Psychopathology (222 pages).pdf

1 Psychopathology (222 pages) Schizophrenia spectrum and psychotic disorders A diagnosis requires two or more of the following symptoms, present for a significant portion of time during a one-month period: Delusions....

1 Psychopathology (222 pages) Schizophrenia spectrum and psychotic disorders A diagnosis requires two or more of the following symptoms, present for a significant portion of time during a one-month period: Delusions. Hallucinations. Disorganized speech. Grossly disorganized or catatonic behavior. Negative symptoms (e.g., reduced emotional expression). One of the symptoms must be either (1), (2), or (3). Additionally, continuous signs of the disturbance must persist for at least six months. Causes of Schizophrenia Genetics: A higher risk if there is a family history of schizophrenia. Brain structure and chemistry: Imbalances in neurotransmitters may play a role. Environmental factors: Stressful or traumatic events might trigger schizophrenia in those predisposed to it. Developmental factors: Issues during brain development before birth.  2 Treatment Options for Schizophrenia Antipsychotic medications: Psychotherapy: Cognitive-behavioral therapy (CBT) and other forms can help manage symptoms. Psychosocial interventions: These include skills training, employment assistance, and social skills training. Coordinated specialty care: A team-based, holistic approach to treatment, especially effective in early-stage schizophrenia. Main features – psychotic symptoms Disturbance in thought and perception à difficulties in recognizing reality. Mental disintegration of the inner world (affects the sense of self, thinking and perception, but also motor functions, speech, feelings) Disruption in exchanging information and energy between internal and external world (dysfunctional patterns of communication) Recurrence of symptoms, increase of social impairment, gradual withdrawal. Psychotic symptoms Positive Delusions Hallucinatons, Negative Inc. flattened affect lack of motivation, Cognitive  3 Historical view on schizophrenia First classification df: 1896 dementia praecox - Emil Kraepelin (Germany) Premature deterioration based biologically. Eugene Bleuler (1857-1939) (Switzerland) –serious, chronic, recurrent but with possible recovery (also biological explanation, brain disease). Adolf Meyer (1866-1950) – outcome of impaired learning and interpersonal process, American psychiatry. Schizophrenia - Facts Gender Diff In prevalence none Men: earlier onset (15-25 years old); women 25-35 years old.  4 Neuroscience: (1) Mesolimbic dopamine pathway model (old, no direct evidence, replaced with striatum dopamine model) Based on correlation between schizophrenia symptoms with mesolimbic tumours and epilepsy episodes. (2) Striatum dopamine model: Role of dopamine in onset - increased presynaptic dopamine function in the associative striatum, also GABA and glutamate release and inhibition in the striatum. Specifically dorsal regions of the striatum. Striatum - ”integrative hub for information processing in the brain” (McCutcheon, Abi-Dargham, & Howes, 2019) corticostriatal pathways overlap: limbic, associative, and sensorimotor pathways reports of abnormalities in virtually every neurotransmitter system all licensed pharmacological treatments of schizophrenia affect the dopamine system.  5 Genetic factors: 18—58% of risk among MZ twins (Seligman, Walker, & Rosenhan, 2001) However only 20% risk in first-line relatIves GeneIc proneness to whole spectrum disorders (psychoIc and borderline level) Some genes shared with bipolar disorder Which specifically? Polygenic disorder. A microdeleTIon in a region of chromosome 22 (22q11) may be responsible for small number of cases Region C4 of DNA located on chromosome 6 Region C4 on chromosome 6 Sekar et al. (2016), Harvard Medical School, Nature: C4 is involved in eliminating the connections between neurons — a process called "synaptic pruning," which, in humans, happens naturally in the teen years. Study: Genome data about the C4 gene in 28,800 people with schizophrenia v. 36,000 people without, from 22 countries. The higher the levels of C4 activity, the greater a person's risk of developing schizophrenia. Hope for new drugs acting on inhibiting the process of synaptic pruning. However the exact inheritance pattern is still unknown... Adoption studies point out also to the role environmental factors (in gene expression)  6 Psychosis Childhood trauma, like abuse greatly increase the risk – umbrella review results (Radua et al., 2018) – “environmental exposures during critical developmental periods impact brain, neurocognition, affect, and social cognition” Trauma acts like a viral infection on the brain – triggers specific gene expression. Psychosis as A natural reaction to the abuse A way to survive Psychodynamic and psychoanalytic approach (McWilliams, 2011) Every symptom has its function Psychosis once saved one’s life but today it impairs it There is still need to treat it or at least to cope with it. Expressed emotion (EE) studies (Brown, 1959) former patients who had limited contact with their relatives did better Relapses after 9 months from discharge varied: 58% in high EE families 16% im low EE families  7 High EE = high levels of criticism (disapproval), hostility (animosity), and emotional overinvolvement (intrusiveness, symbiosis) expressed by the families. Symptom criteria for psychotic disorders Delusions Hallucinations Disorganized thinking/speech Grossly disorganized or abnormal motor behavior Negative symptoms Culture-related issues must be always concerned in diagnosing. Delusions False beliefs resist all argumentation and facts sustained even in the face of evidence against them usually bizarre and out of touch with reality Common symptom in a lot of disorders (also depression) Specific for schizophrenia – delusions not congruent with present mood Delusions - kinds  8 Delusions of Grandeur – being especially important, “Jesus Christ”. Religious delusions Delusions of Control – one’s thoughts or behaviors are being controlled by others, “receiving instructions from aliens to be quiet”, thought insertion or withdrawal by outside force. Delusions of Persecution – fear that some group, agency or individual is “out to get me”. Ideas of reference (referential) – certain people or events having special significance for the persons, “special massages on the tv” Somatic delusions – something is drastically wrong with the one’s body, “something rotting inside the body”, “something places beneath the skin”. Hallucinations Perception-like experiences that occur without an external stimulus. (DSM-5) Perception-like false experiences Even in the absence of stimuli Not matching the reality Vivid and clear They are taken for real because they feel real PET scans show activation of the visual or auditory cortex during visual or auditory hallucinations experienced by psychotic patients (Allen et al., 2012). Hallucinations - types Auditory – most common in schizophrenia, probably originating from inner dialogue and confusion of external sounds v. internal thoughts  9 Visual – less common in schizophrenia but more in chemically induced psychosis Olfactory – rare, unpleasant odours Tactile – being touched, common in alcohol delirium psychotic disorder Gustatory – unpleasant tastes General somatic – feelings of body being mutilated or seriously injured, e.g. bugs crawling inside the veins. Disorganized thinking/speech Formal thought disorder Manifested as disorganized speech Symptoms: Shifts from one topic to another (derailment) Little connections in thoughts (loose association) Responses to questions not exactly related or completely unrelated (tangential) Incomprehensible and resembles receptive aphasia in its linguistic disorganization (incoherence or "word salad"). Substantially impairs communication Usually is affected by the sensitivity to the most dominant associations to words and less by the context, e.g. (Seligman, Walker & Rosenhan, 2001, p.422) Pool means the same as: 1. puddle 2. notebook 3. swim 4. none of the above Sometimes affected by the sound of words rather than their meaning, E.g. Clang associations – by the rhythm of words,“my dear, near, seal, here”, “university,..., plausity” Neologisms – “amorition”, ”plausity”.  10 Grossly disorganized or abnormal motor behavior Variety of manifestations - from childlike laughing aloud to unpredictable agitation Often followed by poor hygiene, wearing inappropriate clothes or excess clothing Catatonic behavior – the most bizarre of all disorganized behaviors, though less and less common due to medication; can occur in several disorders, including neurodevelopmental, psychotic, bipolar, depressive; separate condition listed in DSM V (APA, 2013). In 35% of schizophrenia patients Catatonia A marked decrease in reactivity to the environment, e.g. - resistance to instructions (negativism or opposition) - lack of movement, frozen like (stupor) -lack of communication (mutism) - allowing to be placed in uncomfortable position (waxy flexibility) But also purposeless and excessive motor activity without obvious cause (catatonic excitement) - stereotyped movements, staring, grimacing, and the echoing of speech etc. Catatonia – DSM V (APA, 2013) 3 (or more) of the following symptoms: 1. Stupor (i.e., no psychomotor activity; not actively relating to the environment). 2. Catalepsy (i.e., passive induction of a posture held against gravity). 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).  