Kaplan and Sadock's Comprehensive textbook of Psychiatry 8th edition

Page 1 of 11

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 1 - Neural S ciences > 1.1: Neural S ciences : Introduction and

1.1: Neural S c ienc es : Introduc tion and Overview J ac k A. Grebb M.D. P art of "1 - Neural S ciences " A paradox in the ongoing effort to unders tand the brain is that it is wis e to know everything there is to in the area of neural s ciences, but nothing should be believed. Much like Maurits C . E scher's enigmatic illus tration of a hand drawing itself, it is up to our own brains to discover and diagram how they are put T his paradox should not be s een as nihilis tic, but rather reflecting the tremendous excitement regarding neural sciences in the 21st century, which was us hered in by awarding of the 2000 Nobel P rize in Medicine to three neuros cientists : Arvid C arlss on, P aul G reengard, and K andel. It is the human brain, after all, that is the subs trate for emotions , cognitive abilities, and behaviors that is , everything that humans feel, think, do. E very week, the s cientific journals publish new into the neural sciences, many of which conflict with or least modify previous obs ervations, hypotheses, or theoretical models. Obvious overs implifications from past include the abs olute demarcation between neurological and ps ychiatric dis orders, the absolute categorization of brain regions as devoted to only or emotional activities , and the absolute dogma that 1 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 2 of 11

only release neurotransmitters and dendrites only to neurotrans mitters . Although the sections in this first chapter on neural s ciences do not include everything is to know, they do provide a framework that outlines much of what is currently known. Moreover, each of the sections provides an ins ight into the directions in which that particular field is evolving.

NE UR OA NA TOMY A ND NE UR ODE VE L OP ME NT F unctional neuroanatomy (dis cuss ed in S ection 1.2) is study of interacting and interdependent neurons, glia, groups of neurons and glia (e.g., nuclei), and brain T he three neural systems of most interest in psychiatry the thalamocortical system, the basal ganglia, and the limbic s ys tem. Although previous generations of neuroanatomis ts have ass igned functions, such as sens ation, movement, emotion, cognition, and specific neuroanatomical structures, a general trend in neuroanatomy is to des cribe how networks of brain regions interact to produce what is eventually or obs erved as feelings , thoughts, or behaviors . In as another example of a change to previous dogma, it increasingly becoming accepted that new neurons can form and function in the adult human brain, es pecially regions of the limbic s ys tem, such as the hippocampus. T his area of neural science is covered in S ection 1.3, Development and Neurogenes is , which discus ses embryonic neurogenesis , the migration of neurons, and the outgrowth and formation of neuronal axons and dendrites. T hese developmental proces ses are of to psychiatrists because pathology in neural might later res ult in clinical symptoms , or, conversely, 2 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 3 of 11

clinical pathological states (e.g., excess ive s tres s) affect thes e very same neural development and neurogenes is proces ses in an adverse manner.

INTE R NE UR ONA L MOL E C UL A R S IG NA L S T he two methods for communication among neurons glia are molecular (or chemical) and electrical. T he four most widely recognized class es of molecular signals the monoamines , amino acids , peptides, and the more recently dis covered neurotrophic factors. Although it is reasonable to dis cuss each of thes e clas ses done in this textbook, there are a number of common themes relevant to all four clas ses of molecular signals. F irst, new molecular s ignals are being discovered, both within thes e exis ting clas ses (e.g., previous ly amino acid or peptide neurotransmitters), as well as in novel class es of molecular signals (e.g., nitric oxide, monoxide, adenosine, adenosine triphosphate [AT P ]). S econd, there are hundreds of so-called orphan that have been discovered through examining the sequence of the human genome. T hes e proteins have the characteristics of receptor proteins, but the endogenous ligands for them have not been and, in most cas es , chemicals that activate or inhibit receptor function have not yet been s ynthes ized. T hird, general theme among both known and unknown receptors is heterogeneity, s uch that there are multiple subtypes of receptors for a particular neurotrans mitter, such as the α-adrenergic and β-adrenergic receptors norepinephrine. S imilar to heterogeneity in receptors is heterogeneity in the deactivation of neurotransmitter molecules via multiple s ubtypes of deactivating 3 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 4 of 11

(e.g., monoamine oxidas e, peptidas es ) as well as subtypes of trans porter proteins (e.g., reuptake F ourth, any s ingle neuron can releas e multiple different types of molecular signals (e.g., two different peptides a monoamine) and als o have receptors and receptor subtypes for multiple different molecular signals, thus making each individual neuron capable of exquisite integration and modulation of incoming and outgoing signals . T here are s ix class ic monoamine neurotransmitters: serotonin, the three catecholamines (epinephrine, norepinephrine, and dopamine), acetylcholine, and histamine (S ection 1.4). T he monoamine neurotransmitters, although present in only a small percentage of neurons localized in s mall nuclei in the brain, have enormous impact on total brain function because the diffuse projections of axons from these monoaminergic neurons can affect virtually every brain region. In contras t to the monoamine the amino acid neurotrans mitters are widely dis tributed the brain, and it is poss ible to conceptualize the brain reflecting the balance between the excitatory amino glutamate and the inhibitory amino acid γ-aminobutyric acid (G AB A) (S ection 1.5). In P.2 contrast to the relatively s mall number of different monoamine neurotrans mitters and amino acid neurotransmitters, more than 100 different putative neuropeptide neurotrans mitters have been identified (S ection 1.6). T he neurotrophic factors (S ection 1.7) clas s of protein molecular signals that were more 4 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 5 of 11

discovered than the other molecular signals. T hes e proteins are involved in the growth, differentiation, maintenance, and death of neuronal and glial cells and have been demonstrated to be involved in process es as learning, memory, and complex behaviors .

INTR A NE UR ONA L S IG NA L S T he integrative work of an individual neuron is accomplis hed via intraneuronal molecular signaling pathways, the modulation of the balance between external and internal concentrations of ions , and the conversion of these signals within each individual into the s timulation of axon potentials, the trans cription deoxyribonucleic acid (DNA) into ribonucleic acid and the translation of R NA into proteins . W hen a signal binds to its specific cell surface receptor, a of intraneuronal signals is initiated (S ection 1.8). T here multiple interacting s ignaling pathways within each neuron, and these intraneuronal events s hould actually cons idered the es sential s ites of action for drugs rather than merely the cell surface receptors. T hes e complex intraneuronal s ignaling pathways are additional sites of interest for understanding the pathophysiology neurops ychiatric disorders . T he balance between external and internal of ions is achieved by a wide array of ion channels, which are regulated by neurotrans mitters and others by voltage gradients directly (S ection 1.9). Many of the of interes t in psychiatry act directly on ion channels. benzodiazepines act on G AB A type A receptors that chloride ion channels. P hencyclidine (P C P , or angel acts on a subtype of glutamate receptors that are 5 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 6 of 11

ion channels . Nicotine, the active ingredient in tobacco, acts on nicotinic acetylcholine receptors that are and potas sium ion channels. A more recently property of certain neurons and ion channels is the role of pacemaker, or oscillatory, activity in normal maintenance of wakefulness , attention, and mood. Driving the development of the brain as well as the maintenance and regulation of brain function is the proces s of genetic express ion (S ection 1.10). T he proces s of genetics involves the trans cription of DNA R NA and the translation of R NA into a protein. A system of regulation exis ts for transcription and translation, and the newly dis covered molecules and pathways for this regulation are sites of investigation discoveries in the etiology, pathophysiology, and treatment of mental disorders . Alterations in gene expres sion occur both during development and in adulthood and may be the bas is of abnormal and development and of abnormal and normal adaptation stress .

E NDOC R INOL OG Y, A ND C HR ONOB IOL OG Y In addition to the central nervous system (C NS ), the body contains two other systems that have a complex, internal communicative network: the endocrine system and the immune s ys tem. Mostly becaus e of the of the involved molecular s ignals , it is now known that these three systems are integrated with each other, has given birth to the sciences of ps ychoneuroendocrinology (S ection 1.11) and ps ychoneuroimmunology (S ection 1.12). T he 6 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 7 of 11

between the neuroendocrine s ys tem and C NS can easily be s een in the ps ychiatric s ymptoms that can accompany some hormonal disorders (e.g., depres sion C us hing's s yndrome) and also in the identification of disorders of neuroendocrine regulation as potential markers for state or trait variables in ps ychiatric S imilarly, the immune s ys tem is linked with both the and endocrine system through s hared molecular T he other property s hared by the C NS , endocrine and immune s ys tem is that they undergo regular with time. T he s tudy of these changes with time and disorders of time regulation are included in the field of chronobiology (S ection 1.13).

B R A IN IMA G ING C urrent technology allows brain imaging to detect and display electrical brain activity and physical brain as well as functional brain activity. Hans B erger firs t recorded the human electroencephalogram (E E G ) in and s ubs equent advances in this area have resulted in as sess ment of evoked potentials (vis ual, auditory, somatos ens ory, and cognitive), as well as quantitative, computerized as sess ments of topographic E E G s ignals (S ection 1.14). In addition to the standard X -ray techniques, including computed tomography (C T ), a of brain imaging techniques relies on nuclear magnetic res onance imaging (MR I) to as ses s both the structure function of the brain (S ection 1.15). T hes e techniques externally induced manipulations in the magnetic fields nuclei to image brain s tructure (sMR I) and brain (fMR I and magnetic res onance spectroscopy [MR S ]). other major technique for brain imaging uses very amounts of radioactive compounds introduced into the 7 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 8 of 11

brain and then vis ualized by the use of specific imaging cameras (S ection 1.16). T he two major techniques of type are positron emiss ion tomography (P E T ) and photon emis sion C T (S P E C T ). T hese techniques are particularly well suited for the s tudy of receptors, and metabolis m. T hes e techniques can and visualize brain function during increasingly s horter time periods, allowing res earchers to as k s pecific about brain regions and neural networks and their relations hips to emotional, cognitive, and behavioral states and activities .

G E NE TIC S S ince the las t edition of this textbook, the human, the mous e, and other animal genomes have been and, in a s ense, the ans wers are now there, but the questions must be asked with regard to the genetic of mental disorders . B y studying the genetics of both populations and individuals, investigators are to break the code regarding the etiology of mental disorders (S ections 1.17 and 1.18). Increasingly, inves tigators conceptualize mos t complex neurops ychiatric disorders as res ulting from the interaction of multiple s us ceptibility genes rather than a single caus al gene or a small number of causal genes. eventual identification of the key genes, however, potentially allow an entirely different approach to the diagnosis, prevention, and treatment of mental by us ing targeted genetic and pharmacological approaches. One of the key experimental approaches this path of unders tanding human ps ychopathology is us e of transgenic animal models of behavior (S ection T he mous e genome is remarkably s imilar to the human 8 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 9 of 11

genome, and investigators are now able to make manipulations in the mous e genome to produce transgenic mous e models that may evidence behavior treatment res ponses that are relevant to unders tanding and treating human disorders .

C OMP L E X HUMA N B E HA VIOR S T his textbook contains many chapters describing and abnormal complex human behaviors . T hree of such complex P.3 behaviors are sleep (S ection 1.20), appetite (S ection and s ubs tance abus e and dependence (S ection 1.22). the beginning of this s ection, it was mentioned that it is neces sary to know everything and believe nothing and also to be wary of overs implifications from past models the brain and behavior. S leep, appetite, and substance abuse are all examples of thes e less ons , as all three now conceptualized as involving complex systems the brain responding to bodily functions outside of the C NS and changing in res ponse to external influences of biological, psychological, and s ocial

FUTUR E DIR E C TIONS R es earchers in neural s cience will continue to the s equencing of the human genome and advances in brain imaging techniques, as well as other advances in experimental neuroscience. Although the ultimate goal all these efforts is to prevent the development of disorders , the immediate goals are to alter dis ease progres sion and promote recovery. T he pace of 9 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 10 of 11

in neural s cience is, unfortunately, well matched by the complexity of the brain. Nevertheles s, neuroscientis ts finding ways to challenge their own beliefs in the light new data, and it may indeed be one of the readers of textbook that breaks through the current relative ignorance and leads psychiatry into a new paradigm for unders tanding mental illness in the 21s t century.

S UG G E S TE D C R OS S Neurops ychiatry and behavioral neurology are in C hapter 2; the neuropsychological and psychiatric as pects of AIDS are discuss ed in S ection 2.8; the neurochemical, viral, and immunological studies of schizophrenia are discus sed in S ection 12.4; the biochemical as pects of mood disorders are discus sed S ection 13.3; biological therapies are discus sed in 31; and Alzheimer's disease is discus sed in S ection T he future of ps ychiatry is discus sed in S ection 55.3.

R E F E R E NC E S *B urke W : G enomics as a probe for dis eas e biology. E ngl J Me d. 2003;349:969. *Dolan R J : E motion, cognition, and behavior. 2002;298:1191. G ingrich J A, ed. G enetically altered mice in the neurops ychiatry. C NS S pe ctrums . 2003;8:551. McK hann G M: Neurology: then, now, and in the Arch Neurol. 2002;59:1369. 10 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 11 of 11

*R utter M: T he interplay of nature, nurture, and developmental influences . Arch G e n P s ychiatry. 2002;59:996. *S nyder S H: F orty years of neurotrans mitters . A personal account. Arch G e n P s ychiatry. *Zonta M, Angulo MC , G obbo S , R osengarten B , Hos smann K -A, P oss an T , C armignoto G : Neuronas trocyte signaling is central to the dynamic control brain microcirculation. Nat N euros ci. 2003;6:43.

11 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

01/01/2009

Page 1 of 130

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 2 - Neurops ychiatry and B eha vioral Neurology > 2.1: Approach to the P a tient

2.1: Neurops yc hiatric Approac h to the Patient Fred Ovs iew M.D. P art of "2 - Neurops ychiatry and B ehavioral Neurology"

INTR ODUC TION Neurops ychiatry is the ps ychiatric s ubs pecialty that with the psychological and behavioral manifestations of brain dis eas e. Neurops ychiatry is closely allied with the neurological s ubs pecialty that interes ts itself in ps ychological phenomena in patients with brain namely cognitive and behavioral neurology. T he care patients with identifiable, acquired brain dis eas e—such those with epileps y, movement disorders , and brain injury—requires the phys ician to have a base and a familiarity with ass ess ment and treatment methods not usually required for patients with primary ps ychiatric disorders. P atients with organic mental syndromes are common in clinical practice and often difficult to manage for the generalist or for the general ps ychiatris t in consultation with s pecialis ts in other In addition to expert management of patients with mental disorders , from its clinical vantage point, neurops ychiatry can offer a dis tinctive pers pective on idiopathic psychiatric disorders . Moreover, neurops ychiatry draws on a knowledge bas e in the 12 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 2 of 130

cognitive neuros ciences that has the potential to sharpen, and modernize ass ess ment and nosology in general ps ychiatry. T his chapter provides information about as ses sment by history, examination, and paraclinical investigations in neurops ychiatry and des cribes neuropsychiatric ps ychopathology from three pers pectives : anatomy, symptom or s yndrome, and disease. C overage from vantage point is panoramic in the hope that the three perspectives , by triangulation, produce an image of neurops ychiatris t thinks when ass ess ing a patient—the cerebral s ubs trate of behavior, the plausible of dis eas e process es, the clinical phenomena, and elucidation at the bedside. S ome of the points made in description of clinical techniques are illustrated in vignettes in the final s ection of the chapter that focus as sess ment is sues. T he seemingly obvious view that neuropsychiatry is the offspring of ps ychiatry and neurology is his torically mistaken. P s ychiatry differentiated itself as a medical specialty in the early part of the 19th century and neurology somewhat later. Ample evidence s hows that early asylum phys icians, the precursors of cons idered their patients to have brain dis eas es and, moreover, that a large proportion of their patients organic disease, even as it could be identified with the tools of that time. G eneral pares is of the insane (neuros yphilis, as it was later discovered to be), mental retardation, and the complications of alcohol abuse were all common in the 19th-century asylum. On this evidence, one might s ay that general ps ychiatry, was understood for the larger part of the 20th century, 13 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 3 of 130

derived from an earlier neurops ychiatry. E arly neurology, on the other hand, took little part in care of patients with major ps ychiatric disorders, at those requiring hospitalization; but what would later become outpatient ps ychiatry—the care of patients milder mood and anxiety disorders not requiring management, for example—fell into the province of the early neurologis ts. T he theories by virtue of which they unders tood their patients have, fortunately, been cons igned to the dus tbin of his tory. T he mains tream of Anglo-American neurology was ill equipped to give ris e a s cientific neurops ychiatry, and it was not until (as a convenient and meaningful landmark) Norman in 1965 awakened interest in the continental tradition of behavioral neurology avant la le ttre that the of J ohn Hughlings J ackson, Ludwig Lichtheim, Hugo Liepmann, K arl W ernicke, and others could provide impetus for the development of a clinical specialty devoted to scientific understanding of the cerebral mental and behavioral disorder. T o say that neuropsychiatry is devoted to the care of patients with brain dis eas e is not to depreciate the role ps ychological and social factors in the unders tanding of the genes is of s ymptoms or in the formulation of interventions to ass is t patients. T o the contrary, with brain disease are often inordinately reactive to or dependent on influences from the outside world, the social world. Neurops ychiatric case formulation into account both the vulnerability and the setting. T o extent that patients s uffer from brain-based in proces sing information from their environment, their need for as sistance in dealing with ins trumental and 14 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 4 of 130

interpersonal tas ks increas es . Much of the brain, after devoted to process ing social information and devising ways of meeting internal needs in a s ocial context. T he neurops ychiatris t requires a detailed ass ess ment of the patient's functional deficits and the contexts in which arise. T o say that the neuropsychiatris t regards deficits , or for that matter intact behavior, as the manifes tation of based proces ses is not to imply that idiopathic disorders occur in people with normal brains nor that general ps ychiatris ts are unaware of the cerebral origin these disorders . T o the contrary, the evidence for abnormal brain structure and function in the major ps ychiatric disorders is unmis takable, and general ps ychiatris ts often as sert the neurobiological nature of these illnes ses. However, evidence for s uch as sertions often not demonstrable in the individual cas e, all laboratory inves tigations characteris tically falling within the broad range of normal. Moreover, the abnormalities P.324 in question are believed to be, at least in large part and least in mos t illness es , genetic in nature and developmental in pathogenes is . T he recognition and unders tanding of the mental cons equences of acquired diseases of the brain—which form the bulk of the neurops ychiatris t's concern—are likely to require tools from those required by the general ps ychiatris t treating idiopathic disorders . Although a bright line between the two situations is not poss ible, and many neuropsychiatrists maintain a lively interest in 15 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 5 of 130

disorders as schizophrenia and autis m, the dis tinction supports the continued use of the term organic to refer these acquired disorders with pathology identifiable at bedside and by the clinical laboratory, as much as want to see the term interred. T o define neuropsychiatry by how the clinician thinks, however, may be less telling than to define it by what clinician does . Neurops ychiatris ts perform phys ical examinations, not just a focus ed screen for signs , s uch as is within the ambit of mos t general ps ychiatris ts, but a broad as sess ment of cerebral us ing the tools available. Neuropsychiatrists not only neuroimaging and electroencephalographic studies but also review them pers onally, not just to “rule out disease” but to see which organic disease is pres ent where.

NE UR OA NA TOMIC A L B A S IS OF NE UR OP S YC HIA TR IC T he neurops ychiatric brain is more complex than the general ps ychiatric brain. T he latter is a s oup of neurotransmitters, perhaps in “chemical imbalance” (as patients are wont to say), with cons iderable pharmacological, but little anatomical, specificity. Although the benefits of ps ychopharmacological intervention are indis putable, the locus of these effects rarely of concern to clinicians . A neuropsychiatric relies on greater differentiation among brain circuits systems . T he chapter cons iders s everal major brain systems of key importance to neurops ychiatric case formulation.

16 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 6 of 130

L ateralization T he two hemispheres differentially s ubs erve many functions , although in many instances, both participate in naturally occurring behavior, albeit contributing differently to the complex outcome. B rain as ymmetries arise early in vertebrate evolution, and two hemispheres display regional lateral as ymmetries size and differentially innervate viscera and peripheral endocrine tis sues. F or example, the pars opercularis of third frontal gyrus (B roca's area) and the planum temporale (infolded cortex in the pos terior portion of sylvian fis sure) are typically larger on the left, with dendritic branching of the neurons therein (for sake, “left” and “right” here refer to the situation in the average dextral patient). T hes e cortical regions are the substrate of language process ing. Ins ular cortex of right hemisphere regulates cardiac sympathetic drive of the left hemis phere, parasympathetic drive. In cons equence, left hemisphere s troke involving ins ula produces more cardiac destabilization and morbidity right, and lateralization of s eizure dis charges may have implications for autonomic function and unexplained sudden death in patients with epilepsy. Lateral in limbic (hypothalamic and amygdalar) regulation of sexual function als o have clinical implications; for polycys tic ovary syndrome in females may be more commonly ass ociated with left-sided limbic epileps y. Hemispheric s ide of les ion als o affects the cons equences of brain injury. Whether a s ingle tag can accurately contras t the proces sing “styles ” of the hemispheres —“local versus global” or “linear versus context dependent,” for 17 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 7 of 130

example—acros s multiple functions is doubtful. left lateralization of language and right lateralization of visuospatial function are widely recognized, lateral specialization in the prefrontal regions is less obvious of clinical significance. F rontal lobe degeneration the right, more than the left, frontal lobe is particularly as sociated with disinhibition. T raumatic injury to the hemis phere is more ass ociated with depres sion and anxiety, to the left with anger and hos tility. W omen and sinis trals tend to s how less lateralization of language perhaps of other functions ), s o that left hemisphere are les s likely to produce severe impairment. Of cons iderable importance for neurops ychiatric is the ques tion of lateralization of emotional An array of evidence s upports the notion of differential emotional valences in the two hemispheres . On this account, the left hemis phere is specialized for pos itive emotions , the right for negative emotions. T hus left hemis phere destructive les ions are as sociated with pathological crying and right hemisphere ones with pathological laughing; contrariwise, left hemisphere discharging les ions produce gelastic (laughing) and right hemisphere ones , dacrystic (crying) epilepsy. this context, the reported ass ociation of left anterior with depress ion makes s ense. However, much evidence favors as signing a prepotent in emotional process ing in general to the right hemis phere. P atients with right hemisphere damage appear to be more impaired at perceiving emotion regardless of the valence or input medium. Lesions of right hemisphere are ass ociated with impairments in proces sing emotion in speech, a defect known as 18 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 8 of 130

apros odia. P atients may lack the capacity to modulate prosody, so as to encode emotional information into speech, or the capacity to recognize emotional produced by others . S ubtler clinically may be deficits in recognizing emotion in faces or visual scenes . S uch may be part of the bas is for a finding that may s eem counterintuitive, namely that patients with right hemis phere injury have a poorer rehabilitation outcome than their left hemisphere counterparts .

Frontos ubc ortic al C irc uits T he projection of prefrontal cortex to s ubcortical structures in multiple clos ed loops is a crucial feature of behavioral neuroanatomy. T he key concept is that, in loop, a distinct region of prefrontal cortex projects to a distinct portion of the s triatum, then to an output of the bas al ganglia, then, in turn, to a specific nucleus the thalamus , which itself projects to the given area of cortex. T hus, a s et of parallel clos ed loops of frontos ubcortical connections proces ses information in separate domains . In the motor system, premotor and s upplementary motor area project primarily to putamen, the output of which projects via ventrolateral globus pallidus and caudolateral substantia nigra pars reticulata (S Nr) to ventrolateral-ventroanterior and centromedian nuclei of thalamus and then back to the originating cortical structures. Of particular interest to neurops ychiatris ts are the loops involving dors olateral prefrontal, medial and lateral orbitofrontal, and anterior cingulate cortex: Dors olateral prefrontal cortex projects to caudate; projections from caudate go to 19 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 9 of 130

globus pallidus and S Nr. T he output from basal flows primarily to ventrolateral and ventroanterior nuclei of thalamus (but als o to dors omedial nucleus thalamus ), whence it projects to areas 9 and 46 of dorsolateral prefrontal cortex. Lateral orbitofrontal cortex projects to ventromedial caudate, thence to the caudomedial aspect of S Nr. thalamic level of this loop is repres ented in ventral anterior and dors omedial P.325 nuclei, whence projections aris e back to the lateral as pect of area 12 in orbitofrontal cortex. T he medial orbitofrontal cortex loop features projections from gyrus rectus and medial orbital to ventromedial caudate; output from the basal ganglia arises in S Nr and flows to dorsomedial of thalamus, as well as ventrolateral and nuclei, thence back to medial orbitofrontal cortex. Anterior cingulate cortex, in the dorsomedial as pect the hemis phere, projects to ventral striatum, nucleus accumbens and olfactory tubercle (termini the mesolimbic dopamine system), with output from S Nr flowing through ventroanterior thalamus on its way back to anterior cingulate cortex. Dis ruption of each of thes e loops produces a distinctive clinical s yndrome. As is implied by the concept of a deficits similar to those produced by cortical damage also occur with damage to the subcortical connections the cortical region. B efore a sketch of each of these syndromes, note mus t be made that mos t naturally 20 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 10 of 130

occurring les ions do not res pect the anatomic so that clinical presentations are commonly mixed. Nonetheles s, for analytical purposes , the anatomical specificity is of interes t and importance. Interference with the loop involving dorsolateral cortex prominently produces executive cognitive impairment, with decrements in working memory, problem s olving, and related capacities. Damage to loop commonly arises from traumatic brain injury, and basal ganglion degenerative diseases s uch as P arkins on's dis ease. Involvement of the white matter of frontal lobes by small-vess el dis eas e commonly leads interruption of corticos ubcortical connections in this circuit and the picture of subcortical dementia. Damage to orbitofrontal cortex and its connections produces impulsivity, dis inhibition, dampening of the experience of emotion, irritability and lability of affect, poor judgment and decis ion making (es pecially in to social behavior), and ins ightless nes s about thes e impairments . T hese impairments are generally s een bilateral damage, although unilateral right-sided injury may als o produce them. As a neighborhood s ign, often involves the olfactory nerve (which runs along the orbital surface of the brain) with cons equent anos mia— times the only neurological s ign. C ognitive function, as tes ted by the usual beds ide or neuropsychological may be unaffected even in the presence of devastating personality change. T rauma is a common etiology. Damage to dorsomedial prefrontal s tructures may aris e from tumor or s troke. Abulia and apathy, disorders of initiation of action and the experience of motivation, are the res ult. Abnormalities of initiation of movement, with 21 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 11 of 130

akinetic mutis m as the mos t extreme s tate, may occur. C ingulate cortex is a structure of particular interest. E vidence from animal and imaging s tudies its importance in orienting attention under conflicting stimulus demands , modulating focus ed problem and monitoring performance to optimize reward. A cell type s een only in cingulate cortex, the s pindle cell, in evolution only with the great apes and in ontogeny at 4 months of age, concomitant with the infant's increasing capacity to focus attention. Interference with the output of cingulate gyrus , namely by interrupting cingulum—the procedure of cingulotomy—appears to beneficial in a dis order of excess ive attention, namely obses sive-compuls ive disorder (OC D).

L imbic S ys tem L e grand lobe limbique was delineated in the mid-19th century (by P aul B roca of aphas ia fame) as a ring of and s ubcortical structures on the medial aspect of the hemis pheres . J ames P apez drew attention to the formed by projections from hippocampus via fornix to mamillary bodies of hypothalamus, thence to anterior nucleus of thalamus , thence via the anterior limb of internal caps ule to cingulate gyrus , thence back to hippocampus via presubiculum, entorhinal cortex, and perforant pathway. In addition to this “P apez circuit,” amygdala and its reciprocally connected orbitofrontal cortex are taken to form part of a limbic s ys tem, a term us ed by P aul MacLean one-half century ago. Although some anatomists bristle at its inclusivenes s, the nearly universally us ed, probably because it focuses attention on the “emotional brain.” 22 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 12 of 130

T he core limbic structures are characterized by rich reciprocal monosynaptic connections with these are Hippocampus Amygdala P iriform cortex anterior to amygdala on the medial surface of the temporal lobe S eptal nuclei in the medial wall of the hemispheres , immediately ros tral to lamina terminalis S ubstantia innominata in the bas al forebrain P aralimbic cortices res ide in temporopolar, insular, and orbitofrontal regions, which have primary affiliations amygdala, and in parahippocampal, cingulate, and s ubcallosal regions, with primary with hippocampus . In the limbic s ys tem, broad and direct input from cortices into amygdala and hippocampus is extensively proces sed on its way to effector neurons in regulating autonomic and endocrine activity. In addition to this mediation of the regulation of the internal milieu, the limbic s ys tem gates the activity of the motor in the bas al ganglia, regulating action in the external milieu. T his occurs by prefrontal cortical integration of information in the limbic frontosubcortical circuit, which reaches the cortex via projections from ventral pallidum mediodors al nucleus of thalamus . One reas on for the central importance of the limbic in neuropsychiatry is that the threshold for production 23 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 13 of 130

epileptic discharges is lowest in amygdala and hippocampus . T hus, most epileps y in adults is limbic epilepsy. One consequence is the “voluminous mental state,” first identified by Hughlings J ackson. T his refers the range of experiential phenomena encountered as auras in limbic epilepsy: dé jà vu, depers onalization/derealization, microps ia, and and s o forth. S uch s ymptoms are s een not only in but also in mood dis orders and as putative pointers to limbic involvement in paroxys mal disorders not of clear epileptic nature, including those ass ociated with borderline pers onality disorder and with childhood T heir presence, therefore, does not unequivocally mark organic diagnosis. Another reas on for the centrality of the limbic system is that hippocampus, in particular, has a crucial role in explicit memory, further discus sed below. P ers is ting subs tantial amnestic deficits in multiple modalities limbic s ys tem damage.

C erebellum Agains t the prevailing notion that the cerebellum is a motor s tructure, anatomical evidence s hows that cerebellar inputs acces s areas of prefrontal cortex, with relay in thalamus. T hes e areas of cortex project to cerebellum, creating, as with the prefrontal-basal ganglia circuits previously dis cus sed, a set of parallel (relatively) clos ed loops, or channels . T hes e cross ed connections from the cerebellar hemis pheres and the further cros sing of des cending cerebrofugal long tracts mean that motor deficits are manifest ips ilateral to lateralized cerebellar injuries . Additional 24 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 14 of 130

P.326 reciprocal connections link cerebellum with monos ynaptically and with other areas of the limbic via a relay in the bas is pontis. T he phylogenetically vermis and fastigial nucleus can be differentiated from neocerebellum of the cerebellar hemispheres and cons idered a “limbic cerebellum.” G rowing evidence of cerebellar contributions to and affect comes from clinical data and studies. T he data are fraught with uncertainty, however, because many cerebellar patients have disorders that not be limited to cerebellum; for example, cerebellar degenerations may include cortical degeneration, and tumors (and their treatment with radiation and chemotherapy) may have remote effects . Moreover, the phenomenon of cross ed cerebellar dias chisis —the reduction in blood flow to connected neocortical areas after cerebellar damage—means that interpretation of deficits as due to abnormal ce rebe llar process ing, as compared to s hutdown of cerebral cortical proces sing, treacherous . Nonetheles s, patients with stroke les ions clinically and by neuroimaging limited to cerebellum have deficits in executive cognitive function, memory, language, and visuospatial function. T he data sugges t lateralized cerebellar damage is as sociated with the predicted lateralized cognitive phenomena (right damage with language impairment, left with visuos patial impairment). R eports of an affective s yndrome after cerebellar injury are les s systematic. Defects in affect regulation, with irritability and lability, are propos ed to as sociated with damage to the limbic cerebellum, 25 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 15 of 130

the vermis.

White Matter and C erebral C onnec tivity Whereas the volume of neocortex has increased over cours e of phylogenetic history, the volume of white has increased disproportionately. In humans, the white matter tracts occupy some 42 percent of the volume of hemis pheres . T he great majority of thes e fibers serve corticocortical connectivity rather than projections between cortical regions and s ubcortical sites ; for example, thalamic input is estimated to represent only percent of the total input into primary sensory cortex, remainder being from other cortical areas. T he fibers in white matter are of several types . F irst are longer intrahemis pheric fiber tracts : Arcuate fas ciculus, which connects s uperior and middle frontal gyri to the temporal lobe and (via a superior portion of the fas ciculus called s upe rior longitudinal fas ciculus ) the parietal and occipital Uncinate fasciculus , which connects orbitofrontal cortex to temporal cortex and (via an inferior of the fasciculus called inferior occipitofrontal fas ciculus ) the occipital lobe C ingulum, which lies medially beneath cingulate cortex in cingulate gyrus and connects frontal and parietal lobes with parahippocampal gyrus and adjacent structures S econd are the long projection systems linking cortex, 26 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 16 of 130

subcortical nuclei, and lower portions of the neuraxis . Medial forebrain bundle is the primary connection between limbic s tructures and the brains tem and projections from the monoaminergic cells in the and pons. Others are the thalamic peduncle with reciprocal fibers between thalamus and parietal lobe the corticopontine and corticos pinal tracts descending through corona radiata and internal caps ule. F ibers prefrontal cortex descend in the anterior limb of internal caps ule, so that les ions there may have predominant behavioral and a paucity of elementary sensorimotor effects. Lacunes and degeneration of the white matter due to hypertens ive s mall-vess el dis eas e (B inswanger's interrupt these corticocortical fibers and projections. T he result of progres sive los s of communication among cortical regions and between cortex and subcortical gray matter is the clinical state subcortical dementia, which is prominently by slowing of mental proces sing and failure of control process es. T he latter may be explained in part the preferential occurrence of lacunes in frontal but also by the impairment of connectivity. T hird, U fibers are the short, juxtacortical fibers adjacent cortical regions. T hes e fibers are spared in B ins wanger's disease, cerebral autos omal dominant arteriopathy with s ubcortical infarction and lacunes (C ADAS IL), and certain other dis eas e F ourth are the many specific projection systems linking delimited regions s uch as mammillothalamic tract, connects mammillary bodies with anterior nucleus of thalamus , and fornix, which connects mammillary 27 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 17 of 130

with hippocampus. Interesting neurobehavioral syndromes have been described related to rare cas es focal interruption of s uch pathways. F or example, interruption of mammillothalamic tract or of fornix is implicated in amnesia. F ifth, s everal pathways connect the two hemis pheres , notably corpus callosum but also anterior and pos terior commis sures and mas sa intermedia of thalamus . S yndromes due to interruption of the smaller have not s o far been described, although abs ence of mass a intermedia is reported to be as sociated with schizophrenia in women, and anterior commiss ure and mass a intermedia are larger in women than in men. C orpus callos um is congenitally absent in numerous neurodevelopmental syndromes , and its absence has as sociated with s chizophrenia. C ongenital abs ence is however, as sociated with the interes ting disconnection symptoms s een in les ional interruption of the callosum such as by anterior or posterior cerebral artery s troke surgical callosotomy for control of epileps y. T wo callos al dis connection s yndromes are worthy of specific mention. After anterior cerebral artery with anterior callos al infarction, the right hemisphere is deprived of verbal information; a left-hand apraxia is and the patient cannot name uns een objects placed in left hand. R eciprocally, the right hand shows cons tructional apraxia. T his is the anterior s yndrome . After occlus ion of the left posterior cerebral artery with infarction of the left occipital lobe and the splenium (posterior portion) of corpus callosum, the language cortices of the left hemis phere lose acces s to visual information: T he left visual cortex is damaged, 28 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 18 of 130

the projections from the right visual cortex, which cros s the splenium. T hus, reading becomes imposs ible, other language functions are unaffected—the of ale xia without agraphia.

C erebral C ortex T he cerebral cortex develops through complex but increasingly well-unders tood proces ses of cell and migration, axonal projection, and dendritic proliferation and pruning. Abnormalities in these proces ses lead to cortical dysplas ia with clinical cons equences, including mental retardation and S ome 10 percent of intractable epilepsy may be due to such dis orders, and increas ingly, migration are recognizable by imaging before neuropathological examination. F ailure of normal pruning of synapses by elimination of dendrites is now known to be crucial in pathogenes is of the fragile X syndrome and has been speculatively linked to s chizophrenia. R arely, cortical dysplas ia may be pres ent without epileps y or mental retardation; the neurobehavioral cons equences of this abnormality are just coming under investigation. T he organization of s ens ory cortices follows a regular E ach primary s ens ory cortical area projects to as sociation cortices s pecialized for the extraction of features in that particular modality; the unimodal as sociation cortices are dens ely and reciprocally interconnected. F or example, visual ass ociation cortex specialized regions for color, motion, and s hape. T his creates an intricate P.327 29 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 19 of 130

web of s ens ory proces sing; the vis ual cortex in the cat, example, is believed to have 19 process ing regions . Unimodal as sociation cortices project, in turn, to heteromodal cortices , which receive inputs from more than a single sensory modality. Heteromodal cortices located in prefrontal, pos terior parietal, lateral temporal, and parahippocampal regions. Unimodal cortices do project to unimodal cortices in other modalities , only to the higher-level heteromodal cortices . F urther, hippocampal projections to cortex arrive only at as sociation cortices , not primary s ens ory cortices. structural features amount to the isolation of s ens ory proces sing from top-down influences over the first synaptic s tages and presumably increase its fidelity to external phenomena. Lesions of cortical as sociation areas produce an array behavioral and cognitive disorders of intriguing T he specificity can be demonstrated by the occurrence double diss ociations : A lesion in area A produces a in function x but not y; a lesion in area B produces a in function y but not x. T his pattern of findings provides crucial confirmation that the deficits aris e not from task difficulty (if y were s imply more difficult than x, then y would always be dis turbed when x was dis turbed), but from s eparable proces sing components . F or example, some patients s how a greater impairment for naming living things than for naming artifacts after a brain However, occasionally, patients show the opposite greater impairment in naming living things: a double diss ociation. T he explanation of the discrepancy thus cannot depend on ins ufficient process ing res ources but must reveal a property of the organization of the 30 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 20 of 130

system. C ognitive dis orders of the visual s ys tem can s erve as a paradigm of the s yndromes s een with damage to the as sociation cortex. Lesions of primary visual cortex B rodmann's area [B A] 17) produce cortical blindnes s in quadrant, hemifield, or the entire vis ual field. Despite genuine blindnes s, accuracy above chance in visual s timuli can be achieved without awarenes s of the phenomenon of blinds ight, which tes tifies to subcortical visual proces sing inaccess ible to cons ciousnes s. V 1 projects to adjacent cortical regions (B A18 and B A19), which contain neurons that respond specific features of visual s timuli such as color, or s hape. Lesions in thes e cortices produce deficits in identification of these features. T hus arise syndromes as central achromatopsia, demons trated by inability to (as well as to name) colors. T he s tream of information transfer divides into dors al and ventral streams, the specialized for localization of visual s timuli (“where”) the latter for identification of the s timuli (“what”). Dors al lesions involving s uperior parietal lobule can produce impaired reaching under vis ual guidance (optic ataxia), part of B alint's syndrome; the deficit testifies to the integration of vis ual information with motor output in as sociation cortex. V entral les ions, involving inferotemporal cortex, produce defects in recognition (agnos ia). Agnos ic patients are not only unable to elements within the domain of agnos ia but also are to demons trate their us e or show recognition of the in other nonverbal ways. C entral auditory dis orders include cortical (or central) deafness ; pure word deafnes s, the inability to 31 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 21 of 130

words presented in the auditory modality despite preserved vis ual–verbal function; and auditory agnos ia, the inability to recognize words or complex s ounds the meaning of the ringing of a telephone). C entral deafness requires bilateral les ions involving primary auditory cortex in s uperior temporal gyrus or auditory radiations in white matter. P atients with pure word deafness generally have bilateral les ions of as sociation cortex more anteriorly in superior temporal gyrus , although unilateral left lesions , presumably left from right cortices by s ubcortical damage, also are reported. P rimary auditory cortex is partially s pared in these cas es . In agnosia for nonverbal environmental sounds, right hemisphere damage is sufficient to the deficit. Amus ia, the incapacity to recognize musical sounds, is ass ociated with cortical damage, but the laterality is complex, dependent in part on the preinjury level of mus ical s kills . F ull evaluation of these dis orders requires techniques go well beyond beds ide examination or routine paraclinical tools . At iss ue in the agnos ic dis orders is extent to which a deficit is apperceptive—that is , due to impairment in analysis of subtle perceptual elements presumably dependent on more ups tream cortical regions —and as sociative—that is , occurring in the absence of definable perceptual abnormalities and presumably due to dysfunction of more downstream cortical analyzers . T his dis tinction requires detailed neurops ychological and often psychophysical

Modulators of B rain S tates T his account of cognitive proces sing in cortex seems to 32 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 22 of 130

many ps ychiatris ts to leave out of consideration the matters with which they are mos t concerned: pervasive states of altered mood, drive, and behavior. T hat such states are behaviorally pervas ive does not argue that are anatomically global. Limbic structures dis cuss ed provide in part the anatomical s ubs trate for emotional states . F urther, several s ys tems with diffus e cortical projections have the capacity to modulate process ing widespread brain regions. T hes e originate in Intralaminar thalamic nuclei, which project to cortex (es pecially prefrontal and cingulate cortex) and to striatum His taminergic cells in pos terior hypothalamus S erotonergic cells in pontine raphe nuclei Noradrenergic cells in locus ceruleus Dopaminergic cells in the midbrain ventral area giving rise to the mesocortical and mes olimbic systems C holinergic cells in bas al forebrain nuclei s uch as nucleus basalis of Meynert T he last of these is of relevance to cholines teras e treatment of dementia, the preceding three of to treatment of mood, anxiety, and ps ychotic dis orders . T he hypothalamic histaminergic projections are in arousal. “Nons pecific” thalamic projections may have important role in executive dys function s een after lesions . S o as not to become complacent about current unders tanding of s uch pathways, recall that only within the pas t few years were a previously unknown 33 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 23 of 130

neurotransmitter and its pathways recognized, and the discovery of orexin/hypocretin and its hypothalamic anatomy exposed the secrets of narcoleps y. Neurops ychiatric anatomy is not a closed book.

