray & Bentovim (1996): General theme of unresolved loss: "…of 37 mothers, five (14%) … had experienced a loss or bereavement concerning children …. The fears of the loss of a child were linked to other significant losses... Four (11%) had experienced at least one bereavement of a significant adult… (a parent or other supportive family member), and 12 (32%) had experienced the loss of a partner either through separation or divorce,…" Subtypes Libow & Schreier (1986): identified 3 different subtypes – ‘help seekers’, ‘doctor addicts’ and ‘active inducers’: Help Seekers Make up children’s symptoms to get help with their own issues, anxieties or feelings of inadequacy as parents.​ Relatively inclined to give up on factitious symptoms once treatment help offered, and prognosis relatively good: "…when these Help Seeker mothers are offered psychotherapeutic services or the immediate placement of their child out of home by Protective Services, these interventions are generally met with relief and cooperation." p.605 Help Seekers: Case Study Case Study: "…Ms. B., a 25-year-old ….mother of three, brought her nine-week-old baby girl to the emergency room. She reported that the baby had suffered vomiting and diarrhea for five days, … Examination revealed a well developed, well-nourished two-month-old in no distress. …History … revealed that there were numerous unnecessary outpatient visits for normal infant problems such as congestion and spitting up, and an admission at two weeks of age to another hospital for unwarranted maternal concerns about feeding. A decision was made to hospitalize the baby for social reasons. …However, Ms.B. presented as hostile, defensive, and anxious to get away from her baby. …[she] also indicated she was a victim of domestic violence and had been highly ambivalent about this latest pregnancy.... A decision to place the child in foster care temporarily was met by an initial show of anger and opposition but overall relief on the mother's part." Libow & Schreier (1986) p.605 Doctor Addicts Repeated presentations to doctors/hospitals of medical conditions in their children, but not apparently physically inducing such states.​ Will typically appear completely convinced that the condition or symptoms described are real: "These mothers were personally convinced that their children were ill, despite repeated tests and examinations which showed the contrary, and their use of deception did not generally extend beyond false reporting of history and symptoms." p.606 Hughes (1984): "... mothers were neither significantly reassured nor encouraged by the absence of biological abnormalities but continued their efforts to help their children through an anxious, pessimistic pursuit of medical solutions." (p.152) Doctor Addicts: Case Study "Steven was a ten-year-old child with 26 emergency room visits and three hospital admissions for asthma, despite chest X-rays which did not indicate this degree of severity. …The latest admission was for complaints of severe, crushing chest pain, blackouts, and irregular, rapid heartbeat. …His mother… seemed very involved and agitated about this chest pain, demanding a diagnosis and cure before she would leave the hospital. An extensive cardiac workup yielded no clear diagnosis and the patient was discharged…. Two weeks later he was readmitted after complaining of chest pain and collapsing in a state of apparent unconsciousness which, according to Ms. Z., lasted for ten minutes. …his electroencephalogram was within normal limits…[and] was discharged eight days later with no clear explanation of the chest pain. Two months later, he was again readmitted for chest pain; this time he was more obviously withdrawn and depressed while Ms. Z.'s affect was peculiarly positive. … Steven was eventually transferred to an inpatient unit for a more extensive psychological workup at a location distant from his mother." Active Inducers Most commonly described/most sensational of cases.​ Marked by direct efforts to cause dramatic symptoms of illness in a child, e.g. suffocation, adulteration of i.v. solution, poisoning.​ By contrast, mothers generally come across as above suspicion, very cooperative, concerned and loving parents. "…notoriously resistant to therapeutic intervention and typically flee from contact. The few instances where they have been engaged in therapy are usually because the courts have mandated it as a condition of home placement of the child victim…There is a pattern of disturbed marital relationships with a peripheral husban