11 4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]). 5. Negativism (i.e., opposition or no response to instructions or external stimuli). 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity). 7. Mannerism (i.e., odd, circumstantial caricature of normal actions). 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements). 9. Agitation, not influenced by external stimuli. 10. Grimacing. 11. Echolalia (i.e., mimicking another’s speech). 12. Echopraxia (i.e., mimicking another’s movements). Negative symptoms A reduction in normal behavior Usually appear before positive symptoms Associated with schizophrenia less manifested in other psychotic disorders. 2 negative symptoms prominent for schizophrenia: Diminished emotional expression – blunted, flatted affect, lack of facial expression, monotonous voice, emotionally unresponsive, followed by alogia. Avolition – lack of energy and interest in activities, without engagement. Other: Alogia - diminished speech output. Anhedonia - decreased ability to experience pleasure from positive stimuli or a degradation in the recollection of pleasure previously experienced. Asociality - lack of interest in social interactions. Schizophrenia and other psychotic disorders – DSM-V (APA, 2013)  12 Disorders organized along a gradient of psychopathology... Diagnosis should be careful and follow the guidelines (APA, 2013, p.88): Clinicians should first consider conditions that do not reach full criteria for a psychotic disorder or are limited to one domain of psychopathology. Then they should consider time-limited conditions. Finally, the diagnosis of a schizophrenia spectrum disorder requires the exclusion of another condition that may give rise to psychosis. Schizophrenia and other psychotic disorders – DSM-V (APA, 2013) Schizotypal personality disorder – noted here but fully described within personality disorders Delusional disorder (> 1 month of delusions but no other psychotic symptoms) Brief psychotic disorder (1 day 1 month) Schizophreniform disorder (16 months of schizophrenia symptoms, no functioning decline) Schizophrenia (at least 6 months and includes at least 1 month of active-phase symptoms) Schizoaffective disorder Catatonia Substance/medication induced psychotic disorder Psychotic disorder due to another medical condition Other specified and unspecified Schizotypal personality disorder - DSM-V (APA, 2013) A pervasive paWern of social and interpersonal deficits incl.: reduced capacity for close rela/onships; cogni/ve or perceptual distor/ons; and eccentrici/es of behavior. Usually beginning by early adulthood but in some cases first becoming  13 apparent in childhood and adolescence. Abnormali?es of beliefs, thinking, and percep?on are below the threshold for the diagnosis of a psycho?c disorder. Delusional disorder – DSM V (APA, 2013) Presence of delusions At least for 1 month Criterion A for schizophrenia has never been met. Hallucinations, if present, are related to the delusional theme (consistent). Functioning is not markedly impaired, and behavior is not obviously bizarre. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. The disturbance is not attributable to the physiological effects of a substance or another medical condition. Differential diagnosis: body dysmorphic disorder or OCD. Life-time prevalence: 0.2% Usually social and legal consequences. But less impairment than in schizophrenia. Some people meet schizophrenia criteria in some time. Gender differences: none. Specify whether (central themes): Erotomanic type - being in love Grandiose type – own greatness Jealous type – unfaithful spouse Persecutory type – being conspired against, spied, followed Somatic type – involving bodily functions Mixed type – without dominant theme  14 Unspecified type – e.g. referential without any dominant theme Specify if: with bizarre content – agents replacing organs with artificial ones and not leaving scars; without bizarre content – ex-girlfriend breaking in to steal or displace things in the apartment. After 1 year duration – course specifiers First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode - period in which the symptom criteria are fulfilled. First episode, currently in partial remission: improvement after a previous episode is maintained and the defining criteria of the disorder are only partially fulfilled. First episode, currently in full remission: after a previous episode, when no disorder-specific symptoms are present. Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous: Symptoms remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course. Unspecified Brief psychotic disorder – DSM V (APA, 2013) 1 day 1 month Presence of at least 1 of the following (1,2,3):  15 1. Delusions. 2. HallucinaIons. 3. Disorganized speech Op@onal: 4. Grossly disorganized or catatonic behavior. Onset is sudden (not gradual!) Eventual full return to premorbid level of funcIoning (!) Differen@ate with: major depressive or bipolar disorder with psychoIc features or another psychoIc disorder such as schizophrenia or catatonia, and is not aiributable to the physiological effects of a substance (e.g., a drug of abuse, a medicaIon) or another medical condiIon. Note: Do not include a symptom if it is a culturally sancIoned response. Brief psychotic disorder – DSM V (APA, 2013) Increased S risk in the acute phase. 9% of all first-onset psychosis episodes (US data, APA, 2013). Onset across the whole lifespan but most typical: mid 30s. If it doesn’t end after 1 month and a full recovery does not appear à change of diagnosis (usually to schizophreniform or delusional disorder). Risk factors: schizotypal PD, borderline PD, suspiciousness (temperamental), cannabis use (5 x higher risk). Specify if: With marked stressor(s) - (brief reactive psychosis)- in response to stressful events. Without marked stressor(s). With postpartum onset - during pregnancy or within 4 weeks postpartum. Specify if: With catatonia Schizophreniform disorder – DSM V (APA, 2013) 1 month 6 months (if untreated; otherwise provisional)  16 Inc. prodromal, active, and residual phases At least 2 of the following during a 1-month period & at least 1 of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms Differential: Schizoaffective disorder and depressive or bipolar disorder with psychotic. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Lack of a criterion requiring impaired social and occupational functioning Schizophreniform disorder – DSM V (APA, 2013) Development and onset similar to schizophrenia. 2/3 of diagnosed patients at some point are diagnosed with schizophrenia or schizoaffective disorder. Risk factors: relatives diagnosed with schizophrenia. Specifiers: With good prognostic features: presence of at least 2 of the following onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity; good premorbid social and occupational functioning; absence of blunted or flat affect. Without good prognostic features (may progress into schizophrenia)  17 Specify if: With catatonia. Schizophrenia - DSM V (APA, 2013) > 6 months (if untreated) At least 2 of the following during a 1-month period & at least 1 of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinahons. 3. Disorganized speech. 4. Grossly disorganized or catatonic behavior. 5. Negahve symptoms, For a significant porhon of the hme since the onset of the disturbance, level of funchoning in areas, such as work, interpersonal relahons, or self-care, is markedly below the level achieved prior to the onset (or, when the onset is in childhood or adolescence there is failure to achieve expected level of interpersonal, academic, or occupahonal funchoning Anosognosia – lacking insight of the disorder. Schizophrenia - DSM V (APA, 2013) During prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or symptoms in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). Differential diagnosis: Schizoaffective disorder and depressive or bipolar disorder with psychotic features. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical  18 condition. earlypsychosis.ca Life-time prevalence: approx. 1% S risk: 20% attempts S; 5-6% dies from S. Highest risk - depressive symptoms, being unemployed, period after a psychotic episode or hospital discharge. Schizophrenia - DSM V (APA, 2013) Gender differences: males express more negative symptoms, longer duration, poorer prognosis. Onset - between late teen years and mid 30s - av. Early-mid 20s for men and late 20s women - earlier onset – worse predictor (e.g. childhood). Prognosis – 20% get periods of well recovery, small % live symptom free with medication, but most need living support. Symptoms diminish over the life course, - probably effect of normal age-related decline in dopamine activity. Comorbidity: substance-related disorders >50% tobacco dependence; anxiety, OCD, undiagnosed chronic diseases (e.g. cancer) and reduced life expectancy. Schizophrenia- DSM V (APA, 2013) Specifiers after a 1-year duration: First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. First episode, currently in partial remission: improvement after a previous episode is maintained and the defining criteria of the disorder are only partially fulfilled.  19 First episode, currently in full remission: after a previous episode, when no disorder- specific symptoms are present. Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous: Symptoms remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course. Unspecified Specify if: With catatonia Subtypes of schizophrenia- no longer listed in DSM V Paranoid – hallucinations & delusions in the center Disorganized/Hebephrenic – symptoms concentrate on disruption in speech and behavior, less delusions and hallucinations. Catatonic – core symptom is due to catatonia. Undifferentiated - do not meet the criteria for paranoid, disorganized, or catatonic types. Residual – after at least one episode of schizophrenia, when residual symptoms remain only („residual leftovers”). Schizoaffeccve disorder – DSM V (APA, 2013) An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with schizophrenia major symptoms. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. The disturbance is not attributable to the effects of a substance (e.g., a drug of  20 abuse, a medication) or another medical condition. Functioning impairment is not a defining criterion (v. schizophrenia!). Differentiate: with mood disorders comorbid with schizophrenia, bipolar and depressive disorder with psychotic symptoms. Schizoaffective disorder – DSM V (APA, 2013)  21 Schizoaffective disorder – facts Prevalence: 3 hmes less common than schizophrenia; approx. 0.3% Gender differences: higher incidence in women. Onset: throughout lifehme, usually early adulthood usually earlier another psychohc disorder has been diagnosed. Prognosis: beper than schizophrenia but worse than depressive disorder. Risk factors: first-line relahves diagnosed with schizophrenia, bipolar and schizoaffechve d. S risk – already included in the schizophrenia risks of dying of S (pulled 5%). Possible course: An individual may have pronounced auditory hallucinations and persecutory delusions for 2 months before the onset of a prominent major depressive episode. The psycho4c symptoms and the full  22 major depressive episode are then present for 3 months. Then, the individual recovers completely from the major depressive episode, but the psycho4c symptoms persist for another month before they too disappear. (...) The total period of illness lasted for about 6 months, with psycho4c symptoms alone present during the ini4al 2 months, both depressive and psycho4c symptoms present during the next 3 months, and psycho4c symptoms alone present during the last month (APA, 2013, p. 108) Psychotic disorders induced by another condition – DSM V (APA, 2013) Substance/medication induced psychotic disorder - a physiological consequence of a drug of abuse, a medication, or toxin exposure and cease after removal of the agent. alcohol, cannabis, phencyclidine, sedative, hypnotic, anxiolytic, amphetamine, cocaine, other... With onset during intoxication or with onset during withdrawal Up to 25% of all first psychotic episodes reported. Psychotic disorder due to another medical condition- a direct physiological consequence of another medical condition with delusions/with hallucinations PERSONALITY DISORDERS  23 Personality disorders - df ”Chronic character traits or styles that lead to clinically significant interpersonal and behavioral problems” (Miovic & Block, 2007) DysfuncTonal and inflexible personality traits that deviate significantly from cultural expectahons and are shown across many situahons, e.g.: Significant effect on general func\oning Deviates significantly from individual's culture Difficulty in geqng along with people Presen\ng rigid traits like being irritable, demanding, hos\le, manipula\ve or fearful Ac\ng on unconscious automa\c uncontrolled impulse Pervasive & stable No acute episodes Symptoms become more visible under stress Expressed by thoughts, emo\ons and behaviors 2 models approach  24 An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. Manifested in 2 (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events). 2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response). 3. Interpersonal functioning. 4. Impulse control. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. Not due to substances or another mental or medical condition Challenges Needs an evaluation of the individual's long term patterns of functioning, and the particular personality features must be evident by early adulthood It’s not just detecting specific symptoms. Assessing the stability of personality traits over time and across different situations to be diagnosed in an individual younger than 18 years, the features must have been present for at least 1 year (!) Exception: Antisocial PD cannot be diagnosed below 18 years old (v. Pauline Kernberg’s work with children) More difficult to be diagnosed by less experienced clinicians. Also because of their high prevalence (15%) And because the experience is ego-syntonic.  25 Facts Prevalence: up to 15% of general population comorbid with another PD Onset: adolescence and early adulthood. Most remain unrecognized and undiagnosed. Comorbid with: anxiety disorders, depressive disorder, brief psychotic episode but also lower general health (Frankenburg & Zanarini, 2006) 60% of substance dependent people meet PD criteria. Biological explanations Genetics Brain funcTIoning differences (e.g. mirror neurons in anDsocial PD) Psychological explanations A{achievement disruptions, childhood neglect, abuse, non-suppor/ve environment  26 CLUSTER A: CLUSTER B: CLUSTER C: Other: Odd or Dramatic, Anxious or Personality eccentric; erratic, or fearful; Change Due to emotional: Another Medical Condition Paranoid PD Antisocial PD Avoidant PD Other Specified Schizoid PD Borderline PD Dependent PD Other Schizotypal PD Histrionic PD Obsessive-Com Unspecified Narcissistic PD pulsive PD CLUSTER A: Odd or eccentric; Paranoid personality disorder - descriptive features Pattern of distrust and suspiciousness such that others are plotting against the individual, threatening, following. Suspiciousness based on little evidence But not so out of touch with reality as in psychosis. E.g. “Doctors and drug companies are making up diseases to sell their medicine and make money”.  27 May gather trivial and circumstantial "evidence" to support own beliefs. Cold and distant in relationships. Excessive need to be self-sufficient. Strong sense of autonomy. Strong need for control. Unable to collaborate. Counterattacks in response to the perceived threats May be perceived as "fanatics" In childhood and adolescence: poor peer relationships, social anxiety, underachievement in school, hyper sensitivity, peculiar thoughts and language, and idiosyncratic fantasies. DSM-5 At least 4 of the following present: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. Reads hidden demeaning or threatening meanings into benign remarks or events. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. Differentiate with: schizophrenia, bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder. Not attributable to the physiological effects of another medical condition. But: could be premorbid to schizophrenia (post factum diagnosis).  28 May develop major depressive disorder, agoraphobia and obsessive- compulsive disorder. Alcohol and other substance use disorders frequently occur. Prevalence: 2.3%-4.4%. More common in men. Shares genetics with schizophrenia. Schizoid personality disorder Pattern of social isolation and restricted emotional experience and expression. Experience of social anxiety, paranoid fears, and eccentric behavior, perceptions, and thoughts. Severe introverts Unable to create close relationships Restricted range of expression of emotions Perceived as cold and aloof Lack of need to get involved Introverted “loners” Withdrawn and solitary Socially awkward but without eccentric ideas of thoughts. Not bothered about what others think of them. Difficulty expressing anger. Beginning by early adulthood and present in a variety of contexts Attachment disorders Preference for mechanical or abstract tasks, such as computer or mathema/cal games. No close friends  29 Solitariness, poor peer rela/onships, and underachievement in school, Subject to teasing. May have very li{le interest in having sexual experiences date infrequently, and often do not marry May do well when they work under condi/ons of social isolaTIon Under stress may experience very brief psychotic episodes (minutes/hours long) A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. 4(or more) of the following: Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidants other than first-degree relatives. Appears indifferent to the praise or criticism of others. Shows emotional coldness, detachment, or flattened affectivity. Differentiate with: schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder, autism. Not attributable to the physiological effects of another medical condition. Could be “premorbid” to schizophrenia. Prevalence: 3.1%-4.9%. Slightly more common in men. Share genetics with schizophrenia spectrum.  30 Schizotypal personality disorder In children and adolescents: - bizarre fantasies or preoccupations - lack of friends - anxious in social situations - solitariness, - underachievement in school, - hyper sensitivity, peculiar thoughts ,and language. In adulthood: - beliefs that they have magical control over others, which can be implemented directly (e.g., believing that their spouse’s doing the dishes is the direct result of thinking an hour earlier it should be done). Listed also within schizophrenia spectrum and other psychoic disorders A pervasive pakern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relaSonships + cogniSve or perceptual distorSons and eccentriciSes of behavior. Beginning by early adulthood and present in a variety of contexts. Symptoms are not due to: schizophrenia, a bipolar disorder or depressive  31 disorder with psychoic features, another psychoic disorder, or auism spectrum disorder. Could be „premorbid” in schizophrenia course. 