MODUL A R ITY A ND NE UR OP S YC HIA TR Y T hese focal behavioral syndromes , and many others, compel attention to local proces sing in the brain and almos t irresistibly s uggest a particular model of brain organization. One imagines a box-and-arrow diagram, which each box—representing an elementary cognitive function—maps on to a specialized region of cortex. area of cortex has its job to do, and a lesion of any produces a distinctive, delimited, and predictable T his model rais es the iss ue of modular organization of brain. T he general topic of modularity in cognitive proces sing des erves further cons ideration because it is crucial to the theoretical perspective of neuropsychiatry and, in particular, becaus e it bears on the value of neurops ychiatric data for the understanding of ps ychiatric disorders. Modularity in cognitive refers to a brain organization P.328 characterized by multiple computational devices , each which operates on characteris tically encapsulated input with prewired (perhaps innate) rules, thus being rapid, efficient, and reliable. F or example, elementary visual proces sing can be considered modular, inasmuch as it res tricted input with hard-wired feature extraction (e.g., motion, color, s hape). In another domain, consider that 34 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 24 of 130

easier to teach an animal to as sociate a tas te than a stimulus with the aversive effects of an inges ted toxin. finding implies domain-specific, innate learning cons traints. T he class ic cognitive example of domainspecific prewiring is language—for example, observation that children generate language errors that they have never heard: “He bringed me here,” the child might s ay, although he or s he has never heard an adult say “bringed.” T he implication is that a languageproces sing module pos sess es innate grammatical that have generated a grammatical form without experiential foundation. E volutionary psychologis ts have forcefully argued the for modular process ing, as oppos ed to domain-general problem-solving devices. T he core of the evolutionary argument is that cerebral organization is the res ult of natural selection operating on the adaptational fitness humans' P leistocene hunter-gatherer ances tors . specific proces sing has advantages of speed and that neces sarily lead to an advantage in fitness . T he availability of preexperiential information about the content of domain-specific process ing carries a large advantage over the “combinatorial explosion” of informational pos sibilities requiring evaluation by a domain-general proces sor. F or example, detection of cheating in s ocial exchanges is an es sential element of adaptation in a population group featuring cooperative behavior. Is it a function of a domain-general logical problem-solving device, or is there a “cheatermodule? C ross -cultural evidence s hows that people better at detecting violation of s ocial exchange rules at solving problems of equivalent logical complexity 35 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 25 of 130

posed in other terms, and focal les ions can affect cheater detection. T he implication is that mechanisms, presumably located in a particular brain are “tuned” to recognize and reason about this adaptationally crucial behavior, jus t as innate subs erve language learning and toxin recognition. One the s trengths of the evolutionary approach is to direct attention to proces sing domains the modularity of is plaus ible on adaptational grounds. However, many of the “modules ” that have attracted clinical interest are not plaus ibly directly the objects of natural selection. R eading and writing are clear T hese have arisen too recently in evolutionary time to been the product of natural selection and, thus, must depend on the workings of process ors that are, at leas t this extent, domain general. Moreover, much of the literature on modularity is from a cognitive-ps ychological or philosophical perspective, with les s attention to the “wetware” (i.e., actual brain s ubs tance) implementation of the devices . A foundation in cognitive neuros cience and evolutionary biology can enrich clinical theories, but it creates the potential for mis understanding by clinicians interes ted in the functioning of patients with brain T he modules of the evolutionary biologis ts and philosophically inclined cognitivis ts do not map directly onto brain areas . One of the s triking res ults of neuroimaging experiments is that, however the function under s tudy is delimited, multiple areas of brain are found. A metaanalysis of reports of positron tomography (P E T ) s tudies of cognition found that the mean number of activation peaks per experiment was 36 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 26 of 130

10.24! E ach tas k engaged a mean of 3.3 B rodmann's contrariwis e, each B rodmann's area was engaged by a mean of 3.42 perceptual or cognitive tasks. E ven that s eem ps ychologically fundamental are not implemented in a s imple way, and local process ing components may be recruited into networks s ubs erving variety of tas ks . T his seems to be the case in respect limited number of frontal sites involved in a wide range executive tasks. T he specialization of regions is on input from other regions ; specialization is not dependent on intrinsic properties but partially on topdown influences. T he is sue is not whether different cerebral regions out different modes of information process ing. T his is unques tionably so, and neither unreconstructed holists who believe in the equipotentiality of cortex nor strict localizationis ts who believe only in fully autonomous proces sing devices figure on the current neuros cientific scene. T he question is how regions are linked in out tas ks . F unctions are implemented by networks , or all of the nodes of which participate in multiple functional networks . T his pattern of cerebral has been termed s e le ctively dis tribute d proce s s ing or s pars e ly dis tribute d ne tworks . Although cortical regions have specialized capacities for information process ing, functions cannot be localized to regions (as Hughlings J ackson explicitly warned a century and a half ago). It erroneous, for example, to believe that an area crucial face recognition contains all of the neurons, and only neurons , that respond to faces . Moreover, normal individuals may differ in how they recruit regions into networks. T he methods us ed in 37 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 27 of 130

studying groups of s ubjects in functional imaging experiments may obscure s uch individual differences . example, robust individual differences in patterns of activation emerged in a memory tas k, differences putatively reflecting different s trategies in performing tas k. T he differences were stable within individuals time, yet analys is of group data revealed activations in regions activated in only some of the subjects and disclos e activations in regions cons istently activated in others . Individual differences in organization of cortex are evident clinically in the unusual, but not negligible, occurrence of cross ed aphasia (aphas ia due right hemisphere injury in a dextral), cross ed (lack of aphasia with a left hemisphere injury that to cause aphasia in a dextral), and aphas ic deficits anomalous in res pect to the predicted effects of lesions both dextrals and sinis trals. Another crucial critique for neurops ychiatry of the modularity hypothes is derives from developmental ps ychology. T renchant arguments contradict the as sumption that a mapping of deficits to specific brain structures could be s tatic over developmental time. T o contrary, how the brain performs cognitive tasks with development. Development entails changing patterns of interaction among brain components , and localization may alter as neurons and regions become “tuned” in res pons iveness bas ed on their initial characteristic process ing biases and their patterns of inputs and connectivity. T his reorganization of cortical function could mean that the same behavior has subs trates at different developmental epochs. F or example, in adult s ubjects with Williams s yndrome, 38 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 28 of 130

number proces sing and good language s kills are characteristic; however, in infancy, the opposite pattern seen. W hatever the fundamental process ing disorder genetic origin may be, it cannot be seen as having “knocked out” a module. A large expanse of nonlinear brain development lies between the gene and the phenomena, an expanse that can be unders tood only a better theory than neophrenology (F ig. 2.1-1). T he development of modularity can be anomalous . Indeed, the Williams syndrome cases , magnetic res onance (MR I) data disclos e an anomalous, diffuse pattern of activation for music perception, an area of preserved or enhanced ability in these patients . F ocal syndromes in adults provide an appropriate place to s tart in hypothes es, but a deficit s een in an idiopathic dis order cannot be as sumed to have its bas is in dysfunction in same simple locus as a phenomenologically similar seen after a focal brain lesion occurring in an adult.

39 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 29 of 130

40 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 30 of 130

FIGUR E 2.1-1 A phrenological head as pictured in (A) and 1957 (B ). Des pite the interval of 67 years, are s uspicious ly alike. (F rom F owler OS , F owler LN. S elf-Ins tructor in P hre nology and P hys iology. New F owler & W ells ; 1890:iii; and P olyak S . T he V is ual S ys te m. C hicago: T he University of C hicago 1957:456, with permis sion.) P.329 Nothing in this line of argument diminis hes the interes t focal neurobehavioral s yndromes , which are clinical and have a s ubs tantial heuris tic value for the cognitive neuros ciences. Neuropsychiatry, along with other brain specialties , has the task of importing into clinical theory the unders tanding of the mind and brain that is developing in cognitive neuros cience. T he s earch for ps ychopathological unders tanding based on of deficits in cognitive modules that are relatively well unders tood in normal subjects has been termed ne urops ychiatry. T his purs uit inevitably results in deconstruction of the ps ychiatric diagnoses of the fourth edition of Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ) or the International Dis eas es P.330 (IC D) into s ymptoms or s yndromes becaus e the diagnostic categories are generally based on folkps ychological notions (s uch as the divis ion between 41 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 31 of 130

“thought” and “affective” disorders ). Much of this chapter is devoted to the anatomical mode thought practiced by neurops ychiatris ts . However, clinicians appear to hope that neuropsychiatry will a localizing taxonomy of behavioral syndromes, s o that particular psychiatric dis orders will carry the same localizing power as, s ay, the B abinski s ign for the corticos pinal tract—the nuclear s yndrome of schizophrenia to the left temporal lobe, for example. the contemporary cognitive neuros cience perspective reviewed, this seems likely to be fals e hope. T he sign is a limiting, not a paradigmatic, cas e of brain– behavior relations hips. F or the fullest understanding of complex mental s yndromes, notably those traditionally the realm of ps ychiatry, a more adequate theory of function is needed than can be offered by the localizationis t tradition.

C L INIC A L E VA L UA TION T he neurops ychiatric perspective places great reliance information that can be gathered at the bedside. No practical inquiry and examination can include all items ; rather, the clinician selects from a toolbox of of the his tory and of the patient's functioning in the examination room to confirm or refute hypotheses generated by the emerging clinical picture. S creening items should have high s ens itivity but not necess arily specificity. B eyond s creening, elements of the his tory examination that might potentially elucidate the nature the disease process under consideration form the corpus of medical ass ess ment and cannot be dealt comprehensively in this chapter. F or example, the 42 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 32 of 130

neurops ychiatris t cons idering liver dis eas e as the explanation for delirium wants to estimate the liver during the physical examination, but techniques for so are not discus sed below. T he discus sion here is on both common iss ues and techniques dis tinctive to neurops ychiatry.

Neurops yc hiatric His tory T he initial s teps in screening for the presence of disease in patients with mental s ymptoms are eas ily T he phys ician s hould obtain a general medical his tory, including a his tory of dis eas es pos sibly relevant to the neurops ychiatric s ymptoms under consideration, and a review of s ys tems in potentially relevant areas. W ith a cognitively impaired or ps ychotic patient, s uch history taking may be unreliable. C ollateral his tory from a member or other informant and review of medical are almos t always es sential. With virtually every patient, the clinician s hould inquire to a history of Heart, lung, liver, kidney, skin, joint, and eye Hypertension Diabetes T raumatic brain injury S eizures, including febrile convulsions in childhood Unexplained medical symptoms S ubstance misus e C urrent medication 43 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 33 of 130

F amily history of neuropsychiatric disorder T he inquiry about thes e disorders in some settings can quite general. F or example, the question “have you had heart problems ? ” along with a few questions in the review of s ys tems may suffice to screen for heart a young, apparently healthy patient. In other settings, more detailed information mus t be gathered. T he review of systems as well s hould vary according to setting. P os itive res pons es should of course lead to inquiry. T he clinician s hould be practiced in inquiring about C ons titutional symptoms: fever, malaise, weight pain complaints Neurological s ymptoms : headache, blurred or vision, impairment of balance, impairments of auditory acuity, swallowing disturbance, focal or transient weakness or sensory loss , clumsines s, disturbance, alteration of urinary or defecatory function, altered s exual function P aroxysmal limbic phenomena: micropsia, metamorphops ia, dé jà vu and jamais vu, dé jà and jamais é couté, forced thoughts or emotions , depers onalization/derealization, autos copy, paranormal experiences such as clairvoyance or telepathy T hyroid s ymptoms: heat or cold sens itivity, cons tipation or diarrhea, rapid heart rate, alopecia change in texture of hair R heumatic dis eas e s ymptoms : joint pain or 44 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 34 of 130

mouth ulcers , dry mouth or eyes , rash, pas t spontaneous abortions

B irth His tory and E arly Development B ecaus e brain development s tarts before birth, s o does neurops ychiatric history. T he clinician should note Maternal s ubs tance mis us e, bleeding, and during the pregnancy C ours e of labor F etal dis tres s at birth, including Apgar s cores, if available P erinatal infection or jaundice Motor and cognitive miles tones s uch as the age the child crawled, walked, s poke words , s poke T he infant's temperament T he child's s chool performance (including special education and anomalous profiles of intellectual strengths and weaknes ses ), usually the best guide (absent ps ychometrical data) to premorbid function T he role of perinatal injury in cerebral palsy and mental retardation has commonly been overestimated; in instances, developmental disorder is present in before the perinatal misadventure, which may in fact from the preexisting abnormality. However, perinatal injury, in particular hypoxic injury, is probably with later s chizophrenia. 45 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 35 of 130

Head Injury and Its S equelae Head injury is common and potentially a factor in later mood and ps ychotic dis orders as well as cognitive impairment, epileps y, and pos ttraumatic s tres s disorder (P T S D). T he clinician should inquire about a his tory of injury in virtually every patient. T he nature of the injury should be clarified by eliciting the circums tances , including ris k-taking behaviors that may have to injury and others who were injured in the s ame often an emotionally powerful aspect of the event. T he loss of cons cious nes s is not a prerequisite to important sequelae; even a period of being stunned, “seeing can presage later neurops ychiatric symptoms . T he of los s of cons cious nes s, or coma, should be ideally with the ass istance of contemporaneous records . T he period of retrograde amnesia—from last memory before the injury to the injury itself—and of anterograde amnes ia—from injury to recovery of the capacity for consecutive memory—should be noted.

A ttac k Dis orders P aroxysmal dis orders of neurops ychiatric interes t epilepsy, migraine, panic attacks, and epis odic P.331 of aggress ion. T aking a his tory of an attack has features irrespective of the nature of the dis order. T he clinician should track through the chronology of the attack. T his starts with the poss ible presence of a prodrome, a warning of an impending attack in the or days before one. T he attack its elf may be presaged an aura, lasting s econds to minutes . In the cas e of an 46 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 36 of 130

epileptic seizure, this represents the core of the s eizure its elf and may carry important localizing information the side and s ite of the focus . T he pace of buildup, onset to peak of the ictus, is of differential diagnos tic importance. F or example, epileptic seizures begin abruptly; panic attacks may have a more gradual development to peak intens ity. T he mental and features of the ictus its elf should be elicited in detail collateral informants as well as from the patient, if T he duration of the spell and the mode of its should be elicited. Inquiring whether the patient has one s ort of spell or more than one is an es sential to establishing the frequency of episodes , both at and at maximum and minimum in the pas t. B y interviewing the patient and collateral informants , information necess ary to make a differential diagnos is us ually be elicited. T he differential diagnos is between epilepsy and ps eudoseizures can be difficult, but at if asked properly, the patient makes the diagnosis for clinician by reporting “two kinds of s eizures ,” one of is clearly epileptic and the other of which is clearly dependent on emotional s tates.

C ognitive S ymptoms R ecognizing cognitive symptoms in patients without es tablis hed dementia is a crucial element of neurops ychiatric history taking. S uch symptoms may outweighed by more dramatic behavior or mood but identification of cognitive impairment can reorient diagnostic evaluation of a late-life depres sion, for No doubt the mos t common complaint along cognitive lines is of memory problems. In the s etting of 47 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 37 of 130

the more intense the complaint of memory impairment, the less likely it is to have an organic bas is and the likely to testify to depres sive ideation and attentional failure. T he clinician s hould establish whether forgotten material (for example, an acquaintance's name or a meant to be performed) comes to the patient later, as a matter of absentmindedness rather than amnestic C ertain other complaints are highly characteristic of organic disease. T hese include a los s of the capacity divided attention or for the automatic performance of familiar tasks. A patient might report, for example, no longer being able to read and listen to the radio at the same time. G etting los t or beginning to us e aids for such as a notebook, are sugges tive of organic failure.

A ppetitive S ymptoms and C hange Alterations of s leep, appetite, and energy are common idiopathic ps ychiatric disorders , as well as transiently in healthy population, and cannot be interpreted as brain dis eas e. C ertain patterns of altered s leeping and eating behavior and personality, however, are pointers organic disease. E xces sive daytime s leepiness or attacks rais e the question of s leep apnea or narcoleps y in a different temporal pattern, K leine-Levin s yndrome. Abnormal behavior during s leep raises the ques tion of parasomnia. Of particular interes t is rapid eye (R E M) behavior disorder, which may be due to a lesion but, when a focal lesion is abs ent, strongly ingraves cent Lewy body dis eas e. Much more rarely, nocturnal oneiric behavior repres ents a prion dis ease, notably fatal familial ins omnia. Los s of dreaming occurs 48 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 38 of 130

with parietal or bifrontal damage; loss of vis ual imagery dreams occurs with ventral occipitotemporal damage, of the C harcot-Wilbrandt s yndrome (loss of vis ual with brain damage). In medial hypothalamic disease, eating behavior is marked by lack of satiety and obesity. In the K lüver-B ucy s yndrome of bilateral temporal damage (involving amygdala), patients mouth nonfood items . W ith frontal damage, patients may s tuff food into the mouth, a form of utilization behavior, sometimes with alarming or even fatal cons equences. “gourmand” syndrome of exces sive concern with fine eating has been ass ociated with right anterior injury. C hanges in sexual behavior are common brain disease. Hyposexuality is common in epileps y, poss ibly as a consequence of limbic dis charges . A in habitual s exual interests, quantitative or qualitative, developing in midlife sugges ts organic dis eas e. It is poss ible, although understudied, that relevant organic disease, such as the s equelae of traumatic brain injury, common in s exual offenders. Other changes in such as the development of shallownes s of affect, irritability, loss of sense of humor, or a coarsening of sens ibilities , may indicate ingraves cent organic example, frontotemporal dementia.

Handednes s Approximately 90 percent of people designate as dextral, almost all the rest as sinis tral, and a very ambidextrous . T he true state of affairs is somewhat complicated, in that handednes s may be considered dimensionally—that is , as a matter of degrees rather categories . A patient may call hims elf or herself right49 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 39 of 130

handed but us e the left hand preferentially for certain tas ks . Inquiring about a few s pecific tasks —writing, throwing, drawing, using s ciss ors or a toothbrus h— helpful information. A family his tory of s inistrality may be relevant.

Neurops yc hiatric Phys ic al T o the neurops ychiatrist, the physical examination is a central feature of clinical evaluation. In principle, any as pect of the general physical or neurological may be relevant to neuropsychiatric diagnos is, if only in revealing an incidental clinical problem in a neurops ychiatric patient. Here, the focus is on the physical examination with specific relevance to detection and identification of organic dis ease in with mental presentations . T he mental examination, including the cognitive examination, is discuss ed below as sociation with syndromes of behavioral disorder and insofar as it can elicit or elucidate thes e s yndromes in cons ultation room.

G eneral P hys ic al E xamination GE NE R AL APPE AR ANC E Dys morphic fe ature s include so-called minor physical anomalies, s ome of which are captured in the widely Waldrop s cale. T hes e are as sociated with disorders , including s chizophrenia. S ome of thes e are lis ted in T able 2.1-1. T hes e features center on the hands , and feet. No single minor anomaly is diagnos tic pathological development, but the coincidence of anomalies argues that development has gone awry. specific developmental dis ability s yndromes can be 50 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 40 of 130

diagnosed by the constellation of dysmorphic features presented. C le ft lip or palate is as sociated with brain malformations and frontal cognitive impairment. As ymme try of the extremities, often bes t s een in the thumbnails, or of the cranial vault points to a developmental abnormality. Occas ionally, a patient reports wearing s hoes of different s izes on the two feet. T he larger extremity and the s maller side of the head ipsilateral to the abnormal cerebral hemis phere. S hort s tature is an important feature of many developmental syndromes, both common, s uch as fetal alcohol and Down s yndrome, and uncommon, such as mitochondrial cytopathies . Abnormal habitus , s uch as marfanoid habitus of homocys tinuria, may be a clue to diagnosis. W e ight los s is an important P.332 clue to s ys temic dis eas e, s uch as neoplasia; it should be dis miss ed, even in a patient with depres sion, which may—but may not—account for the weight los s. gain equally may point to limbic or systemic disease, es pecially an endocrinopathy, or may reflect toxicity of ps ychotropic drugs .

Table 2.1-1 S elec ted Minor Anomalies Head and face

Mouth 51

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 41 of 130

   Head circumference a

   High arch of palate a

   Hair whorls a

   F urrowed tongue a

   F ine electric hair that will not comb downa

   G eographical tongue a

   Abnormal philtrum    F rontal boss ing

   C left uvula

E yes

E xtremities

   W ide-spaced eyes a

   C linodactyly a

   E picanthus a

   Abnormal palm creas e a

   S hort palpebral fis sures

   T oe 3 longer than toe 2 a

   Iris dis coloration or

   P artial

E ars

   G ap between 1 and 2 a

   Adherent lobes a

   S mall nails

   Malformationa

   S ingle creas e 52

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 42 of 130

5    As ymmetrya

   

   S oft and pliable a

 

   Low s eateda

 

   P reauricular s kin tag

 

aAnomaly

is part of W aldrop s cale.

VITAL S IG NS E le vate d te mpe rature or he art or res piratory rate never be ignored, even in a patient whose agitation or anxiety might s eem to explain the abnormality. Doing ris ks miss ing infection, neuroleptic malignant connective tis sue disease, or other important caus es of morbidity. Abnormal re s piratory patterns occur in hyperkinetic movement disorders (including tardive dyskinesia). Y awning is a feature of opiate withdrawal serotonergic toxicity.

S K IN Alopecia or ras h may point to systemic connective disease. Alopecia is als o a feature of drug toxicity and hypothyroidism (where thinning of the lateral part of the eyebrow is characteris tic). T he malar ras h of s ys temic 53 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 43 of 130

erythematosus is typically slightly rais ed and tender extends to both cheeks in a “butterfly” pattern while sparing the nasolabial folds. Dis coid rashes in lupus characterized by hyperkeratosis, atrophy, and los s of pigment; the s trong tendency to scarring means that presence of a dis coid ras h does not neces sarily active disease. A pink periungual rash is also of lupus. A vasculitic ras h is clas sically palpable and may be s een in lupus or other connective tis sue diseases . Livedo reticularis, a net-like violaceous the trunk and lower extremities , is not s pecific but the question of S neddon's s yndrome, in which s troke or dementia is a clinical accompaniment. T he neurocutaneous s yndromes have typical skin manifestations: adenoma s ebaceum (facial as h-leaf macules , depigmented nevi, and s hagreen patches (thickened, yellowish skin over the area) in tuberous s cleros is; a port-wine stain (typically involving both upper and lower eyelids) in S turgesyndrome; neurofibromas , café au lait spots, and freckling in neurofibromatos is .

HE AD Head circumfe re nce s hould be meas ured in patients question of developmental dis order. Most reference give normal ranges for head circumference in children but not for adults , and extrapolation is F ortunately, adequate data to establis h normal ranges exis t. Although height and weight need to be taken into account along with gender, the normal range for adult men is approximately 54 to 60 cm (21.25 to 23.50 in.), women, 52 to 58 cm (20.50 to 22.75 in.). O ld s kull 54 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 44 of 130

intracranial s urge ry us ually leaves palpable evidence.

E YE S E xophthalmos us ually indicates G raves' disease, may reveal a space-occupying les ion, es pecially if unilateral. Dry e ye s , along with dry mouth, rais e the question of S jögren's s yndrome, although drug toxicity the aging process is a common confound. Inflammation the anterior portion of the eye, uveitis , can be at the beds ide by the pres ence of pain, rednes s, and a cons tricted pupil; this is commonly ass ociated with connective tis sue dis ease. T he K ays e r-F le is che r ring is brownis h-green discoloration at the limbus of the it sensitively and s pecifically indicates Wilson's pupils, optic disks, vis ual fields, and eye movements discuss ed below.

MOUTH O ral ulce rs can be s een in lupus, B ehçet's s yndrome, other connective tis sue disease. Dry mouth is a part of sicca s yndrome along with dry eyes, dis cus sed above. V itamin B 12 deficiency produces atrophic glos s itis , a smooth, painful, red tongue.

HE AR T AND VE S S E L S A carotid bruit indicates turbulent flow in the vess el but poor predictor of the degree or potential ris k of the vascular lesion. A thickened, tender te mporal artery to giant cell arteritis ; here, the phys ical examination is excellent guide to clinical significance. C ardiac valvular disease, marked by cardiac murmurs , is important in as sess ing the cause of s troke, and congestive failure 55 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 45 of 130

be relevant in delirium. In a schizophrenic patient, a murmur may imply the velocardiofacial syndrome. with developmental dis abilities may have multiple anomalies, including structural heart dis eas e.

E XTR E MITIE S J oint inflammation as an indication of s ys temic disease is dis tinguis hed from noninflammatory degenerative joint dis eas e (osteoarthritis) by the of swelling, warmth, and erythema and is seen in wrists , ankles, and metacarpophalangeal joints, compared with the involvement of the bas e of the distal interphalangeal joints, and spine in degenerative joint dis eas e. R aynaud's phe nome non and signs of connective tiss ue disease.

Neurologic al E xamination OL FAC TION Hypos mia is common in neurological disease but even more common in local dis eas e of the nas al mucos a, must be excluded before a defect is taken to be of neurops ychiatric s ignificance. As ses sment of olfaction often ignored (cranial nerves II through XII normal), but easily performed and gives clues to the integrity of otherwis e hard to as ses s, notably orbitofrontal cortex. olfactory nerve lies underneath orbitofrontal cortex; projections go to olfactory tubercle, entorhinal and piriform cortex in the temporal lobes , amygdala, and orbitofrontal cortex. T esting of olfaction is bes t us ing a floral odorant such as scented lip balms, which inexpens ive and s imple to carry. Although a dis tinction be made between the threshold for odor detection and 56 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 46 of 130

that for identification of the s timulus with differing anatomies , at the bedside without special equipment, best one can achieve is recognition of a decrement in sens itivity—that is , whether the patient s mells anything, even without being able to identify it.

E YE S P upillary dilation may indicate anticholinergic toxicity; pupillary constriction is a characteristic feature of toxicity. Argyll R obertson pupils are bilateral, small, irregular, and reactive to accommodation but not to the finding is characteristic of paretic P.333 neuros yphilis but also is present in other conditions. P apille de ma indicates elevated intracranial pres sure; earliest and mos t s ens itive feature is loss of venous pulsations at the optic dis k. A homonymous upper quadrantic fie ld defe ct is present when temporal lobe disease affects Meyer's loop, the portion of the optic radiation that dips into the temporal lobe. A field defect a delirious patient may point to an etiology in focal vascular disease (as dis cus sed below). T he normal spontaneous blink rate is 16 ± 8 per minute. Hypodopaminergia is as sociated with a reduction in rate. Impairment of voluntary eye opening is s een in as sociation with extrapyramidal s igns , making the common denomination of “apraxia” of eye opening a misnomer. Impairment of voluntary eye closure is s een after frontal or basal ganglia damage. B oth saccadic and pursuit eye move me nts s hould be examined. T he former are ass ess ed by asking the 57 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 47 of 130

to look to the left and the right, up and down, and at the examiner's finger on the left, right, up, and down. eye movements are examined by asking the patient to follow a moving s timulus in both the horizontal and vertical planes . T hese maneuvers test supranuclear of eye movements; the oculocephalic maneuver (doll's head eyes )—that is , moving the patient's head—tes ts brains tem pathways and may be added to the if saccades or purs uit is abnormal. Limitation of upgaze is common in the normal elderly. A limitation of voluntary downgaze, however, in a patient with extrapyramidal s igns or frontal cognitive impairment suggest progress ive supranuclear pals y. S lowed are characteris tic of Huntington's diseas e. Impairment initiation of voluntary s accades, requiring a head thrus t head turning, amounts to apraxia of gaze and is s een developmental disorders as well as Huntington's and parietal damage. C ontrariwise, impairment of inhibition of saccades repres ents a vis ual gras p, with forced gaze at environmental stimuli. T his can be tes ted by placing s timuli (a finger and a fist) in the left right vis ual fields of the patient and asking the patient look at the fist when the finger moves and vice vers a. patient's inability to perform horizontal pursuit or movements without turning the head may represent the same impairment of inhibition.

FAC IAL MOVE ME NT B oth spontaneous movements of emotional expres sion and movement to command s hould be tes ted. In pyramidal disorders , spontaneous movements may be relatively s pared when the face is hemiparetic for voluntary movements. C ontrariwise, in nonpyramidal 58 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 48 of 130

motor dis orders , voluntary movement may be poss ible despite a hemipares is of s pontaneous movement. T he latter s ituation is s een inter alia in temporal lobe including temporal lobe epilepsy, for which it has lateralizing value. V ertical furrowing between the eyebrows is known as V eraguth folds and is as sociated depres sion.

S PE E C H A variety of s peech abnormalities is tabulated in T able 2. A s ys tematic examination of speech may include the patient to produce a s ustained vowel (“ahhh…”), performance being as sess ed for voice quality, and loudness ; then s trings of cons onants (“puh-puhand alternating cons onants (“puh-tuh-kuh-puh-tuhthe performance being as sess ed for rate, rhythm, and clarity.

Table 2.1-2 S peec h S yndromes S yndrome

Output

C harac teris tic Les ion Loc ation or As s oc iations

Aphemia

Initial mutis m, recovery

B roca's area (B A44), foot of

59 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 49 of 130

without agrammatism

left third gyrus

Apraxia of speech

Inconsis tent and s lowed articulation, flattened volume, abnormal prosody

Left insula

Ataxic dysarthria

S lowed, equalization of or erratic (s canning), imprecis e articulation

C erebellum, es pecially superior anterior left > right

P yramidal dysarthria

S lowed, strained, slurred

Anterior hemis pheres , us ually bilateral; may be accompanied by ps eudobulbar palsy (dysphagia, drooling, pathological

60 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 50 of 130

laughing and crying) E xtrapyramidal dysarthria

Hypophonia, monotony of intonation, trailing off with longer

B as al ganglia

B ulbar dysarthria

Nas ality, breathines s, slurred articulation

B rainstem

F oreign syndrome

P honetic and prosodic alterations like those of dysarthria cortical damage but giving listener feeling of foreign accent

Motor or premotor cortex or subjacent white matter of left

Developmental stuttering

R epetition, prolongation, arrest of sounds; if overcome in

?

61 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 51 of 130

childhood, reemerge stroke, onset P arkins on's disease Acquired stuttering

No dys tonic facial movements as are seen in developmental stuttering

V arious hemis phere sites

C es sation of stuttering

Not an abnormality but the of an abnormality

V arious hemis phere sites

E cholalia

Automatic repetition of interlocutor's speech or words heard environment, sometimes with reversal pronouns, correction of grammar,

V arious anatomies , but seen in frontotemporal dementia, transcortical aphas ias , settings

62 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 52 of 130

completion of well-known phrases P alilalia

Automatic repetition of own final word or phras e, increasing rapidity and decreasing volume

Usually extrapyramidal system

“B lurting,” “echoing approval”

Automatic utterance of stereotyped or simple res ponses “yes, yes ”)

F rontal system

T he mute patie nt poses a special problem in neurops ychiatric as sess ment. Mutism may occur at the onset of aphemia or transcortical aphas ia due to lesions , and it commonly develops late in the cours e of patients with frontotemporal dementia or primary progres sive aphas ia. T he examiner s hould ass es s nonspeech movements of the relevant musculature, for example, tongue movements , s wallowing, and Other means of communication should be attempted 63 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 53 of 130

as gesture, writing, or pointing on a letter board or word board.

AB NOR MALITIE S OF MOVE ME NT T he neurops ychiatric examiner should pay attention to weaknes s, abnormality of mus cle tone, abnormal gait, involuntary movements . W e akne s s due to muscle, peripheral nerve, or lower motor neuron dis eas e is as sociated with atrophy, fas ciculations, characteris tic distributions , loss of reflexes , and tendernes s in the muscle dis eas e. Of greater relevance to P.334 cerebral mechanisms, pyramidal weaknes s, greatest in distal musculature, is accompanied by increased tone in a s pas tic pattern (flexors in the upper extremity, extensors in the lower extremity, with the sudden loss increased tone during pas sive movement, the “clas pphenomenon), los s of control of fine movements, bris k tendon jerks , and the presence of abnormal reflexes as the B abins ki sign (discus sed below). Less well recognized is the nonpyramidal motor syndrome s uch seen in caudate or premotor cortical les ions: decreased s pontaneous us e of effected limbs , weaknes s but production of full s trength with coaxing. Mild degrees of impairment can be elicited with the pronator tes t by s eeking pronation of the outs tretched supinated arms; the forearm rolling tes t, by asking the patient to roll the forearms around each other first in direction then in the other, looking for one s ide that less , thus, appearing to be an axis with the other around; or fine finger movements, with the hands 64 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 54 of 130

facing up on the thighs, the patient touching each to the thumb in turn and repeatedly. Mus cle tone can be increased not only in the pyramidal fas hion just des cribed but als o as a manifestation of extrapyramidal or diffus e brain diseas e. In the latter paratonic rigidity, or G egenhalten, is manifes ted by an erratic, “ps eudoactive” increase in res is tance to movement. T he fluctuating quality of the resis tance reflects the presence of both oppositional and facilitory as pects of the patient's respons e to pas sive T he facilitory as pect can be evoked by repeatedly and extending the patient's arm at the elbow, then abruptly ceas ing and letting go when the arm is the abnormal respons e, facilitory paratonia, is for the patient to continue the s equence by flexion. In the case extrapyramidal diseas e, tone is increas ed in both and flexors and throughout the range of movement, s ocalled lead-pipe rigidity. T he “cogwheel” or ratchety feel the rigidity is imparted by a coexis ting tremor and is not intrins ic to the hypertonus; when paratonic rigidity cooccurs with a metabolic tremor, a delirious patient may mistakenly be believed to have P arkinson's disease. G ait s hould always be tes ted, if only by focus ed to the patient's entering or leaving the room. Attention should be paid to the patient's station, postural stride length and base, and turning. P os tural re flexe s as sess ed by as king the patient to stand in a fas hion, then pus hing gently on the ches t or back, with care taken to avoid a fall. G ait should be stress ed by the patient to walk in tandem fashion and on the outer as pects of the feet. T his may reveal not only mild (representing cerebellar vermis dysfunction), but also 65 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 55 of 130

as ymmetric pos turing of the upper extremity (in nonpyramidal motor dys function). Akine s ia is manifes ted by delay in initiation, s lowness execution, and difficulty with complex or simultaneous movements. Mild akines ia may be obs erved in the patient's lack of spontaneous movements of the body while s itting or of the face or elicited by as king the to make repeated large amplitude taps of the forefinger the thumb (looking for decay of the amplitude). characteristically accompanied by rigidity. T hes e s igns, plus rest tremor and postural ins tability, repres ent the features of the parkins onian syndrome, seen not only idiopathic P arkinson's disease (IP D), but in several degenerative, “P arkins on-plus” disorders , such as progres sive s upranuclear palsy and multiple system atrophy, as well as in vascular white matter dis eas e. tremor is les s common in thes e other dis orders than in Dys tonia is s ustained mus cle contraction with twis ting movements or abnormal pos tures . T ypically, dystonia in the upper extremity is manifes ted as hyperpronation, in the lower extremity as inversion of foot with plantar flexion. Dystonia may occur only with certain actions , such as writer's cramp; focally, s uch as blepharos pas m or oculogyric cris is; or in a generalized pattern, such as torsion dys tonia ass ociated with mutations in the DY T 1 gene. T he symptoms and s igns often do not comport with a naäve idea of how things ought to be in organic disease; only expert knowledge suffices for recognition. F or example, a patient with tors ion dystonia may be able to run but not walk the latter action elicits leg dystonia. Or a patient with intens e neck muscle contraction may be able to bring 66 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 56 of 130

head to the midline by a light touch on the chin, a antagonis te ” diagnostic for dystonia. T re mor is a regular oscillating movement around a re s t tre mor, the movement occurs in a relaxed, extremity and is reduced by action. Often an upper extremity res t tremor is exaggerated by ambulation. frequency is us ually 4 to 8 Hz. T his is the distinctive of P arkins on's dis eas e. In pos tural tre mor, s us tained posture elicits tremor. It may be amplified if obs cured placing a sheet of paper over the outs tretched hand. Hereditary es sential tremor pres ents as postural predominantly in upper extremities but als o at times involving head, jaw, and voice. A coars e, irregular, postural tremor is often s een in metabolic encephalopathy. In intention tremor, the active limb os cillates more prominently when approaching its such as touching the examiner's finger with the index finger. Maximizing the range of movement increas es sens itivity of the tes t. Intention tremor is one form of kine tic tremor—that is , tremor elicited by movement; another s ort of kinetic tremor is that elicited by a action, s uch as writing tremor or orthos tatic tremor on standing upright. T he examiner can characterize observing the patient with arms s upported and fully at res t, then with arms outs tretched and pronated, then arms abducted to 90 degrees at the s houlders and the elbows while the hands are held palms down with fingers pointing at each other in front of the ches t. T he patient should also be observed during ambulation. Anxiety exaggerates tremor; this normal phenomenon, example, when the patient is conscious of being should not be mis taken for ps ychogenes is . A good test 67 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 57 of 130

ps ychogenic tremor relies on the fact that, although organic tremor may vary in amplitude, it varies little in frequency. A patient can be as ked to tap a hand at a frequency different from the tremor frequency; if tremulous body part entrains to the tapped frequency, ps ychogenic tremor is likely. C hore ic movements are random and arrhythmic movements of s mall amplitude that dance over the patient's body. T hey may be more evident when the patient is engaged in an activity such as ambulation. the movements are of large amplitude and forceful, the disorder is called ballis m. B allistic movements are unilateral. Myoclonus is a sudden, jerky, shock-like movement. It more discontinuous than chorea or tremor. T he of myoclonus is as terixis , a sudden lapse of muscle contraction in the context of attempted maintenance of posture. B oth phenomena, but more s ens itively are common in toxic-metabolic encephalopathy (not hepatic encephalopathy). Asterixis should be carefully sought by observation of the patient's attempt to extension of the hands with the arms outs tretched because it is pathognomonic for organic diseas e and is never seen in acute idiopathic psychosis or other nonorganic disorders . Myoclonus is additionally an important feature of nonconvulsive generalized s tatus epilepticus , Has himoto's encephalopathy, and J akob disease. Unilateral as terixis rarely may be seen parietal, frontal, or (most often) thalamic structural T ics are sudden, jerky movements as well, but they more complex than myoclonic jerks and are characterized by 68 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 58 of 130

P.335 an impulse to perform the act and a s ens e of relief for having done s o (or mounting tens ion if restrained from doing so). C ompulsions are not eas y to differentiate complex tics; the tiqueur may, like the patient with compuls ions, report deliberately performing the act. R epetitive behavior s uperficially s imilar to compulsions may occur in organic disease but represents driven behavior and does not have the s ame s ubjective structure as compulsive behavior. F or example, a with frontal disease may repeatedly touch an alluring object without an elicitable subjective impulse and without anxiety if separated from the object. Organic obses sions and compuls ions occur as well and have as sociated with globus pallidus les ions , among others . Akathis ia is defined by both its s ubjective and its features. T he patient exhibits motor restles sness , for example, by shifting weight from foot to foot while standing, and expres ses an urge to move. At times , ps ychotic or cognitively impaired patients cannot the subjective experience clearly, and the examiner be alert for the objective s igns to differentiate akathis ia from agitation due to anxiety or ps ychosis . T he and the signs in akathisia are referable to the lower, the upper, extremities ; the anxious patient may wring or her hands , the akathis ic patient shuffles his or her Myoclonic jerks of the legs may be evident in the recumbent patient. T he phenomenon occurs in IP D with drug-induced dopamine blockade but also rarely extensive frontal or temporal structural lesions . Ataxia is a dis order of coordinating the rate, range, and 69 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 59 of 130

force of movement and is characteristic of disease of cerebellum and its connections. In the limbs, dys metria represents dis ordered determination of the dis tance to moved, s o that the patient overs hoots or unders hoots target; if the reaching limb oscillates in the proces s, the clinician observes intention tremor. As king the patient touch the examiner's finger and then his or her own tes ts this s ys tem. Accurately touching one's own nos e eyes closed requires both cerebellar and function. E ye movements als o may be hypermetric or hypometric. T he patient's difficulty in performing rapid alternating movements, such as s upination/pronation of the hand or tapping of the foot, is called dys diadochokines ia. T he failure of coordination of movement is also demons trated by loss of check, should not be elicited by arranging for the patient to hit hims elf or herself when the examiner's hand is the normal situation, if the outstretched arms are only a s light waver is produced; the ataxic patient does damp the movement. G ait may be affected by midline cerebellar (vermis) dis eas e in the abs ence of limb which is related to cerebellar hemisphere dis eas e. G ait unsteady, with irregular stride length and a widened (In the normal s ubject, the feet nearly touch at their neares t point; even a few inches of s eparation widening of the bas e.) G ait and limb ataxia may be complemented by cerebellar dysarthria (des cribed in 2.1-2) and by eye movement dis orders , including nystagmus (us ually gaze paretic), slowed s accades , saccadic pursuit, and gaze apraxia. T he catatonic s yndrome has been various ly defined. core of the syndrome is a mute motionles s s tate; 70 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 60 of 130

added are abnormal movements, including grimacing, stereotypy, echopraxia, and catalepsy. T he latter, also as fle xibilitas ce rea (waxy flexibility), refers to of a limb in the position in which it is placed by the examiner or in some other unnatural position. It is not in all or even mos t cases of catatonia, and it can be apart from the catatonic s yndrome in patients with contralateral parietal les ions (as described below as avoidance s ign of parietal dis eas e). C atatonic refers to the sudden eruption into overactivity of a catatonic patient; this probably usually represents ps ychotic mania. T he catatonic s yndrome occurs in the cours e of schizophrenia or mood disorder, or without other psychopathology as idiopathic catatonia, or in the setting of acute cerebral metabolic or s tructural derangements . In the latter case, it is best thought of nonspecific reaction pattern, s uch as is delirium, a comprehensive clinical and laboratory evaluation to the cause of the behavioral disturbance. An important instance is catatonia as part of the neuroleptic syndrome, the diagnosis of which requires exclus ion of other metabolic encephalopathy, notably s ys temic infection. C atatonia is thus a medical emergency, prompt attention to diagnostic evaluation as well as supportive care (fluids, nutrition, meas ures to avoid complications of immobility, including venous thrombosis). Motor s equencing tests as say function of premotor areas and striatum and are related to deficits in cognitive function seen with dysfunction of the dorsolateral prefrontal loop. T he ring/fist test involves as king the patient to alternate between making a ring 71 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 61 of 130

his thumb and first finger and making a fis t with the hand: “ring, fist, ring, fist…” T he abnormal respons e is perseveration of one or the other posture or disorganization of the s equence. At times, patients are unable to perform the correct s eries even when the verbal cues aloud. A more complex alternation is between striking the table gently with the fist, then the edge of the hand, then the palm: “fis t, edge, palm, fis t, edge, palm…” A different approach is to ask the patient extend the arms, make a fis t with one hand while the other hand flat, then switch hands. T he abnormal res ponse has the patient ending up with two fis ts or palms outstretched. Much can be accomplished in the neurological examination by asking the patient to stretch out his or arms. W ith a few additional maneuvers (tapping the outstretched pronated hands, s upinating them and the patient to close his or her eyes , then asking the to touch his or her nos e with the eyes still closed, then as king the patient to perform the alternating fists test), of the following can be as ses sed in a matter of a so: postural and intention tremor, los s of check, and myoclonus , a pronator sign, dysmetria, and motor sequencing. Doing this, plus testing mus cle tone, plus observing the patient's natural and stress ed gait, plus checking tendon jerks and abnormal reflexes , takes few minutes and does not elucidate disorders of nerve, and spinal cord but repres ents a rather as sess ment of the central organization of the motor system.

AB NOR MALITIE S OF S E NS ATION 72 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 62 of 130

Dis orders of sensation are sometimes difficult to reliably in patients with cognitive and behavior Nonetheles s, s everal points s hould be familiar to the neurops ychiatris t. Distal loss of s ens ation, often accompanied by loss of ankle jerks , is characteristic of peripheral neuropathy. Often, all modalities of are dis turbed. If proprioception is s ufficiently s everely reduced, R omberg's s ign is pres ent. R omberg's s ign that clos ing the eyes produces s ubs tantial impairment balance; it is elicited by as king the patient to s tand, allowing the patient to seek a comfortably balanced position, then as king the patient to close the eyes (ensuring against a fall). Loss of s ens ation from sensory cortex injury is limited to complex dis criminations such as (recognizing numbers written on the palm), (identifying uns een objects in the hand), and two-point discrimination (telling whether the examiner is touching with one or two points , as these come closer together space). However, patients with parietal s troke may ps eudothalamic sensory s yndrome (with impairments elementary s ens ory modalities and s ubs equent dysesthesia) or other anomalous patterns of s ens ory At times, thes e patients pres ent with P.336 ps eudomotor deficits : ataxia, fluctuating muscle tone strength (dependent in part on vis ual cueing), and “levitation” and awkward positioning of the arm contralateral (or at times ips ilateral) to the lesion. In the acute phase, the combination of deficits can amount to “motor helpless ness .” T hese deficits result from the 73 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 63 of 130

sens ory input to regions in which motor programs T he less ons are that “cortical” sens ory deficits s hould sought if there is a ques tion of cortical involvement and that more dramatic or unus ual sensory abnormalities also occur with cortical lesions .

S OFT S IG NS An extensive literature about “soft s igns ” of dysfunction is difficult to comprehend becaus e of the varied definitions and batteries used in the various Most of the s igns s ought in these batteries are this chapter under their more s pecific headings , s uch graphes thesia under Abnormalities of S ens ation and alternating fis t (Oserets ky) tes t in the paragraph on sequencing. F rom the corpus of test batteries , a few maneuvers can be extracted that may make a to the neurological examination of the patient with a mental presentation. While the patient is touching each finger to the thumb, examiner can watch the oppos ite hand for mirror movements. Obligatory bimanual s ynkinesias are s een specifically in disorders of the pyramidal pathways , the K lippel-F eil s yndrome, and in agenesis of the callosum but also in putative neurodevelopmental disorders such as s chizophrenia. Asking the patient, eyes closed, to report whether the examiner is touching one or the other hand (with the patient's hands on the lap), or one or the other s ides of the face, or a is called the face–hand test. T he examiner touches the hand and right face s imultaneously. If the patient only the touch on the face—that is , extinguishes the peripheral stimulus —then the examiner can prompt 74 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 64 of 130

(once): “Anywhere els e? ” T hen the examiner touches right hand and left cheek, left hand and left cheek, right hand and right cheek, both hands , and both cheeks . E xtinction of the peripheral s timulus is the pathological res ponse and has been ass ociated with schizophrenia dementia.

AB NOR MAL R E FL E XE S T he B abins ki sign is the s hibboleth of the neurological examination. It s hould be elicited by stroking the lateral as pect of the foot from back to front, with the leg extended at the knee, us ing a pointed object s uch as orange stick or a key. T he response of extens ion of the great toe with or without fanning of the other toes indicates corticos pinal tract dis eas e. T wo confounding factors in as ses sment of the B abinski s ign are the toe and the plantar grasp. T he striatal toe is extens ion the hallux without fanning of the other toes or a flexion synergy in the other mus cles of flexion of the leg. It occur spontaneously or on elicitation in patients with P arkins on's dis ease in the absence of evidence of pyramidal dysfunction. T he plantar grasp, the of the familiar palmar gras p, may mask an extens or res ponse to lateral foot s timulation when stimulation in the midfoot brings about flexion of the toes . Other important reflexes for the neuropsychiatrist are Myers on's sign, a failure to habituate to regular, per-second taps on the glabella (with the tapping hand outs ide of the patient's vis ual field), present in parkinsonis m and diffuse brain disease Hoffmann's s ign, flexion of the thumb with s napping 75 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 65 of 130

of the dis tal phalanx of the patient's middle finger, upper extremity s ign of pyramidal dysfunction, although s ometimes present bilaterally in normal subjects G rasp, flexion of the fingers with stroking of the patient's palm toward the fingers during dis traction and despite instructions to relax, as sociated with disease of the contralateral supplementary motor Avoidance, extension of the wrist and fingers to the same s timulus as the grasp, a less well-known s ign points to contralateral parietal cortex abnormality S everal other “primitive reflexes” are les s specific in they are commonly present in the normal subject and, thus, are less us eful for diagnostic purposes. T hes e the suck, s nout, and palmomental reflexes .

FOC A L NE UR OB E HA VIOR A L S YNDR OME S T he idea that the brain is regionally specialized had a difficult gestation in the 19th century, and the key to its acceptance lay in recognition of the effects of focal lesions . At the end of the 18th century and early in the 19th century, phrenology drew adherents to the claim personality traits could be inferred by inspection of the cranium. T his claim was faulty, but phrenology had an underlying theory that was an important step forward the brain s ciences; in particular, the beliefs that the was the organ of the mind and that the mind could be fractionated into functions gave impetus to the development of neuros cience in a modern form. In the middle of the 19th century, the gradual realization that 76 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 66 of 130

aphas ia occurred with damage to s pecific areas of the hemis phere was another crucial s tep. T he subsequent identification of numerous s yndromes of localized damage—such as apraxia, agnos ia, visuospatial impairment in its various forms, and s o forth—is a fas cinating story of as tute and painstaking clinicopathological, and later clinicoradiological, correlation. P atients' introspective access to their deficits may be limited. Much of cognitive proces sing is unconscious, in the sense of being excluded from awareness by motivated defens e, but in the s ens e that it is not even principle open to introspection. J onathan Miller, in his television s how T he B ody in Q ues tion, displayed this by as king pass ers by in a pers on-in-the-street interview, “S ir, where is your spleen? ” No one can s ay from intros pection where the spleen is . T he same is true of much of cognitive process ing. E xplanations provided patients may be confabulations that fill in s uch intros pective gaps in a situation in which the brain is functioning abnormally in a way not fores een in its In neurops ychiatry, s ubjective experience and behavior separate explicanda. F or instance, in the realm of the networks s ubs erving conscious experience— “feelings”—and those underlying the emotional forces influencing behavior are dis tinct, although overlapping, with the amygdala notably absent from the former. T he patient's appraisal of his or her own situation is always relevant to collaboration with treatment and its outcome and s hould be explored in every clinical encounter.

Dementia 77 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 67 of 130

Although dementia is characteris tically considered a syndrome of “global” cognitive impairment, implying global or diffuse brain dysfunction, each dementing disorder produces a distinct pattern of brain pathology and corres ponding pattern of cognitive dys function. F or this reas on, and against tradition, dementia is under the rubric of focal neurobehavioral s yndromes. In Alzheimer's dis eas e, the earliest neuropathological abnormality is characteristically medial temporal accumulation of plaques and tangles, initially in cortex and subiculum (the input and output zones of hippocampus ). T he disease progres sively involves as sociation cortices in temporoparietal and prefrontal regions. T his burden of pathology determines the characteristic early memory P.337 impairment with ensuing anomia, failure of grasp, and coars ening of pers onality. On occas ion, Alzheimer's disease pathology is predominantly posterior, with concomitant predominance of vis uos patial impairment the clinical cours e. B y contras t, in frontotemporal dementia, the earliest dis eas e manifes tations are pathologically in frontal or temporal cortex, clinically presenting as primary progres sive aphasia, s emantic dementia, or a frontal apathy or disinhibition syndrome. none of these situations is a view of dementia as a impairment of brain function jus tified by the clinical or pathological facts; rather, s elective dis ruption of anatomical networks corres ponds to s ymptomatic features. E xtens ive s ubcortical white and gray matter damage 78 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 68 of 130

to s mall-vess el dis eas e is a common caus e of and, in this s ituation, the clinical picture is dominated slowed mental proces sing, forgetfulness with relative preservation of recognition memory (as opposed to recall), and executive cognitive dys function. located s ingle infarctions can also produce dementia. T hese strokes can involve left angular gyrus , genu of internal caps ule, and (perhaps most commonly) medial thalamus . T he thalamic and internal caps ule strokes produce cognitive impairment by interfering with frontal networks .

Delirium C las sically a s yndrome of “global” brain dys function toxic-metabolic infectious encephalopathy, delirium also point to focal brain dis eas e. Delirium may be due infarction in the right pos terior s uperior temporal gyrus caus ed by occlus ion of the inferior division of the right middle cerebral artery or to infarction in the inferior temporo-occipital cortex on the left or bilaterally due to posterior cerebral artery occlusion. In both instances, neurological signs may be limited to a vis ual field cut or absent entirely. F inding bilateral asterixis or multifocal myoclonus strongly indicates a toxic-metabolic brain derangement, and the history and physical examination should provide pointers for the ess ential laboratory confirmation of the abnormality. F eatures of the mental state are of little us e in determining the caus e of the syndrome except that agitation is far more common in certain disorders such as substance withdrawal, and the syndromes of left posterior cerebral artery or of right middle cerebral artery territory s troke with 79 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 69 of 130

involvement of the temporal lobe.

Aphas ia Acquired impairment of lexical or s yntactical is termed aphas ia. Lexicon and s yntax do not exhaust domain of language, and attention is devoted below to prosody and discourse pragmatics . At the beds ide, the clinician s hould be able to distinguis h language impairment from other sources of abnormal discours e (s uch as ps ychos is), delineate the features of in the patient's linguistic function, and tentatively the locus of brain injury. A s imple dis tinction between “expres sive” and defects has s ome power to dis tinguis h between and posterior les ion sites, but it is not in current use in aphas iology because mos t aphas iogenic lesions some impairment in both production and of language, and these impairments are of multiple A widely accepted approach to examination and clas sification in aphas ia identifies six domains for elucidation: s pontane ous s pee ch, naming, re pe tition, reading, and writing. Attention to speech reveals dys fluency and word-finding difficulties . T he dysfluent speaker produces shorter phrases and utterances without a natural “flow.” S ubstantives and verbs ) may be preserved at the expense of words (s uch as prepositions) and grammatical (s uch as tens e endings ), leading to agrammatical utterances that are nonetheles s relatively information Lesions dis rupting fluency are characteris tically the left hemis phere or involve putamen. Naming performance requires the adequate functioning of a 80 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 70 of 130

network, including posterior temporal, temporoparietal, and inferior frontal sites. T his is ordinarily tes ted by confrontation (“What do you call this? ”), which can be conveniently done using body parts or common items the bedside. Naming from description (“What do you the vehicle that travels under water? ”) is an alternative mode of testing, particularly us eful for visually impaired agnos ic patients . C omprehens ion is tes ted bes t using probes with minimal demand on output, so “yes/no” questions (“Does a stone s ink in water? ”) are better motor commands , which may be impaired by apraxia. Impairment of comprehension results from posterior temporal les ions. Disordered repetition is disclos ed by asking the patient to produce longer utterances, reiterating the examiner: “airplane, and s he are here…” R epetition may be s urprisingly (the so-called transcortical aphas ias ) or affected (conduction aphasia). T he latter depends on lesions of insula or external capsule. R eading comprehension (not reading aloud, a different skill) comprehension with a different input modality from comprehension, and s ome patients s how significant diss ociations . S imilarly, writing tests output in a modality from s peech. W riting is a particularly s ens itive probe for the anomia s een in early Alzheimer's disease the disorganization s een in delirium. A clas sification of the aphasias using the data from an examination as just outlined is s hown in T able 2.1-3. C linicians recognize, however, that many patients do fit well into the categories created by this scheme.

81 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 71 of 130

Table 2 Aphas ic S yndrome

S pontaneous R epetition S peech

Naming

G lobal

Impaired

Impaired

Impaired

B roca's

Dys fluent, effortful, agrammatic

Impaired

Impaired

Wernicke's

F luent, paraphasic, absence of subs tantive words

Impaired

Impaired

C onduction

F luent, paraphasic

Impaired

Impaired

82 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 72 of 130

with phonemic errors T ranscortical Dys fluent motor

S pared

Impaired

T ranscortical F luent, sens ory paraphasic

S pared

Impaired

Mixed transcortical

Dys fluent

R elatively spared

Impaired

Anomical

F luent, paraphasic

S pared

Impaired

83 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 73 of 130

Ide omotor apraxia commonly occurs together with aphas ia. T his is a dis order of performance of s killed movements to command in the abs ence of explanatory elementary s ens ory and motor disturbances . Oral is revealed by the patient's incapacity to show, for example, how to blow out a match or lick a pos tage Limb apraxia is shown by the patient's incapacity to for example, how to wave good-bye or us e a hammer screwdriver. P atients with these deficits may, be able to follow whole body commands: “S how me boxer stands ,” for example. P atients rarely complain of apraxic deficits , in part because they are artifacts of the examination in the s ense that they may not be present the us e of real-world items .

Attention S everal related phenomena cluster under the clinical description of attentional disorders . At the mos t fundamental level, alertnes s repres ents a continuum ranging from coma to normal wakefulness . T he faced with a patient who is les s than fully alert should quantify the dis order by ass es sing the patient's to a graded series of probes: Does the patient orient to examiner's pres ence in the room; what does the patient when his or her name is called or when touched or shaken or when a (harmless ) painful s timulus is and s o forth. T hese res ponses s hould be recorded in rather than s ummarized by ambiguous terms s uch as “lethargic.” Alert patients may show deficits in sus tained attention external s timuli (vigilance) or internal stimuli (concentration). Attentional deficits of these sorts are 84 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 74 of 130

characteristic of delirium. V igilance can be ass es sed bedside adaptation of a continuous performance tas k, example, by as king the patient to lift a hand each time examiner says the letter “A” or, to increase the each time P.338 the examiner says the letter “A” after the letter “D.” T he examiner then produces a series of random letters at a deliberate and steady rate over an extended period. error of omiss ion or commis sion repres ents a failure. as king the patient to count from 20 to 1 or give the the week or the months of the year in revers e, the examiner can appraise concentration. Digit span— the patient to repeat a lis t of numbers spoken at a slow, steady rate without separation into chunks —is a clas sic tes t of attention; the lower limit of normal for digit span five. A “higher” level of attentional function is the capacity to manipulate information kept in consciousness over a period—a test of working memory. An excellent is alphanumeric sequencing. T he patient is as ked to alternate between numbers and letters; the examiner provides “1-A-2-B -3-C ” as a model, then allows 30 for the patient to s tart at 1 and give as many as poss ible. If only the number of correct alternations is counted (ignoring errors ), the lower limit of normal is comparable, s imple tas k is alphabetizing the letters of word “world” (or any s imilar word). W orking memory is known to require intact process ing in dorsolateral prefrontal cortex. Hemine gle ct is a focal disorder of attention almos t 85 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 75 of 130

of left hemis pace in a patient with acute right disease. Most characteris tically, the lesion is parietal, distinguishable patterns of hemineglect occur with and cingulate lesions . G ros s neglect can be recognized the patient's ignoring, or even denying the owners hip the left limbs or not attending to objects and people in hemis pace. S ubtler degrees of neglect can be elicited presenting an array in which the patient mus t s earch both hemifields to point to items, for example, all the yellow dots in a s timulus card with dots of varied colors both left and right. In the phenomenon of hypermetamorphosis, part of the K lüver-B ucy s yndrome of bilateral anterior temporal damage, animals or patients exhibit an increased level attention to individual items in the environment.

Amnes ia T he term me mory is us ed in s everal ways by clinicians ps ychologists . T he amnes tic s yndrome features impairment of learning of new material (anterograde amnes ia) and a variable period of impaired recall the ons et of the s yndrome (retrograde amnesia). It is to damage to hippocampus or to anterior thalamus P.339 (including mammillothalamic tract). Memory proper is distinguished from retention in consciousness of over the cours e of a few seconds, which may be called “working” or “iconic” or “short-term” memory. T his function is s pared in the amnes tic s yndrome because it depends on frontoparietal mechanis ms dis tinct from hippocampal and thalamic pathways damaged in 86 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 76 of 130

Deficits due to hippocampal and thalamic les ions are dependent on the lateralization of the damage, leftdamage producing verbal and right-sided damage producing figural memory impairments . A distinction between free recall and recognition is of neuropsychological s ignificance and generally can made adequately, if imperfectly, at the beds ide. Hippocampal and thalamic patients show accelerated forgetting, so that cues (s uch as providing the semantic category) are relatively ineffective in aiding recall. R ecognition memory is always better than free recall absolute scale; exaggeration of the dis parity—that is , sparing of recognition memory—is characteristic of memory impairment due to dysfunction of frontal mechanisms of effortful search. In addition, frontal patients s how impairments of for the temporal context or s ource of information. T his deficit is probably relevant to the occurrence of confabulation. S pontaneous confabulation occurs in minority of amnestic patients and depends on ventromedial frontal damage. Memory is s o commonly impaired in brain dis orders should be tested in all patients undergoing neurops ychiatric evaluation. R ecall of a test phras e (for example, a name and addres s) over a several-minute distraction is a valid and s imple screening test. more detailed analys is of memory is necess ary in with dis orders likely to affect memory mechanis ms , including (among many others) head injury, epilepsy, dementing disorders. T esting s hould include both and nonverbal material. F or example, tes ting recall of words and three s hapes or three words and three 87 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 77 of 130

directions over s everal minutes' delay is easily F urther, the examiner should be prepared with cues, including appropriate (incorrect) foils, to as ses s sparing the capacity to make use of cues in frontal memory impairment. F or example, if one of the words provided “piano,” the examiner could cue, “One was a mus ical instrument,” and further provide “guitar, piano, violin” multiple-choice options . Only rough inferences can be drawn from this beds ide ass es sment, as compared formal neurops ychological evaluation. Apart from patients with persisting amnestic the neuropsychiatrist may be pres ented with patients experienced an amnestic s tate trans iently or rarely may one during a transient amnes tic state. T he s yndromes transient global amnesia and transient epileptic and their differentiation have been fully des cribed and require thorough his tory taking, neuropsychological evaluation, and electroencephalography (E E G ) T he neuropsychiatrist s hould als o know that amnesia criminal offenses is common; certainly it is not confined those who committed a crime while in a delirious , ictal, postictal s tate, as is sometimes claimed for legal

Vis uos patial Dys func tion T he requirement to test visual, as well as verbal, has just been mentioned. Drawing and copying tasks further the ass ess ment. C opying inters ecting (as in the Mini-Mental S tate E xamination [MMS E ]) or incidental performance) the s hapes used in the tas k begins the as sess ment. W ith more complex failures with a slavish element-by-element s trategy are characteristic of patients with right hemisphere 88 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 78 of 130

as is neglect of the left side of the stimulus . T he variety of dis orders of higher visual function has already been mentioned in des cribing the complex structure of visual ass ociation cortices . P ros opagnos ia defect in recognition of faces. S uch a defect may be obvious from the his tory or may be a more s ubtle abnormality; it can be s potted at the bedside, albeit insensitively, with the us e of a few pictures of famous people. Defe cts of topographical s kill, although rarely presenting in an isolated form, als o occur with right hemis phere dys function. T he patient can be as ked to describe a route between familiar places or a question believed to be within premorbid capacities (“If you're going from New Y ork to Los Angeles , is the Ocean in front of you, behind you, to your left, to your right? ”). T he incapacity to grasp in attention multiple visual at once is known as s imultanagnos ia. T he patient may in des cribing a complex vis ual scene by virtue of only a s ingle, perhaps peripheral, element. T ogether ps ychic paralysis of gaze (inability to direct gaze voluntarily, or ocular apraxia) and optic ataxia (a of mis reaching under vis ual guidance), it makes up syndrome, the archetypal disorder of the dorsal visual pathway. T he patient with impairment of reaching visual guidance s hould be examined without vis ual guidance (e.g., pointing to parts of his or her own body with eyes closed) to confirm the defect.

E xec utive C ognitive Dys func tion E xe cutive cognitive dys function refers to initiation of cognition and action, their maintenance in the face of 89 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 79 of 130

distraction, organized but flexible purs uit of goals, and self-monitoring with error correction. E xecutive are crucial in adaptive function, and performance in this realm is better correlated with real-world outcomes of brain-injured patients than are many other domains traditionally analyzed in neuropsychology or many ps ychos ocial variables . B edside exploration of function is of central importance in the neurops ychiatric examination. Analys is of behavioral dis turbance and neurops ychological deficits in patients with cerebral suggests that multiple dis sociable proces ses compos e executive cognitive function, and certainly these are ins tantiated by anatomically dis tributed systems . C urious ly, however, many different tasks recruit a identical set of regions in the middors olateral prefrontal cortex, midventrolateral prefrontal cortex, and anterior cingulate. Nonetheles s, the clinical examiner must that no single probe can screen for all dysfunctions. Many as pects of executive function are illuminated by attention to the patient's performance of elements of history taking and examination. Dis inhibition may be in abnormalities of comportment during s ocial Motor impe rs is te nce , the failure to sustain actions that be undertaken properly, may be noted in the patient's “peeking” when as ked to keep the eyes clos ed, looking back at the examiner's face when lateral gaze (es pecially to the left) is attempted, or not keeping the arms extended or the tongue protruded when to do s o. P ers eve ration is the continuation of elements past actions into present activity. P ers everative may be noted when tes ting naming or attention. E chopraxia, for example, the patient cross ing his or her 90 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 80 of 130

arms when the examiner (spontaneously) does s o, when some other behavior has been reques ted, can be observed during the interview and examination. be havior is an automatic tendency to make use of in the environment, for example, picking up a pen and starting to write des pite this behavior's being inappropriate to the setting. More focused efforts to as sess executive function are almos t always indicated in the neurops ychiatric examination. P ers everation may be specifically s ought the motor s equencing tas ks described above or with a sample of s pontaneous writing. A tapping tas k with conflicting ins tructions may illuminate the inflexibility of goal-directed P.340 behavior that gives rise to pers everative res ponding. patient is instructed to tap once if the examiner taps and twice if the examiner taps once. T he examiner taps on the table in a random s eries of one or two taps . T his can be directly followed by a go/no-go tapping in which the patient is instructed to tap once if the examiner taps once, not at all if the examiner taps Intrusions from the previous task's instructions perseverative res ponding; echopraxic respons es just like the examiner) represent failures of inhibition. Inhibition of reflexive gaze can be tes ted during the examination of eye movements . Looking at the moving stimulus rather than in the oppos ite direction as amounts to a vis ual gras p response and represents of inhibition. S pontaneous word-list generation (“T ell all the animals you can think of” or “T ell me all the 91 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 81 of 130

that s tart with ‘s ’”) depends on the capacity for effortful search of s emantic s tores . A greater decrement in to semantic cues (“animals ”) than to phonemic cues (“words with ‘s ’”) is seen in Alzheimer's disease the degradation of semantic stores due to damage. W orking memory can be ass es sed with the alphanumeric sequencing task described above. Anatomical inferences from dis sociations in on thes e tasks are limited. G o/no-go tas ks depend on integrity of orbitofrontal cortex, other tasks on the dorsolateral prefrontal cortex and its circuit. is as sociated with right hemis phere dysfunction. A diss ociation is between executive cognitive and personality change in frontal injury. E specially with orbitofrontal lesions , executive function can be spared even in the face of grave alterations in emotion and comportment; the two domains cannot s imply be cons idered two sides of the s ame coin. Nonetheless , it bears repeating that neuropsychiatric examiners should cons ider executive cognitive function in their formulation of cases .

Dis ordered Mood and E motion S everal syndromes of dis ordered emotion in organic disease can be delineated. Dis turbance s of re cognition expre s s ion of e motion with right hemisphere les ions already been mentioned. P atients and their familiars rarely aware of these deficits and do not complain of rather, the examiner must recognize the deficit and it into a formulation of the patient's social and functional decline. Impairment of prosodic expres sion s hould not mistaken for depress ed affect. T esting of affective 92 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 82 of 130

can be undertaken at the beds ide without s pecial equipment. T he examiner should as k the patient to say emotionally loaded sentences in a emotional manner, expres sing s urprise, fear, pleas ure, and anger. P eople cons iderably in their native acting talents, and the normal performance is wide. T he examiner als o can neutral sentences in various emotional tones : “I am to the store,” stated with surpris e, and s o forth, with the examiner's face turned away from the patient to avoid providing a s econd input channel. P atients should be to recognize the affect. S eparately, if tes ting materials available, the examiner can as sess the patient's identify emotions in visual scenes and facial Lesions that involve both limbic and heteromodal in the right hemis phere especially impair performance recognizing emotional facial expres sions. P athological laughing and crying also are mentioned as lateralized behavioral dis turbances. T he phenomena displays of affect incongruent with inner experience elicited by inappropriate, nonemotional, or inadequate stimuli. T he examiner may, in the extreme, be able to full displays of affect by waving a hand in front of the patient's face. T he patient is often embarrass ed by the pathological expres sion of affect. T he traditional explanation is that a lesion of des cending frontopontine pathways releases from inhibition a “laughing center” “crying center” in the brains tem. Indeed, features of ps eudobulbar palsy are often pres ent in thes e patients. However, the relevant centers have never been and the poss ibility that the phenomena res ult from cerebellar dis connection has been raised. A broader of affe ctive dys re gulation, which may be called 93 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 83 of 130

“emotionalis m,” is commonly s een, us ually in the of tearfulness . P atients report that they are more emotional than previous ly and that the tears are unexpected, and uncontrollable. However, they are generally congruent with the patient's s ubjective state. S uch patients are often cognitively impaired; les ions the left frontotemporal region. T he rare phenomenon of fou rire prodromique (mad prodromal laughter) acute vas cular les ions of the brains tem or thalamus . Apathy is an emotional dis turbance marked by of affect and motivation. G oal-directed behavior is reduced, and emotional res ponses are lacking. T he distinction from depress ion is crucial: P atients do not report negative emotional states or ideational content. Although they may meet criteria for depres sion the loss of interest in activities , they are mentally empty rather than full of distress . R ecognizing apathy rather mistaking it for depress ion may imply treatment with different pharmacological agents, for example, us e of dopamine agonis ts. E uphoria refers to a pers is tent and unrealistic sense of well-being without the increased mental or motor rate of mania. Although often in connection with multiple sclerosis , it is unusual and almos t always as sociated with extens ive dis ease and subs tantial cognitive impairment. T he K lüve r-B ucy s yndrome , as described in the captive monkey, includes reduction in aggres sion (tamenes s), excess ive and indis criminate sexual behavior, hypermetamorphos is (forced attention to environmental stimuli), and hyperorality (mouthing nonfood items ). mixture of emotional, perceptual, and motivational changes is dependent on bilateral damage to 94 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 84 of 130

human patients, pathologies including trauma, herpes simplex encephalitis , and frontotemporal dementia can produce the s yndrome, us ually in partial form. Depre s s ion is common in patients with brain dis eas es , including s troke, multiple sclerosis, traumatic brain and P arkins on's dis ease. C ertainly, this is in part a to altered circums tances and distress ing dis ability. Nonetheles s, the s yndromal nature of the depres sed and its imperfect correlation with measures of disability have prompted extens ive efforts to seek anatomical correlations. C onverging evidence leads to a model of alterations in a distributed network involving neocortical and limbic elements. In particular, a dors al involving dorsolateral prefrontal cortex, inferior parietal cortex, and the dorsal and posterior portions of gyrus shows underactivity in the depres sed s tate; regions are believed to mediate the cognitive and impairments of depress ion. Invers ely, a ventral compartment containing anterior insula, subgenual cingulate, hippocampus , and hypothalamus is these elements are believed to mediate somatic (“vegetative”) features of the depres sed s tate. between the two compartments are mediated through thalamus , basal ganglia, and, especially, rostral Mania is s ubs tantially les s common than depres sion brain injury. Mania is ass ociated with right-sided involving paralimbic cortices in orbitofrontal or basotemporal regions or s ubcortical sites in caudate or thalamus . S ome evidence s uggests that s ubcortical are more likely to produce a bipolar picture, cortical unipolar mania. As with depress ion, the abnormal state does not necess arily appear in close temporal 95 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 85 of 130

as sociation with the injury, so determining whether the mood dis order is organic or idiopathic is not always straightforward. T he absence of a pers onal history of disorder is an obvious criterion, but the presence of a family history of mood dis order may mark a factor not operative in the P.341 absence of the brain les ion. Age of onset is relevant, es pecially for mania: T he ons et of idiopathic mania years of age is rare. A particularly common iss ue in neuropsychiatric as sess ment is the patient with late-onset depress ion in whom evaluation reveals executive cognitive and s ubcortical white matter dis eas e. T his state of “vascular depres sion” is marked by the presence of vascular ris k factors, notably hypertension, a tendency ps ychomotor retardation and anhedonia and not ps ychos is or guilty ideation, and poor outcome with treatments . S ome, but not all, of these patients have apathy rather than depress ion.

Abnormalities in Agenc y Ordinarily, the person performing an action has the of being the one performing it. T he prototype of this normal subjective sense is the “alien hand” phenomenon. P atients with parietal les ions may report sens e of strangenes s of the hand, and the limb may levitation or avoidance reactions. More dramatically, medial frontal or callos al les ions , the hand may engage unwilled behavior (representing unilateral utilization behavior), or intermanual conflict may occur. 96 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 86 of 130

Abnormal S oc ial B ehavior T he multitude of behaviors exhibited in s ocial has, of cours e, multiple underpinnings . S everal complexes , the neurobiology of which has come under scrutiny, can be obs erved in their abnormal form in patients and, at times, understood from an anatomical phys iological point of view. T he intens ity of social interaction manifes ted by with temporal lobe epilepsy may be due to deficits in social cognition or to a limbic lesion reinforcing s ocial cohes iveness . F ailures of empathic understanding are common in patients with frontal injury. T hes e res ult both from cognitive inflexibility in ass es sing complex social s ituations, es pecially in patients with dorsolateral prefrontal les ions, and from emotional impoverishment, es pecially in patients with orbitofrontal lesions . T he capacity of humans to understand the mental others —and thus to recognize not just another's goals intentions but also the other's deceptions or pretense— has been termed me ntalization or the ory of mind. and lesion data s ugges t that this capacity depends critically on prefrontal cortex (particularly right medial prefrontal cortex adjacent to anterior cingulate gyrus ), right temporoparietal cortices , and amygdala. P atients with is olated les ions of amygdala are rare, but deficits theory of mind are seen in patients with frontal dis ease and may contribute to their s ocial failure. P atients with right hemisphere les ions have a range of deficits in interaction that may be characterized as a dis order of pragmatics. Although they may grasp the propositional 97 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 87 of 130

content of language correctly, they mis take as pects of communication that require apprais al of the intent, for example, whether an utterance was intended a joke. P ragmatic disorders due to frontal and right hemis phere damage may impair narrative coherence through verbos ity, vaguenes s, and dis regard for the listener's informational needs . T hus, for example, us e may be s yntactically correct but the referents of pronouns obscure to the listener. Although language is normal, the way language is embedded in social interaction is not.