5 (or more) of the following: Ideas of reference (excluding delusions of reference). Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”). Unusual perceptual experiences, including bodily illusions. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped). Suspiciousness or paranoid ideation. Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric, or peculiar. Lack of close friends or confidants other than first-degree relatives. Excessive social anxiety that does not diminish with familiarity and tends to be as asociated with paranoid fears rather than negative judgments about self. When seeking help: usually because of anxiety or depressive disorder (30-50% of schizotypal in-patients are admitted because of depression) may experience transient psychotic episodes (lasting minutes to hours). Prevalence: from 0.6% (Norway) to 4.6% (US) à approx. 3% globally.  32 Genetics: more prevalent among the first-degree biological relatives of individuals with schizophrenia than among the general population Only a small proportion develops schizophrenia spectrum disorder. Slightly more common in males. CLUSTER B: Dramatic, erratic, or emotional: ANTISOCIAL PERSONALITY DISORDER Psychopathy. Sociopathy. Dyssocial personality disorder. An extreme disregard for and violaIon of the rights of others. Involves problemaIc interpersonal styles such as arrogance, lack of empathy, and manipulaIveness, e.g. lying, impulsivity, irritability aggressiveness, irresponsibility, lack of remorse, low tolerance for frustraIon, involvement in criminal acts to gain personal profit or pleasure ($, sex, or power). „People who are so emotionally disconnected that they can function as if other people are objects to be manipulated and destroyed without any concern,”, prof. Robert Hare A pervasive pattern of disregard for and violation of the rights of others, occurring:  33 since age 15 years. 3 (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. Not diagnosed below 18 years old. Childhood - conduct disorders before 15 years old Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. 4 categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules. Adulthood functioning – 3 signs of psychopathy 1. Lack empathy - tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. 2. Inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them) Excessively opinionated, self-assured, or cocky.  34 3. Glib, superficial charm and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic). These 3 signs of psychopathy are more predictive of recidivism in prison or forensic settings (APA, 2013). Lack of empathy: emotional-blindness, but… it’s not about cognitive aspect of empathy but emotional (e.g. compassion) Not being able to recognise clues of others emotional responses (cognitive empathy deficit) à autism spectrum disorder Recognising but not taking into considertion à antisocial PD Antisocial PD is linked with higher abilities to recognise emotions correctly and there are no differences in emotional expression (Kunecke et al., 2018) Highly ego-syntonic. Job placement: Irresponsible work behavior, significant periods of unemployment, or abandonment of several jobs. Possible pattern of repeated absences from work. Financial irresponsibility is indicated by acts such as defaulting on debts, failing to provide child support. Snakes in Suits: When Psychopaths go to Work – Hare and  35 Babiak (2006), study on 203 corporate professionals, 4% met psychopathy criteria. Out of 261 CEOs 21% present clinical level of psychopathy (Brooks, 2016). Gender: Much more common in men. But women easier pass genetic vulnerability to their offspring. Prevalence: 0.2%-3.3% In forensic, prison and substance abuse settings – 70%(!). Higher prevalence in low socio-economic status populations. Therapy seeking because: May also experience dysphoria, complaints of tension, inability to tolerate boredom, and depressed mood – usually the only reason for seeking help. Comorbid anxiety disorders, depressive disorders, substance use disorders. Treatment (rehabilitation or prevention counselling) based on behavioral consequences – “if you don’t change your behavior you go to jail”, this is one of the worst prognostic disorders in treatment. Early prevention is better than intervention. Evolutionary: psychopathic traits aren’t necessarily disadvantages; some antisocial traits probably have been a successful strategy, well functioning in high-level political and organizational contexts. Environmental: experience of childhood onset of conduct disorder (before age 10 years) and accompanying ADHD, Other factors: child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline, violence.  36 Adoptive children are also at risk (environmental factor very important, not just genes!). Genetics: there is a hereditary factor (MZ twins studies, studies of children born to criminal antisocial fathers). Risk of biological relatives of antisocial females is higher than of antisocial males (unclear). Physiological: atypical electrodermal and cardiovascular responses (reduced heart rate and skin conductance) from childhood is a risk factor for further PD development (Wang et al., 2012) but may also explain deficit in emotional empathy. BORDERLINE PERSONALITY DISORDER Patterns of impulsivity, self-harm, unstable affect and interpersonal relationships, and suicidality. A lot of efforts to avoid real or imagined abandonment and rejection (self-image instability). Impulsivity leads often to self-harm (incl. S). Difficulty with emotion control (especially anger, emotional outbursts out of proportion, usually due to fear of being rejected). Paranoid thoughts and dissociative states (e.g. not feeling own body, being out of the body experience). Chronic experience of “emptiness” (self-harm as an attempt to fill that void). Relationships intensive and unstable. Seeking psychological help  37 Instability in a lot of areas of functioning Experienced suffering Fluctuations of depression, anger and anxiety High risk of Suicide Self-mutilations are common Instable relationships Casual sex Substance abuse Other impulsive behaviors Borderline means that it is between neuroTIc and psychoTIc level of personality organisaTIon (both higher and lower level of funcTIoning is possible). Some may develop psychoTIc symptoms under stress.  38 A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity,. 5 (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. 2. Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness.  39 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms. Beginning in early adulthood chronic instability, episodes of serious affective and impulsive discontrol and high levels of use of health and mental health resources (APA, 2013). Seeking therapy themselves Psychodynamic Transference Focused or Interpersonal therapy Improvement begins during the first year of therapy. Follow-up studies of outpatients from mental health clinics indicate that after about 10 years 50% no longer meets full criteria for borderline personality disorder (APA, 2013). Fear of abandonment present especially when Therapist announce the end of session Around anticipated holidays React with panic and fury May present more psychopathological symptoms as an unconscious threat in the face of abandonment Demanding patients, spouses, friends Lacking ambivalence and easily attributing bad intensions Self-image instability May concern goals, sexual identity, values, friends, also feelings of “not existing at all” due to experience of inner void and emptiness. Prevalence: from 1.6% to 5.9% Higher prevalence rates in psychiatric facilities: Outpatients: 10% Hospitals: 20% Gender differences: 75% are females.  40 Risk of S – 8%-10% completed S Usually help seeking is a response to uncompleted S Self-mutilation – even more common In states of dissociation (detachment from physical and emotional experiences, e.g. being out of own body, not feeling the body) Brings relief Fills in the emptiness Emotional instability (depression, anger, anxiety, panic, despair) Shifts lasting usually hours, not longer than a couple of days (not meeting cyclothymia criteria) Emotional and verbal outbursts Typical reaction to situations perceived as abandonment Starts with outrage (when the neglect is perceived), vivid expressions of anger and ends with a lot guilt and feeling evil for acting it out. Acting out – means that a lot of emotional states are not comprehended well and instead of working through, are acted out as impulsive behavioral response. Typical for borderline personality disorder.  41 HISTRIONIC PERSONALITY DISORDER Based on the concept of hysteria. “Drama queens”, “aienIon seekers”. An excessive need for aienIon, superficial and fleeIng emoIons, and impulsivity. InteracIons with others are marked by inappropriate or seducIve behaviors. Physical appearance is used to draw aienIon. AcIons seems dramaIc and emoIon expression is exaggerated, theatrical. RelaIonships are experienced as much more inImate than they really are. Need for constant admiraIon. Begins in early adulthood and present in a variety of contexts Usually seek help due to developed symptoms of depression or anxiety (not personality itself) Highly ego-syntonic, May exaggerate their problems to seek attention, Being flattering, Bringing gifts, Presenting dramatic symptoms changing visit to visit, Compliments fishing, Calling therapist by the name, “my dear”, “my friend”. Feels angry and unappreciated and angry when not in the center of attention Temper tantrums Turned on and off quickly.  