Abnormal B eliefs and E xperienc es Hallucinations are a common feature of diseas es of the brain. V is ual hallucinations in the abs ence of auditory hallucinations are s ugges tive of organic dis ease. V isual hallucinations may occur in a hemifield blind from disease, so-called releas e hallucinations . V is ual hallucinations in the s etting of vis ual impairment due to ocular disease, usually in the elderly, are known as the C harles B onne t s yndrome . T he hallucinations are characteristically vivid images of living figures, and the patient is aware of their unreality. Other is absent, but treatment aimed at the hallucinations is us ually ineffective. E laborate-formed visual may occur with lesions of thalamus or upper brains tem, called peduncular hallucinos is. T he symptoms are the evening (crepuscular), and again, the patient is of the unreality of the visual experiences . P rominent, visual hallucinations in the context of progress ive dementia may s uggest dementia with Lewy bodies . Auditory hallucinations occur rarely with pontine 98 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 88 of 130

More common are mus ical hallucinations in the setting hearing impairment, akin to the C harles B onnet Unilateral hallucinations are characteris tically ips ilateral the deaf ear. Olfactory hallucinations occur as a limbic in partial epilepsy, but they also occur in idiopathic ps ychiatric illnes s. P alinops ia and palinacous is refer to pers is ting or perceptual experiences after the object is gone in the visual and auditory domains, res pectively. Les ions in as sociation cortex—parieto-occipital and temporal, res pectively—are res pons ible, although (for the vis ual sphere more than the auditory) drug toxicity is often the explanation. T he content of de lus ions may yield clues to causative organic disease and its nature. Most notably, misidentification delus ions have been ass ociated with dysfunction of face proces sing and clearly linked—in but not all cases —to right hemis phere dysfunction. Misidentification of place is regularly ass ociated with visuospatial and executive cognitive dys function. Misidentification delusions have been of s pecial cognitive neuropsychiatry, with a focus on face recognition impairment in s uch patients. P erceptual recognition without a s ens e of familiarity (as in syndrome and perhaps the nihilistic delusions of syndrome) may reflect a dis ruption of vis ual–limbic connections . In a s ens e, it is the revers e of dé jà vu, amounts to familiarity without perceptual recognition. However, many patients with mis identification have no evidence of organic disease. Although such patients may have dys function of similar underlying mechanisms to patients with as certainable organic 99 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 89 of 130

disease, the similarity of clinical phenomena cannot be taken to prove an identity of mechanis m. P articular delusional themes may mark delirious such as a focus on danger or harm to others, as the more s elf-centered cons tructions in idiopathic ps ychotic dis orders. However, most delusions in with brain disease are of more banal nature, often with persecutory elements that bespeak cognitive failure theft of one's purse, for example, repres enting a failure memory as to its location). C omplexity or delus ional ideation is as sociated with preservation of intellect, and delus ions tend to become les s complex progres sion of dementia.

L A B OR A TOR Y INVE S TIG A TIONS S pecialized laboratory investigation forms a major part the neuropsychiatrist's arsenal. S ometimes patients are referred for neuropsychiatric cons ultation when a inves tigation—such as a s creening MR I or E E G —gives unexpected abnormal res ult; the neurops ychiatris t is called on to ass es s the meaning of the finding in the ps ychiatric context.

Neuroimaging S tructural neuroimaging with computed tomography and later with MR I revolutionized practice in the clinical neuros ciences. No longer was the organ of interes t invis ible within the carapace of the skull. C T relies on differential absorption P.342 of X-rays by brain tis sues and on the power of 100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 90 of 130

computerized methods to integrate data from multiple perspectives . T he s trengths of C T are its speed and its sens itivity to blood and bone. T hus, for purpos es, situations in which a patient cannot tolerate prolonged imaging procedure may mandate C T . T his problem often aris es with an agitated demented or ps ychotic patient. B ony abnormalities , parenchymal depos ition of calcium, and intracranial hemorrhage are particularly well as sess ed by C T . S uch questions arise acute aftermath of trauma in particular. T he advent of MR I was an advance over C T in several res pects . T he anatomical resolution is substantially and the discrimination of white matter abnormalities exceptionally so. T he capacity to display data from a acquisition in multiple views —sagittal, axial, and coronal—allows improved anatomical understanding. (or s hort relaxation time [T R ]) images give maximal anatomical resolution. T 2 (or long T R ) images and intermediate-weighted (proton dens ity) images give maximum s alience to areas of abnormality, characteristically bright against a darker parenchyma. attenuation invers ion recovery (F LAIR ) images mark the lesions even better, with dark cerebrospinal fluid providing better contrast with regions of abnormality the bright C S F of T 2 images. G radient echo images sens itively reveal the sequelae of hemorrhage and may us eful in as ses sing the damage from trauma. Infusion gadolinium for contrast enhancement is not neces sary delineation of nonvascular anatomical s tructures , s uch is the goal in the case of atrophy or old s troke or but can identify areas of breakdown of the blood–brain barrier s uch as in the meninges in meningitis or in 101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 91 of 130

parenchymal lesions of active multiple s cleros is , tumor, acute stroke. S pecial imaging s equences should be for the identification of cortical dysplas ia or mesial temporal s cleros is . V olumetric MR I allows diagnos is by quantitative ass es sment of delineated brain s tructures such as hippocampus in the cas e of temporal epilepsy potentially Alzheimer's diseas e. One imagines the day the near future when the s cans come (as electrocardiograms now do) with quantitative routinely accompanying the analog image. Magnetic res onance angiography (MR A) allows the delineation medium and large vess els without the adminis tration of contrast material, as is required for conventional angiography. S tenos is of thes e ves sels, such as the of the neck, or the presence of vas cular malformations aneurysms is reliably as certained. However, resolution not sufficient to allow as sess ment of small vess els ; some forms of vasculitis cannot be excluded with MR A require contras t angiography. Additional MR I s equences include diffusion-weighted imaging, which captures acute vas cular injury; diffusion tensor imaging, which dis clos es patterns of white matter; and magnetization transfer imaging, promis es even greater sens itivity to brain lesions than F LAIR imaging. E xcept for diffusion-weighted imaging acute stroke, none has an es tablis hed clinical use. Magnetic res onance spectroscopy is a method for analyzing the regional chemical composition of the T he benefits of its ability to identify neuronal loss and proliferation are s till under investigation, although in certain circums tances , s uch as dis tinguishing radiation necros is from recurrent brain tumor, it is of proven 102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 92 of 130

us efulnes s.

Func tional Neuroimaging F our methods of functional neuroimaging are available: single photon emis sion computed tomography P E T , functional MR I, and brain mapping by quantitative E E G . All are exciting research avenues, but the clinical role for functional imaging is limited. All the techniques have a place in the pres urgical evaluation epileptic patients. S P E C T or P E T in the patient with frontotemporal dementia typically dis closes the lobar nature of the dys function, although their value diagnostically over and above neuropsychological demonstration of the s ame phenomenon is S imilarly, in exactly which circums tances bilateral temporoparietal hypoperfusion advances the diagnosis of Alzheimer's dis ease is not yet clear. T he demonstration of occipital hypoperfus ion strongly supports a diagnosis of dementia with Lewy bodies . evidence for other clinical us es of functional imaging is present limited or anecdotal.

E lec troenc ephalography T he expectation of the originators of E E G was that it allow tracking of mental process es . T his hope has not realized. E E G does have the advantage over other available brain imaging tools that it reflects function at high temporal res olution, res olution corresponding to time cours e of mental proces sing. T hus , at least from a res earch perspective, meas urement of brain potentials relation to stimuli—the technique of evoked has the capacity to identify anomalous modes of 103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 93 of 130

proces sing. R ecordings from electrode placements in subdural or cortical sites provide irreplaceable about the origin and s pread of epileptic dis charges , but this invasive technique is jus tified only under circums tances . F rom today's practical point of view, E E G has s everal uses : Inves tigation of epileps y to confirm the diagnos is clarify the type of epilepsy Differentiation of delirium from acute nonorganic ps ychos is R ecognition of C reutzfeldt-J akob disease Dis tinction of frontotemporal dementia Only 30 to 50 percent of patients with epilepsy show an epileptic abnormality on a single interictal waking E E G . With s leep deprivation, s leep during the recording, and repeated recordings , s ens itivity improves to 70 to 80 percent. Anterior temporal electrodes add to the sens itivity and localizing power of the E E G , but nasopharyngeal electrodes, which are quite uncomfortable for the patient, do not provide additional sens itivity, and are not recommended. A reasonable protocol s tarts with a routine E E G , including anterior temporal leads ; if this is negative but suspicion remains high, a second E E G with sleep deprivation can be undertaken. A third and fourth E E G may be us eful, but rate of dis covery of abnormalities decreas es after that. E ven then, some epileptic patients will not have been shown to have interictal abnormalities. At times , ambulatory E E G is of use to ascertain the epileptic of undiagnosed events, but the restricted montage of 104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 94 of 130

ambulatory equipment limits its us efulness . Hos pitalization for video-E E G recording may be for clarifying the nature of puzzling s pells . Delirium is characterized by s lowing of the E E G , a never s een in acute idiopathic psychosis. T his point can be decisive in a confusing clinical s etting. However, E E G is not indicated as a routine in the of psychotic patients. Among the dementing disorders , frontotemporal dementia is dis tinctive in having a E E G even as the clinical s tate becomes moderately In C reutzfeldt-J akob disease, the E E G is always s low may ultimately (not neces sarily immediately) show the diagnostic feature of ps eudoperiodic complexes. E E G s at weekly intervals may clinch this diagnosis in a puzzling case. E voked potentials can identify abnormalities in neural transmis sion along myelinated pathways such as the pathway or the s ens ory pathways of the s pinal cord brains tem. T his can help in the diagnosis of dis orders as multiple sclerosis or vitamin B 12 deficiency. P.343

L aboratory Inves tigations In general, empirical evidence for the usefulness of laboratory s tudies supports only a limited role for or s creening investigations; for the most part, tes ts should be performed as guided by the his tory and examination. A full discus sion of laboratory strategies all neuropsychiatric s ituations is beyond the scope of chapter. In regard to dementia, a complete blood cell count (C B C ), chemistry panel, vitamin B 12 as say, and 105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 95 of 130

thyrotropin (T S H) as say are indicated as screening addition to a test for s yphilis (the fluorescent antibody test [F T A]) in those areas of the United S tates which the prevalence of s yphilis jus tifies the testing. region of high incidence is a broad belt acros s the addition to s ome urban areas in the North; 30 U.S . contribute more than one-half of the national total of cases.) T he reason the F T A is the tes t of choice is that reagin tes ts (the V enereal Dis ease R esearch [V DR L] or R apid P lasma R eagin [R P R ]) revert to intercurrent antibiotic treatment or with the pas sage of time and, thus , are insufficiently sensitive to serve as screening tes ts for neurosyphilis . Appropriate s creening tests for mental pres entations than dementia, for example, first episode psychosis , less well es tablished. Unfortunately, no cohort studies applying a cons is tent laboratory diagnos tic approach available to provide guidance as to the s ens itivity and specificity of tes ting or even as to the prevalence of organic disease in this s ituation. T he first s tep should neurops ychiatric history and examination. A laboratory screen might include C B C , chemistry panel, urinalys is, and urine toxicology. If it is cons idered to screen for rheumatic disease, an antinuclear tes t (ANA) is adequate for this purpos e, being almos t all cas es of lupus , although not sufficient to that diagnosis. (F als e positives from ps ychotropic induced ANA tests are an important confound.) E xces sive laboratory testing is to be deplored; on the hand, limiting laboratory tes ting to generally familiar diseases is inexpert. C onsideration of rare metabolic diseases s hould be within the neuropsychiatrist's 106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 96 of 130

R uling out aminoacidurias or organic acidurias in with adoles cent or young-adult ons et of ps ychos is be considered, es pecially if unexplained fluctuations poss ibly due to dietary factors , unexplained physical or unexplained cognitive impairment is pres ent. A reasonable broad s creen includes ammonia, plas ma amino acids , and urine for organic acids, although this to detect s uch conditions (known to be as sociated with ps ychiatric pres entations ) as G M 2 ganglios idosis (hexos aminidas e A deficiency) and F urther testing with s pecific metabolic or genetic should be performed as circums tances indicate.

E xamination of the C erebros pinal E xamination of C S F obtained through lumbar puncture sometimes a crucial element of the diagnos tic proces s, particular to diagnos e infection or inflammation, more rarely in neuropsychiatric practice to seek evidence of neoplasia (s uch as meningeal carcinomatos is ). as says are available for the diagnosis of neurops ychiatrically relevant infectious agents s uch as polymerase chain reaction (P C R ) for the herpes virus (HS V ) genome to diagnose herpes encephalitis or cryptococcal antigen ass ay to diagnos e this fungal meningitis. In rheumatic diseases involving the brain, white cell count may not be elevated, but elevated and evidence of intrathecal elaboration of antibodies give evidence of inflammatory activity. T he latter is by the ratio of immunoglobulin G (IgG ) to albumin or, better, by the IgG index, which requires meas urement serum IgG by immunoelectrophores is . C S F antibodies are uncommon but s pecific for cerebral In the future, ass ay of C S F cytokines may provide 107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 97 of 130

as sistance in the difficult diagnos is of these diseases . Meas urement of the neuron-derived 14-3-3 protein has adequate s pecificity and s ens itivity to as sist in the diagnosis of C reutzfeldt-J akob disease as long as the pretes t probability of this rare disease is sufficiently In practice, this means that us e of the tes t should be confined to patients with a progres sive dementia of than 2 years' duration. Meas urement of tau and peptides is not yet of s atisfactory validity for general the diagnosis of Alzheimer's dis eas e. R emoval of C S F by lumbar puncture or external also plays an important role in the evaluation of suspected of shunt-revers ible normal press ure hydrocephalus.

Neurops yc hologic al As s es s ment Neurops ychological evaluation has an important role to play in neuropsychiatric care, both for diagnos is and for management. S ound us e of the clinical as a cons ultant requires , as a first step, formulation of cogent cons ultative question. T he more s pecific the cons ultant's ques tion, the more able the neurops ychologist is to integrate the ps ychometric data with the res t of the clinical picture. Much of the early literature on neuropsychological as sess ment focus ed identifying and localizing organic brain dis eas e. W ith advent of neuroimaging, neuropsychological testing is seldom the mos t powerful means of addres sing this although it certainly continues to play s uch a role, for example, in lateralizing cognitive deficits as a tool in epileptic patients. Nor is the role of the 108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 98 of 130

neurops ychologist to make a dis eas e diagnosis, at times the psychometric picture is strongly s ugges tive a particular diagnosis. In several areas of as sess ment, the neuropsychiatrist particular reas on to turn to the neurops ychologis t. If subs tantial confounds make bedside diagnos is difficult, neurops ychological data may be of cons iderable as sistance. F or example, identifying supervening impairment in a mentally retarded or poorly educated patient or s ubtle impairment in a highly intelligent may be imposs ible for the clinician to do with whereas quantitative ass ess ment may allow these diagnoses. Another example of us ing as sess ment as a probe of brain function is disclos ing a pattern of cognitive s trengths and weakness es to right hemis phere learning dis abilities in a patient with clinical picture s uggestive of pervasive developmental disorder or a clus ter A pers onality disorder. Obtaining neurops ychological data about a dementing patient allows more precis e targeting of behavioral more s pecific education of families , and more confident as sess ment of decline or of benefit from treatments . One common us e of neurops ychological as ses sment requires a word of caution: identifying cognitive impairment in an older patient presenting with mood disorder or psychos is. No neurops ychological findings should deter the clinician from aggress ive treatment of ps ychiatric symptoms, and nons pecific, s tateattentional and motivational factors may confound the neurops ychological res ults. R ather than devoting res ources of time and energy to pinpointing a moving 109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 99 of 130

target in the acute phase, deferring the as sess ment symptoms are reduced is often the wiser course. Another caution about neuropsychological ass ess ment falls under the rubric of ecological validity. T his term to the extrapolation P.344 of results obtained in the neuropsychological laboratory by artificial “paper-and-pencil” methods to real-world performance. T he concern aris es in particular with orbitofrontal lesions , which may produce a paucity of cognitive findings but devas tating personality change. Deriving clinical meas ures from the developing realm affective neuros cience suitable to characterize such patients is a current challenge to neurops ychology.

B rain B iops y B iopsy of the brain has a limited role in evaluation. T he morbidity and mortality of the as performed by an experienced neurosurgeon, are but the sensitivity of the procedure is lower than one might expect. F or example, the sensitivity of biops y for primary angiitis of the central nervous system (C NS ) be only 75 percent. In some circums tances , biops y of a peripheral tis sue can s ubs titute for brain biops y in a patient with primarily cerebral symptoms at lower ris k. example, lung or muscle biopsy may make a diagnosis sarcoid, skin biopsy a diagnosis of vasculitis if a rash is present or of C ADAS IL, temporal artery biops y of giant arteritis. In neuropsychiatric s ituations, the major indication for biops y of the brain is cons ideration of inflammatory disease when the nature and 110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 100 of 130

of treatment depend on a tiss ue-proven diagnosis . Although of course it cannot be cons idered a clinical diagnostic test, autopsy s hould not be overlooked by neurops ychiatris t as a learning tool.

C OMMON NE UR OP S YC HIA TR IC C ONDITIONS T his s ection provides a s urvey of s ome is sues brought to the attention of neuropsychiatrists . T he emphasis is on the priorities for clinical and laboratory as sess ment for a variety of presentations . T he is by disease and syndrome, as a complement to the anatomical and s ymptom-oriented discus sion provided far. T his perspective is distinctive for neuropsychiatry within psychiatry; the disease proces ses underlying symptoms in the idiopathic disorders are unknown. F or neurops ychiatric patients, one can hope and work to uncover the disease causing the s ymptoms and, on fortunate occasions , to provide dis eas e-specific

Dementia An extensive lis t of dis eases produces the clinical state dementia. A shotgun laboratory approach to “ruling out treatable disease” is unwise, if only because finding revers ibility is s o unusual. Moreover, clinical clues to revers ible disease are available in the history and examination: us e of ps ychotoxic medicines , rapid mildnes s of cognitive impairment (even s hort of fully meeting criteria for dementia), subcortical features of cognitive disorder, and pres ence of motor s igns. T able 4 provides specific guidance to be gained from clinical clues . T he differential diagnos is of dementia needs to 111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 101 of 130

include differential diagnos is among the degenerative disorders , an exercise that depends very largely on findings rather than imaging or laboratory data. In particular, apolipoprotein E testing is by cons ens us not recommended for routine diagnos tic purposes at the present time.

Table 2.1-4 C lues to the Diagnos is of Dementia in the Neurologic al E xamination Abnormal eye findings    C eliac disease    G aucher's disease type 3    Mitochondrial cytopathy    Multiple s cleros is    Niemann-P ick dis eas e type C    P rogres sive supranuclear pals y    S yphilis    V ascular dementia 112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 102 of 130

   W ernicke-K ors akoff s yndrome    W hipple's dis ease    W ils on's dis eas e Ataxia    C eliac disease    C erebellar degenerations    G M 2 ganglios idosis    Hypothyroidism    Multiple s cleros is    Niemann-P ick dis eas e type C    P rion dis eas e    P rogres sive multifocal leukoencephalopathy    T oxic-metabolic encephalopathy    W ernicke-K ors akoff s yndrome    W ils on's dis eas e

113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 103 of 130

Dys arthria    C erebellar degenerations    Dementia pugilistica    Dialysis dementia    Motor neuron dis eas e    Multiple s cleros is    Niemann-P ick dis eas e type C    Neuroacanthocytosis    P antothenate kinase–as sociated neurodegeneration    P rogres sive multifocal leukoencephalopathy    P rogres sive supranuclear pals y    W ils on's dis eas e E xtrapyramidal signs    Alzheimer's dis eas e    C erebellar degenerations 114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 104 of 130

   Dementia pugilistica    Dementia with Lewy bodies    F ahr's syndrome    G M 1 ganglios idosis, type III    Huntington's disease    Multiple s ys tem atrophy    Neuroacanthocytosis    Niemann-P ick dis eas e type C    Normal press ure hydrocephalus    P antothenate kinase–as sociated neurodegeneration    P arkinson's diseas e    P rogres sive supranuclear pals y    P ostencephalitic parkins onism    S ubacute sclerosing panencephalitis    T oxic-metabolic encephalopathy 115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 105 of 130

   V ascular dementia    W ils on's dis eas e G ait dis order    Adrenomyeloneuropathy    C erebellar degenerations    Dementia pugilistica    HIV encephalopathy    Multiple s cleros is    Normal press ure hydrocephalus    P arkinson's diseas e    P rogres sive supranuclear pals y    S yphilis    V ascular dementia    W ernicke-K ors akoff s yndrome Myoclonus

116 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 106 of 130

   Alzheimer's dis eas e    C eliac disease    Dialysis dementia    K ufs' disease    Lafora's body dis eas e    Mitochondrial cytopathy    P rion dis eas e    S ubacute sclerosing panencephalitis P eripheral neuropathy    Adrenomyeloneuropathy    B 12 deficiency    HIV encephalopathy    Metachromatic leukodys trophy    P orphyria    T oxic-metabolic encephalopathy

117 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 107 of 130

P yramidal signs    Adrenomyeloneuropathy    B 12 deficiency    C erebellar degenerations    G M 2 ganglios idosis    HIV encephalopathy    K ufs' disease    Metachromatic leukodys trophy    Motor neuron dis eas e    Multiple s cleros is    P antothenate kinase–as sociated neurodegeneration    P olyglucos an body disease    P rogres sive multifocal leukoencephalopathy    S yphilis    V ascular dementia 118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 108 of 130

HIV , human immunodeficiency virus . Modified from S andson T A, P rice B H: Diagnos tic tes ting and dementia. Neurol C lin. 1996;14:45–

T he clinician needs to gather data relevant to management iss ues other than purported reversibility, such as safety of living arrangements , driving ability, preparation of a will and advance directives . patients often develop psychiatric s ymptoms, which res pond to pharmacological and behavioral treatment. these considerations s hould prompt the clinician to cast wide net in data gathering regarding the demented patient. P.345

E pileps y Major concerns in patients with epileps y include differential diagnosis, psychosis, pers onality change, depres sion, violence and other epis odic behaviors , and ps eudoseizures . T he last will be dealt with below along with other conversion dis orders. A 67-year-old woman pres ented with at leas t 1 year of progres sive memory impairment, confus ion, then irritability and s us piciousness . T he mental s tate was 119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 109 of 130

of Alzheimer's dis eas e, and the phys ical examination disclos ed only bris k tendon jerks . An E E G , done earlier because of a spell of uncertain nature, had shown left temporal s pikes . Neurops ychological as ses sment had shown a pattern typical for Alzheimer's dis eas e, with memory impairment characterized by rapid forgetting, semantic–phonemic verbal fluency deficits , and MR I, however, demonstrated extens ive white matter disease, with bilateral confluent hyperintensities, which extended into the gyri and involved U fibers . C S F examination was entirely normal. S kin biops y for and s creening genetic as say for C ADAS IL were R epeat E E G s howed bilateral temporal spikes, and carbamazepine (T egretol) was begun. T he clinical diagnosis was leukoencephalopathy due to cerebral amyloid angiopathy, poss ibly with Alzheimer's disease. T he patient's mother had died at 86 years of age, suffered from “the same thing” as the patient. F our of mother's five s iblings demented in the 8th or 9th of life, none earlier, in most cases with a diagnos is of Alzheimer's disease. T he patient was an only child. patient's two daughters, both young adults, were very concerned that they might inherit the same dis eas e as their mother, and they ins is ted the patient undergo the brain biopsy that a geriatrician had recommended. T his disclos ed pronounced congophilic angiopathy. Immunos taining for A-beta confirmed the vess el abnormality and showed neuropil plaques ; immunos taining for tau did not reveal neuritic plaques . Nonetheles s, Alzheimer's diseas e could not be No inflammation was seen. However, s everal days biops y, she developed s tatus epilepticus . 120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 110 of 130

P atients with attack disorders can be misdiagnosed as having epilepsy when they do not or as having a disorder when epilepsy is the correct diagnosis. P aroxysmal s ymptoms from panics, cardiac disease syncope or near syncope, endocrine dis orders (pheochromocytoma, carcinoid, systemic conversion dis order can be mistakenly labeled contrariwis e, epileps y can be mis sed when a diagnosis panic dis order, in particular, is accepted. A 59-year-old man was evaluated for 7 years of problems and s pells refractory to treatment on a of panic dis order. T hese spells characteristically lasted 10 seconds and recurred as often as hourly; he was sometimes amnestic for the s pells afterward. During an attack, he had goos eflesh, and his s peech became once at church, he was believed to be s peaking in E xtens ive treatment trials with benzodiazepines and serotonergic drugs had given no consistent benefit. from hyperlipidemia, he had no significant medical E E G had been negative on three occas ions, MR I on Holter monitoring and S P E C T on one each. T he neurological and mental s tate examinations were An attack was witnes sed during the examination: He showed 10 s econds of facial flushing and stereotyped hand movements . T he attacks were s ubs equently abolished by a trial of an antiepileptic drug. T he case illus trates that epileps y is primarily a clinical, not an diagnosis. A 52-year-old woman was referred for the evaluation of spells. In her 30s s he had been hos pitalized for and was subsequently treated intermittently as an 121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 111 of 130

outpatient. T he family history included s everal with depress ion or bipolar dis order. T wo years before evaluation, s he pres ented with headache and proved have an unruptured aneurys m, which was clipped a craniotomy. S everal months later, s he had a convuls ion. S he went on to have s pells at a rate of up a day. T hey were stereotyped and abrupt in ons et and termination; s he could not identify provocative factors social contexts. During a s pell, s he felt cold and had goosefles h for approximately 3 minutes. T hen she rigid and unable to s peak or interact, although she hear others ' s peech. T his las ted s everal minutes. T hen began to cry. T he whole sequence las ted 6 to 10 S he was on phenytoin with a therapeutic s erum level. P revious trials of divalproex (Depakote) and topiramate (T opamax) were not tolerated. E E G s had shown only frontal s lowing with no epileptic features on several tracings. T he neurological and cognitive examinations were normal, and she was not depress ed at the time of evaluation. T he clinical picture was inconclus ive: In epilepsy were the abrupt ons et and termination, stereotyped nature of the s pells , and background of craniotomy; agains t epilepsy were the weeping, length the ictus (if all the phenomena were taken to be ictal), of respons e to treatment, relatively inactive E E G , and background of depress ion. V ideo E E G done after medication withdrawal recorded three complex partial seizures with right anterior inferior temporal ons et with her typical s emiology and no ps eudos eizures . In exploring the psychiatric concomitants of epilepsy, clinician needs to be aware of the nature of the Most adult epilepsy is focal (“localization-related 122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 112 of 130

epilepsy”), with the ictal ons et in the temporal lobe. However, other forms of epilepsy, including frontal epilepsy and primary generalized epileps y, are T hese dis tinctions , and the laterality of the focus , can be inferred from the semiology of the seizures as or as observed clinically. A history of febrile childhood and age of onset of epileps y are relevant to likelihood of mesial temporal sclerosis as the pathology. B ody asymmetry and dis sociated facial should be sought as indicators of laterality. T he MR I E E G provide crucial information on pathology and type. Almost all the findings relating ps ychiatric epilepsy are concerned with partial epileps y of onset; linking psychiatric s ymptoms to epileptic syndromes other than temporal lobe, or limbic, epilepsy generally goes beyond the evidence. F urther, to what extent ps ychopathology is as sociated with the epileps y per se and to what extent with the underlying brain disease remain controversial. W ithout ques tion, impairments are related to the lateralization of the temporal focus . P sychotic s tates in epileptic patients are usually into those occurring during the epileptic ictus , often epile ptic twilight s tate s ; thos e occurring for a delimited period in the aftermath of a seizure or, more flurry of s eizures , s o-called pos tictal ps ychos is ; and that are chronic, called interictal ps ychos is . Us ually, chronology can be ascertained by inquiry, but at times, E E G monitoring is necess ary to identify the occurrence seizures in relation to ps ychopathological phenomena, es pecially becaus e patients can be amnes tic for partial seizures . A further iss ue to be elucidated from 123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 113 of 130

history is of a relations hip between s eizure treatment control and the level of ps ychopathology, especially ps ychos is . An inverse relationship is s ometimes P.346 noted, better s eizure control being as sociated with occurrence of ps ychos is, a phenomenon known as normalization. On the other hand, frequent seizures certainly can caus e an increase in confusion and failure in functional capacity. A 35-year-old woman with lupus and intractable was admitted several times with pers ecutory and delus ions (“I'm dead”) and depres sive s ymptoms . Inves tigations to identify active cerebral lupus were unrevealing, even when she had evidence of peripheral activity of the dis eas e. In fact, MR I disclos ed the hippocampal sclerosis, s ugges ting that the epilepsy idiopathic and not due to old cerebral lupus . W ithout specific treatment, the psychotic s ymptoms diminished over the cours e of several days ; this als o was believed make a diagnosis of cerebral lupus unlikely. B etween episodes , s he s howed no ps ychotic phenomena. T he interictal pers onality s yndrome of temporal lobe epilepsy (the G as taut-G eschwind s yndrome) is characterized by hypergraphia; religios ity or deepened metaphys ical interest; intens ified emotionality with a tendency to holding grudges and aggress ion; hypos exuality; and an alteration of social behavior with intens ity of interaction, an inability to end interactions , circums tantiality of discourse (phenomena confus ingly denominated as “viscos ity”). T he syndrome remains 124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 114 of 130

controvers ial; what is of importance for as sess ment is that inquiry be directed to phenomena, as hypergraphia, that are not included in the review of symptoms of idiopathic ps ychiatric disorder. E pisodic aggress ion is often s us pected of being ictal very rarely is . Aggress ion occurring during s eizures is almos t always disorganized, not carefully directed. A threshold is jus tified in attributing a violent act to in the abs ence of typical epileptic features. Amnesia for serious violence is common and not a s trong pointer to epileptic origin. A s pecial is sue in neurops ychiatric as ses sment of the epileptic patient is the presurgical evaluation. S urgical treatment, especially of temporal lobe epilepsy due to mesial temporal sclerosis, is underused; ideally, more more patients with medically refractory epileps y will be evaluated for their s uitability for surgery. Along with intens ive electroencephalographic evaluation, MR I, and neurops ychological as sess ment, the patient's ps ychiatric state s hould be s ys tematically evaluated. patient's ability to cons ent and is sues s uch as the capacity to cope with the stress of monitoring and as well as the expectations held for surgery should be addres sed. Neither depress ion nor psychosis is an contraindication to s urgery, although a chronic probably will not be alleviated by s urgery. Indeed, few, any, psychiatric findings contraindicate s urgery, but ps ychiatric evaluation may well reveal deficits that be taken into account in developing a treatment plan.

Traumatic B rain Injury T raumatic brain injury is epidemic in society, with 125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 115 of 130

advances in emergency medical care leading to growth the prevalence of survivors of s evere injury. Is sues commonly facing the neuropsychiatrist include aggres sion, depres sion and anxiety, and the deficits (sometimes for legal purpos es ) in patients with mild traumatic injury. T he features of the head injury should be as certained, ideally with confirmation from medical records. T he altered behavior and personality common after traumatic brain injury are more burdensome for families than are the physical disabilities. Dis inhibition and aggres sion are particularly uncomfortable and often to treat. A complicating factor is that preinjury and s ubs tance abus e are common, as they predis pos e head injury. A 24-year-old woman was s een 19 months after an automobile collision in which she was an unres trained pass enger. S he was comatose for 3 months and underwent surgical evacuation of a left-sided hematoma. S he had a few weeks of rehabilitation after regaining consciousness and returned home after spending most of a year in a nursing home. T he family at wits' end over epis odes of aggres sion, which to be directed angry behavior elicited by frus tration. did not have depress ive symptoms. On examination, showed severe bilateral s pas ticity, including s pas tic dysarthria, drooling, and a bris k jaw jerk. S he was able recall dates and other details of her illness accurately, she disclaimed behavioral or emotional alterations . Her language comprehens ion was adequate, but output telegraphic. Affect was labile. B ehavior during the 126 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 116 of 130

cons ultation was initially appropriate, with an obvious effort to cooperate with the evaluation, although she greeted the examiner with, “I love you.” At the end of examination, however, she urgently requested the examiner's bus iness card and rammed him with her wheelchair while cutting off his access to the door. C hronic-phase C T s howed atrophy and left temporal encephalomalacia. A 59-year-old man was referred by a court for of his ability to take part in proceedings related to his divorce. T hree months before evaluation, he was several times by an unknown as sailant during an altercation regarding who was to get the us e of a taxi. suffered contusions of the left periorbital area but no overt injury. He was able to recount the events in s ome detail, but he explained that this was because, over by comparing notes with others, he had “put it all back together”; of his own recollection, he could remember first punch that s truck him but not the s econd or subs equent events of the altercation. Although he not be certain of the duration of the gap in his it was clearly a matter of some s econds , conceivably a minute or two, and at no time was he uncons cious . In aftermath, he was “confused” and had a headache. He found that he could not come up with names , dates, or numbers, although this information generally came to him later or with considerable unaccus tomed effort. also noticed that he “couldn't visualize” geographical scenes, so that in planning to go to a familiar place, he unable to picture it in his mind. Although he did not get lost, he found that he turned the wrong way or mis sed turn because of inattention and had to correct himself. 127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 117 of 130

noted that his memory, previous ly highly trustworthy, could not be counted on: “I had to write everything He found that he had to “take time to think,” “strain my brain to focus .” He distanced hims elf from busines s decis ions and relied on trus ted subordinates to counsel him. He acknowledged s ens itivity to light, noting that had begun to wear sunglass es even when the weather cloudy and to turn off the room lights when he was watching televis ion. T o a less er extent, he was noise. He noted that he was more readily irritated than characteristic of him. He did not have depress ive symptoms, intrusive recall of the altercation, or nightmares . T he s ymptoms had gotten gradually less severe. T he history included s everal head injuries in adoles cence, two of which resulted in los s of cons ciousnes s of a few hours without recognized sequelae. T he noncognitive mental s tate and P.347 examinations were normal. He s cored 21 on the Mental Alternation T es t, a clearly normal performance on a mental s peed and working memory. He s cored 16 out 18 on the F rontal As ses sment B attery, a collection of as sess ing executive cognitive function. T he two lost were on the go/no-go tas k, on which he made perseverative errors. He was mildly dis organized on performing the ring/fis t tes t of motor s equencing. MR I E E G had been normal. T he picture was believed to be cons istent with organic s equelae of traumatic brain T he case underlines the importance of prior traumatic brain injury in determining the effects of s eemingly mild trauma and that los s of cons cious nes s is not a 128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 118 of 130

for significant s equelae.

Movement Dis orders C ognitive impairment due to involvement of subcortical structures is a common neuropsychiatric feature of the movement disorders . T his applies to cerebellar, as well basal ganglia, diseas es for the anatomical reas ons described above. T he anatomy of the clos e relation between emotion and movement was als o described above. C linically, mood disorders are common in IP D other movement disorders . Anxiety disorders , although less emphas ized in the literature than depres sion, are common. T he evaluator s hould take into account that mood and anxiety can fluctuate according to the timing doses of dopaminergic drugs . A mood dis order can occasionally pres ent in advance of overt movement abnormalities , s o IP D mus t be considered in the differential diagnosis of late-onset mood disorders . A 43-year-old woman with no personal or family history ps ychiatric illnes s developed a ps ychotic depress ion. had a s evere extrapyramidal reaction to risperidone (R is perdal). T wo years later, when euthymic and unmedicated, she developed progres sive shuffling gait, upper-extremity tremor, and micrographia. S he then suffered another episode of depres sion. T hree years she had s evere anxiety, no cognitive impairment, and motor features of IP D. P sychotic reactions to dopaminergic drugs are an important feature of movement dis orders. S ometimes is the res ult of overuse of prescribed dopaminergic in an effort to increas e time in the “on” state. 129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 119 of 130

A 63-year-old man with long-standing IP D developed delus ions while being treated with high-dose levodopa (S inemet) on a five-times -a-day s chedule, pramipexole (Mirapex), tolcapone, and amantadine (S ymmetrel). Under inpatient obs ervation for several on the pres cribed dos es, he remained ps ychotic. He res ponded well to quetiapine (S eroquel).

Developmental Dis abilities Adult patients with developmental dis abilities are enormously unders erved by the medical and s ocial communities and are frequently referred for neurops ychiatric attention. F ew of thes e patients have adequate diagnostic evaluation for the caus e of the disability. B eyond clinical as sess ment, with particular attention to dysmorphology becaus e features of the mental s tate and neurological examination are nonspecific, the most us eful diagnostic tes ts are MR I karyotyping. S pecific genetic probes can confirm clinical recognition of syndromes of mental retardation. P atients with developmental disabilities are indeed, es pecially vulnerable—to the mood, anxiety, ps ychotic dis orders that can afflict anyone and can be treated effectively for these; diagnostic overs hadowing (attributing all psychological and behavioral to “retardation” tout court) is to be avoided. T hese syndromes may pres ent atypically in the disabled population, and the clinician mus t be alert to indirect indicators of mood dis turbance or psychotic experience. F or example, although the patient may not report depres sed mood verbally, the caregivers may the loss of interest in favorite activities and the other 130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 120 of 130

features of a depres sive syndrome. Of particular neurops ychiatric interes t is the question of behavioral phenotypes, specific psychological developmental s yndromes. S yndromes recognized to behavioral phenotypes (and their correlates ) include Lesch-Nyhan s yndrome (s elf-injury) P rader-Willi syndrome (exces sive eating) Williams s yndrome (anomalous cognitive profile, elevated s ociability) V elocardiofacial syndrome (schizophrenia)

Infec tious and Inflammatory Infectious and inflammatory diseases of the brain need always to be cons idered in acutely or s ubacutely mental disorders . Among the infectious dis eas es, HS V encephalitis has a particular claim on attention delay in diagnos is , even by hours , can lead to increased morbidity and mortality. Definitive diagnosis poss ible without biopsy by as saying for HS V in the with the P C R , but treatment may be indicated if is high in advance of firm diagnos is . C hronic example, from infection with fungi, is a rare in subacutely evolving dementia; the definitive tes ts are C S F ass ays or serological tes ts (e.g., for toxoplas mos is ). In the acquired immunodeficiency syndrome (AIDS ) era, infection with opportunis tic and with the human immunodeficiency virus itself to be kept in mind, even in circumstances not suggestive of AIDS . 131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 121 of 130

Noninfectious inflammatory dis eas es include the rheumatic dis eases , of which the prototype is systemic lupus . A rheumatic disease review of systems is importance in exploring the differential diagnosis of a puzzling case, es pecially in a young woman. Although ps ychos is is often cons idered the ps ychiatric hallmark lupus , in fact, psychotic states (other than delirium) are unusual, and a variety of other ps ychiatric pictures be included in the clinician's consideration. F ew clinical features of lupus are risk factors for cerebral disease, even dis eas e activity, which may be misleading in positive or a negative direction. One feature that is a factor for neuropsychiatric s ymptoms , including impairment, is the presence of antiphos pholipid antibodies; the primary antiphos pholipid syndrome similarly carries mental risk. A 40-year-old woman pres ented with the typical of a ps ychotic depress ion. T here was a family history depres sion, and s he had s uffered two episodes of depres sion earlier in her adult life, both of which were brief, nonpsychotic, and res ponsive to treatment. F or previous year, however, her depress ion had been res ponsive to pharmacological and electroconvuls ive therapy (E C T ) treatment P.348 E xamination dis closed no definite cognitive abnormality and brisker reflexes on the left. R eview of MR I her previous treatment venue, presumably performed routine before the adminis tration of E C T , evinced areas of white matter abnormality in the right 132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 122 of 130

E xtens ive laboratory inves tigation, s hort of and biops y, revealed only high-titer IgA anti-β2glycoprotein-1 antibodies . Neurops ychological performed after partial remis sion of the depres sion showed deficits in attention and mental proces sing T he working diagnostic formulation was that an ordinary idiopathic depress ive disorder had been treatment resistant and gravely s evere by a wave of cerebral injury due to the antiphospholipid syndrome. less on of the case is to always look at the imaging. Other rheumatic dis eas es, such as S jögren's s yndrome the vasculitides, are als o of neurops ychiatric Has himoto's encephalopathy—subacutely developing cognitive impairment and myoclonus or s eizures with high-titer antithyroid antibodies—is important in the differential diagnosis of C reutzfeldt-J akob disease and subacute confus ional s tates. P rominent among nonrheumatic inflammatory dis eas es is paraneoplas tic limbic encephalitis, an autoimmune complication of several tumors, notably small cell carcinoma of the A 60-year-old woman was admitted for confusion. S he been drinking more heavily than us ual after a forced retirement several months earlier. T he family noted that she had been forgetful and behaviorally erratic for 1 to months. S he s moked cigarettes and had hypertension. examination, s he had mild gait instability but no other phys ical s igns. T hought was disorganized, but no ps ychotic ideas were present. P s ychomotor rate and were normal. S he s howed verbal memory impairment disinhibition, with many errors of commis sion on a go tas k and inability to inhibit reflexive gaze. C S F 133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 123 of 130

examination revealed a mild lymphocytic pleocytos is no other abnormalities. E E G s howed intermittent slowing. T he following were negative or normal: serological studies, thyroid function and antibody tests, anti-Hu, MR I, MR A, ches t and abdominal C T (except a benign adrenal tumor), and cerebral angiogram. T he patient's family refus ed brain biops y. On a differential diagnosis of primary angiitis and paraneoplas tic encephalitis , the patient received a puls e of (IV ) methylprednisolone, without benefit, then a cours e oral cyclos phosphamide and prednis one, again without benefit. S ome months after dis charge, she died Autops y revealed pulmonary embolus to be the cause death. P erivas cular T -cell infiltrates and activated were seen in the medial temporal lobes and to a less er degree wides pread in the cortex. No tumor was found the lungs or elsewhere. Nonetheless , the pathology supported the clinical consideration of “paraneoplastic” encephalitis , which has been reported to occur in otherwis e typical form but without a dis coverable Often, extens ive evaluation is necess ary for patients suspected of inflammatory brain dis eas e; at times , extensive evaluation does not s uffice.

C onvers ion Dis order Neurops ychiatrists often see patients whose symptoms appear to arise from brain diseas e but do not. T hes e patients' conditions have been described under various names : hys teria, functional disorder, psychogenic conversion dis order, and medically unexplained symptoms. None of the designations is entirely satis factory. F or example, the DS M-IV -T R 134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 124 of 130

conve rs ion dis orde r is based on an outmoded notion of conversion of emotions into phys ical form. W hatever designation, such patients are not uncommon. C omplicating matters is the common coexis tence of organic disease and conversion s ymptoms . F or sizable minority of patients with pseudos eizures have epilepsy as well. B rain disease may, in s ome of these patients, have produced organic pers onality change reduction in the maturity of defens es and the too-easy res ort to s omatization. V arious techniques have been advocated for of nonorganic disease by the physical examination. have several shortcomings . F irst, they easily lend thems elves to a countertherapeutic alliance in which examiner is trying to trick the patient—not a good start the treatment, whatever the findings. S econd, they fail distinguish deliberate fals ification on the patient's that is , malingering—from convers ion dis order. T hird, most s uch findings are commonly pres ent in patients organic disease who are trying to help the examiner the diagnosis. T hat is, they may mark a patient as or s ugges tible but fail to rule out organic disease. T hus, example, reporting a difference in vibratory sensation between the two sides of the s ternum is by no means confined to patients with convers ion disorder. to this caution occur in cases in which the nonphysiological finding is precisely the phenomenon the complaint. E ven then, however, the phenomena of brain dis eas e are sufficiently odd that the examiner maintain an attitude of humility about achieving diagnostic certainty by recognizing the at a glance. Of the described “signs of hys teria,” 135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 125 of 130

the best is Hoover's s ign. T he examiner places a hand underneath the heel of the affected leg of a supine who complains of leg weaknes s. Asked to press down the heel, the patient does not generate power with the Asked to raise the opposing leg, however, the patient produces an automatic s ynergistic downward of the affected leg. R ecent systematic findings of progress ively greater methodological s ophistication confirm the belief that experiences of abus e in childhood are common in the background of patients with conversion dis order. T his indirectly account for another progres sively more subs tantiated finding, namely, that the prognos is of conversion dis order is poor. Although a given s ymptom may wax and wane or dis appear, patients commonly a chronic course of dis ability, interpers onal difficulties , ps ychiatric symptoms, and fruitles s s eeking after help. Although hys terical symptoms have often been taken to represent s ymbolically a psychological conflict, the fundamental difficulty is that patients who make prominent use of somatization have a dis order of the symbolic function its elf. T he goal of the examiner not be to catch the patient out but to establish an that allows exploration of areas of the patient's life the presenting symptoms and cons truction of a plan to reduce dis tres s (including focused treatment of coexisting depress ive disorder) and to develop ways of seeking attention and as sistance for dis tres s.

NE UR OP S YC HIA TR IC T he neurops ychiatris t thinks anatomically about mental state disorders , even as cognitive neuroscientis ts 136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 126 of 130

to construct a sufficiently s ophisticated model of largescale brain function to do justice to the complex mental states of neurops ychiatric interes t. T he relies on rich data gathered at the bedside and on laboratory methods of inves tigating brain s tructure and function and of P.349 diagnosing diseas e. T he effort is to identify not jus t behavioral s yndromes as found in DS M-IV -T R or IC D, the pathological proces ses underlying them in two F irst, neurops ychiatry s eeks medical diagnoses of or brain dis eases to account for the patient's illness . S econd, neurops ychiatry seeks to understand clinical phenomena in terms of the disruption of elementary mental proces ses, the nature of which is beginning to elucidated by the cognitive neuros ciences . T he res ult is highly differentiated diagnostic enterprise. With refreshment from a multidisciplinary bas e—ranging cognitive neuros cience to general medicine—the neurops ychiatric approach to the patient is certain to remain exciting.

S UG G E S TE D C R OS S S ection 1.2 provides a review of neuroanatomy. 1.15 discus ses nuclear MR I and S ection 1.16 covers radiotracer imaging. T he other s ections in this chapter in detail with neuropsychiatric aspects of various proces ses. T he s ections inC hapter 7 deal with the diagnostic process in general ps ychiatry, including the examination of the mental s tate (see S ections 7.1 and neurops ychological evaluation (s ee S ection 7.5), and 137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 127 of 130

laboratory tes ting (see S ection 7.8).

R E F E R E NC E S *B ogouss lavs ky J , C ummings J L, eds. B ehavior and Dis orde rs in F ocal B rain L e s ions . C ambridge: Univers ity P res s; 2000. D'E s posito M, ed. Neurological F oundations of Neuros cie nce . C ambridge, MA: MIT P ress ; 2003. Dolan R J : E motion, cognition, and behavior. 2002;298:1191. Duchaine B , C osmides L, T ooby J : E volutionary ps ychology and the brain. C urr O pin N eurobiol. 2001;11:225. Duncan J , Owen AM: C ommon regions of the frontal lobe recruited by divers e cognitive demands . T re nds N euros ci. 2000;23:475. Duus P . T opical Diagnos is in N eurology. 3rd ed. Y ork: T hieme; 1998. F riston K J , P rice C J : Dynamic repres entations and generative models of brain function. B rain R es B ull. 2001;54:275. G eschwind N: Dis connexion s yndromes in animals man. I. B rain. 1965;88:237. G eschwind N: Dis connexion s yndromes in animals 138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 128 of 130

man. II. B rain. 1965;88:585. G olomb M: P s ychiatric symptoms in metabolic and other genetic dis orders: Is our “organic” workup complete? Harv R e v P s ychiatry. 2002;10:242. Halligan P W , David AS : C ognitive neurops ychiatry: T owards a s cientific psychopathology. Nat R e v 2001;2:209. J ohns on MH, Halit H, G rice S J , K armiloff-S mith A: Neuroimaging of typical and atypical development: A perspective from multiple levels of analysis. Dev P s ychopathol. 2002;14:521. K opelman MD: Dis orders of memory. B rain. 2002;125:2152. Levitin DJ , Menon V , S chmitt J E , E liez S , White C D, G lover G H, K adis J , K orenberg J R , B ellugi U, R eiss Neural correlates of auditory perception in W illiams syndrome: An F MR I s tudy. Neuroimage . Liddle P F . Dis orde re d B rain and Mind: T he N eural Me ntal S ymptoms . London: G as kell; 2001. *Lis hman W A. O rganic P s ychiatry: T he C ons equences of C e re bral Dis orde rs . Oxford: S cience; 1998. Lloyd D: T erra cognita: F rom functional to the map of the mind. B rain Mind. 2000;1:93. 139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 129 of 130

*Mesulam MM. B ehavioral neuroanatomy: Largenetworks , as sociation cortex, frontal syndromes, the limbic s ys tem, and hemispheric s pecializations. In: Mesulam MM, ed. P rinciple s of B e havioral and Neurology. London: Oxford University P ress ; 2000. Mesulam MM: F rom s ensation to cognition. B rain. 1998;121:1013. Middleton F A, S trick P L: B asal ganglia and loops : motor and cognitive circuits. B rain R es B rain R ev. 2000;31:236. Miller MB , V an Horn J D, Wolford G L, Handy T C , V alsangkar-S myth M, Inati S , G rafton S , G azzaniga E xtens ive individual differences in brain activations as sociated with epis odic retrieval are reliable over J C ogn Ne uros ci. 2002;14:1200. *Ovsiew F . B eds ide neurops ychiatry: E liciting the phenomena of neurops ychiatric illnes s. In: Y udofsky Hales R E , eds . Ame rican P s ychiatric P ublis hing of Ne urops ychiatry and C linical Ne uros cie nces . Was hington, DC : American P sychiatric P ublis hing; Ovs iew F : S eeking revers ibility and treatability in dementia. S emin C lin Ne urops ychiatry. 2003;8:3. Ovs iew F , B ylsma F W : T he three cognitive S emin C lin Ne urops ychiatry. 2002;7:54. Ovs iew F , J obe T . Neuropsychiatry in the his tory of 140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 130 of 130

mental health s ervices. In: Ovs iew F , ed. and Me ntal H ealth S e rvices . W ashington, DC : P sychiatric P ress ; 1999. P aterson S J , B rown J H, G sodl MK , J ohns on MH, K armiloff-S mith A: C ognitive modularity and genetic disorders . S cience . 1999;286:2355. S chmahmann J D, S herman J C : T he cerebellar affective syndrome. B rain. 1998;121:561. *S hallice T . F rom Ne urops ychology to Mental C ambridge: C ambridge Univers ity P res s; 1988. S ilver J M, McAllister T W : F orensic iss ues in the neurops ychiatric evaluation of the patient with mild traumatic brain injury. J Ne urops ychiatry C lin 1997;9:102. S tone V E , C osmides L, T ooby J , K roll N, K night R T : S elective impairment of reas oning about social exchange in a patient with bilateral limbic s ys tem damage. P roc Natl Acad S ci U S A . 2002;99:11531. S ugiyama LS , T ooby J , C osmides L: C ros s-cultural evidence of cognitive adaptations for social among the S hiwiar of E cuadorian Amazonia. P roc Acad S ci U S A. 2002;99:11537.

141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

01/01/2009

Page 1 of 80

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 3 - C ontributions of the P s ychological S ciences > 3.1: S ens atio P erception, and C ognition

3.1: S ens ation, Perc eption, and C ognition Louis J . C ozolino Ph.D. Daniel J . S iegel M.D. P art of "3 - C ontributions of the P sychological S ens ation, pe rce ption, and cognition refer to three broadening tiers of human information proces sing. S ens ation is us ually defined as the immediate res ult of stimulation of s ens ory neurons , whereas pe rce ption involves the organization and evaluation of thes e sens ations to obtain information about the inner or environments . C ognition refers to a set of vas tly proces ses, such as language, problem solving, and thinking, that apply plans and strategies to s ens ations perceptions. Although dis tinguis hing between perception, and cognition has a long history, the and value of s eparating them are increasingly unclear light of growing knowledge of nervous system functioning. Most information proces sing depends on the brain. B ecaus e the brain is built and maintained through the interaction of biological, psychological, and s ocial the study of s ens ation, perception, and cognition is neces sarily broad and far reaching. T he rapid increase knowledge of neuroanatomy and the development of 142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 2 of 80

hypothetical models to unders tand its functioning this an exciting time in the cognitive s ciences . T his reflects the juxtapos ition of many new and old models , containing much of the excitement and uncertainty that emerge as res earchers strive to understand how perceive and understand the world.

C OG NITIVE S C IE NC E T he fields relevant to this overview are a part of the interdisciplinary s tudies of cognitive science, which includes cognitive ps ychology, developmental ps ychology, ps ycholinguis tics, computational science, the emerging field of interpers onal neurobiology. E ach these dis ciplines provides an important and unique perspective on the human ps yche. B iological, ps ychodynamic, and s ocial ps ychiatry find a common home within cognitive s cience in which the usual of nature versus nurture and biology vers us ps ychology disappear in an examination of the building of the brain and the origins of mental proces ses. In recent years , discoveries in the neuros ciences have revealed a wide range of findings relevant to One of the major dis coveries was that the brain's and function are a res ult of the transaction of s everal factors , including genetic, physiological, and variables . In particular, brain development requires forms of experience to foster the growth of neural involved in a wide array of mental proces ses, including attention, memory, emotion, attachment, and selfreflection. T hus, experiences shape the unfolding of genetically programmed development of the central nervous s ys tem (C NS ). G enes function as a template 143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 3 of 80

information and as a mediator of trans cription of the proteins that determine neural structure. E xperience directly shapes the selection and timing of how the of genes influences the structure of the brain. T he human brain, especially the cerebral cortex, is immature at birth. T his immaturity requires that the brain use the caregiver's brain to grow and to organize. F indings from developmental neuros cience point to the centrality of interpers onal relations hips in the development of the brain. T he cooperative communication of infant–caregiver attachments is thought to provide the infras tructure not only for emotional development, but als o for abstract reasoning and cognitive abilities. T he patterns of interaction child and caregiver have a direct impact on the way the brain develops and the mind of the child functions. T hus, cognitive proces ses need to be considered as way in which the mind emerges from within the genetic, phys iological, and experiential factors that shape the development and maintenance of mental function.

Hot and C old C ognition T raditionally, cognition was studied by experimental ps ychologists in university laboratories, whereas were explored by ps ychoanalys ts in cons ulting rooms. C ognitive psychologis ts, striving to avoid the subjective and imprecis e nature of emotions, devised flowcharts algorithms s imilar to thos e us ed to describe proces ses within organizations or, later, in programming Input was calibrated, output was measured, and were generated des cribing what happened within the “black box” of the brain. T he increasing complexity of 144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 4 of 80

these models did not s eem to improve their power, and words s uch as motivation and emotion invariably aris e. As knowledge of brain functioning has increased, it is becoming increasingly clear that neural networks in sensation, perception, and cognition are inextricably interwoven with other networks process ing survival emotion, motivation, and s omatic states . T he myth of cognition, that is, cognitive proces ses devoid of influence, is gradually fading. F low charts and other diagrams depicting linear input-output proces ses are being replaced with more s ophisticated models to the complex neural s ys tems that psychologists are attempting to des cribe. Not all cognition is “hot,” such traumatic memories or scanning the environment for dangerous or s exually attractive others . S ome may be cool, such as adding rows of figures or checkbook. T hese s ame tasks, for s omeone with math anxiety, during an P.513 examination, or before an Internal R evenue S ervice may become warm or even hot. T he fundamental principle, however, is that s ens ation, perception, and cognition occur in the context of feed-forward and feedback networks , interwoven with and guided by complex (and largely uncons cious) emotional determinants.

E motion What is an emotion? T he answer to this question is as complex as the mind its elf. Although the lack of clear 145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 5 of 80

definitions and good animal models has hindered empirical res earch, it is clear that emotions play a role in perceptual and cognitive proces ses. One view considers emotion as a primary value s ys tem the brain, allowing activations to be s electively F or example, emotionally charged experiences may be more readily recalled than uneventful ones . According this view, the mos t fundamental aspect of emotion is arousal-appraisal s ys tem in which the brain responds given stimulus with the signal of “this is important— note and pay attention now!” E motion thus gives value a repres entation by arousing attentional mechanisms by focus ing a s potlight of attention on the s timulus. T he second s tage would then appraise the meaning of s uch emotional arousal by as sess ing its hedonic tone: “Is good or is this bad? S hould this be approached or avoided? ” E motion thus directs the flow of energy—the activations within s pecific circuits of the brain—as the arousal-appraisal system focuses cognitive process es elements of the internal and external environment. A level of emotional process ing is the elaboration of this appraisal into a more specific form, called a categorical emotion, s uch as joy, interest, surpris e, fear, anger, or s hame. T hes e categorical emotions have universal expres sions of affect found in all cultures, which may distinct ps ychophysiological manifes tations . An additional view examines the way in which the in the body's state are repres ented in the brain in the of what Antonio Damas io has called a s omatic marke r. According to this view, the energizing or deenergizing bodily responses let the brain know how the individual feels about an experience. S uch a s omatic marker can 146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 6 of 80

be us ed in future emotional ass es sments , or gut to an experience. A part of the brain called the orbitofrontal corte x has implicated as the s ite of s omatic marker proces sing or what is called intuition. Allan S chore has als o noted the importance of early experiences with caregivers in the maturation of this region and als o its central role in coordinating self-regulatory functions early in development with bas ic emotional reactions and s ocial functioning. T he orbitofrontal cortex has been not only in monitoring, but also in regulating bodily and may pos sibly be involved in psychiatric ranging from autis m to mood dis orders. Disorders in organization and social functioning may be better unders tood by examining the central role of emotion perhaps , the orbitofrontal cortex and related regions in development and maintenance of dysfunctional mental states . S tudies also sugges t that this region is for the capacity for s elf-knowledge and the s ubjective experience enabling the mind to reflect on the s elf in past, pres ent, and the potential future. Inborn and experiential factors may play important roles in allowing this region to develop the capacity to integrate a wide range of important functions of the mind, including the appraisal of meaning, emotional regulation, social cognition, and autobiographical consciousness .

NE UR A L NE TWOR K G R OWTH INTE G R A TION T he growth and s elective connectivity of neurons is the basic mechanism of all learning and adaptation. can be reflected in neural changes in a number of 147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 7 of 80

including (1) the growth of new neurons , (2) the of existing neurons, and (3) the changes in the between exis ting neurons . All of thes e changes are expres sions of plas ticity, or the ability of the nervous system to change. T he birth of new neurons , or neurogenes is , is a controversial field of study. S ome res earch s ugges ts that new neurons are generated in different areas of primate and human brains, es pecially regions involved with new learning, s uch as the hippocampus , the amygdala, and the frontal and lobes . E xisting neurons grow through the expansion and branching of the dendrites they project to other T here is now sufficient evidence for the fact that demonstrate growth and changes in reaction to new experiences and learning. Although neurons to form neural networks, neural networks , in turn, integrate with one another to perform increas ingly complex tas ks . T he brain is modular, that is , different networks have evolved to perform divers e tasks. networks converge and coordinate to perform higher level tas ks . F or example, networks that in language, emotion, and memory interact and for humans to recall and to tell an emotionally story with the proper affect, correct details , and appropriate words . Ass ociation areas within the brain serve the role of bridging, coordinating, and directing the multiple neural circuits to which they are connected. E xecutive within ass ociation areas , like a s witchboard operator, the capability to interconnect different neural networks. Although the actual mechanisms of this integration are 148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 8 of 80

not yet known, they are likely to include some combination of changes in (1) the biochemical within neurons, (2) the s ynaptic connections between neurons , (3) the relations hips between local neuronal circuits , and (4) the interactions between functional systems . C hanges in the synchrony of activation of multiple neural networks may also play a role in the coordination of their activity. If everything humans experience is repres ented within neural networks, then psychopathology of all kinds, the mildest neurotic symptoms to the mos t s evere ps ychos is , must be repres ented within and between neural networks. Healthy functioning requires proper development and functioning of neural networks organizing cons cious awarenes s, behavior, emotion, sens ation. P s ychopathology correlates with the suboptimal integration and coordination of neural networks . P atterns of dys regulation of brain activation specific disorders support the theory of a brain-based explanation for the s ymptoms of psychopathology. In general, ps ychological integration sugges ts that the cognitive functions of the executive brain have access to information across networks of sensation, behavior, and emotion. Dis sociation among these proces ses can occur when biochemical changes high levels of s tres s inhibit or disrupt the brain's integrative abilities. P hys ical trauma, disease genetic predispositions that disrupt the development functioning of neural networks can all result in neural dysregulation and ps ychiatric s ymptomatology. Applying this model to treatment, ps ychotherapy, ps ychopharmacology, and psychosurgery can be s een 149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 9 of 80

ways of creating or res toring integration and between various neural networks . F or example, has demonstrated that success ful ps ychotherapy correlates with changes in activation in areas of the hypothes ized to be involved in disorders , s uch as obses sive-compuls ive disorder (OC D) and depress ion. return to normal levels of activation res ults in reestablishing positive reciprocal control between neural structures and networks.

MIND A ND B R A IN A generally accepted view of the mind is that it from a portion of the activity of the brain. W hat is this activity of the brain, P.514 and how does it give rise to s uch mental process es as perception and cognition? How do the human of s ens ation, thought, emotion, attention, selfand memory emerge from neural proces ses? T he brain is compos ed of approximately 10 to 20 billion neurons . An average neuron is connected to approximately 10,000 other neurons at s ynaptic With hundreds of trillions of connections within and among thousands of web-like neural networks, there countles s combinations of poss ible activation profiles . term ne ural net profile is us ed to describe a certain of activation of the complex layers of neural circuits . neural net profile is the fundamental way in which proces ses are created. T hes e activations can lead to neural proces ses in a cas cade of dynamic interactions produce a range of internal events and external 150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 10 of 80

T he es sential components of the mind come directly how these neural events create the flow of energy and information.

E NE R G Y A ND INF OR MA TION T he mind is a proces sor of patterns in the flow of and information within the brain (T able 3.1-1). of individual neurons , groups of neurons, circuits, or networks of neurons all involve the flow of energy the complex system of the brain. T his energy reflects flow of ions acros s membranes, the consumption of oxygen and nutrients by neural cells, and the active transport of molecules into and out of nervous tis sue. However, the mind is much more than s ome outcome energy flow—the function and purpose of this flow of energy are to process information.

Table 3.1-1 B as ic Ideas of the T he mind is a proces sor of energy and E nergy is contained within the activations of circuits . Information is contained within the patterns of activation, termed a ne ural net profile or me ntal re pre s e ntation.

151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 11 of 80

T hese representations serve as symbols that further effects in the mind, leading to the of information.

Information is created within the brain by a proces s of representation. F or example, when an individual s ees E iffel T ower, the brain res ponds in particular regions of visual s ys tem with the activation of a neural net profile. When the E iffel T ower is recalled at a later time, the cortex activates a similar neural net pattern, and the T ower is visualized. T he activation of a particular neural firing thus contains within it information about something (the E iffel T ower). E xamples of forms include perceptual, s ens ory, linguistic, and more abstract repres entations of concepts and categories.

INF OR MA TION P R OC E S S ING S everal elements of the brain's function as an proces sor can be des cribed (F ig. 3.1-1). At the mos t level (F ig. 3.1-1A), energy leads to neural respons es. energy can be in the external form of light on the retina sound waves vibrating the tympanic membrane. It may also take an internal form in which the flow of energy within neural activations thems elves produces neural res ponses.

152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 12 of 80

FIGUR E 3.1-1 Information-proces sing models. A s econd level of unders tanding information (F ig. 3.1-1B ) is in the idea that an input (internal or external) leads to a repres entational respons e (a profile of activation), which, in turn, produces a downstream effect or output. T his output can be such as the generation of other repres entations, or external, in the form of observable behavior. proces sing becomes even more complex when the thems elves carry information. W ithin cognitive ps ychology, these information-proces sing events can seen as the contrasting, comparing, generalizing, chunking, clus tering, differentiating, and extracting proces ses that lead to interwoven sets of increasingly complex mental repres entations. A third level of viewing information process ing in the (F ig. 3.1-1C ) is the conceptualization of forms of perception, attention, and memory. According to this external energy is s ens ed by the peripheral nervous system and is registered as s ens ation within the brain. 153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 13 of 80

selective process ing of aspects of thes e s ensations , filtering, leads to the production of perception. T hes e perceptions are thems elves s ubject to further filtering in which only a s elect few are placed within working memory. T his is sometimes called the “chalkboard of mind.” It is within working memory that representations can be cons cious ly manipulated, contrasted, clustered, and reass embled. T hus, cons cious nes s may be related to this as pect of mental functioning. S ens ation refers to the initial s tages of the basic information-proces sing model (F ig. 3.1-1). In traditional experimental paradigms , sens ory memory is conceptualized as las ting for approximately 0.25 Items in sensory memory are then filtered into working short-term memory, where they last for approximately minutes. W hen humans attempt to cons cious ly learn information, working memory is able to handle approximately s even items, unless further process ing creates linkages to other items within longer-term memory. R ehears al allows thes e repres entations to for longer periods of time. C ognitive process es that can group bits of information into large chunks (chunking) increase the capacity of working memory by making unit more information rich. R epresentations are then proces sed and placed within long-term memory from which they can be retrieved for future us e.

A TTE NTION Attention is the proces s that controls the focus and flow information process ing. T hereare many aspects to attention that may derive from P.515 154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 14 of 80

their neuroanatomical localization. T hree components attention (s electivity, capacity, and sustained concentration) have traditionally been us ed to describe cognitive deficits in psychiatric disorders such as schizophrenia and attention-deficit/hyperactivity (ADHD). All aspects of attention in normal and patient populations are influenced by the emotional or motivational value of the s timulus. E arly conceptualizations of attention were based on Donald B roadbent's idea of a filter that s elects a limited amount of incoming stimuli to be further proces sed. Limited capacity of attention was thus attributable to inability to proces s the overwhelming amount of stimuli. An attention bottleneck was des cribed as occurring early in the sens ory process (automatic) or the perceptual proces sing s tage (identification and clas sification).

S elec tive Attention One aspect of attention is that it focuses a spotlight on external s timuli or internal mental representations. In B roadbent's conceptualization, selectivity has three dimens ions: (1) filtering, focusing specific attributes (e.g., large s quares vs . s mall categorizing, based on stimulus class (e.g., attending letters in whatever script they are written); and (3) pigeonholing, reducing perceptual information needed place a stimulus into a s pecified category (e.g., using long hair to clas sify individuals as female). E ach of as pects of attention acts on incoming s timuli to make a determination of fit for the sought-after characteristic. 155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 15 of 80

S chizophrenic patients, for example, s how greater difficulty with pigeonholing than with filtering when they are symptomatic. Another conceptualization of selective attention distinguishes between two interactive ways of sens ory input. P reattentive proce s s ing (a parallel as sess es global, holistic patterns and appears to be an early component of the perceptual process . F ocal (a s erial process ) follows preattentive process ing and involves a detailed analysis of stimuli characteristics . attention can be directed at one s timulus form only and thus limited in its capacity. In contras t, parallel (preattentive) attention process es do not appear to limited capacity and can detect ges talt as pects of environmental s timuli from numerous sources . T he to hear one's name called out by a nonattended voice crowded, noisy room is an example of an ongoing proces s with the ability to detect gestalt features and extremely familiar (and thus automatically process ed) stimuli.

Attention C apac ity T he concept of proces sing capacity involves the idea given task makes a demand on a limited pool of A task with a high process ing load draws more from the finite pool than does a task with a low load, thus inhibiting the access ibility of resources for simultaneous functions drawing from the same pool. attention requires cognitive effort and thus has a high– proces sing load demand. C ognitive models describing several resource pools sugges t an executive process distributes res ources to various cognitive functions. 156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 16 of 80

proces ses that demand process ing capacity inhibit the simultaneous action of other s erial high-load contrast, parallel proces ses have low or no process ing capacity demands and can function simultaneous ly numerous other functions without inhibiting them. Optimal performance is attained with moderate levels arousal that allow for the es tablis hment of task goals feedback from the performance of the tas k, leading to appropriate res ource allocation. Low levels of arous al impair those proces ses and lead to inadequate allocation. High levels of arousal may be detrimental to performance because of poor dis crimination of stimuli diminis hed efficiency of allocation, resulting in poor attention functioning.

S us tained Attention T he ability to sustain attention is called vigilance and be tes ted with task demands for alertness and concentration over a period of a few minutes to an T he tes ts usually involve detection requirements for stimuli that occur infrequently at random intervals . An example of s uch a test is the C ontinuous P erformance which has been us ed to s tudy various psychiatric disorders . Important aspects of the tests are derived signal detection theory and include the factors of sens itivity and res ponse criterion. S ensitivity is the distinguishing of target s timuli from nontarget s timuli. res ponse criterion is the amount of perceptual required to support the decision regarding a target item versus a nontarget item.

FOR MS OF R E P R E S E NTA TIONS 157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 17 of 80

T he es sential feature of information process ing in the is that the patterns of activation of neural circuits (the neural net profile) contain information. T hese mental representations, in turn, produce further neural events . T he location and pattern of neural activations the nature of what the neural net profile repres ents. F or example, activity in the optic nerve in response to light leads to a cascade of neural res ponses within the cortex generating a visual s ensation. F uture activation those layers in the visual cortex in that general pattern the experience or recollection of the vis ual image. and localization determine the kind of repres entation the information that it specifically contains .

S E NS A TION A ND P E R C E P TION F orms of repres entations include sens ory and ones that derive from input from the external world via peripheral sensory nervous s ys tem. T he initial s tage of encoding a vis ual representation is called an iconic and is held within sensory memory for a brief period. F eatures of the initial stimulus , s uch as its s ize, and color, are the information held within this sens ory representation. S ens ory repres entations are the least proces sed of mental representations and are thought be as close as the brain can get to representing the as it is. T his is a form of proces sing termed bottom-up proce s s ing and is in contrast to more elaborately representations that are directly influenced by more abstract aspects of prior experience, called top-down proce s s ing. As the initial s ens ory activations are (clas sified, compared, and linked to repres entations prior experience) they become influenced by higherproces ses and become organized as perceptual 158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 18 of 80

representations. Attentional proces ses at the level of s ens ory memory on the initial image with higher cognitive functions , as clas sifications and chunking. In their es sence, these down proces ses compare, contras t, and transform the initial repres entation to create new perceptual images within working memory. S tudies of patients with schizophrenia reveal s pecific deficits at this early stage perceptual proces sing. P erception is created by the top-down transformations sens ory images but does not neces sarily involve the experience of consciousness . T his has important implications in that patients may be influenced by and s timuli that they cannot cons cious ly recall. cons cious, focal attention is involved in perception, the representations are proces sed differently. T he involvement of focal attention appears to be necess ary the activation of the hippocampus in memory which allows for the encoding of explicit, consciously access ible, autobiographical memory. P os ttraumatic diss ociative s tates may involve the blockage of focal proces sing P.516 of perceptual repres entations , thereby leading to a disconnection among cons cious and nonconscious elements of experience. Imagery involves the activation of brain circuits res ponsible for perceptual proces sing. R epres entations (neural net profile activation patterns ) can thus be by external or internal means . Mental imagery can 159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 19 of 80

the generation, ins pection, retention, and of perceptual images . T his proces sing involves s imilar effort and timing as when the object is perceived from external s ource. T hus , complex visual images require effort and time to rotate in internal and external reality. T he ability of the mind to generate mental images is in various forms of psychotherapy and may also be an important mechanis m in the pathological production of hallucinations and illus ions seen in several disorders .

ME MOR Y S YS TE MS T he neural networks of the brain are capable of res ponding to experience by the activation of particular patterns of dis tributed activation. Donald Hebb a bas ic principle of memory that has been repeatedly supported by research: “Neurons that fire together, together.” Neurons that are activated in a particular pattern at one time tend to fire together in a s imilar pattern in the future—this is the ess ence of memory. T he brain has various forms of circuits res ponsible for different s ys tems of memory (T able 3.1-2). T he form of memory mos t commonly thought of as me mory is explicit or de clarative memory. T his form involves the cons cious sensation of s omething being recalled at the time of retrieval and allows for the awarenes s of the autobiographical or factual knowledge to be s hared, verbally, with others and the s elf. T his explicit memory system requires the involvement of focal attention and activation of the hippocampus for encoding and Items focally attended to are placed in working proces sed further, and then placed in long-term After a period of weeks to months , items are thought to 160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 20 of 80

undergo a process called cortical cons olidation that them in permanent memory, where their retrieval no longer requires the hippocampus . C ortical helps to explain the phenomenon of retrograde after head trauma.

Table 3.1-2 Memory S ys tems Implicit    A behavioral, emotional, and perceptual form of memory devoid of the subjective internal of recalling of s elf, or of pas t. C an include mental models that are s ummations of representations from numerous experiences .    Also known as early, procedural, me mory. C annot be express ed in words.    P resent from birth. Does not involve the hippocampus or require focal, cons cious P robably involves various circuits, including those the bas al ganglia, limbic s ys tem (amygdala, cingulate, and orbitofrontal cortex), and cortices . E xplicit

161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 21 of 80

   A form of memory requiring cons cious and involving the s ubjective sense of recollection and, if autobiographical, of s elf and pas t.    Also known as late , epis odic or s e mantic, or de clarative memory. C an be express ed in words drawings .    T he autobiographical component of explicit memory does not fully develop until pas t the firs t years of life, as the hippocampus and cortex on which it depends are maturing.

B efore explicit autobiographical memory process ing becomes available after the first years of life (during time the hippocampus and cerebral cortex are form of memory called implicit or nonde clarative already in place and remains active throughout the life span. Implicit memory involves a wide range of including behavioral, emotional, and perceptual When these circuits are activated in retrieval, they do include the cons cious s ens ation of something being recalled. F or example, when riding a bicycle, a pers on not recall having learned to ride and may not even feel that anything is being recalled. S imilarly, a pers on with fear of dogs may be unable to explicitly recall any event that may explain s uch an emotional T he exis tence of intact implicit recollection in the of explicit memory is found in various conditions , 162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 22 of 80

including s urgical anes thes ia; the advers e effects of benzodiazepines; neurological conditions, such as K ors akoff's syndrome and bilateral hippocampal and childhood amnesia. S uch diss ociation may also in res pons e to trauma. T hus, patients with stress disorder (P T S D) may have an inability to recall a traumatic event and yet may avoid contextual stimuli similar to the initial trauma, may evidence s tartle res ponse and anxiety, and may have intrus ive images for the event. T hese latter symptoms may the cons cious awarenes s of implicit memory retrieval lacks the s ubjective s ens ation that s omething is being recalled.

C ONS C IOUS NE S S T he vast majority of mental proces ses are outside of cons cious awarenes s. C ons cious awarenes s is a as pect of some cognitive process es. In general, many authors ' views converge on the idea that there exis t fundamental forms of consciousness : a he re -and-now a pas t-pre s e nt-future form of awarenes s. T hes e two proces ses are likely mediated via the integration of different neural circuits in the brain. T wo hypotheses focus on the way in which representational process es are linked or bound during the flow of informational transformations within the mind. One hypothes is sugges ts that a 60-cycle-persecond s weeping process extends from the thalamus the neocortex. T his s weep may s erve to bind representational process es together in the internal experience of consciousness . P roces ses that are the time of the sweep thus become linked within 163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 23 of 80

cons ciousnes s. Another view implicates the role of the lateral prefrontal cortex and its role in working memory. Working memory s erves as the chalkboard of the mind, and representational process es that become linked to activity in this region are then a part of the attentional spotlight of conscious awarenes s. B as ed on a biological as sess ment of brain function, E delman's theory describes two forms of that derive from the res onant interactions between of neurons . In his model, primary cons cious nes s s tems from the interaction between perceptual and conceptual categorizations. T his form of cons ciousnes s, called the re membere d pre s e nt, is also found in higher animals and is unable to trans cend momentary awarenes s. It is embedded in the pres ent is influenced by categorizations from the past. In beings , the capacity for lexical or language proces sing enables a secondary or higher-order cons cious nes s to and s tems from the resonance between thos e and conceptual categories. Higher-order frees inner experience from the prison of the present allows for views of the pas t and plans for the future. Included in these forms of consciousness is a scene of present s ituation in which the s elf is placed in a temporospatial context. C ortically blind patients state that they cannot see stimuli, but they res pond behaviorally as if they were sighted. T hey describe being unaware of vis ual but they make eye and P.517 hand movements that reflect the proces sing of 164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 24 of 80

information about stimulus location, shape, orientation, and direction of motion. In information-proces sing behavioral tests reveal that blind-sighted patients do sens e and perceive visual s timuli but do not have cons cious awareness of the perceptual process , an example of a dis sociation of the normally as sociated proces ses of perception and consciousness or of phenomena. Misidentification syndromes are other examples of subjective, cons cious experience disturbances . In prosopagnosia, patients are unable to cons cious ly memories regarding persons familiar to them. C apgras syndrome patients are able to recognize a familiar face but feel that it is not really that person. B eing as in recognition, is one as pect of cons cious nes s as a cognitive process . T he pathological uncertainty of with OC D theoretically can be viewed as a disturbance that as pect of cons cious functioning. C ons cious nes s provides a sense of continuity. Many ps ychiatric patients experience a profound s ense of discontinuity and confusion that may be related to a dysfunction in the s ense-making, continuity-creating proces s of cons cious nes s. S ome ps ychiatric including derealization and depers onalization, may be unders tood in terms of alterations in conscious functioning (as s een in some patients with mood dis orders, anxiety dis orders, dis sociative P T S D, and s ome personality disorders ), distorted body image (as in eating dis orders or mood disorders ), memories and flashback phenomena (as in P T S D), hallucinations (as in ps ychotic s tates). 165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 25 of 80

Mental Models and S c hemata S tudies of perception and memory support the view the mind has organizational s tructures that influence interpretation of s ens ory data, s hape the encoding of information into long-term memory, bias the retrieval of items stored in memory, and help determine the behavioral res ponse. T hose organizing cognitive are called me ntal mode ls or s che mata. Mental models are unconscious, highly organized, structural process es derived from pas t experiences guide in interpreting present s timuli and influence the direction of behavior. Mental models exis t for various situations. W hen a s ituation activates a given mental model, that model, in turn, guides s ubs equent proces sing and behavior. T he adaptational value of a mental model depends on an accurate reading of the survival demands of the s ituation. T he downside of models is s een when their unconscious and automatic activation occurs in s ituations in which they are inappropriate. Aaron B eck's theory of depress ion is on the idea that mental models or s chemata can depres sive thinking and depres sed moods . J ohn us ed the concept of internal working models to the development of early forms of s chemata for attachment relations hips. Difficulties in intimate relations hips and related behavioral dysregulation can seen as derivatives of models of inadequate early attachment and the presence of multiple, conflictual models. T he inner obje cts of ps ychodynamic theory are examples of mental models. Mardi Horowitz's view of certain personality dis orders and maladaptive interpersonal behavior also includes the role of mental 166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 26 of 80

models or pers on schemata. S ome ps ychiatric s igns symptoms can be s een as derivatives of conflicted schemata and s ituations. C lass ic des criptions of interpersonal patterns in some patients with pers onality disorders , such as idealization and devaluation, can be seen as maladaptive s chema functions .