42 High degree of suggestibility Emotions and opinions are easily influenced by others. Theatrical behavior Role of “a princess” or “a victim”. Close relationships Are a way to get the desired attention Duality: seeking to control partner through emotional manipulation or seductiveness on one level, while displaying dependency at another level Impaired relationships with same-sex friends because of sexually provocative behavior Long-term relationships are less thrilling than novelty of the new ones Job settings Craving novelty, stimulation, and excitement Great project initiators but very poor conductors (lost of interest) Ego-syntonic They seek therapy due to comorbid depression or anxiety disorder Benefit from treatment when they get insight on their condition and learn to control their behavior better (French & Shreshta, 2019). A pervasive pattern of excessive emotionality and attention seeking. 5 (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention. 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. 3. Displays rapidly shifting and shallow expression of emotions. 4. Consistently uses physical appearance to draw attention to self.  43 5. Has a style of speech that is excessively impressionistic and lacking in detail. 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion. 7. Is suggestible (i.e., easily influenced by others or circumstances). 8. Considers relationships to be more intimate than they actually are. Course: begins in early adulthood. Prevalence: about 2% Gender differences: in general population none In clinical settings is 4 times more commonly recognised in females (French & Shrestha, 2019) Is there a gender bias? Women more likely develop depression and seek help? Etiology: Environmental: Hypothesis of a childhood trauma (most likely sexual abuse) Parental style: lack of boundaries, or inconsistent; parents with histrionic traits (dramatic, erratic, volatile, or inappropriate sexual behavior) Genetics: some; runs in families. NARCISSISTIC PERSONALITY DISORDER Normal/healthy narcissism Integrated self experience Positive self-regard Support basis  44 Greek mythology: self-admiration ends in inability to create close relationships and finally death. S. Freud: libidinal investment of self (instead of object). A. Green: libidinal & aggressive investment of self. Pathological narcissism --> Narcissistic personality disorder - Descriptive features - Clinical symptoms GRANDIOSE SELF ENVY TOWARDS OTHERS - Self-centered - Conscious and unconscious envy - Self of entitlement - Greediness and exploitiveness - Over dependency on admiration - Devaluation - Fantasies of success and - Incapacity to depend grandiosity - Avoidance of contrary realities - Lack of commitments - Struggle of insecurities - Negative therapeutic reaction - Fragile idealization (Kernberg, 2015)  45 A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. 5 (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration. 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).  46 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes. WHAT IS DSM V DF MISSING CLINICALLY? Wider spectrum of narcissism (Caligor, 2015) Grandiose type vs. vulnerable type, Extroverted and charming vs. shy (covert narcissism) or insufferable, Professionally successful vs. unable to keep employment, Asymptomatic vs. suffering from anxiety or depression, Model citizens vs. prone to antisocial criminal acts. They all have in common – narcissistic tragedy Identity and self-value diffusion constant support of their value or feeling impotent instead The grandiose self is a way to defend the fragile real self protects from humiliation, inferiority, being a victim, ashamed But the grandiose self (for the sake of protection) sacrifices genuine close relationships with others and full connection with reality Most important needs are still unsatisfied, they are just denied. Course: begins in early adulthood, narcissistic tendencies it teenagers are not risk factors (developmental narcissism). Prevalence: approx. 6%  47 Gender differences: 50%-75% are men. Treatment: severe cases approx. 10 years of psychodynamic or psychoanalytic therapy, not necessarily with the same therapist Common therapist devaluation and drop outs Risk of severe acting out and painful envy Negative reaction towards therapist Risk of severe depression (as a part of the process of acknowledging limits of the self) Finally recovery of ability to relate to others. Genetics: inherent temperamental factors Environmental: insecure childhood attachments, abandonment, child abuse, disturbed early object relations: Lack of relationships based on normal dependency and care “Psychopathology of envy: hatred of what is needed” (Kernberg, 2015) Only weak people depend on others. If I don’t need anything from anyone, no one can control or hurt me. Admiration instead of unconditional loving Need to keep superiority Unwanted aspects of the self are seen in others (projection) Parents who are overstimulating, using devaluation and splitting Basically Cluster B parents. CLUSTER C: Anxious or fearful AVOIDANT PERSONALITY DISORDER Extreme shyness. Loner.  48 Pattern of anxiety, feelings of inadequacy, and social hypersensitivity. Feeling of inadequacy make person to feel inhibited in new social situations. Assumes that the one is unappealing to others, inferior, inept, ”doesn’t belong”. Avoids all kind of risks, uninterested in trying new activities because of the anticipated embarrassment. Preoccupied with thoughts about being judged, criticized and rejected by others. Chooses social isolation because of the fear, not preference Person desires affection and social contact but is too afraid to get involved. Job settings: individual, not involving contact with people, lab-based or computer based assignments, may decline promotion offers to avoid working closer with people. Relationships: family-based or in a close circle of a very few friends (who already proofed to Vicious circle of experiencing social rejection New social situa/ons bring fear of being inadequate and evaluated nega/vely Because of that person avoid adequate proper connec/ng with new people Withdraws, avoid eye contact, etc. These behaviors may be perceived by others as odd and concerning Others restrain themselves from making contact with the person Person understands it as a confirma/on of own low social value, inadequacy, being boring etc. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.  49 4 (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. 2. Is unwilling to get involved with people unless certain of being liked. 3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4. Is preoccupied with being criticized or rejected in social situations. 5. Is inhibited in new interpersonal situations because of feelings of inadequacy. 6. Views self as socially inept, personally unappealing, or inferior to others. 7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. Course: begins in early adulthood. Childhood signs: shyness, isolation, fear of strangers and new situations (not developmental), preserved till adulthood. Comorbid: anxiety disorders (especially social phobia), depressive and bipolar disorders. Prevalence: approx. 2.5%. Gender differences: none. DEPENDENT PERSONALITY DISORDER Craving caring. Excessive need to be cared for, leading to submissiveness, clinging behavior, and fears of separation.  50 Complicated decision making Looking for outside opinions, not able to make up own mind Changing decisions and opinions easily due to someone’s influence Avoiding arguments with others at all costs Because of the fear of abandonment and rejection Hidden anger and hostility (prone to more passive-aggressive responses) Mood depending on feeling accepted (prone to mood swings when rejected). Perceived often as Pessimistic Self-doubt Self-criticizing Looking for opportuni/es to get support and care from others “forever paIents” as geyng beier would mean the end of care given by therapist. Not taking responsibility for own choices and life development ExpecIng others to decide, then implicitly blaming them. Difficul/es to take care of own feelings and concerns Others are reservoirs for geyng rid of unwanted feelings, emoIonally exploiIve, “emo@onal vampires”. Vs. not able to leave violent and sadisIc partner Common involvement in relaIonship with narcissisIc, anIsocial, violent, abusive partners – high tolerance of verbal, physical, or sexual abuse (APA, 2013). Not able to stay alone for long. Job placement: failure in independent individual work, need constant guidance and even control, despite of own skills and experience. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. 5 (or more) of the following:  51 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. 2. Needs others to assume responsibility for most major areas of his or her life. 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self- confidence in judgment or abilities rather than a lack of motivation or energy). 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close re lationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself. Course: beginning by early adulthood. Prevalence: less than 1% More common in people with serious medical condition or disability Gender differences: : in general population none In clinical settings is more commonly recognised in females Comorbidity: depressive disorders, anxiety disorders, and adjustment disorders borderline, avoidant, and histrionic personality disorders Etiology environmental: experience of chronic physical illness or separation anxiety disorder in childhood or adolescence.  