Thought, L anguage, and C ognition T here is no universally accepted definition of thought. S ugges ted bas ic elements include propos itions containing meaning), images, and lexical and s emantic symbols . C ognitive proces ses can be carried out in simultaneously, and without cons cious nes s. C ognitive proces ses, such as thoughts, are often directly known through translation into cons cious nes s and language. in the study of mental models, clinical obs ervation and experimental paradigms can infer the nature of thought proces ses only through indirect meas ures . T hese are important in defining the term thought dis orde r. T hinking involves the mental representation of s ome as pect of the world or of the s elf and the manipulation those representations . T hinking depends on explicit implicit memory of prior experiences . In addition, proces ses are influenced by a pers on's emotional mental models, and other uncons cious determinants. basic components of the cons cious components of thinking include categorization, judgment, decision making, and general problem s olving. T he as signment representations of events or objects to categories is important to s ubs equent thought process ing, because thoughts can act on the general clas s to which an item belongs rather than on individual repres entations; this 167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 27 of 80

another example of top-down proces sing influences. R ational thought contributes to the ability to judge the probability of uncertain events and the decis ion to among various options. T hes e process es contribute to problem s olving in which data are as sess ed, class ified, transformed, and compared on the bas is of logical produce a choice that s olves a problem. F ailures in steps can res ult in limitations and distortions in normal thought proces ses. P s ycholinguis tics focus es on the cognitive process of language formation and s emantic analysis. C ognitive science has traditionally viewed language as a dominant influence on s ubjective experience. It is the medium that dominates human communication and is one of the major features distinguishing Homo s apie ns from other species. shapes the ways in which the world is perceived, the manner in which desires are communicated and and the way in which society responds.

Modes of Proc es s ing and L aterality T he mind is capable of dis tinct modes of proces sing mental repres entations. A serial mode us es sequential proces sing in a linear fashion, which is said to be slow energy-cons uming, becaus e only a few items can be proces sed s erially at a time. F ocal, conscious attention believed to occur in s erial fashion. A parallel mode the simultaneous manipulation of large numbers of representations in a nonlinear fas hion. P attern is an example of s uch a rapid, low-energy consuming proces s that can deal with a wide array of s timuli at the same time. Another dis tinction in contras ting modes of proces sing 168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 28 of 80

has been identified in the type of mental proces ses primarily attributed to the right or left cerebral hemis phere. S tudies drawing on the findings in patients whos e corpus callosum has been surgically severed, have unilateral neurological lesions , or in s ubjects undergoing brain-imaging protocols have found a remarkable cons istency in trends of left-hemis phere functioning vers us right-hemis phere functioning. S ome general principles from this array of studies s uggest many proces ses involve both hemis pheres ; however, are distinct patterns primarily originating from each side the brain. T he following generalizations relate to right-handed individuals and to most left-handed people as well. In right hemisphere are fast-acting, parallel, holistic proces ses, including vis uospatial perception. T he right specializes in repres entations, s uch as images and sens ations, and the nonverbal meaning of words, sometimes referred to as analogic re pres e ntations . T he right hemisphere is thought to work as a pattern recognition center, capable of as sess ing the ges talt context of a s cene and providing a s ynthetic interpretation. P.518 On the left s ide are primarily more slowly acting, linear, time-dependent, serial proces ses . Left-hemis pheric proces ses manipulate the verbal meaning of words in a logical analytical mode of process ing. A generalization from a number of s tudies is that the right hemisphere tends to note the patterns in the world and creates contextual meaning; the left hemis phere can only make 169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 29 of 80

rationalization of the details of what it perceives to sens e of meaning from a logical view that lacks context and thus may actually seem like a dis continuous and irrational set of data. T he proces sing of emotion also appears to have a lateralized distribution. T he expres sion of emotion to be mediated primarily by the right hemisphere. recognition of the affective expres sion of others als o appears to be a specialty of the right hemisphere. Of is that the right hemisphere appears to have a more integrated repres entation of the body's s tatus, that may be ess ential for individuals to know how they feel. J erome B runer has described the distinction between earlier mode of thought, called narrative cognition, the later mode, called s cie ntific, logical, or paradigmatic cognition. Narrative thinking is a context-dependent of proces sing that incorporates the internal the teller and the perceived expectations of the lis tener the production of a story. S tories als o involve the subjective experiences of the characters involved in the unfolding sequence of events . Logicos cientific paradigmatic proces sing is s aid to occur in a contextindependent manner that focus es on abs tract concepts and their logical, caus e-and-effect relationships . develop narrative thinking by 2 years of age, and the cons truction of s tories between parent and child is a primary mode of communication in all cultures throughout the world.

Metac ognition and S elf-R eflec tive C apac ity 170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 30 of 80

Metacognition concerns cons cious proces ses that act cognitive process es—thinking about thinking. of cognition appears to develop by approximately 6 of age; this knowledge takes various forms , including is known as the appearance -re ality dis tinction (things not be as they appear). T wo components of this are repres entational diversity (the s ame object may to be different to different people) and repres entational change (thoughts today are different from those of yesterday and may be different again tomorrow). T his of knowledge about the pers on-specific meaning of cognitive repres entation requires s ome s ens e of the person's awarenes s of the s eparateness of minds, a theoretical domain in developmental cognitive ps ychology called the the ory of mind. T he regulation of cognition, als o called me tacognitive monitoring, includes s uch proces ses as planning monitoring activities, and checking outcomes . Metacognitive monitoring may involve the ass ess ment thinking sequences for fallacious logic, factual errors , contradictions in the content of speech. P eter F onagy colleagues explored the development of reflective function, or an internal obs e rve r of mental life. P arents teach children how to be self-reflective by including own internal state in interactions and by encouraging children to s hare their own. C hildren who have been taught to tell s tories that include mental s tates demonstrate a greater frequency of s ecure attachment. B eing able to unders tand and to consider the mental states of s elf and others has als o been s hown to dependency on defensive s trategies. R es earch that what is created in parent–child narratives about 171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 31 of 80

experience is not just a s tory. E mbedded within the storytelling is the s election of information to be how it is process ed and understood, and if it is or has multiple s ubjective centers (empathic capacity).

S oc ial C ognition B ridging the fields of social ps ychology and cognitive ps ychology, the s tudy of social cognition focus es on mental proces ses involved in s ocial interactions . T he domains include the s tudy of empathy, interpersonal communication (verbal and nonverbal), pers on perception, relations hip scripts , and group process es . Other related areas include s tudies of attribution bias , memory for social interactions , s tereotyping, mental control of social cognitive process es, and cognitive of a s ens e of self. S ocial cognition can be s een as a of social ps ychology that us es information-proces sing theory to as sess the components of attention, encoding, memory, retrieval, and s chemata. A theme in social cognition res earch has been that topdown, theory-driven proces sing influences of social s ituations and actions in s uch s ituations. Developmental ps ychologis ts have focused on the of social cognitive functioning and its deviations. F or example, children with autistic disorder have significant deficits in empathic capacity and in the ability to social cues . S ocial cognitive deficits may be present in different domains in other ps ychiatric dis orders.

Dis c ours e and Narrative Dis course is communication from one pers on to is thought to involve a sense of intention or plan. 172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 32 of 80

discours e follows a set of rules that ens ures the and effectivenes s of communication: W hat is intended be stated by the s ender is unders tood by the listener or receiver. S ome researchers support the idea that is a cognitive function that follows the basic principles information process ing, including a s chema for communication, and of social cognition, s uch as taking into account the listener's pers pective. Incoherent discours e can be noted by analyzing unlicens ed of the primary maxims of discours e. Another technique that of dis course analysis , which examines the ways in which dis course deviates from an as sumed discours e T he exact method to quantify abnormalities in remains controversial, but clinical impres sions of incoherence remain important for ass ess ing deficits in social communication. T he deficits may res ult from behavior, inherent cognitive abnormalities in thought or language, or deviations in s ocial cognitive functioning. Deviations from normal discours e can be a general in need of further as sess ment. Abnormal discours e is clinically evident in ps ychos is , s pecifically in Narrative is a broad domain ranging from the literary of fiction to the developmental psychology of the origin of autobiographical accounts . F rom a cognitive point of view, narrative is important in unders tanding the relations of language, memory, cons ciousnes s, mental models, self-schemata, and cognition. Narrative can be generally defined as the which a person creates a verbal account of a s equence events in the world and the internal s ubjective of the characters of the s tory. Autobiographical narrative begins early in life as the 173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 33 of 80

capacity for language develops. S tudies of early monologues find that young children interpret and meaning to events in their world from an early age. Narrative helps record and make s ens e of the pas t, interpret the present, and anticipate the future. T he has been called an “anticipation machine,” and mental models, pros pective memory, and narrative are the ways in which top-down proces sing attempts to for the pos sible future. T he enactment of narrative directly affects the way in which individuals live out the story of their lives. Anthropologists who study psycholinguistic acros s cultures have described a phenomenon called cons truction, in which family members collaboratively create a s tory of daily events P.519 in their lives. How thos e family behaviors influence the child's emerging capacity to organize experiences and encode them into long-term memory to be retrieved in the production of autobiographical narrative is a fundamental ques tion for many dis ciplines in cognitive science as well as a primary focus of ps ychodynamic of ps ychotherapy. S pecific deficits in early family experiences and in innate cognitive capacities may theoretically impact the child's narrative capacity. differences can be s een in how different individuals tell stories of their lives and the way that they make in life.

C ognitive Development Developmental theories and research can be divided 174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 34 of 80

several views . S tage theories (J ean P iaget, and the sociocultural s chool of Alexander Luria and V ygots ky) des cribe dis continuous periods of with times of s tability and consolidation alternating with instability and trans ition. Information-proces sing have not been explored in as much detail with regard child development, but the models postulate a theory, in which the emergence of cognitive capacity is continuous process that does not require a s et of sequences. S tage and nonstage views embrace the that a hierarchical integration and an ongoing differentiation are fundamental as pects of cognitive development. Another dis tinguis hing feature is the degree to which theories view the contributing role of innate, biological factors and the role of culturally determined s ocial experiences . Do cognitive capacities emerge from a genetically determined plan, as in the P iagetian view, they develop in respons e to experience, as in the sociocultural view? Developmental ps ychologists have found features of both views , s upporting the idea of a transaction between innate factors and environmental experiences . More recent conceptualizations have on the functioning of complex systems to conceptualize development as the continual emergence of ever more complex capacities . P sychiatric dis turbances in cognition may reflect patterns of normal cognition (as in mental retardation), deviant developmental pathways (e.g., s ocial cognitive functioning in persons with autis tic disorder), and cognitive impairments (e.g., s chizophrenia) that may been present early on or only became evident as life 175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 35 of 80

requirements, such as s chool, became demanding cases of ADHD). Investigations into the developmental features of these dis orders is a major focus of the field developmental ps ychopathology.

S elf-Organizational Proc es s es An understanding of the development and s ubjective experience of cognitive process es has been greatly informed by the insights from the fields of evolutionary neurobiology and the nonlinear dynamics of complex systems , otherwis e known as chaos the ory. W ith neurons , each with an average of 10,000 synaptic connections with other neurons , the brain is capable of organizing an incomprehens ible number of pos sible activation patterns. In s electionist theory, the billions of neurons become clus tered into groups that have functions and, when activated, become reinforced. Neuronal groups that are not activated die off; thos e are activated s urvive. In other words , the brain divers ity of activity that can then be s elected by interaction with the environment. In addition, the brain has value s ys tems that s electively reinforce the activity neuronal groups that enhance s urvival. In this way the brain's neuronal groups compete and differentiate the brain and create an ongoing and evolving system. C haos theory s uggests that complex s ys tems adhere specific s et of principles . T hree principles — self-organizational process es, and movement toward complexity—are es pecially relevant to psychiatry. Nonline ar refers to the finding that s mall changes in (or initial conditions) can lead to large and 176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 36 of 80

changes in output. C omplex s ys tems function on the of probability, which predict that certain combinations activity within the s ys tem are more likely than others tend to move the s ys tem toward s elf-organization. T his probability also predicts that the s ys tem moves its elf toward increasingly complex s tates of functioning. T he state of activation of the various parts of the can clus ter into repeated patterns called s tate s . In the brain, a s tate of mind or me ntal s tate describes the way which various neuronal groups may become activated given time. R epeated patterns of neuronal group activation, a neural net profile, can become reinforced they occur frequently or if the value s ys tem of the brain ingrains their profile. T hese ingrained patterns of activation are called attractor s tate s ; thos e s tates that least likely to occur are called re pe llor s tate s . T he states are determined by the constraints on the Modification of constraints allows the nature of attractor and repellor s tates to be altered. C onstraints are and internal. T hus , features of the external such as the way other people behave and relate to an individual, can directly affect which mental state is likely to be activated within the pers on. Internal cons traints include the synaptic strengths of as determined by constitutional features and genetics, those learned from experience, as encoded within proces ses. Daniel J . S iegel has propos ed that complexity theory offer a us eful working definition of mental health applicable to individuals , families , and larger social systems . In complex systems , s elf-organizational that move the system's states toward maximal 177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 37 of 80

are mathematically shown to be the mos t s table, and flexible. T hese features may be us eful in defining he althy s ys tems. T he movement toward complexity is between the extremes of samenes s, with rigidity and on the one s ide and change, randomnes s, and chaos the other. C omplexity is achieved when the of the system achieve a balance in the two proces ses of differentiation (specialization in function) integration (coming together as a functional whole). F or single individual, such a balance can be achieved as genetically and experientially influenced growth of circuits combines differentiation of s pecialized regions with their functional integration via neural fibers that connect widely distributed areas into a functional similar balance would be seen in larger systems as Dis order can be seen in this view as occurring when a system is stress ed in its flow toward complexity, as revealed in movement toward either extreme: rigidity or chaos . T rauma may impair integration in an individual, revealed in the finding of negative effects on the integrative regions of the corpus callosum and hippocampus in abused and neglected individuals . A dysfunctional family s ys tem would be conceptualized occurring when the individuals are excess ively differentiated (without emotional connections ) or integrated (enmeshing that inhibits individuality from being expres sed). S uch s tres sed s ys tems are limited in their movement toward complexity and, hence, their stability, flexibility, and adaptability. P sychiatric dis turbances may be conceptualized as disturbances in s elf-organizational process es. Inherited and experiential internal determinants and ongoing 178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 38 of 80

external, environmental, and social influences on the cons traints of the s ys tem can thus directly affect the development and effective use of s elf-regulatory mechanisms. C linical interventions may function at the level of external constraints (ps ychotherapy) or internal cons traints (pharmacological treatments ) that alter the ways in which the individual's mind is able to achieve healthy forms of self-organization. V iewing psychiatric disturbances P.520 in this way allows for a synthesis of the views of ps ychodynamic, biological, and s ocial psychiatry.

S tates of Mind One way of des cribing the brain's self-organizational proces s is in the concept of s tates of mind. R epeatedly reinforced patterns of neuronal group firing link the cognitive process es of attention, perceptual bias, mental models, behavioral res pons e patterns, and emotional tone and regulation. T hese states of mind in the patterns of cognitive, emotional, and behavioral symptoms s een in various ps ychiatric disorders . F or example, in a depres sed s tate of mind, one may pay cons cious attention to negative aspects of experience, may interpret incoming stimuli in a pess imis tic manner, may have greater acces s to depres sing past may have the activation or instantiation of a mental of the self and others as bad or guilty, may have the behavioral pattern of withdrawal, and may have a depres sed mood with difficulty regulating intense Healthy mental functioning may depend on a flow of 179 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 39 of 80

states of mind through time, allowing for flexible adaptation to an ever-changing environment. C haos theory sugges ts that nonlinear complex s ys tems mus t move continually toward maximizing complexity. Achieving such a goal requires a balance between predictability and novelty. Dys functional mental s tates may be conceptualized as a dis ruption toward either of this balance: with exces sive rigidity, as in the case of character pathology, or excess ive fluidity, as in the disorders of thought or of mood.

S E NS A TION, P E R C E P TION, A ND C OG NITION IN P S YC HIA TR IC DIS OR DE R S S ince the time of E mil K raepelin and E ugen B leuler, ps ychiatris ts have known that certain disorders include profound disturbances in cognitive functioning. S ince 1950s , res earchers have attempted to determine the nature of s uch deficits. W ith advances in computer technology and an increasing technical ability to stimulus presentation and respons e times on the order tens of milliseconds , cognitive ps ychologists have been able to devis e res earch paradigms capable of tes ting presence of increasingly s ubtle as pects of cognitive proces sing. P roces sing res earch has focused on all three domains sens ation, perception, and cognition. S ensorystudies focus on posts timulus events for as long as a maximum of 1 s econd, using simple stimuli. P erceptual studies examine process ing after a period of as long as approximately 5 seconds after a slightly more complex stimulus . C ognitive proces sing experiments can 180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 40 of 80

the early aspects of proces sing (e.g., phenomena within the first 30 s econds ) of complex, as well as longterm, process es that occur over hours , days, or years . R ecent attempts have been made to correlate complex cognitive findings with clinical pres entations. A general problem correlating cognitive process es with clinical populations is the divers ity of patients falling the same syndrome clas sification. S chizophrenia, major depress ive disorder, and P T S D are all by symptomatic heterogeneity. T hus, the array of dysfunctions identified for certain syndromes mus t be interpreted in light of the diversity of patient A related problem is the distinction between general specific deficits . C are mus t be taken in interpreting experimental data that s how differences among normal controls and patient groups. Do ps ychiatrically ill perform les s well on a given paradigm because they or becaus e of a deficit s pecific to the disorder? F or example, ps ychomotor slowing, as meas ured by time and respons e rate, is s een in schizophrenia, depres sion, and other psychiatric and neurobehavioral disorders . T he side effects of medications can also influence proces sing and respons e s peed. on the creative design of experimental tas ks to help distinguish between general and s pecific deficits. A comparis on of target patient populations with matched healthy persons and other ps ychiatric patients can help determine dis order-specific cognitive dys function. Another general iss ue is that of s tate markers versus markers. F or example, a patient with s chizophrenia have a cognitive deficit when actively ps ychotic (state) also when asymptomatic (trait). T hes e abnormal 181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 41 of 80

have been found in certain cognitive tests of attention correlate with improvement on medications; some abnormal results are als o found in the non-ill firstrelatives of schizophrenic patients. Is the marker of vulnerability a coincidental finding or part of the core deficit in s chizophrenia? An exploration of the of thes e cognitive abnormalities for the daily life of the patient is an important application of the res earch to clinical psychiatry.

S c hizophrenia In the late 1890s, K raepelin described a primary deficit in his elaborate clinical des cription of patients schizophrenia. Numerous investigators have since attempted to define the nature of the cognitive deficits schizophrenia. A general approach is that an early perceptual process ing deficit leads to problems in perceptual organization and cognition. In general, information-proces sing models note that two things are proces sed: energy (in the form of external stimuli impinging on the senses) and information (a stimulus carries a signal value bas ed on s ignificance derived the prior process ing of s imilar energy configurations ). S chizophrenia patients appear to have deficits in the proces sing of energy as well as information. S ome cognitive tasks have been identified as traitmarkers of schizophrenia: reaction time cross over, backward masking, dichotic listening, s erial recall vigilance (s us tained attention) tas ks requiring high proces sing loads, and span-of-apprehens ion tes ts with large vis ual arrays. Deficits in those areas have been explored through many s tudies examining various 182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 42 of 80

of proces sing.

R eac tion Time C ros s over and S hift E ffec ts T hese paradigms examine the general finding that schizophrenic patients have a slower than usual on tas ks that require rapid reaction times . A s timulus is presented with varied combinations of warning signals and preparatory intervals . S chizophrenic patients s how advantage only with s hort preparatory intervals and res ponse times with regularly spaced s timuli, a pattern distinct from that of normal controls (cross over effect). related paradigm, when the modality of the stimulus is varied (e.g., light is inters pers ed with tone), the latency (delay) of the respons e in schizophrenic patients, when compared with controls , is longer if the preceding was of a different modality. T hat is termed the modality s hift e ffect, revealing a greater degree of cros s-modal retardation in s chizophrenic patients than in controls . A number of theories have been proposed to explain effects. T hey may be quantitative rather than distinctions from normal control groups . However, the cross over and modality shift effects support the idea schizophrenic patients are overly influenced by s timuli that occurred immediately before the effect. T he information-proces sing s tages that explain the of prior stimulus effects are under investigation.

Vis ual B ac kward Mas king, G ating, and Habituation In vis ual backward mas king, a stimulus is followed by interval of time, and then a s ubs equent s timulus is 183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 43 of 80

presented. P.521 F igure 3.1-2 s hows a typical masking experiment. T he presentation of the secondary s timulus leads the schizophrenic patient not to report (or mask) the initial stimulus . Lengthening of the interstimulus interval 500 milliseconds can lead to normalization, with no masking pres ent. T hus, the rapidity of pres entation of secondary s timulus is the factor determining whether it influences the perception or at leas t the reporting of the initial s timulus. S ome studies find that the impairment improves with treatment by medication and can be induced in normal patients given catecholaminergic agents . Other studies find that the impairment may be marker of increas ed vulnerability to s chizophrenia.

FIGUR E 3.1-2 Diagram showing the difference in the reports of normal vers us schizophrenic s ubjects with a s ingle backward mas king trial with a 100inters timulus interval (IS I). T he T repres ents the target stimulus , and the Xs represent the masking stimulus . 184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 44 of 80

B raff DL, S accuzzo DT , G eyer MA. Information dysfunctions in s chizophrenia: S tudies of visual masking, s ens ory motor gating and habituation. In: S teinhauer S R , G ruzelier J H, Zubin J , eds . Handbook S chizophre nia. V ol 5. Neurops ychology and Information P roces s ing. New Y ork: E lsevier S cience; 1991, with permis sion.) S ensorimotor gating and habituation are the proces ses which the reaction to s timuli decreas es with repeated presentation. S ens ory gating and habituation are to involve automatic preattentive process ing, whereas visual mas king requires higher cognitive functions. S chizophrenic patients show a markedly diminished capacity to habituate. One common s tudy examines persis tent acous tic s tartle reflex as the pers on blink with repetitive tones . Lysergic acid diethylamide (LS D) adminis tration and the intracerebral injection of dopaminergic agents in rats lead to similar findings , supporting the idea that excess ive dopamine activity, thought to be central in s chizophrenia, can induce deficits . In general, deficits in habituation and vis ual backward masking lend support to the idea that s chizophrenic patients have a diminished capacity to regulate the flow rapidly presented information. T hey experience being inundated by stimuli that are filtered out in the brain of normal person. Deficits in process ing externally derived stimuli, as demons trated in experimental paradigms , also occur with internally generated s timuli. 185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 45 of 80

S elec tive A ttention In general, selective attention paradigms pres ent the person with a target stimulus and dis tracters . In listening tas ks , the s ubject is as ked to attend to presented to one ear and to ignore mes sages the other ear. S tudies of schizophrenic patients have revealed cons is tent deficits in their ability to repeat the mess age they were as ked to focus on. Analys is of findings sugges ts that schizophrenic patients have an impairment in their ability to avoid distracting stimuli (to filter) and to pigeonhole (to us e category features to reduce stimulus qualities needed to res pond). T he suggest that dis tractibility is a core cognitive deficit, supported by its high incidence in genetically persons, its worsening in acutely psychotic s tates , and improvement with medications. T hese findings were explained by us ing the framework an impaired filtering structure and pigeonholing but recent conceptualizations have examined a generalized impairment of the information-proces sing capacity in s chizophrenia. T he capacity model the way in which a pool or pools of attention capacity be allocated across mental activities. T wo components quantity of res ources available (capacity) and allocation policy. Other areas of deficit may involve an impaired respons e s election process , leading to res ults on tas ks . S everal pos sibilities have been proposed to explain attention deficits in schizophrenic patients on the basis the capacity model: (1) deautomatization of normally automatic preattentive process es, (2) disproportionate 186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 46 of 80

allocation of attention to schema-relevant but task-irrelevant information, (3) inability to s ustain controlled proces ses needed to maintain attention allocation without shifting, (4) inability to shift allocation biases to correct wandering attention, and (5) res ponse s election because of heightened arous al distracting conditions . S tudies of s elective attention begin to examine these pos sibilities in a capacity rather than in the previous ly explored s tructural framework.

S us tained A ttention S us tained attention, or vigilance , is required to proces s stimuli of long duration. T he most common res earch paradigm us ed to examine sustained attention is the C ontinuous P e rformance T e s t. T he test consis ts of a presented set of tasks with varied spacing and timing target and nontarget stimuli. T he process ing load for a C ontinuous P erformance T es t can be varied by blurring the stimuli presented or by changing the pace of presentation. V igilance tes ts, such as the C ontinuous P erformance require analysis of res ponse features on the basis of signal detection theory. T he two elements are sensitivity and the res pons e criterion. Diminished sens itivity is a sign of decreas ed vigilance and res ults high mis s rate (errors of omis sion). T he respons e can be diminis hed, leading to a high false-positive rate (error of commiss ion). T he analysis is important in the interpretation of res ults. T he vigilance studies using the C ontinuous P erformance T es t reveal that patients have a deficit in their ability to dis tinguis h 187 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 47 of 80

stimuli from nontarget s timuli when the s timuli are presented as brief signals at a rapid pace. S chizophrenic patients als o appear to have a s pecific diminis hment in sens itivity but not a lowering of the res ponse criterion for verbal and s patial stimuli. T he impaired respons es were s ignificantly as sociated with specific clinical features in patients and their firs trelatives . T est abnormalities, although pres ent in other disorders , appear to be most robus t in s chizophrenia. P os itron emis sion tomography (P E T ) in s chizophrenic patients performing a C ontinuous P erformance T es t lower metabolic activity than in normal persons in the prefrontal cortex bilaterally but normal or elevated activation in the occipital region. T hat finding is with other findings supporting the idea of impaired functioning in s chizophrenia. P.522

L anguage and Dis c ours e Ass es sments of language dys function in schizophrenia have focused on the bas ic question of whether the abnormalities in speech are reflections of a core thought or an abnormality in s peech production. T he search for a s chizophrenic language has yielded conclus ions. Discours e analyses of conversations with schizophrenic patients s uggest that they may have significant difficulties in the maintenance of a specific topic (derailment) and in the lack of a dis course plan directing speech (disorganization). Other inves tigators have argued that schizophrenic patients have impaired capacities to perceive the 188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 48 of 80

others and may be schema driven in the direction of speech, rather than intending to communicate One s tudy s howed that delus ion-cons istent material presented in the nonattended channel in a dichotic listening tas k leads to diminis hed attention to the target channel. A clinical implication of this experimental is the pos sibility that s chema-driven proces sing during speech production may be diverting attention to stimuli and away from the potentially confusing s ocial demands of convers ation.

S pan of A pprehens ion In the span-of-apprehens ion tes t, an array of letters is displayed for a brief period (from 50 to 100 most studies). One of the letters is a T or an F , and the person must detect which letter is present. T he number nontarget letters is increased, and s ignificant detection are found for dis plays of ten or more letters . F igure 3.1-3 provides an example of a vis ual dis play for span-of-apprehens ion tes t.

189 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 49 of 80

FIGUR E 3.1-3 S ample arryas us ed in the wideangle vers ion of the partial report span-ofapprehens ion task.(C ourtesy of R obert T he serial scanning proces s is an element of focal attention. P arallel process ing in the s earch involves increased as pects of ass ess ment of figure-ground and textual s egregation and is thought to be an automatic proces s. S tudies have shown that the s equential of the attention spotlight is directly affected by the complexity of certain dis play characteristics , increased errors in detection. T his is logical, because iconic image has a limited dis play time, and the of the image may be incomplete by the time it decays such an ultrabrief form of memory. 190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 50 of 80

S chizophrenic patients show significantly increased in the s pan-of-apprehens ion tes t under conditions of increased complexity of dis play. T heir s cores are als o wors e in ps ychotic conditions and are improved with symptomatic improvement while taking medications. Increased errors are als o found in nons chizophrenic mothers of children with s chizophrenia. T hus the s panapprehens ion tes t is a meas ure of s tate and trait in cases of s chizophrenia. Only approximately one-half of the patients with the diagnosis of s chizophrenia have abnormal results on of-apprehens ion tes ts. T hos e who do have abnormal res ults also have the clinical s ymptom of anergia. ps ychiatric disorders studied did not reveal these T hus, the abnormal res ults on the test appear to be to some forms of schizophrenia. S hort-term and longoutcome studies have found that those patients with abnormal test res ults whos e s cores improve after antips ychotic medication have a good clinical res ponse pharmacotherapy. T he span-of-apprehens ion tes t taps into some aspect cognitive function specific to s ome patients with schizophrenia, their nonschizophrenic relatives , and persons at ris k for developing the s ymptoms of schizophrenia. T o s can the iconic image, the person (1) engage attention to the iconic regis ter, (2) move the focus of attention, and (3) dis engage the focus of attention. Impairments in performing any one of thos e tas ks can explain the test-res ult abnormalities . Another caus e of the deficiency may be that, with each fixation attention, les s information is process ed. T hus, although individual s teps of iconic s canning may be intact, les s 191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 51 of 80

visual information is process ed, and more errors occur. third poss ibility is that the initiation of the attention proces s is delayed; this pos sibility is consistent with the increased reaction times revealed on numerous other tas ks . T he delay in the face of a rapid decay rate of memory places the patients at a disadvantage when res ponses are required; this pos sibility is als o with the other forms of attention deficit described previous ly. S chizophrenic patients may have a number structural and capacity deficiencies , and thes e are not mutually exclus ive. F urther studies are needed elucidate the nature of the cognitive state-trait marker schizophrenic patients and persons vulnerable to the disorder.

Attention-Defic it/Hyperac tivity Dis order In the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ), integrates two categories from the revised third edition the Diagnos tic and S tatis tical Manual of Me ntal (DS M-III-T R ): ADHD and undifferentiated attentiondisorder. Diagnostic criteria embrace a number of the syndrome, and res earch into the cognitive deficits outlined a wide array of tas ks in which attention abnormal. T he pervasive findings of cognitive in the s etting of numerous intact cognitive functions left the res earch field with no clearly accepted view of a core deficit in the disorder. C linically, child and patients pres ent with problems in school, with peers, at home that reflect academic and behavioral dysfunctions. Many s tudies sugges t that the cognitive behavioral dysfunctions in the disorder may be 192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 52 of 80

independent process es with different bases . F or example, the finding that children with are impulsive may be true behaviorally but cannot be stated as a generalization about their cognitive functioning. R es earchers have attempted to find clear-cut criteria to help clarify the dis order, but individuals clas sified as meeting diagnostic criteria at this point appear be quite heterogeneous. T here is no definitive for the dis order nor is a positive res ponse to ps ychopharmacological intervention pathognomonic. B iochemical studies have found abnormal urinary catecholamine metabolites that normalize as the behavior improves when taking ps ychostimulants . findings and P E T scan data suggest abnormal brain functions in patients with ADHD. P.523 Data from numerous studies s how that the patients ADHD have dysfunctions on a variety of tasks ranging those involving monitoring, perception, memory, and motor control. Intact performance has been found on a number of memory tas ks requiring verbal process es digit span, word tes ts, and s tory recall) and nonverbal proces ses (e.g., recall, visual arrays , and block s eries). A number of theories have been elaborated to explain those differences between patients with the disorder normal persons. E ach theory has s trengths , and varied support from the data, but each highlights complexity of the cognitive dimens ions of the disorder. general, patients with the dis order evidence behavior 193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 53 of 80

has been compared to that of patients with frontal lobe damage: deficits in the control of motor res ponses , in execution of fine-motor movements , and in the of ongoing res ponse patterns. Memory tas ks and basic as pects of information process ing are intact, but the patients have impaired performance across modalities (auditory, vis ual, motor, and perceptual-motor), suggesting s ome global deficit. T he patients also be unusually s usceptible to boredom when the required tas ks are long and repetitive. Another view examines two propos ed systems —an underactive behavioral inhibition s ys tem and an behavioral reward s ys tem—to explain the behavioral problems that children with the disorder often have. A related view is that the rule-governed behavioral not intact; patients with the disorder appear to do es pecially poorly in a system with delayed or rewards, as in tasks that require s ustained attention, accuracy, or task-directed activity governed by another person's direction or rules . Under those conditions, the patient's poor regulation and inability to meet functional demands are revealed. A related is sue is a diminished motivational drive and, poss ibly, a diminis hed arousal regulation system. Y et another approach supported by research data is the patients have metacognitive deficits. According to perspective, metacognitive process es that help plan, monitor, and regulate performance are impaired. T he patient's ability to as sess the tas k and to determine strategies also has deficits . T hat is an example of topas pects of attention, with impairment of the higher cognitive process es that regulate information flow. 194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 54 of 80

Additional bottom-up deficiencies involve bas ic as pects attention focus because of abnormalities in arous al, selectivity, and capacity. T he finding that numerous factors can influence the appearance of deficits led V irginia Douglas to the hypothes is that ADHD is a self-regulatory disorder with pervas ive effects. T he impairments affect each of four domains —attention, inhibition, reinforcement, and arousal—res ulting in deficits in several aspects of selfregulation: (1) the organization of information including planning, metacognition, executive functions, adapting appropriate cognitive s ets for a given tas k, regulating arousal levels and alertness , and s elfmonitoring and s elf-correction; (2) the mobilization of attention, including the deployment and the of adequate attention; and (3) the inhibition of inappropriate respons es, such as withholding extraneous s timuli and reinforcers. T hese deficits in regulation imply that increased process ing demands would lead to a diffusion of attention process es and to subs equent impairment of the in-depth, coherent acquisition of knowledge and understanding. One line of research has been based on the additive method, in which experimenters attempt to is olate the stage of the deficit. T he model for that approach entails four stages : encoding (the identification of a s timulus), serial comparis on (of the stimulus with elements the category in long-term memory), decis ion (pertaining the category into which the s timulus is s tored), and translation and res ponse organization. S tudies us ing evoked potentials s ugges t that deficits are found after search and decision s tages (the first three stages ). T he 195 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 55 of 80

res ponse preparation and execution process es appear be impaired. F eatures that increas e the process ing such as s peed demands, complexity of s timuli, leading to divided attention, and increased duration of tas k—reveal different areas of deficit. T his fact may the divers ity of methods and res earch data supporting various theories . T he variables affecting outcome information-proces sing demands , the availability of alternate s timuli to which to attend, and the presence of an external regulator. T he divers ity of research findings and theoretical explanations is paralleled by the clinical finding that children who are severely impaired in the clas sroom have no attention problems in the confined, one-on-one setting of the psychiatrist's or psychoeducational examiner's office. S uch children may also be able to for indefinite periods to video games and yet be unable follow complex conceptual information. T he important principle is that cognitive dys function in ps ychopathological conditions may be tas k s pecific as function of the nature of the cognitive impairment. T he patient's clinical history and evaluation mus t cons ider potentially hidden domains of abnormal cognition.

Autis tic Dis order E arly descriptions of autism delineated the s ocialfunctioning deficits that impair normal functioning. Autistic children were seen as having difficulties in emotional contact. C ognitive dysfunctions in autis tic disorder were des cribed later and were found to number of areas , including abstraction, sequencing, language, and comprehens ion. R es earchers are now 196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 56 of 80

focus ing on the nature of the core deficit in the Is sues of s pecificity and universality of areas of in the dis order are important. How the cognitive relate to the s ocial-affective deficits is of particular S eventy-five percent of patients with autis tic disorder also mentally retarded. Mental retardation involves cognitive and language impairments that may make it difficult to distinguis h autis tic dis order features. G eneral cognitive impairments may be es pecially difficult to if language functioning is s everely limited. S tudies of functioning patients with autis tic dis order have various deficits to be determined. S tudies of the cognitive deficits in autis tic disorder have distinguished an array of dysfunctional areas , including numerous language problems , excess ive or impaired res ponsiveness to stimuli of various modalities , encoding of auditory stimuli, and impairment in the to extract important features from incoming information. T his range of deficits is thought to require the transformation of s ymbolic representations . In contras t, some patients with autistic disorder have relatively visuospatial and gestalt functions , mus ical abilities, and rote memory. P erformances on s tandardized tests relatively good results in object ass embly and block but poor results in comprehens ion. Language deficits vary and include s yntactic and phonological domains . T hese findings initially left-hemis phere deficit, but other findings , including deficits in pros odic and pragmatic language functions, suggested right-hemis phere involvement as well. T he findings can be interpreted as deviations from normal language functioning as well as delays in language 197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 57 of 80

functioning. T he wide array of dys functions in autis tic disorder may be due to a number of subtypes, with characteristic deficits and poss ibly different brain loci of dysfunction. Other studies have focused on the social cognition of patients with autis tic disorder. T hey have examined the nature of the patient's emotional P.524 behavior and understanding to as ses s the earliest descriptions of an abnormal emotional connection between autis tic children and their parents . R ecent neurobiology sugges ts a role of the orbitofrontal cortex and the cerebellum in mediating s ome of thes e deficits . T wo findings s upport the initial impress ions: Autis tic children are much less likely than usual to imitate adult vocalizations and ges tures, and they show much les s sophisticated repres entational play with objects than do normal children. T hes e findings led to the sugges tion a core deficit in autis tic disorder is the representation of representations (metarepres entations), leading to in symbolic play and the inability to unders tand the mental s tates of others. T he inability to transfer representations into language symbols may als o be a related metarepres entation deficit. A s eries of studies explored the relation of thes e cognitive impairments to s ocioemotional behavior. In contrast to clinical lore, children with autistic disorder found to look at their parents; they had eye contact with their parents when s ocial interactions were parentally elicited, and they revealed normal behavioral patterns attachment. T he s tudies found a marked lack of s ocial 198 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 58 of 80

referencing (looking to parents for emotional cues in ambiguous s ituations) and protodeclarative gestures (pointing to objects and s howing objects to familiar adults ). T hree domains have been propos ed to explain these findings: (1) Autistic children may not have the capacity to have a representation of another pers on as having ideas , perspectives, or emotions that can be T his proposal is cons istent with a theory-of-mind hypothes is, in which the core deficit is believed to be inability to have a sense of another's mind. (2) Autis tic patients may have an impaired ability to perceive or to comprehend the emotional (us ually facial) s ignals of others . (3) T he core deficit may involve a lack of others or an avers ion to responding to others . S tudies found that although children with autistic disorder do expres s emotions, they have les s positive affects in res ponse to their (relatively infrequent) periods of joint attention. F urthermore, they have an impairment in res ponsivity to the dis play of s trong emotion by whether of distress or of pleas ure. T es ts of high-functioning autis m patients reveal poor performance on emotion-recognition tasks, little comprehension of and empathy with depictions of situations, and difficulty in talking about s ocially derived emotions , s uch as pride and embarrass ment. Autis tic patients with relatively high intelligence use adaptive cognitive s trategies to interpret s ocial stimuli to compens ate for impaired emotion-proces sing abilities. development of s ocial cognition and socioemotional unders tanding requires complex interactions among cognitive, perceptual, and emotional process es . A interactive elements es sential to the development of 199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 59 of 80

unders tanding has been proposed (F ig. 3.1-4). T his describes the basic precursors of emotional res ponsiveness : the ability to attend to, to encode, and interpret verbal and nonverbal social s timuli; the awarenes s of one's own and others' emotional and the ability to contrast ones elf with others. Out of matrix develops the ability to unders tand others ' views , desires, and beliefs . Accordingly, a deficit in any of basic elements may explain the characteris tic deficits observed in the s ocial understanding of persons with autis tic dis order.

FIGUR E 3.1-4 S igman's model for the development of socioemotional unders tanding.(C ourtesy of M.S igman.)

Mood Dis orders In contras t to schizophrenia, ADHD, and autis tic the mood disorders do not appear to have core deficits that are diagnos is s pecific. Instead, cognitive abnormalities appear to be related to the degree of ps ychopathology and to the severity of the mood 200 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 60 of 80

disturbance. Mos t s tudies have examined patients with depres sion; only a few studies have as sess ed functioning in patients with bipolar I dis order in a manic state. In depress ed patients, the severity of the has ranged from mild depress ion in s tudents to s evere illness in hos pitalized patients with major depress ive disorders . T he studies have primarily examined and memory for neutral and emotionally toned s timuli. the majority of these studies, the concept of s elforganizational process es and state regulation has not the primary focus of attention. T hes e recent conceptualizations of the brain's functioning as a nonlinear complex s ys tem capable of s elf-organization may aid in the future investigation of the primary deregulatory aspect of disorders of mood.

Depres s ive Dis orders Depress ed patients often complain of difficulties with concentrating, learning, and remembering. S tudies documented that s uch patients perform poorly on tas ks that require sustained attention or effortful and rehears al. T hus , controlled limited-capacity proces ses appear to be impaired in major depres sive disorder. limitation on access to capacity-demanding res ources appears to be directly related to the s everity of the depres sion and normalizes with remiss ion from a depres sive epis ode. Depress ed patients have als o been found to have an increased res ponse criterion; they require increas ed supportive data from the presented s timuli to respond tes t s ituation. W hether this need to be certain before res ponding is a psychological respons e to being 201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 61 of 80

depres sed or a specific feature of the depress ion its elf not yet been determined. T he reluctance to res pond to be cons idered in interpreting research data and interview findings . T he attention and memory findings have suggested several theoretical frameworks that are clinically useful. schema theory of depres sion outlines a positive loop in which negative s elf-schemata prime pers ons to have negative thoughts, to recall negative events in lives , and to interpret present events with a negative Whether as a caus e or as a maintaining influence, depres sogenic s chemata are thought to create a s eries cognitive functions that produce and maintain a depres sed mood. A network theory of memory and emotion has been supported by res earch on depres sed and persons in which mood P.525 leads to a spreading activation of items in memory that congruent with the mood. T hus, emotion directly influences retrieval by a proces s of s tate-dependent learning and memory. While depress ed, patients are to encode items in a form that makes them readily access ible when retrieved in a depress ed state; mood thus becomes an internal context cue that depres sion-related memories . T he network and schemata theories of depress ion are cons onant with res earch findings but do not explain all cognitive and clinical findings in depres sion. T hey a framework for unders tanding how emotions and 202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 62 of 80

influence cognitive proces sing, such as memory and mental models. T he conceptualization may be applicable to transient mood s tates and s evere mood episodes . T hus, emotions in health and illness can the mental state instantiated at a given time and thus as a context cue, leading to the activation of previous ly formed schemata for ones elf and others. T he activated schemata, in turn, can produce retrieval biasing and behavioral res ponses, fundamental to a mental state, can further elicit a negative emotional res ponse. A reinforcing loop is established to support the of the depres sed mood and depress ive cognition. S ome patients may be es pecially prone to marked cognitive alterations because of an emotional s tate that may be a fundamental part of a clinical presentation. rapid s hifts in s tate of mind may be a learned or cons titutional feature of the individual. F rom the dynamics view, these rapid s hifts in mental s tate can conceptualized as sudden and intens e changes in the cons traints on the s ys tem, which determine the flow of states of mind across time. Activating a s et of that es tablis h and maintain a depres sed s tate can then lead to the pers is tence of the factors that created the in probabilities of that s tate being active. T he state becomes a deeply ingrained attractor state that becomes difficult to alter. P harmacological may directly alter the s ynaptic cons traints maintaining such a s tate. P sychotherapeutic interventions , s uch as cognitive-behavioral and interpersonal therapy, can be propos ed to produce changes in the internal cons traints and in external social cons traints ,

203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 63 of 80

B ipolar I Dis order P atients with manic episodes present with a s pectrum cognitive dysfunctions that appear to be related to the severity of their mood epis ode and that normalize with remis sion. T he disturbances have been described as rapidly paced thinking and speech, quick self-generated or other-generated s timuli, grandiosity, increased distractibility. F ormal studies of patients with bipolar I dis order are technically difficult to carry out because of the patient's lack of cooperation and res tless nes s, and becaus e patients are few in number. T he s tudies have high rate of combinatory thinking, the inclus ion of as sociated but related intrus ions, and increas ed distractibility. T he clinical impress ion of humor (even in face of an underlying dysphoria) in some patients with bipolar I disorder is corroborated by playful, or flippant elaborations and intrus ions in s peech. T hes e findings seem to indicate primarily state-dependent symptoms that improve on recovery. T hus , forcedspan-of-apprehens ion and backward masking tas ks impairments similar to those seen in actively patients but unlike thos e s een in s chizophrenic patients who have persistent deficits in the remitted state. disorder patients who are not actively ill reveal normal information process ing. T hus, bipolar dis orders can viewed as a disorder of s elf-organization in which the system fluctuates between the extremes of highly activated manic and highly deactivated depres sed of mind.

204 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 64 of 80

Pos ttraumatic S tres s Dis order S tudies of P T S D have extended the findings of information-proces sing abnormalities in anxiety attention bias es toward fear-related and threat-related stimuli. Many of the s tudies were hampered by poorly defined clinical populations and control groups. some general trends, noted es pecially in the wellcontrolled paradigms , are promising and provide important ins ights into the psychopathological cognitive mechanisms in P T S D. C ognitive s tudies of patients with anxiety dis orders focus ed primarily on attention or memory. V arious res earch paradigms have been applied to as ses s bias and memory retrieval for neutral and emotionally activating s timuli. S tudies find that anxious patients an increas ed tendency to attend to fear-related and related words . One research approach includes a listening tas k in which an anxious patient is more easily distracted than are controls by fear-related stimuli in nonattended channel. T his finding s ugges ts that the patients have automatic, parallel attention process es are primed to detect certain types of stimuli. Another approach uses the S troop paradigm, in which words presented in different-colored inks , and the person's to look at the word and s tate the color of the ink. patients have a s ignificant delay in their res ponse times fear-related words , a finding that sugges ts that attention capacity or cognitive proces sing is necess ary when those words are perceived and the color of the determined. One theory that explains these findings is the idea of a 205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 65 of 80

network that encodes fear-related information in a memory s tructure that is readily access ible and able to influence cognitive, motor, and ps ychophysiological res ponses . T he theoretical fear networks, which may similar to mental models, are thought to contain three related forms of information: fear-eliciting s timulus specific res ponse patterns , and the meaning of the and the res ponses for that particular pers on. According this theory, patients with anxiety disorders are believed have fear networks that are es pecially coherent and and that require few environmental cues to become activated. P atients with P T S D have been found to have attention biases toward threat-related stimuli s pecific to the experienced traumatic event. Many of the patients were combat veterans, and further work is needed to es tablis h the generalization of those findings to other forms of P T S D. T he dis order is clinically characterized intrus ive proces ses (memories, images , emotions , and thoughts) and avoidance elements (psychic and numbing, amnes ia, behavioral avoidance of cues res embling the initial trauma). T he patients are thought to have a unique configuration of fear networks with s timulus cues (environmental s timuli), res ponse components (cognitive, motoric, and ps ychophys iological), and meaning elements (e.g., the moral implications of the trauma, survivor guilt, and the meaning of intentional trauma vs. accidental trauma). S ome theories argue that states of exces sive arous al during trauma impair attention capacity and memory encoding during the event. E motional process ing and after the traumatic experience may als o be 206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 66 of 80

by the s tates of ps ychophys iological arousal and memory s torage. T he part of the brain necess ary for explicit memory process ing, the hippocampus , has shown to be abnormal in individuals experiencing P T S D. T he s ubs equent clinical s yndrome may have as pects that are adaptive: C ognitive attention bias es are primed to detect fear-related stimuli may permit the early detection of threatening s ituations that, if not avoided, would produce incapacitating ps ychophys iological arousal. Automatic, noncons cious behavioral avoidance respons e patterns, embedded in propos ed fear networks or mental models, allow the patients to minimize excess ive arous al by avoiding trauma-related situations . P atients who us ed mechanisms during P.526 and after a traumatic experience appear to be at far greater risk for developing P T S D. Diss ociation is a proces s that ess entially involves the disass ociation of us ually ass ociated process es, such as attention, perception, memory, consciousness , and sens e of self. T he ps ychopathological as pects of P T S D can be cognitively exemplified as follows : A combat veteran chronic P T S D may have no direct recall (impaired memory) of a helicopter cras h in which his bes t friend, was seated next to him, was killed. Y ears later, avoidance of airports , amnes ia for combat, general and s ocial withdrawal (avoidance elements) combined with startle res pons e, panic attacks , intrus ive images, nightmares (intrus ive components) all sugges t intact implicit memory for the combat trauma. T he veteran is 207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 67 of 80

emotionally, behaviorally, and cognitively impaired.

S peec hles s Terror S cott L. R auch and colleagues explored the of intense fear us ing patients with P T S D. T hey took patients with P T S D and exposed them to two One was emotionally neutral, and the other was a a traumatic experience. W hile they were listening to tapes , measures of their heart rate and regional blood flow (rC B F ) were meas ured via P E T s cans. rC B F greater during traumatic audio tapes in right-sided structures , including the amygdala; the posterior orbitofrontal, insular, anterior, and medial temporal and the anterior cingulate cortex. T hese are the areas thought to be involved with intens e emotion. An extremely interesting and potentially important finding was a decreas e in rC B F in B roca's area (left frontal and middle temporal cortex). T hes e findings suggest a potential active inhibition of language during trauma. B ased on these results , speechless often reported by victims of trauma, may have neurobiological correlates consis tent with what is about brain architecture and brain–behavior T his inhibitory effect on B roca's area impairs the of conscious memory for traumatic events at the time they occur. It then naturally interferes with the development of narratives that s erve to proces s the experience and lead to neural network integration and ps ychological healing. Activating B roca's area and left cortical networks of explicit epis odic memory may be es sential in ps ychotherapy with patients experiencing P T S D and other anxiety-based disorders . 208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 68 of 80

T he evaluation and treatment of patients can be greatly enhanced by an unders tanding of development, diss ociation, and cognitive proces ses (including and its careful application to the ass ess ment of symptoms and s igns. S everal areas that have clinicians for decades have become of great societal concern. T wo topics that inspire intense controversy the delayed recall of repress ed memories of traumatic events and the s uggestibility of patients influenced by clinicians , s ociety, or friends to believe that they are the victims of childhood trauma.

Delayed R ec all Many scientis ts and clinicians believe in the cognitive capacity of patients to be unaware for years or severely traumatic experiences that took place in their childhoods. Other researchers dis agree and paucity of s tudies of corroborated cases of childhood trauma that have been followed prospectively into adulthood with documentation of impaired acces s of cons ciousnes s to events presumably stored in cognitive s cience view of delayed recall can examine role of memory proces ses and development and the of trauma on the proces sing of information to des cribe theoretically coherent but yet-to-be-proved set of mechanisms. A repres sed memory can be thought of as originating the active, intentional suppres sion of memory from cons ciousnes s. T he mechanisms underlying the then may become automatic, and the contents of may be inhibited from retrieval into conscious ness . T he blockage may exist to avoid flooding the pers on's 209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 69 of 80

awarenes s with information that is ass ociated with excess ive anxiety or fear that would impair normal functioning. T his is an example of knowledge is olation which information may be layered in the nervous and certain as pects may be kept from conscious awarenes s. In contras t, a traumatic event may be s o overwhelming that normal process ing may be impaired. If focal is divided, the nonfocally attended (traumatic) material only process ed implicitly. T hus , to adapt to a traumatic event, some pers ons may have the capacity to focus attention on a nonthreatening aspect of the or on their imagination during the trauma; this may be underlying mechanism in a proces s called dis s ociation. T raumatic memory that has been only implicitly affects behavior and emotions and pos sibly contains intrus ive images and bodily s ens ations that are devoid sens e of pas t, of self, or of something being recalled. may partly explain the findings of P T S D with amnes ia (blocked conscious access to a memory or its origin) in setting of avoidance behaviors , hyperarousal, intrus ive images, and flas hbacks. T hus, two distinct mechanis ms that may explain recall of childhood trauma are the concepts of memories and diss ociated memories . A pers on may both mechanisms for different as pects of a traumatic event. R ecollection of the traumatic memory may take different forms . R epress ed memories may have been proces sed to some degree in narrative form, whereas diss ociated memories probably lack that more proces sing. T he latter form thus may be experienced nonpas t and nons elf, making the intrus ive retrieval of 210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 70 of 80

diss ociated memories a confusing and frightening experience. S tudies of the development of memory in children that the s hared cons truction of narratives about experienced events is often crucial in making the access ible to long-term retrieval. T he establishment of personal memory system appears to be a function of memory talk in which parents discus s with children the contents of their memory. In children who have been forced to keep traumatic events a s ecret, as may occur childhood abus e, the normal developmental process of narration may be blocked. T his may be an additional cognitive mechanism underlying the inacces sibility of some forms of childhood trauma to cons cious nes s in patients.

S ugges tibility K nowledge is olation, s uch as in dis sociation and repress ion, provides a theoretical s cientific explanation the underlying mechanisms that may lead to delayed recall of childhood trauma, but clinicians mus t also be aware of other cognitive proces ses that influence Numerous s tudies have demonstrated that the human mind is eas ily influenced. Human sugges tibility can be us ed to the benefit or detriment of others. S uggestibility adaptive for a s ocial being that relies on the others to inform its knowledge of the world and thus to increase its chance for survival. T hus, lis tening to the stories of others, reading a textbook, and being athletics all require the receiver to accept data from the sender. T he learner (lis tener) needs to trus t the the teacher (teller) to accept the incoming information. 211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 71 of 80

C ritical analysis of the data received is an important component of learning. T he metacognitive function of as sess ing the accuracy or us efulness of newly information may be s us pended under certain including hypnosis, drug-altered states , and conditions severe threat. S tudies of human s ugges tibility indicate that postevent questioning can bias the metamemory process es that determine the P.527 source and accuracy of a retrieved memory. T he verbal nonverbal cues given by the interviewer may influence person to believe that as pects of an event or an entire event that may have never happened actually took A person can be convinced of the accuracy of an event despite its lack of corres pondence with actual F actors that may influence the biasing of interviewees include a belief in the trustworthines s and authority of interviewer, not being aware that “I don't know” is a permis sible res ponse, repetition of a ques tion that has been ans wered, and the interviewer's beliefs as communicated through emotional tone and nonverbal gestures. It is crucial for clinicians to be aware of human suggestibility to avoid iatrogenic distortions. S imilarly, it important for persons who experienced severe trauma early in life to receive informed and empathetic evaluations and treatment. T here is a delicate balance between supportive neutrality and active advocacy in as sess ment and intervention. Awareness of these fundamental cognitive process es may help guide the 212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 72 of 80

clinician toward achieving that goal. Approaches to the treatment of patients with P T S D careful evaluation but generally include the view that impaired emotional process ing of the traumatic event requires the active recollection, in explicit terms , of the details of the experience. T he process of effectively treating unresolved trauma us ually involves the active cognitive process ing of s pecific memories, including emotional res ponses , derived belief s ys tems, and the ps ychophys iological arousal at the time of the event. T he provis ion of new cognitive information in the cours e of psychotherapy can, in theory, alter the configuration of the fear networks and can allow previous ly inaccess ible information to be explicitly proces sed and made available to conscious ness for incorporation into an ongoing autobiographical S pecific techniques , s uch as those which facilitate such cognitive process ing of previous ly diss ociated or in ways isolated cognitions, such as beliefs, images , and sens ations, may be us eful in alleviating the s ymptoms dysfunction after acute or chronic trauma. S uch and changes in mental process ing may diminis h the avoidant and intrusive components of the clinical syndrome of P T S D and may improve s ocial, emotional, cognitive functioning.

C omplex P TS D C omplex P T S D occurs in the context of prolonged and inescapable s tres s and trauma. It is complex becaus e extensive phys iological effects and its impact on all of development and functioning, es pecially if it occurs during early childhood. E nduring pers onality traits and 213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 73 of 80

coping s trategies evolving from traumatic s tates tend to increase the individual's vulnerability to future trauma. T his manifes ts in a traumatic resonance through engagement in abus ive relationships , poor judgment, a lack of self protection. Long-term P T S D has been to correlate with the pres ence of what are called ne urological s oft s igns , pointing to s ubtle neurological impairments . T hese neurological s igns could s uggest a vulnerability to the development of P T S D or reflect the impact of the long-term phys iological dysregulation caus ed by P T S D. When confronted with threat under normal the process es related to arousal and the fight-or-flight res ponse become activated; the threat is dealt with and soon pas ses . F or obvious reas ons , children are not equipped to cope with threat in this way. F ighting and fleeing may actually decrease their chances for because their survival depends on dependency. When child firs t cries for help, but no help arrives, or when trauma is being inflicted by a caretaker, he or she may from hyperarous al to dis sociation. T raumatized who are agitated may be misdiagnosed as having attention-deficit disorder, whereas the numbing in infants can be misinterpreted as a lack of sensitivity pain. T his may als o be true for women who are often unable to outrun or outfight male attackers . Until recently, surgery was performed on infants anesthes ia, becaus e their gradual lack of protest was mistakenly interpreted as insensitivity to pain, as to a traumatic reaction to it. R ecent s urvey res earch suggests that less than 25 percent of phys icians performing circumcis ion on newborns use any form of 214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 74 of 80

analgesia, despite physiological indications that are experiencing stress and pain during and after the procedure. T hes e practices appear to be a holdover of beliefs that newborns do not experience or do not remember pain. It makes sense that an appreciation for poss ibility of P T S D reactions in neonates and young children has lagged behind other areas . Dis sociation allows the traumatized individual to the trauma via a number of biological and proces ses. Increas ed levels of endogenous opioids sens e of well-being, pain reduction, and a decreas e in explicit proces sing of the overwhelming traumatic situation. P sychological process es, such as and depers onalization, allow the victim to avoid the of his or her s ituation or to watch it as an obs erver. proces ses provide the experience of leaving the body, traveling to other worlds , or immers ing oneself into objects in the environment. Hyperarousal and in childhood es tablis h an inner biops ychological environment primed to es tablish boundaries between different emotional s tates and experiences for a it is too painful to experience the world from ins ide body, s elf-identity can become organized outside the phys ical s elf. E arly traumatic experiences determine biochemical and neuroanatomical networking, impacting experience and adaptation throughout development. T he tendency diss ociate and dis connect various tracks of process ing creates a bias toward unintegrated information acros s cons cious awarenes s, s ensation, affect, and behavior. G eneral diss ociative defens es res ulting in an aberrant organization of networks of memory, fear, and 215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 75 of 80

the social brain contribute to deficits of affect attachment, and executive functioning. T he of thes e interdependent s ys tems res ults in many res ulting from extreme early stress . C ompulsive related to eating or gambling and somatization in which emotions are converted into phys ical can all be unders tood in this way. P T S D, borderline personality dis order, and self-harm can all reflect adaptation to early trauma.

FUTUR E DIR E C TIONS C ognitive s cience offers a breadth of for unders tanding the way in which the mind functions health and dis ease. T he broad interdis ciplinary field provides numerous research paradigms that are helpful further elucidating the nature of ps ychopathology techniques from the neuros ciences to computer brain functioning and biological applications of chaos theory. T he cognitive unders tanding of emotions and cons ciousnes s may als o expand psychiatry's knowing about human s ubjective experience. C linical tools , from medications to in-depth ps ychotherapy, may also find wider application as the process es of s elforganization and psychological change are better unders tood. P sychiatry, in turn, has much to offer the field of science. T he long history of descriptive and the attempt to s ynthes ize views of the mind and brain can provide nonclinical cognitive s cientists with unique data and relevant ques tions. P sychiatry is join in the s earch for understanding the cognitive proces ses of the human mind. 216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 76 of 80

P.528

S UG G E S TE D C R OS S P iaget and emotional development are discuss ed in 3.2, memory is dis cuss ed in S ection 3.4, cognitive are dis cuss ed in C hapter 10, s chizophrenia is C hapter 12, mood disorders are dis cuss ed in C hapter and anxiety disorders are dis cuss ed in C hapter 14. Dis sociative disorders are dis cuss ed in C hapter 17, and personality disorders are dis cuss ed in C hapter 23. therapy is discus sed in S ection 30.2, hypnosis is S ection 30.3, and cognitive therapy is dis cus sed in 30.6. Mental retardation is discuss ed in C hapter 34, disorders are dis cus sed in C hapter 35, pervasive developmental disorders are dis cuss ed in C hapter 38, ADHD is dis cuss ed in C hapter 39.

R E F E R E NC E S Andreas en NC : Linking mind and brain in the study mental illness es: A project for a s cientific ps ychopathology. S cience. 1997;275:1586. B addeley A: W orking memory: Looking back and forward. Nature . 2003;4:829. *C ozolino LC . T he Neuros cience of P s ychothe rapy: and R ebuilding the Human B rain. New Y ork: W .W . 2002. Damasio AR . Des carte s ' E rror: E motion, R eas on and Human B rain. New Y ork: P utnam; 1994. 217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 77 of 80

Douglas V I. C ognitive deficits in children with deficit disorder with hyperactivity. In: B loomingdale S ergeant J A, eds . Atte ntion Deficit Dis orde r: C ognition, Interve ntion. Oxford, UK : P ergamon 1988. F onagy P , S teele M, S teele H, Moran G S , Higgitt capacity to understand mental states: T he reflective in parent and child and its s ignificance for s ecurity of attachment. Infant Me nt He alth J . 1991;12:201–218. J ohns on MH, Magaro P A: E ffects of mood and on memory process es in depress ion and mania. B ull. 1987;101:28. J ohns on-Laird P N. Me ntal Mode ls : T owards a S cience of L anguage, Infe re nce and C ambridge, MA: Harvard University P ress ; 1983. K andel E R : A new intellectual framework for Am J P s ychiatry. 1998;155:457. K os slyn S M. Image and B rain: T he R es olution of the Image ry De bate . C ambridge, MA: MIT P ress ; 1994. Le Doux J . T he S ynaptic S e lf. New Y ork: V iking 2002. Lewis MD: S elf-organizing cognitive appraisals. E motion. 1996;10:1. MacLeod C . Mood disorders and cognition. In: 218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 78 of 80

MW , ed. C ognitive P s ychology: An Inte rnational C hichester, E ngland: W iley; 1990. Main M. Metacognitive knowledge, metacognitive monitoring, and s ingular (coherent) vs. multiple (incoherent) models of attachment: F indings and directions for future research. In: Marris P , Hinde J , P arkes C , eds. Attachment acros s the L ife New Y ork: R outledge & K egan P aul; 1991. Mesulam MM: R eview article: F rom sens ation to cognition. B rain. 1998;121:1013. *Metcalfe J , S himamura AP . Me tacognition: about K nowing. C ambridge, MA: MIT P ress ; 1994. Milner B , S quire LR , K andel E R : C ognitive and the study of memory. Neuron. 1998;20:445. Morris R G M, ed. P aralle l Dis tributed P roce s s ing: Implications for P s ychology and Ne urobiology. UK : C larendon; 1989. Osherson DN, S mith E E , eds . T hinking: An C ognitive S cie nce . V ol 3. C ambridge, MA: MIT 1990. *P os ner MI, ed. F oundations of C ognitive S cience . C ambridge, MA: MIT P ress ; 1989. R auch S L, van der K olk B A, F is ler R E , Alpert NM, S avage C R , F is chman AJ , J enike MA, P itman R K : A 219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 79 of 80

symptom provocation s tudy of P T S D using P E T and script driven imagery. Arch G e n P s ychiatry. 387. *S chore AN. Affe ct Dys re gulation and the Damage S elf. New Y ork: Norton; 2002. S iegel DJ : T oward an interpersonal neurobiology of developing mind: Attachment, “minds ight” and integration. Infant Me nt Health J . 22:67–96. S iegel DJ . An interpers onal neurobiology of ps ychotherapy: T he developing mind and the res olution of trauma. In: S olomon M, S iegel DJ , eds . Healing T rauma. New Y ork: Norton; 2003:1–55. *S iegel DJ . T he Deve loping Mind: T oward a of Inte rpers onal E xperie nce . New Y ork: G uilford; S igman M. W hat are the core deficits in autis m? In: B roman S H, G rafman J , eds. Atypical C ognitive Deve lopme ntal Dis orde rs : Implications for B rain Hillsdale, NJ : E rlbaum; 1994. S pringer S P , Deutsch G . L e ft B rain, R ight B rain. 5th New Y ork: W H F reeman; 1998. S teinhauer S R , G ruzelier J H, Zubin J , eds . S chizophre nia. V ol 5. Neurops ychology and P roces s ing. New Y ork: E lsevier S cience; 1991. T aber K , R ausch S , Lanius R , Hurley R : F unctional 220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 80 of 80

magnetic res onance imaging: Application to posttraumatic stress disorder. J Ne urops ychiatry Neuros ci. 2003;15:125. van der K olk B A: T he neurobiology of childhood and abuse. C hild Adole s c P s ychiatr C lin N Am. 2003;12:293. Watts F N, ed. Neurops ychological P e rs pe ctive s on E motion. V ol 7. C ognition and E motion. Hills dale, E rlbaum; 1993. Wheeler MA, S tus s DT , T ulving E : T oward a theory episodic memory: T he frontal lobes and autonoetic cons ciousnes s. P s ychol B ull. 1997;121:331.

221 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

01/01/2009

Page 1 of 121

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 4 - C ontributions of the S ociocultural S ciences > 4.1 T he S cientist and the P s ychoa nalys t

4.1 The Ps yc hiatric and the Ps yc hoanalys t Armando Favazza M.D. M.P.H. P art of "4 - C ontributions of the S ociocultural S ciences " B ehavior is determined by the interplay among a environment, life experiences, and biological C ulture is the matrix within which these psychological, social, and biological forces operate and become meaningful to humans; it is important for ps ychiatry, because it affects not only patients ' experiences of illness , but als o lay and profess ional theories of diagnostic procedures, and therapeutic approaches . C ulture is not a thing that a pers on has, but rather is an ongoing process created by s hared interpersonal experiences that reverberate throughout a s ociety and affect its institutions and the daily life of its members. Matter is neutral; molecules and energies are until they are pers onally interpreted, explained, and accepted as reality through the cultural proces s. Health and illness are cultural categories bas ed on universal biological events and culturally diverse bodily experiences that may be interpreted and acted on differently. S uppos e, for example, that a woman somewhere in the world experiences an enduring and difficult-to-control s ens e of apprehens ive expectations , 222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 2 of 121

tense muscles , irritability, and difficulty falling as leep. reaction to this complex of experiences depends on her culture. Does her culture provide a word or a cons truct to identify and to explain what s he is experiencing? S hould her experiences be cons trued as normal s uffering or as evidence of a moral flaw, a disharmony of inner energies , an exis tential crisis, deflected rage, nerves , or generalized anxiety What is the culturally accepted limit that she must before dis closing her experiences ? W hom does her sanction to receive her dis closures? G od, perhaps, or a priest, a congregation, a local healer, a televangelis t, a help group, a friend, a family member, a counselor, a phys ician, or a psychiatrist? T he remedies she may be offered—prayer, acts of contrition, increased group participation, change of diet, exercise, interes ting changing jobs, going on a vacation, family or marital couns eling, individual therapy, meditation, are culturally determined, as are the criteria us ed to the efficacy of the remedy.

C UL TUR E C ulture is a vast, complex concept that is us ed to encompas s the behavior patterns and lifestyle of a society—a group of pers ons sharing a s elf-sufficient system of action that is capable of existing longer than life s pan of an individual and whos e adherents are recruited, at leas t in part, by the s exual reproduction of group members . C ulture consis ts of s hared s ymbols, artifacts, beliefs , values, and attitudes. It is manifes ted rituals , customs , and laws and is perpetuated and in shared sayings, legends , literature, art, diet, religion, mating preferences , child rearing practices, 223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 3 of 121

entertainment, recreation, philos ophical thought, and government. C ulture serves many purposes. It overall cons is tency to a society's patterns and over the generations. It helps organize diversity and mediate between the forces of s tability and conformity and those of new ideas and actions . B y class ifying phenomena into good and bad, right and wrong, and s ick, desirable and undes irable, people are with behavioral guidelines and an interpretation of life's events. B ecause cultural components change at speed (for example, technological advances may a s ociety's capacity to deal with new ethical is sues), cultural s ys tems attempt to minimize s tres s. C ulture is learned through contact with family, friends, teachers, significant persons, and the media; the term this process is enculturation. It res ults in a personal belonging to one's own s ociety and in a native identity. E xcept, perhaps, for a few totally is olated, small s ocial groups , there are no pure cultures. S ocieties are not Acces s to printed media, radio, telephone, televis ion, easy travel, as well as geopolitical changes , has a great deal of cultural blending. Adults s uch as or refugees who only in part adopt the culture of a hos t society are said to be as s imilate d, whereas those who as sume a new cultural identity consonant with that of host culture are s aid to be acculturated. P ersons who, voluntarily or by force, abandon their native culture but to be ass imilated or acculturated usually lose their identity or purpos e in life and are at high ris k for subs tance abus e, and alcoholism. T he holis tic and functional concept of culture also for the exis tence of s maller subcultural groups and 224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 4 of 121

patterns within the larger society. Native Americans, for example, have distinct cultures, es pecially in tribal that live on reservations . On a smaller, les s scale, there are many subcultural groups and units in which there are s hared feelings , ideas , and behaviors , example, cults , neighborhood ass ociations , institutional inmates, athletic teams, s tudents and teachers at a and unions. Many s ubcultural patterns serve to and to integrate the general society, but s ome may be socially disruptive (organized criminal groups ) or truly destructive (terroris t organizations). E ach family may said to have its own microculture. Although the term culture is a grand abstraction that implies stability, homogeneity, and coherence, social life is often replete with change, heterogeneity, and inconsistencies . Anthropologists traditionally have been the major profes sional group to s tudy culture, whereas have studied P.599 social class . A culture is not the same as a s ocial class . Within every society, one may find the five levels described for social s tratification ranging from clas s I, characterized by high financial income, pres tigious occupations , and poss ess ion of des iderata, to clas s V , characterized by just the oppos ite. In a geographical one or more differing cultural systems may be present, each containing members of the five s ocial class es. such as the culture of pove rty and me ntal he alth of the are misleading, becaus e they imply that all members of lowest social clas s s hare a common culture. It may be that impoverished areas outwardly appear similar and 225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 5 of 121

slum dwellers s hare some common attitudes and patterns, but these s ocioeconomic phenomena s hould be confus ed with culture. Anthropologists and s ociologis ts have s eparate methodologies, and points of view. Anthropologis ts, for example, study acculturation, whereas sociologis ts migration. B oth of thes e proces ses s hare identical referents in many ins tances . Acculturation studies emphasize s mall-scale, non-Wes tern populations, contact between investigators and their subjects, and a focus on behavior itself; however, migration studies typically emphas ize sociodemographic variables, ps ychiatric us e rates , large W estern populations , and or no direct contact between investigators and their subjects . S ociologists do not have mus eums; anthropologis ts do—this reflects the anthropological concern for biology and artifacts , as well as for B oth sciences are pertinent to medicine, in general, ps ychiatry, in particular. Medical anthropologists s tudy the impact of proces ses on health and on people's experiences of es pecially by us ing cross -cultural comparisons. T heir studies on the lives of patients in mental hospitals and then, after deinstitutionalization, in the community have had direct clinical impact. More than any other medical specialist, ps ychiatris ts have developed expertise in unders tanding sociocultural proces ses and in using this unders tanding clinically. American psychiatric interest culture began in the mid-1800s when mental hos pitals admitted a large number of Iris h and G erman T oward the end of that century, E uropean ps ychiatris ts African, As ian, and C aribbean colonies described a 226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 6 of 121

of unus ual s yndromes s uch as latah, amok, and koro. R . R ivers , a B ritis h psychiatris t renowned for the field of s ocial anthropology, did research on healing and on the perception of pain in S outh P acific Is landers that he then us ed in treating mentally traumatized s oldiers in World W ar I. At the turn of the century, E mil K raeplin traveled from E urope to Asia, des cribed differences in s ymptomatology among patients, and developed the field of comparative ps ychiatry. S igmund F reud's psychoanalytic office was filled with archeological relics, and, as he dug through the layers his patients ' neurotic minds , he believed that he could recons truct past epochs of human behavior and Among the conclusions of his widely read books written between 1913 and 1938, T ote m and T aboo, T he Illus ion, C ivilization and its Dis contents , and Mos e s Monotheis m, are that culture and repres sion are reciprocally related and that the superego was socially created to control the dangerous human des tructive instinct. Many psychoanalysts , including Otto R ank, T heodor R eik, and C arl J ung, publis hed studies of and myth. G eza R oheim, E rik E rikson, and G eorge Devereux were ps ychoanalyst anthropologists with field experience. R oheim founded the series known as P s ychoanalytic S tudy of S ocie ty. He used his vas t of arcane cultural details to support his extreme ps ychoanalytical theories and then to twit his anthropological colleagues , whom he accused of obvious proof of the oedipal complex becaus e of their own repres sed conflicts. E riks on wrote psychocultural studies of Mahatma G andhi and Martin Luther. His 227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 7 of 121

experiences with Dakota and Y urok Indians ins pired C hildhood and S ocie ty, written in 1950, in which he the intrins ic wis dom and uncons cious “planfulness ” of cultural conditioning with the ongoing process es of individual psychosocial development. Devereux, with American P lains Indians, believed that s hamans caus ed a social remis sion in patients by repatterning ethnopsychologically s uitable defens e mechanis ms. In treating Mohawk Indian patients, he explicated such as dream interpretation and trans ferencecountertransference, which are encountered in clinical work with ethnically diverse populations . B ecause ps ychoanalys is developed from the s tudy of the its application to cultural phenomena is at least one removed and is open to ques tion. Als o, the concepts of mind and mental process es may not be applicable or meaningful when applied to non-Wes tern groups . T he trend among some ethnopsychoanalysts attend to informants' explanations of their behavior and synthes ize ps ychological and sociocultural exemplified in R obert LeV ine's work and in articles published in the J ournal of P s ychoanalytic and in P s ychiatry, a journal founded by Harry S tack with the as sistance of E dward S apir, a cultural anthropologis t. Modern cultural psychiatry began in 1955, when a T ranscultural P s ychiatry Divis ion was started at McG ill Univers ity in Montreal with the leadership of E rick Wittkower and H. B . M. Murphy. R aymond P rince and, recently, Laurence K irmayer have continued leading Divis ion, including publication of the journal P s ychiatry. In 1971, a T rans cultural P s ychiatry section 228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 8 of 121

es tablis hed in the W orld P s ychiatric Ass ociation; recent directors include W en-S hing T seng, a C hines ewho wrote the first truly comprehensive Handbook of C ultural P s ychiatry in 2001; W olfgang J ilek, an C anadian with extens ive experience in working with refugees in S outheast Asia and Africa; and G offredo B artocci, an Italian who has vitalized E uropean cultural ps ychiatry and who has published in the area of the United S tates , the journal C ulture, Me dicine and P s ychiatry was es tablis hed in 1976 by Arthur prominent cultural psychiatric researcher, and B yron a medical anthropologis t. T he S ociety for the S tudy of P sychiatry and C ulture was founded in 1979 by F avazza, E dward F oulks , J ohn S piegel, J oseph Wes termeyer, and R onald Wintrob. S imilar exis t in C hina, G ermany, Italy, J apan, and the United K ingdom.