52 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER Preoccupation with orderliness, perfectionism, and control, including excessive dedication to work. Constant style of functioning Expressed in many areas not specific ones (vs. OCD) Perceived by others as: Neat and concerned with details Perfectionists Dedicated to their tasks Excessively thorough Taking too long to complete tasks that could be finished earlier Difficulties with prioritizing A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. 4 (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.  53 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. Shows rigidity and stubbornness. Course: beginning by early adulthood. Prevalence: up to 8%. Gender differences: 2 times more common in males. Comorbidity: anxiety disorders and obsessive-compulsive disorder But the majority of OCD patients do not meet the OC PD criteria(!) DISORDERS RELATED TO STRESS AND TRAUMA TRAUMA- and STRESSOR-related DISORDERS Used to be treated as anxiety disorders mostly Anxiety is a core affective state in most of them They are all reactions to external events (stressor or trauma) It distinguishes them from anxiety disorders We can always trace back a trigger event Experience of extraordinary loss Pathological ways of coping with stress and trauma Bring more suffering than relief Expressed by psychopathology symptoms  54 Devastating and long-lasting effects Impairing everyday functioning What do they share? Exposure to a traumatic or stressful event Development of a broad range of symptoms, including: anhedonicand dysphoric symptoms, externalizing anger and aggressive symptoms, or dissociative symptoms. Children disorders related to stress and trauma Reactive Attachment Disorder Disinhibited Social Engagement Disorder Both are a response, a way of unsuccessful coping with trauma of neglect, abuse and attachment deprivation. Reactive Attachment Disorder Attachment – behavioral system aimed at seeking proximity with a caregiver when child is upset or threatened (Bowlby, 1969).  55 Evolutionary mechanism. Survival oriented. Basis for developing ability to engage in close relationships with trust and comfort. Reactive Attachment Disorder – DSM V (APA, 2013) A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: The child rarely or minimally seeks comfort when distressed. The child rarely or minimally responds to comfort when distressed. A persistent social and emotional disturbance characterized by at least 2 of the following: 1. Minimal social and emotional responsiveness to others. 2. Limited positive affect. 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). The child has a developmental age of at least 9 months (child must be able to create selective attachment to be diagnosed).  56 Ecology Environmental: Neuroscience: Besides social neglect, changes in brain activity, instable, especially in the temporal lobes. limited, deprivating environment Maternal drug or alcohol use. Mother’s or baby’s illness after birth (being separated etc.) Usually begins after birth and within the first 3 years of life Becomes evident at age of 5 If signs of absent-to-minimal attachment behaviors between 9 months-5 years à diagnosis. Usually occurs with developmental delays (shared factor: deprivation in basic attachment needs by environment) Prevalence: no population data Increased prevalence in clinical populations Only 10% of children who are neglected, depreciated in their needs, raised in institutions, present signs of this disorder Hypothesis of psychological resilience of 90% of children There must be some neurobiological diversity as well, therefore.  57 Disinhibited Social Engagement Disorder A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at 2 two of the following: 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults. 2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation.  58 The child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 of the following: Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). The child has a developmental age of at least 9 months. Course: disorders manifests in children from 2 years old through adolescents (APA, 2013). Adult manifestations are unknown Comorbid with developmental delays (shared factor: deprivation in basic attachment needs by environment) Prevalence: no population data Increased prevalence in clinical populations 20% of children who are neglected, depreciated in their needs, raise din institutions, present signs of this disorder There must be neurobiological diversity. Etiology: Environmental neglect must be present before 2 years of age to develop the symptoms Studies shows no manifestations in children who experience neglect later Providing warmth stable care modifies the symptoms like a healing factor. Neurobiological  59 Post-traumatic Stress Disorder First diagnosed in veterans of the Vietnam war Azer WWII used to be called “combat fatigue”. Other conditons: events involving a threat of death, injury, or a threat to physical integrity of self or others E.g. torture, rape, watching a bloody accident, shooIng, natural disasters, manmade crisis, migraIon, genocide, life-threatening medical condiIons and their treatment. Course: may be delayed (first symptoms occur >6M post trauma) acute (symptoms last 3M). Persistent and usually doesn’t dissolve on its own 32% of traffic accident vicIms present PTSD symptoms 1 year later (Koren, Arnon, & Klein, 1999) WWII combat veterans presented symptoms 20 years later (Archibald & Tudenham, 1965)  60 Depressed mood Restlessness Irritability Excessive jumpiness Easily fatigued Waking during night Difficulty concentrating Sweaty hands or feet Severe headache Difficulty going to sleep Difficulty in memory Momentary blackouts Dizziness Smoking to excess Abdominal discomfort  61 Heart palpitating Combat dreams Pervasive disgust Shortness of breath Sighing and yawning Diarrhea Difficulty swallowing A very complex disorder, manifesting in a lot of areas: Cognitive Emotional Behavioral. Leading to quite severe impairment in everyday functioning. Diagnosed up from 1 year old. Exposure to actual or threatened death, serious injury, or sexual violence in 1 (or more): 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse). Note: does not apply to exposure through electronic media, television, movies, or  62 pictures, unless this exposure is work related. Experience of 1 (or more) of the following intrusion symptoms associated with the traumatic event: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring - the most extreme is a complete loss of awareness of present surroundings. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Persistent avoidance of stimuli associated with the traumatic event(s) as one or both of: efforts to avoid distressing memories, thoughts, or feelings efforts to avoid external reminders (people, places, conversations, activities, objects, situations). Negative alterations in cognitions and mood, present as 2 or more: 1. Inability to remember an important aspect of the traumatic event(s). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the event(s) by blaming himself/herself  63 or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Marked alterations in arousal and reactivity associated with the traumatic event(s), expressed by 2 or more: 1. Irritable behavior and angry outbursts (with little or no provocation) typically ex pressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Duration of the disorder > 1 month & starts 3months after the trauma. Disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. PTSD common dissociacve symptoms (APA, 2013) Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g. feeling a sense of unreality of self or body or of time moving slowly). Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as  64 unreal, dreamlike, distant, or distorted). “Flashbacks” with auditory pseudo-hallucinations. PTSD in children younger than 6 years old special criteria Trauma (not learning about the trauma but direct witnessing or living it): 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others, especially primary care givers. May include developmentally inappropriate sexual experiences without physical violence or injury. Expressions: Repetitive play of the trauma themes Frightening dreams don’t have to be explicitly representing trauma Specific trauma re-enactment in play Developmental regression, e.g. loss of language Dissociative symptoms in flashbacks as if the trauma was happening right now Etiology environmental: trauma exposure is a criteria by definition (!) Neurobiology: PET scans show increased levels of a subtype of glutamate receptor in the brain, metabotropic glutamate receptor-5 (mGluR5), in patients with PTSD (Holmes et al., 2017). Course: occurs in children and adults. Symptoms start and increase after the traumatic event. Lasts at least 1 month. Could be with delayed expression if starts >6M past trauma.  65 Prevalence: lifetime up to 9% (US) vs. Europe up to 1%; highest risk in people whose job puts their at higher risk of the traumatic exposure (soldiers, firefighters, police, emergency medical specialists). Gender differences: more prevalent among women, it has longer course. S risk: is higher than in general population but most likely due to trauma experience not PTSD symptoms itself (similar rates as in rape victims not necessarily suffering from PTSD). Comorbidity – 80% of PTSD patients develop other mental disorders (e.g., depressive, bipolar, anxiety, or substance use disorders). Acute Stress Disorder Reaction to an unusually stressful situation that is severe and feels like the one is not able to cope with it. Situation like: life-threatening, sexual violation, injury, accident.  66 Prevalence: in recent trauma-exposed populations  67 20%-50% of interpersonal assault traumatic events - assault, rape, mass shooting witness. 20% of events that do not involve interpersonal assault; 13%-21% of motor vehicle accidents, 14% of mild traumatic brain injury, 19% of assault, 10% of severe burns, 6%-12% of industrial accidents. Comorbidity: 50% of PTSD patients are previously diagnosed with Acute Stress Disorder. Gender differences: more common in women. Adjustment Disorders Feelings of not coping well enough with some kind of life change perceived as a stressful event. Examples of events (Mayo Clinic, 2017): Divorce or marital problems Relationship or interpersonal problems Changes in situation, such as retirement, having a baby or going away to school Adverse situations, such as losing a job, loss of a loved one or having financial issues Problems in school or at work Life-threatening experiences, such as physical assault, combat or natural disaster  68 Ongoing stressors, such as having a medical illness or living in a crime-ridden neighborhood. A more specific set of bereavement-related symptoms - Persistent Complex Bereavement Disorder (needs further studies) (APA, 2013). Stressors – recurrent (e.g. seasonal job evaluations) or continuous (progressing disability) Reaction lasts longer than 6 months. Feeling sad, hopeless or not enjoying things you used to enjoy Frequent crying Worrying or feeling anxious, nervous, jittery or stressed out Trouble sleeping Lack of appetite Difficulty concentrating Feeling overwhelmed Difficulty functioning in daily activities Withdrawing from social supports Avoiding important things such as going to work or paying bills Suicidal thoughts or behaviour Stress-related disturbance in functioning. Diagnosed when symptoms are developed due to identifiable stressor (not trauma). Stressor must occur within 3 months of the onset of symptoms and symptoms end in less than 6 months once the stressor is removed. Symptoms: Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. Significant impairment in social, occupational, or other important areas of functioning.  69 Does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder. Does not represent normal bereavement. Specifiers: With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct: Unspecified: Feeling sad, hopeless or not enjoying things you used to enjoy Frequent crying Worrying or feeling anxious, nervous, jittery or stressed out Trouble sleeping Lack of appetite Difficulty concentrating Feeling overwhelmed Difficulty functioning in daily activities Withdrawing from social supports Avoiding important things such as going to work or paying bills Suicidal thoughts or behaviour Stress-related disturbance in functioning. Diagnosed when symptoms are developed due to identifiable stressor (not trauma). Stressor must occur within 3 months of the onset of symptoms and symptoms end in less than 6 months once the stressor is removed. Symptoms: Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence  70 symptom severity and presentation. Significant impairment in social, occupational, or other important areas of functioning. Does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder. Does not represent normal bereavement. Specifiers: With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct: Unspecified: Course: begins within the 3 months after the stressor occurred and ends 6 months after it ends (or its consequences). Prevalence: one of the most common disorders. Especially in clinical populations. Outpatients: up to 20% Hospital consultations (Psych-ER): 50% Risk factors: Experienced trauma or severe stress as a child Suffering from other mental disorders Having a number of multiple stressors S risk: increased, as well as completed S rates  71 DISSOCIATIVE DISORDERS Characterized by disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior (APA, 2013). Disorders potentially disrupt every area of functioning. Common trauma aftermath (may be a part of PTSD or acute stress disorder symptoms).  72 2 kinds of experiences 1. Positive (added) dissociative symptoms Intrusions (uncontrolled access) into awareness and behavior, with accompanying losses of continuity in subjective experience: Fragmentation of identity, Depersonalization: experiences of unreality or detachment from one's mind, self, or body. Derealization: experiences of imreality or detachment from one's surroundings. 2. Negative (depleted) dissociative symptoms Inability to access information or to control mental functions: Dissociative Amnesia - inability to recall autobiographical information, no awareness of the amnesia, „amnesia for amnesia”. Dissociative Identity Disorder Dissociative Amnesia With dissociative fugue Depersonalization/Derealization Disorder Other Specified Dissociative Disorder Unspecified Dissociative Disorder Dissociative Identity Disorder Used to be called Muliple Personality Disorder. Years of discussion and doubts if it really is a diagnosic category. Some believed it is a possession.  73 Used as a court evidence – Billy Milligan found not guilty because of insanity (1955) Disruption of identity characterized by 2 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. These signs and symptoms may be observed by others or reported by the individual. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. The symptoms are not attributable to the physiological effects of a substance or another medical condition. Alters can have different genders or even different species. Different age Different physical features (e.g. allergies) Possession-form identities - appear as if a "spirit," supernatural being, or outside person has taken control, such that the individual begins speaking or acting in a distinctly different manner (APA, 2013) In most cases it’s not so spectacular... they do not overtly display their discontinuity of identity  74 only a small minority present to clinical attention with observable alternation (depicted in books and movies) More common are perceptions of different voices ”My inner dialogue is fragmented into many voices and I call it a system” (person with DID) feelings that a person suddenly become depersonalized observer of "own" speech and actions, which may feel powerless to stop (sense of self) strong emotions, impulses, may suddenly emerge, without a sense of personal ownership or control (self of agency) sudden shift in attitudes, outlooks, and personal preferences (e.g., about food, activities, dress) (APA, 2013) Dissociative amnesia manifestations in DID (APA, 2013) 1) gaps in remote memory of personal life events (e.g., periods of childhood or adolescence; some important life events, such as the death of a grandparent, getting married, giving birth); 2) lapses in dependable memory (e.g., of what happened today, of well-learned skills such as how to do their job, use a computer, read, drive); 3) discovery of evidence of their everyday actions and tasks that they do not recollect doing (e.g., finding unexplained objects in their shopping bags or among their possessions; finding perplexing writings or drawings that they must have created; discovering injuries; "coming to" in the midst of doing something). Dissociative fugue – discovering signs of recent travel without any memory of it, finding oneself in differen place, different part of the house,not remembering how the one got there. Psychological decompensation and overt changes in identity after: 1) removal from the traumatizing situation (e.g., through leaving home); 2) the individual's children reaching the same age at which the individual was originally abused or traumatized;  75 3) later traumatic experiences, even seemingly inconsequential ones, like a minor motor vehicle accident; 4) the death of, or the onset of a fatal illness in, their abuser(s). Prevalence: 12-month rate 1.5% in US population. Gender differences: prevalence similar, 1.6% males and 1.4% females. Females - more acute states (e.g., flashbacks, amnesia, fugue, functional neurological [conversion] symptoms, hallucinations, self-mutilation). Males – more criminal and violent behavior. Comorbid with depression, anxiety, substance abuse, self-injury, non-epileptic seizures, paranoia, cognitive disorders due to dissociative amnesia etc. Seek treatment because of comorbid disorders. May not be aware of DID condition. Course: onset may happen at any time from childhood to adulthood. S risk: 70% of DID patients tries to commit S at some point. EBology: most severe trauma during childhood - Especially physical and sexual abuse - 90% of DID paIents report childhood abuse or severe neglect - Rest 10% report severe medical procedures, , war, childhood prosItuIon, and terrorism – memory frozen and fragmented (amnesia) from self along with personality part, (possibly captured in child alters) - Cultural factors: in seyngs where normaIve possession is common, the fragmented idenIIes may take the form of possessing spirits, deiIes, demons, animals, or mythical figures Neurobiology:  76 Involved brain regions, including the orbitofrontal cortex, hippocampus, parahippocampal gyrus, and amygdala. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition. The disturbance is not better explained by DID, PTSD, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder. Specifier: Without dissociative fugue With dissociative fugue - apparently purposeful travel or bewildered wandering that is associated Dissociative Amnesia Localized amnesia the most common form of dissociative amnesia, amnesia of events during a circumscribed period of time e.g., months or years associated with child abuse or in tense combat. Selective amnesia the individual can recall some, but not all, of the events during a circumscribed period of time. Generalized amnesia  77 a complete loss of memory for one's life history, is rare. Individuals with generalized amnesia may forget personal identity. Systematized amnesia Lost of memory for a specific category of information (e.g., all memories relating to one's family, a particular person, or childhood sexual abuse). Continuous amnesia an individual forgets each new event as it occurs. Prevalence: 12 month rate around 1.8% (US data) Gender differences: more common in females 2.6% vs. males 1% Etiology/risk factors Environmental: traumatic experiences (e.g., war, childhood maltreat ment, natural disaster, internment in concentra/on camps, genocide), risk increases with number of traumas, their severity and violence involvement. Removal from the trauma/c circumstances underlying the dissocia/ve amnesia (e.g., combat, home) may bring about a rapid return of memory Commonly expressed as flashbacks. Course: onset is sudden, may be episodic in lifetime, single episode predisposes to next ones, some people get access to memories years later. Most critical period: when begins to remit Function: protection from a memory that cannot be worked through or comprehended; when the protection dissolves --> appearance of thoughts, feeling, memories related to trauma bring dysphoria, grief, rage, shame, guilt, psychological  78 conflict and turmoil, and suicidal and homicidal ideation, impulses, and acts. Like opening Pandora’s box. S risk: increased. Depersonalization/Derealization Disorder - features Experience of “going crazy”, difficult to explain symptoms. Altered sense of time Time and place confusion Accompanying anxiety and depression Common fear of brain tumour or other Depersonalization Derealization Detachment from own: Detachment from the world and Emotions “I know I feel reality: something but I don’t FEEL it”; subjective visual distortions, Sense of own being “I have no blurriness, self”; heightened acuity, Thoughts "My thoughts don't feel widened or narrowed visual field, like my own," "head filled with two-dimensionality or flatness, cotton”; exaggerated Sense of agency – „I feel like a three-dimensionality, robot/stone”; altered distance or size of "out-of-body experience" (most objects severe). macropsia micropsia Alice in Wonderland Syndrome  79 The presence of persistent or recurrent experiences of depersonalization, derealization, or both: Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/ or physical numbing). Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, life less, or visually distorted). During the depersonalization or derealization experiences, reality testing remains intact. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g., seizures). The disturbance is not better explained by another mental disorder. Prevalence: 50% of all adults have experienced at least one lifetime episode of depersonalization/derealization. Lifetime prevalence of the full disorder criteria approx. 2% Gender differences: none. Course: mean onset age 16 years old but may start even earlier. Comorbid with: unipolar depressive disorder and anxiety disorders. risk factors/etiology Temperamental: Environmental: harm-avoidant temperament, childhood interpersonal traumas  80 immature defences – less prevalent as in other (idealiza/on/devalua/on, projec/on dissociative and ac/ng out) disorders OverconnecUon schemata - emotional abuse and neglect - impaired most autonomy with themes of strongly associated with the dependency, vulnerability, and disorder incompetence. other: physical abuse; witnessing domestic violence; growing up with a seriously impaired, mentally ill parent; or unexpected death or suicide of a family member (APA, 2013). SOMATIC SYMPTOM AND RELATED DISORDERS Old: somatoform disorders somatizations DSM-IV term somatoform disorders was confusing overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses centrality of medically unexplained symptoms negative diagnosis based on excluding medical causes DSM V: somatic symptom disorders may accompany diagnosed medical conditions (not appearing in the lack of them!) diagnosis based on positive symptoms distressing somatic symptoms + abnormal thoughts, feelings, and behaviors in response to  81 them medically unexplained symptoms remain a key feature in conversion disorder and pseudocyesis Some other mental disorders may manifest with soma?c symptoms (e.g., major depressive disorder, panic disorder) soma/c component adds severity and complexity to their course and impairement Comorbidity among soma?zing individuals (presen?ng soma?c disorders) Soma?c symptoms are frequently associated with psychological distress and psychopathology (e.g. in chronic diseases). Somatic symptom and related disorders: core definition focus on somatic concerns and their initial presentation mainly in medical rather than mental health care settings; 75% patients who received hypochondria diagnosis meet this criterium 25% of hypochondria patients present high anxiety but lack of somatic symptomsà current health anxiety disorder. Etiology/risk factors Genetic and physiological vulnerability e.g., increased sensitivity to pain. Psychological: High neuroticism as a trait  82 Environmental: Early traumatic experiences (e.g., violence, abuse, deprivation), And learning through conditioning (e.g., attention obtained from illness), Cultural/social norms that devalue and stigmatize psychological suffering as compared with physical suffering Lower educated and lower socioeconomic status Recent experience of stressful life events Medical family history DSM V Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder (Functional Neurological Symptom Disorder) Psychological Factors Affecting Other Medical Conditions Factitious Disorder Imposed on Self, Imposed on Another Other Specified Somatic Symptom and Related Disorder Unspecified Somatic Symptom and Related Disorder  83 Symptoms may represent normal bodily functions and sensations or discomfort that does not generally sig- nify serious disease E.g. digestion sensations, heart beating Common catastrophic explanations Repeated screening for body abnormalities Screening may decrease risk of real death (epidemiological data) Symptoms may or may not be associated with another medical condition Always: very high levels of worry about illness Distress, frustration and suffering is real In severe cases: symptoms may have a central role in the individual's life, becoming a feature of his or her identity and dominating interper sonal relationships Prevalence: lifetime approx. 5-7% Gender differences: more common in females. Illness Anxiety Disorder Preoccupation with having or acquiring a serious illness. Somatic symptoms are not present or, if present, are only mild in intensity. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doc tor appointments and hospitals). Illness preoccupation has been present for at least 6 months (APA, 2013). Care-seeking vs. care-avoiding type In the past people with Illness Anxiety Disorder were diagnosed as hypochondriacs. Prevalence: up to 8% of ambulatory clinics.  84 Conversion Disorder (Functional Neurological Symptom Disorder) „Functional" - abnormal central nervous system functioning. ”Psychogenic" - assumed etiology (from mental processes). Inner tension/conflict is conversed into somatic symptom. Motor symptoms weakness or paralysis; abnormal movements, tremor; walking abnormalities; and abnormal limb posturing. Sensory symptoms altered, reduced, or absent skin sensation, vision, or hearing. Psychogenic (non-epileptic seizures) - episodic abnormal generalized limb shaking with apparent impaired or loss of consciousness Fainting or coma like episodes of unresponsiveness Dysphonia/aphonia -reduced or absent speech volume Dysarthria - altered articulation Globus (histericus) - sensation of a lump in the throat Diplopia – dual vision. One or more symptoms of altered voluntary motor or sensory funcSon. Clinical findings provide evidence of incompaSbility between the symptom and recognized neurological or medical condiSons. The symptom or deficit is not beder explained by another medical or mental disorder. Causes clinically significant distress or impairment in social, occupa\onal, or other important areas of func\oning or warrants medical evalua\on.  85 Specifiers: with weakness or paralysis; abnormal movement; swallowing symptoms; speech symptom; akacks or seizures; anesthesia or sensory loss; special sensory symptom (e.g., visual, olfactory, or hearing disturbance); mixed symptoms. Acute: 6 months Persistent: over 6 months of symptoms Symptoms are not consciously produced. La belle indifférence - lack of concern about the nature or implica?ons of the symptom; but it is not specific for conversion disorder and should not be used to make the diagnosis (