C UL TUR E A ND THE HUMA N Wes tern science now locates the construct of mind in brain; in past times, it was linked with the heart, the and other organs . J us t as s ome body parts can be through us e patterns —for example, physical exercis e affects mus cle strength and s ize—so too can the neural network be modified. R epetitive thoughts , sounds, s mells , tastes, and touches tend to increase specific neuronal dendritic connections and to intensify neurotransmitters, so that certain sensations and become phys ically patterned in the brain. T he ability to speak a particular language, for example, depends on culture-specific neural organization that influences cognitive process ing and creation of cognitive schema as to structure a pers on's perception and experience of 229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 9 of 121

world. C ulture exerts a great influence on the birth, development, and death of the human body. T wo New G uinean tribes, the E nga and the F ore, provide an of how culture may affect fertility. T he E nga, who live in state of chronic overpopulation and have reached the upper limits of s urvival for their territory, have cultural patterns that s erve P.600 to limit population growth. P remarital s ex is forbidden, celibacy is highly valued, and inces t taboos are broad; woman cannot marry any man related through men to paternal grandfather. Men cannot marry until they are years of age; on the death of a man, his widow is or s trangled to death. Infanticide is practiced, and not a caus e for anguis h. In contrast, the F ore live in an underpopulated area, and their cultural practices serve increase population growth. S exual experimentation early marriage are encouraged, widows are inherited the dead hus band's male relatives, tribal ceremonies erotic elements, and death caus es great communal anguis h. In large, complex societies , fertility rates are affected by monetary incentives, for example, taxation encourage or to discourage large families . In C hina, government policies to lower population growth reportedly have included forced abortion and even infanticide. In Italy, the exceedingly low birth rate secular culture s hift away from the C atholic church's traditional stance that birth control is sinful. C ulture als o affects the ways in which the body is Hunger could be eliminated if all food s ources were but the people of W estern nations are unwilling to eat 230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 10 of 121

cats, dogs, rats, beetles , and grubs . Dietary and food process ing may affect mental status ; pellagra its as sociated dementia are caus ed by a niacindiet. In 1912, J os eph G oldberger discovered that in the American S outh was caus ed by the removal of from corn during the milling proces s. C orn is currently the center of a great s ocial debate over genetically modified foods; proponents argue that genetically modified corn is safe to eat and produces prodigious yields, whereas opponents refer to it as F ranke ncorn call for more tes ting before it is allowed into the marketplace. B eyond its s cientific merit, this debate reflects the cultural conflict between traditionalis m and progres sivis m and mirrors other contemporary cultural clas hes over s uch disparate topics as homos exuality, abortion, global warming, and creationism. P roblems ass ociated with the drinking of alcohol greatly on culture. T he C hines e have a low rate of alcoholism, whereas the J apanese have a high rate of alcoholism. B oth groups contain many pers ons who an unpleasant “flush” reaction to alcohol, but the low alcoholism rate in C hina appears to be the res ult of a cultural emphas is on moderation and s elf-control, low res pect for problem drinkers, the ass ociation of and eating, and a traditional belief in the medicinal of alcohol. Deviant and culturally s anctioned behaviors that alter destroy body tis sue are found in all s ocial groups. Mos t body modification practices are performed to promote beauty and to enhance s exuality, to s ignify a particular group, or to express rebellious ness and individuality; examples of these behaviors are earlobe 231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 11 of 121

piercing to affix jewelry, ins ertion of nipple rings , tattoos identify gang members, and a s imple tattoo on the T he widespread fad of body piercing and tattooing in Wes tern nations has no particularly significant meaning other than, perhaps , a diss atisfaction with an bureaucratic and computer-driven society in which are identified by numbers and in which artificial are replacing “the real thing,” for example, chemical organic s ubs titutes and vitamins in pill form. Although a group of persons who have modified their bodies (excluding s ingle earlobe piercing) probably would more psychopathology than a control group, a diagnosis cannot be inferred simply by the presence of tattoos or piercings. B ody modification rituals, unlike fads and practices , are socially functional, integrative, adaptive, and enduring cultural components . P articipants believe that the promote health, heal pathological conditions, maintain social s tability, enhance s pirituality, and provide for religious salvation. B ody modification rituals for promoting health and illness often focus on the importance of blood. Many native tribes in P apua New G uinea, for example, womb blood to be a pathological s ubs tance that in the circulatory s ys tem of adults . Mens truation allows women to purify thems elves naturally, but men must res ort to periodic penis cutting, tongue abras ion, or hemorrhages. T hrus ting sharp, stiff grass into the once a month induces copious nas al bleeding, thus supposedly eliminating womb blood. Members of the Hamads ha, a Moroccan S ufi healing s ect, believe that healers poss es s a s acred force known as baraka that 232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 12 of 121

promote health and cure mental and physical illnes ses caus ed by jinn s pirits. Afflicted patients gather in a and the healers enter into an ecstatic trance induced rhythmic music and wild dancing. T he healers then open their heads. P atients acquire the healer's baraka eating sugar cubes or bread bits dipped into the flowing blood or by s mearing thems elves with the blood. B ody modification rituals frequently also serve to social s tability; they may help to define group and adult status, to control gender-linked behaviors, to solidify social bonds . E laborate patterns are carved the flesh of T iv (Nigeria) females on reaching puberty. scars repres ent the T iv family, heritage, land, genealogy, and myth, and they duplicate the on sacred objects. T his scarification ritual transforms girl into a woman and into a sacred object on whom the group's fertility depends . In some cultures in which sexuality is cons idered problematic, body modification rituals have been es tablis hed to control women's In an analogy to a ps ychodynamic formulation in which morbid symptom s erves to bind conflict-caus ed anxiety an individual, thes e rituals with their consequent ps ychological, and s ocial morbidity s erve to bind communal anxiety in societies in which s exual conflicts have the potential to disrupt the male–female T hrough the practice of foot-binding, for example, men literally prevented their women from “running around” by crippling them. G irls' feet were tightly bound with bandages to keep them from growing; the flesh became infected, and, s ometimes , one or more toes sloughed off. T he pain lasted for almos t 1 year and diminis hed when the feet became numb. Men extolled 233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 13 of 121

beauty of the “lotus foot” and cons idered it erotic. women with bound feet could not walk any distance without the help of attendants , men could be s ure of whereabouts . T he practice exis ted for a millennium and ended in the 1920s . A more direct approach to the of female sexuality involves genital modification of girls in S udan and S omalia and parts of E thiopia, K enya, and Nigeria. S imple circumcis ion involves off the clitoral prepuce; excis ion involves als o removing the tip of the clitoris. Infibulation involves removal of the clitoris, the labia, and mon veneris ; the vagina is then shut except for a small opening. Immediate or early medical complications include infection, urinary urethral and anal damage, and hemorrhagic shock or death. Long-term morbidity includes chronic pelvic urinary tract infections, dermoid cysts and absces ses , dyspareunia, and complicated childbirth. An infibulated woman is marriageable, becaus e s he is a guaranteed virgin. E xcis ion of the sensitive clitoral area is done to attenuate the woman's sexual desires and to free her personal lus t. Uncircumcis ed women are regarded as unclean and not worthy of being a wife and a mother; Arabic word tahur refers to purity, cleanlines s, and circumcis ion. T he rituals are perpetuated, in part, becaus e marriage motherhood are often the only s ocial roles available to women; attempts to ban them have been modestly succes sful. C ircumcised women who move to cultural settings in which the experience of pleasure in females cons idered desirable may become clinically depres sed P.601 234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 14 of 121

when they realize that an important part of their has been cut away. In many cultures , es pecially ones, dis comfort with female sexuality is evident; a rationalization for this discomfort is that untamed sexuality caus es men to act irrationally. T he path to enhanced s pirituality and religious often involves body modification. In the index ritual of P lains (American Midwest) Indians, the stronges t of the braves , while tethered to a rope affixed to s kewers in ches ts, danced, gazed at the s un, and ripped through muscles in a s truggle to be free from the s nares of the flesh. S evere s elf-flagellation occurs in S hia Islam and C hris tianity. T he C atholic church has canonized many saints who zealously mortified their flesh; s ome “holy” anorectics. In the E as tern Orthodox mys tical tradition, the beardles s, corpulent 18th and 19th castrated themselves to achieve the purity of the firs t Adam, before he ate the forbidden fruit, which G od supposedly grafted onto his body as testicles. In R ome and the Middle E ast, the s elf-emas culation of who was unfaithful to the G reat Mother G oddess , was memorialized annually in the ritual of the Day of when cult pries ts flagellated themselves and cut off genitals; the emperor J ulian called it “a holy harves t.” In Hindu T haipusum festival, many persons pierce their bodies with replicas of Lord Murugan's magic trident. An appreciation of the purposes s erved by culturally sanctioned body modification rituals helps demys tify seeming senseles s deviant s elf-mutilation of the ill. As stated by E dward P odvoll: T he self-mutilator can incorporate into his actions which, to a greater or less er degree, remain 235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 15 of 121

in most of us . T hat is, s uch patterns already exist in intens ities within the patient's s ocial field.… S till the patterns involved are those which elicit s ilent levels of admiration and envy. T he history of these images as far back as the pass ion of the cross and has among some of the most res pected members of our culture. B ody modification rituals and deviant self-mutilation are not alien to the human condition; rather, they are culturally and psychologically embedded in the elemental experiences of healing, social s tability, and religion. T hes e acts acknowledge disruptions within the individual and the collective social body and provide a mechanism for the reestablishment, however brief, of harmony and equilibrium. T he self-inflicted cuts of Wes tern adolescents are not so different from those experienced during the rite of pass age by aboriginal initiates , blood brothers des perate to achieve social acceptance and integration into the adult world.

C UL TUR A L IDE NTITIE S T his s ection deals with three types of identity that as sume or have thrust on them, namely, race, and charis matic group members hip. Among the many other identities that are greatly influenced by culture those ass ociated with age and gender.

R ac e and R ac is m In standard medical cas e presentations, psychiatrists identify patients by age, gender, marital status , occupation, race, and, s ometimes , ethnicity. R ecipients such information immediately proces s it, cons cious ly 236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 16 of 121

unconsciously, and make certain as sumptions. Of concern to cultural ps ychiatry are ass umptions bas ed race or ethnicity, because both of thes e cons tructs are emotionally evocative that they may distort the and therapeutic process . A characteristic of human beings is to compare to other persons for reasons of enhancing s elf-es teem for setting behavioral boundaries. T he comparative is us ually found lacking in one regard or another. T he ability of a group to perceive flaws in a different group so prodigious as to encompas s every aspect of such as political systems , s kin color, religious beliefs , practices , and gender. R elationships between so-called superior and inferior groups range from friendly rivalry enslavement, from covert hostility to mass murder. Depending on the place and time, men have women, whites have dis paraged blacks, free persons disparaged s laves, the rich have dis paraged the poor, heteros exuals have dis paraged homos exuals ; the complete list of superior-inferior polarities is discouragingly long. W hen cultural patterns based on perceived superiority and inferiority continue over generations, their pers is tence may be thought to reflect natural order that culture then s erves to protect. rationalizations , as well as political expediency, are us ed to perpetuate polarities , for example, men have denied suffrage to women in the belief that they s hould tend to cooking, children, and church activities rather deal with political iss ues that are far too complicated for them to unders tand. T he F ounding F athers of the S tates wrote a C ons titution and B ill of R ights that all men are created equal and have a right to 237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 17 of 121

happines s, yet slavery was common at the time in the northern and s outhern s tates. Healthy cultures have capacity to change their s ocial patterns in res ponse to ideas , desires, and technologies; change may come gradually, es pecially when many of the perceived group members come to believe that they are truly inferior, or it may come rapidly with forceful rebellion civil war. T he notion that pers ons can be categorized by race has been abandoned by mos t scholars but universally in the general public. P hysical traits , skin color, are the mos t common lay markers of bas ic divis ions into white, black, red, and yellow races . the 1950s , some anthropologis ts class ified the races C aucas ian with Nordic, Alpine, and Mediterranean Mongoloids with Mongolian, C hinese, J apanese, V ietnames e, and T ibetan groups ; Malays ian and Indonesian; Native Americans ; Negroids with Negro, Melanes ian, Negrito, B ushman, and Hottentot groups; Aus traloids . Deoxyribonucleic acid (DNA) tes ting demonstrates the fallacy of racial divisions, becaus e great majority of human alleles are pres ent in all population groups , although their frequencies vary; genetic variability within populations is greater than the variability between them. Moreover, s kin color, hair nose shape, and other physical traits are independently inherited and are not linked one to another. T he saving grace of ancient beliefs about different was the provision of methods for overcoming alleged faults . B arbarians could gain acceptance from G reeks learning to speak and to write the G reek language. B y religious conversion, R omans and J ews could join the 238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 18 of 121

C hris tian community. Modern forms of differentiation, es pecially those bas ed on the flawed biological of race, however, rarely permit the inferior group to ris e the s tatus of the superior one. Modern racis m began in 15th century S pain, where C hris tians were divided into old and new groups. Old C hris tians had “purity of blood,” whereas the new converted J ews —was hounded by the Inquis ition. On biological grounds, J ews , and later Mus lims, were incorrigibly inferior and therefore were excluded from mains tream S panish society. In the New W orld, conquerors brutalized and enslaved the local to mine for gold; their justification came from s ome theologians who declared that Indians lacked rationality and morality and therefore were, in Aristotelian terms , “natural slaves.” Als o, the famous physician, determined that Indians were s oulles s, inferior beings because they P.602 had not descended from the biblical Adam. A great ensued, and, in 1537, P ope P aul III ruled that “the are truly men.” However, economic interests prevailed, papal declaration was ignored, and harsh slavery continued for several hundred years. B efore the 17th century, there was no tradition of whitenes s among E uropeans or of blacknes s among Africans. Distinctions among groups of people in the in G reek and R oman histories , and in the writings of P olo who traveled from Italy to C hina were made on basis of food preference, cos tume, political s ys tems, rituals ; s kin color was not mentioned. W hite and black 239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 19 of 121

became cultural categories in the 17th century when transatlantic slave trade was developed to stock colonies in the New World. E uropeans and Americans exploited local populations participated in the s lave trade for economic profit. R ationalizations for thes e practices came from philosophical, and then-current scientific theories. (many B ritish referred to all nonwhite pers ons as supposedly were curs ed by G od as des cendents of an Old T estament biblical figure who s aw his father T he S cottis h utilitarian philosopher, Dave Hume, wrote that only white pers ons were capable of creating nations and of producing ingenious manufacture, art, science. During the E nlightenment, the E nglis h philosopher J ohn Locke s upported the degeneracy namely, that the normal natural s tate of human beings typified by the white E uropean and that other races of men developed through biological and psychological degeneration. S cientis ts noted that white was the true color of nature and that the degenerative process persons of different colors might be reversed through expos ure to E uropean culture. Nonwhites were be ps ychologically flawed and unable to rule as demonstrated by the ease with which E uropean colonialis ts s ubjugated vas t areas of the world. E ven as 1963, a noted B ritis h historian took the position that, although black Africans have darkness , only have a history in Africa. In the United S tates, a 19th century profes sor of named S amuel Morton measured the cranial capacity various s kulls by filling them with peppercorns. He that the cranial capacity was unchanged for at leas t 240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 20 of 121

years and was largest for whites , followed by Asians , Americans , and Africans. T his finding was confirmed in 1906 by R obert B ean, P rofess or of Anatomy at T he Hopkins Univers ity in B altimore; bas ed on brain size, reported that Negroes have well-developed lower faculties , s uch as smell and melody, whereas whites well-developed higher faculties, s uch as s elf-control reason. In 1856, a S outhern psychiatrist coined the diagnostic term drapetomania, which was applicable to slaves and cats who had an irres trainable propensity to away from their mas ters . Another diagnos is given to slaves was dys oe s thes ia oe thiopica; s ymptoms idleness , s loth, careless nes s when driven to work by compuls ive power of white mas ters , breaking tools, not paying attention to the rights of others . A 19th scientific theory that became ins titutionalized in the of southern states was based on the trans miss ion of heredity in blood from parents to offs pring. P arental supposedly blended in the offs pring; thus , children received one-half of their nature from each parent, onefourth from each grandparent, and s o on. T his belief ris e to such words as half-bre e ds , quadroons , and octoroons . B lack blood was considered to be more than white blood; a pers on with even one drop of black blood was class ified as negro. T he blood theory is scientifically baseles s. G enes undergo neither blending contamination. At the turn of the 20th century, American psychiatrists published articles in pres tigious journals suppos edly demonstrating that the lower rate of mental illness slaves, as compared to blacks in the free s tates, that s lavery protected the mental health of blacks 241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 21 of 121

of the supervision they received. One study in 1914 concluded that the negro mind is irrespons ible, unthinking, easily aroused to happiness , and rarely experiences depres sion. A W orld Health Organization (W HO) monograph in 1953 perpetuated the myth that black pers ons rarely experience depres sion; the same author noted that Africans are like leukotomized E uropeans, thereby “proving” that Africans did not use the frontal lobes of their brains . In his writings on the collective C arl J ung noted that the brains of blacks probably have whole historical layer less than E uropeans; he also that “racial infection” exercised a tremendous pull on white persons who are expos ed to blacks . S ome educational psychologis ts, namely Lewis T erman, in and Arthur J ens en, in 1969, claimed that racial genetic factors accounted for low s cores by blacks on tes ts . F rantz F anon, a black ps ychiatrist from who studied in F rance and then actively participated in 1950s ' Algerian revolution against F rance, angrily concluded that the color black symbolizes evil, sin, wretchednes s, death, war, and famine in the collective unconscious of Western thought. A trend in many Wes tern societies is the replacement biologically based racis m by s ocial theories and policies that often are meant to attenuate racism but actually may wors en it. A psychodynamic s tudy of 25 American blacks in 1951 cons idered the legacy of to be family dis organization, low self-es teem, pass ivity, and a wretched internal life. Other s tudies negatively out the matriarchal s tructure of black families in the S tates and B ritain, as well as the ps ychological 242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 22 of 121

emas culation of black males . S uman F ernando, a B ritish cultural ps ychiatris t, notes : T he arguments are bas ed on a naive view of human development where negative experiences are ass umed lead to personality defects . T he lack of cohesion of family life and the pas sivity of black people are clearly deductions made by whites. B lack experience is looked from the outside; the fact that oppress ion may uplift as well as depres s s elf-worth and may promote as well as destroy communal cohesion is not cons idered. After all, this argument is applied to the J ewish people, of pros ecution s hould have left them incapable of any leadership quite apart from being able to establish a political s tate. In studying American immigrants, F ranz B oas , the of modern anthropology, found that the head shapes of second-generation children were more like those of dominant, es tablished Anglo-S axon Americans. F or this proof of the plasticity of physical traits clearly contradicted biological theories that claimed that racial groups had fixed physical and, by extrapolation, fixed ps ychological and personality characteris tics. Despite and other evidence debunking the s cientific validity of race, racial prejudice exis ts throughout the world. In the Wes t, it is us ually directed against pers ons of color. P igmentation s uppos edly indicates deficiencies ranging from intellectual capacity to morality to the capability for experiencing normal emotions. R acism is s o culturally embedded in s ocial structures that even rational, wellmeaning persons are not only affected by it, but als o often amazed and taken aback when the racial undercurrents of their behaviors are pointed out to 243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 23 of 121

P sychiatrists are probably les s racis t than mos t groups , but they are not immune from bias es . S tudies show that white ps ychiatris ts dealing with black are more apt to diagnos e s chizophrenia, to prescribe higher dos es of tranquilizing medications, to fail to recognize depres sion, to us e involuntary commitment more frequently, to extend hospital stays , and to ps ychotherapeutic treatment. T he S urgeon G eneral's supplemental report, Me ntal H ealth: C ulture , R ace and E thnicity, concluded that the rates of mental illnes s are similar for African Americans and whites who live in a community; rates are much higher in vulnerable populations in which African Americans are P.603 overrepres ented, s uch as the homeless , prisoners , and children placed in foster care. Mentally ill African Americans are less likely than whites to receive treatment. T hey tend to seek help in primary care and, because they often delay s eeking treatment until their symptoms are more severe, in emergency rooms and ps ychiatric hos pitals . E ven African Americans with adequate insurance coverage are les s inclined to seek ps ychiatric treatment. T he report notes that the legacy slavery, racism, and discrimination continues to African Americans' s ocial status , economic s tanding, health-related behavior; additionally, there is a lack of African-American mental health s pecialis ts. In practice, patients are customarily identified as black or white; with other s kin colors typically are identified by In E uropean-American s ocieties , the revelation that a patient is white is relatively meaningles s and, in fact, 244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 24 of 121

us ually is proces sed as meaning that the patient is not black. On learning that a patient is black, ps ychiatris ts infer that the patient has been victimized to s ome by institutional and personal racism. However, the emergence of a s ubs tantial black middle class , as well high-profile leaders in the pas t s everal decades , along sociopolitical changes, has challenged the concept of a typical black cultural experience. White psychiatrists , in dealing with black patients, must confront their own countertransference and must be attuned to the actual perceived, and unperceived, impact of racial prejudice patients' lives, s ymptomatology, and prognosis.

E thnic Identity E very pers on ass umes multiple roles in the cours e of a lifetime. Infants, for example, mature through adulthood, and old age. P eople also develop personal, family, and group identities that change with circums tances , s uch as remarriage, relocation to a region, religious convers ion, or s witching vocations. E thnicity is a type of group identity based on cultural heritage, including place of origin, cuisine, cos tume, language, and rituals. Unlike the ps eudos cientific biological concept of race, ethnicity is a purely cultural identification that denotes connectednes s to other persons who claim the same identification. T he feelings of connectedness may fluctuate widely as and their s ocial context change. In times of extreme duress , for example, people may deny a certain or they may embrace it fervently, depending on is more psychologically and s ocially advantageous. G overnmental and other programs may reward or persons who select a certain ethnicity. E thnicity is a 245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 25 of 121

phenomenon. It may be a caus e of great s tres s in immigrant families , es pecially when parents cling to the “old ways ” while their children come to identify more host cultural groups . B arriers to interethnic marriages decreasing, especially in W estern countries ; a pers on marry into an ethnic group and adopt its identity. T he children of parents who are Mexican and American decide to identify thems elves initially as Mexican, American, Mes tizo, C hicano, Latino, or Mexican these self-identifications may change over time. T he concepts of race and ethnicity may be Adolf Hitler combined G erman ethnicity with a Aryan race to promote a Nazi s ociety. He s elected two ethnic groups , J ews and gyps ies, for extermination. history of the world is filled with examples of who have exploited ethnic pass ions, even to the point genocide. S ome persons, becaus e of their s kin color phys iognomy, may be stuck with a racial designation makes it difficult, if not impos sible, to change their ethnicity. J oseph Westermeyer studied American Indian mental patients reared in non–American Indian foster, and group homes in Minnesota. As children they developed ethnic identities, s uch as rural, NorwegianAmerican, Lutheran, s mall-town G erman-American C atholic, or urban S cotch-American P res byterian. T hey referred to American Indian people as the y instead of P roblems arose during adoles cence when society to accept their non–American Indian ethnicity. rejections by the s ame ethnic groups with whom they shared values, attitudes, and behaviors gave ris e to and attempts to reject their ethnicity. T hey were red on 246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 26 of 121

outside and white on the inside. T he psychiatric they developed—the apple s yndrome —included alcoholism, drug abuse, s uicide attempts, chronic panic attacks, depres sion, and legal and behavioral problems . All thes e s ymptoms were far in excess of might be expected in persons reared in fos ter, group homes. Mos t of the syndromic patients tried to as sume an American Indian ethnic identity by wearing traditional clothes, adopting American Indian drinking behaviors , and marrying American Indian spous es. attempts usually resulted in failure, and their symptoms became chronic. S ensitivity to ethnicity facilitates accuracy in evaluation and s ucces s in treatment. However, it is pos sible to be overly s ens itive and to mis interpret psychopathology as some sort of ethnic quirk. In uncertain s ituations, the as sistance of pers ons familiar with the patient's sociocultural s tatus s hould be obtained.

C ulture and P ers onality T he culture and personality s chool of anthropology, influenced by ps ychoanalys is and influential in the mid-20th century, attempted to link individual with various identifications , es pecially ethnicity. R uth B enedict's popular book, P atte rns of C ulture , written in 1934, held that cultures were really the summation of individual psychologies over a long time span. S he thought that persons with normal personality types are those who conform to a s ociety's dominant cultural configuration, whereas de viants do not, although s ome deviants might be cons idered normal in a different, congenial cultural s etting. T his formulation is applicable 247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 27 of 121

homos exuals who can lead normal lives in many large American cities but who might be tormented and cons idered deviant in rural towns . In the mid-20th century, anthropologists and s ome ps ychiatris ts developed the concept of national T he personality of R us sian peas ants was supposedly characterized by depres sive and manic traits that from the practice of fairly s evere s waddling of infants farm-worker mothers; the arms were tied close to the with tight cris scross lashing, and the infant was a blanket, so that only its face was visible. Depress ion linked to the impotence experienced in s truggling the swaddling bandages ; mania was linked to orgiastic R us sian feasts and drinking bouts that exemplified the feeding and love that accompanied the removal of bonds . T he rage caus ed by s waddling led to later guilt feelings, such as thos e express ed in Dos toevsky's T he celebrated expres sivity of R uss ian eyes was the of restricted infant mobility that perforce emphasized vision as a means of contact with the world. S uch in the nurs ery” studies were criticized for their reductionism. It als o became apparent that findings were biased, as is evident when the American military commis sioned national character studies of enemies in World W ar II. J apanese brutality was said to res ult from severe toilet training practices , G erman culture was described as paranoid and neurotic, and the hars hsounding G erman language was s een as the of a crude mentality. A 1997 s tudy grouped the of the American national character into six clus ters : reliance, autonomy, and independence; communal volunteerism, and neighborly cooperation; confidence 248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 28 of 121

the trus tworthiness of others ; openness to new experiences ; antiauthoritarianism; and the equality of justice for everyone. T he American national character doubtless ly would be delineated differently from a E as tern or As ian pers pective. Although national stereotypes may contain a kernel of truth, there is more pers onality variability within a group than there is among different groups. T raits perceived to be peculiarly P.604 G erman, F rench, or Italian turn out, in reality, to be generally human, Occidental, or continental E uropean. current cons ens us is that a clinically meaningful about an individual's personality cannot be made on basis of nationality alone.

C haris matic G roups T he proces s of conversion—the des truction of the old and the cons truction of a new self with new cognitive frameworks and behaviors—can take many pathways. naturalis tic settings, the process us ually involves incubation, s teps forward, and backs liding. Artis ts , and others have written about their convers ion after enduring “a dark night of the soul.” In 1934, B ill W ils on, an alcoholic stockbroker and a cofounder of Alcoholics Anonymous (AA), was for depress ion. He was not a s piritual pers on but cried in des pair for G od to show himself. S uddenly, the room up with a great white light, and he was caught up in an indes cribable ecstasy. He pictured hims elf on a in a s piritual windstorm and realized that he had 249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 29 of 121

free man. As the ecstasy subsided, he experienced a world or cons cious nes s. All about him and through him there was a wonderful feeling of the pres ence of G od. great peace came over him, and he thought that, no matter how wrong things s eem to be, they are all right. was reass ured by his ps ychiatris t, W illiam S ilkworth, his experience was not the res ult of a brain damaged alcohol. Wilson's life changed for good when he dis covered J ames' book, T he V arie tie s of R eligious E xpe rience . In learned about the ecs tas y that accompanies religious conversion and the hopeless ness that often precedes change. T he book pres ented many case histories , including that of a homeles s, friendless , dying drunkard who became an active and us eful rescuer of alcoholics after his convers ion. J ames described the s pecial of the state of ass urance that accompany convers ion; a sens e that all is ultimately well, a s ens e of perceiving not known before, and an internal and external s ens e clear and beautiful newnes s. W ils on talked about the hopeless nes s of his condition and his subsequent conversion with a friend. F rom thes e talks, he imagined chain reaction among alcoholics in which the mess age about the poss ibility of change would be s pread. Of special concern to society, in general, and to ps ychiatris ts, in particular, are those convers ions of that occur when young adults, us ually between the 15 and 30, are indoctrinated into charismatic groups us e duplicitous methods, have a totalis tic philos ophy, are as sociated with ps ychological and social morbidity. What distinguishes charis matic groups from other clubs , and ass ociations is their strict control over 250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 30 of 121

behavior and the belief that their leaders or mis sion poss ess es a trans cendent power. C lass ification of groups is problematic, becaus e they may overlap with benign, fringe groups, and becaus e they may be as progres sive in certain cultural settings. Mark includes among these groups cults, zealous religious some highly cohes ive s elf-improvement groups, some political action movements, and terrorist groups. C harismatic groups may be s mall (the S ymbionese Liberation Army of the 1960s had less than a dozen members) or large (R everend S un Myung Moon's neoC hris tian Unification church has thous ands of R ecruiters for these groups cas t a wide net in the hope gaining a few new members. T here is no way of personality type who responds to the bait, although a study of recruits to the Divine Light Mis sion (Hare cult found that 30 percent had previously s ought ps ychiatric help. Many recruits s eem to be quite normal albeit naively idealistic and trusting. S ome may be disillusioned with life, frustrated by romantic failures, and unhappy with s chool. Other vulnerabilities include loneliness and a sense of disorientation that be apparent in newly arrived college s tudents , and runaways. T hey often feel flattered when by a recruiter, often of the oppos ite sex, who offers friends hip, convers ation about s ocial injustices and meaning, and an invitation to attend a meeting or s tudy group. P ersons usually do not know that they are being recruited or the name and purposes of the group. T hey greeted warmly by the group and only hear vague generalities. T hey are then invited to intens e retreats that may las t s everal days, during which they 251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 31 of 121

overwhelmed with attention, exposure to nons pecific laudable generalities on the need for more s elfand s elf-improvement in the world, and joyful of the love and acceptance that group members have one another. T he emotionality of those few days may powerful that the recruits may experience a convers ion, although they are still unclear about to what they are converting; may accept new beliefs ; express high commitment; and develop a sense of well-being that follows a brief dis sociative epis ode. F as cination turns to reliance as recruits continue their indoctrination and s lowly learn the nature and purpos es the group to which they now belong. Any potential res is tance is prevented by a number of techniques, including decreased and eventual total lack of contact with family and friends, participation in many group activities so as to leave no free time and to create the confes sion of doubts to the group in “struggle sess ions,” and the induction of altered cons cious nes s through meditation, chanting prayer s es sions , or drugs . Louis J . W es t described a cult indoctrination s yndrome includes the following features: 



Dras tic alteration of the victim's value hierarchy, including abandonment of previous academic or career goals. T he changes are often s udden and catas trophic, rather than the gradual changes that might res ult from maturation or education. R edirection of cognitive flexibility and adaptability. V ictims answer ques tions mechanically, cult-specific res ponses for what their own reasoned answers might have been. 252

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 32 of 121









Narrowing, blunting, or artificiality of affect. T he may appear emotionally flat and lifeles s or almost frantically cheerful and ebullient. R egress ion. V ictims become childishly dependent the cult leaders, who are expected to make for them. S ometimes there are phys ical changes , s uch as or weight loss , with deterioration in the victim's phys ical appearance, s trange or mask-like faces, stares , or darting, evasive eyes. C lear-cut ps ychopathological changes may appear, including depres sion, dis sociative phenomena, states , obsess ional ruminations , delus ional hallucinations , and various other psychiatric s igns symptoms.

T he disconnection between the “everything's fine” selfperceptions of group members and the perceptions of them by their family members and friends is s triking tes tament to the power of the group. Members their autonomy and their worldly poss ess ions in for a s ens e of being protected. T hey abandon their independence and conform to the group's behavioral norms in return for a sense of well-being and G alanter has described the relief effect that motivates persons to remain with the group: T he relief of neurotic distress depends on the affiliated commitment of the group members . Attempts to leave the group res ult in increased distress . T his can even be seen in members of AA who P.605 253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 33 of 121

become irritable and uncomfortable when they mis s meetings . T he group fosters dependency and group identity, becaus e it then becomes the agent of relief. effect can be seen in what is called the S tockholm s yndrome : Hos tages whos e lives are in deadly peril for period of time become s o dependent on their captors they then may identify with them, come to support their caus e, and even attempt to thwart res cue attempts . T he leaders of charis matic groups often lie to members maintain group morale and to negate unfavorable comments made by outs iders. T hey s olidify the group's boundaries when they feel threatened; techniques staring vacantly as a respons e to outsiders ' ques tions aggres sively counterattacking perceived enemies . the xenophobia of a leader turns to full-blown paranoia, the group members may s hare the leader's delusions ; res ult may be catas trophic. In the 1970s, J im J ones , the charismatic, Africanleader of a neo-C hris tian apocalyptic s ect, moved with followers from S an F rancisco to the remote jungles of G uyana, S outh America. In this captive society, he was called Dad by the members. He demanded total and cons tant vigilance, preaching about persecution by enemies and the extermination of all blacks. He members who committed crimes , such as s moking, even forced a celibate woman to have intercours e with man whom s he dis liked in front of the entire As J ones ' persecutory and grandiose delus ions he repeatedly drilled his followers in preparation for the final battle by arming them with rifles and giving them a red, supposedly fatal liquid to drink. In 1978, he 254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 34 of 121

announced that anarchy was rampant in the United that drought had forced the evacuation of Los Angeles, and that the K u K lux K lan was marching through the former city, S an F rancisco. A month later, a U.S . C ongres sman violated the borders of J onestown by coming to inspect it. W hen four group members to leave with the C ongres sman, J ones attacked him then drilled his group for the true final battle; this time, however, the liquid that they drank was real poison. He succeeded in encouraging more than 900 persons, including 216 children, to die by telling them that they were committing a revolutionary act and not s uicide. Noxious charismatic groups appeal to various human interes ts , such as religion (Universal C hurch of C hrist), outer s pace (the Heaven's G ate group practiced all of its small membership committed suicide in 1997 the expectation of being trans ported to a spaces hip the Hale-B opp comet), and s cience (the C hurch of S cientology is violently antipsychiatry, antimedication, litigious ). P ers ons who eventually leave charis matic groups do because of disgust at the group's behavior and strong ties to family and friends. S ome ex–cult are hired as exit counselors by desperate families to persuade their children to leave the group; elaborate may be used to achieve this goal. T he proces s is difficult and protracted. P s ychiatris ts called on to treat res cued cult members s hould collaborate with reentry couns elors who have knowledge of, and often firsthand experience with, the s pecific groups . V ictims typically display symptoms of what the West terms a disorder characterized by doubts about their “true” 255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 35 of 121

identity, along with depres sion and feelings of and ambivalence about the entire process of indoctrination, group members hip, and res cue. Among therapeutic is sues that need to be address ed are guilt over abandoning their family at the onset and their group at the end, the reestablishment of independent behaviors , and the forging of a new s ens e of self and direction in life. T he prognos is depends on a victim's premorbid pers onality, the s everity of symptoms, family s upport, the use of reentry and, if neces sary, psychiatric care.

C UL TUR E C HA NG E In the broadest sense, persons experience culture when moving into a different culture or by staying put while their own culture changes around them. Acute wide-sweeping change may overwhelm the adaptive mechanisms of individuals and of their social s upport systems . Dis tortions in parenting and in life may occur, and cultural landmarks may become and difficult to interpret; the result may be individual sociocultural disintegration. T he four categories for situations that necess itate coping with marked culture change are (1) s ojourning, (2) s ettling, (3) segregation, (4) changes in society. In a more narrow s ens e, the changes that result from events such as retirement, into a profess ion, marriage, and adoption may be cons idered s ubcultural mobility; these changes require coping s kills that, when deficient, may result in disorders , as well as more enduring psychopathology.

S ojourning 256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 36 of 121

S ojourners are persons who have a brief, usually expos ure to a new culture; examples include touris ts; business repres entatives; s cientific field workers ; cons ultants and aid workers, such as P eace C orps volunteers ; military personnel; and limited contract workers. S wiss mercenaries in the 16th century were described as having the prototypical s ojourner's syndrome; phys icians referred to it as nos talgia and recorded its s ymptoms as fever, diarrhea, delus ions, convuls ions. Later, nos talgia was des cribed as a ps ychos omatic condition. Napoleon's troops reportedly were devastated by nos talgia, and it was cons idered to a mild form of insanity among troops in the American War. T he name was changed to home s ickne s s and diagnostic entity in military ps ychiatry during W orld W ar it was the mos t common maladjus tment reaction experienced by American soldiers. Adjustment can be prevented in s ojourners by a proces s of about the new culture before arrival, by providing to telephone and e-mail communication with supportive persons back home, and by shortening the lengths of in the new culture. E xposure to intense trauma or to unanticipated environmental toxins in the new culture, es pecially during wartime, may res ult in delayed and ps ychiatric symptoms.

S ettling S ettling involves a more permanent, forced, or move to a new culture, for example, a change made by refugees and international or internal immigrants . can be a relatively eas y process or a dramatically one. In general, the stress of settling may be with adjus tment dis orders , panic, anxiety, depres sion, 257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 37 of 121

alcohol and substance abuse, s uicidal behaviors, the triggering of mania, and transient psychotic epis odes . 1932, Odegaard concluded that a higher rate of s tate hospital admis sion for s chizophrenia in Norwegian immigrants to Minnesota than in the native-born Minnesotans or in the population of Norway was bes t explained by s elective migration. S ome s ubs equent studies have s upported this explanation, but others not. E arly African and As ian immigrants to the new of Israel were far more likely to be admitted to a mental hospital than were E uropean immigrants whos e hospitalization rate paralleled that of the local S elective migration may play a minor role, but current evidence demonstrates that enduring psychotic may be exacerbated, but not caused, by s ettling. the factors that affect ps ychopathology in settlers are premorbid mental and physical health status , characteristics of the host society and locale of and conditions necess itating the move. In an ideal immigration scenario, a mentally P.606 and phys ically healthy, intact, multigenerational family voluntarily resettles in a new area in which all the members are welcomed warmly, in which decent and jobs are readily available, in which the language is same as the country of origin, in which an es tablis hed of settlers from the s ame region already lives , and in public and private programs are in place to provide legal, and financial aid. R efugees are typically involuntarily dis placed becaus e warfare and natural disas ters . T hos e who have 258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 38 of 121

and have been the victims of horrific atrocities are at ris k for posttraumatic s tres s disorder (P T S D), panic, depres sion. E ven after real danger is over, refugees are placed in camps often project their fear of their persecutors onto neutral personnel and continue to experience anxiety. T he struggle for self-preservation access to food and shelter may lead to a deterioration moral behaviors; recognition of this deterioration and of the inability to adhere to the values of their lost may result in demoralization and depress ion. R efugees who are res ettled to a foreign land may initially their country of as ylum and may develop s avior about pers ons of authority. However, symptoms may emerge among refugees after the realizations that they may never return to their country origin and that they had been forced to decide among unattractive alternatives in their new place of res ettlement. Most international migration stems from a des ire for upward economic mobility. P remigration mental illnes s tends to wors en with the s tres s of moving to a new culture; this situation may be encountered when healthy immigrants bring mentally ill family members them. C hildren usually adapt better to immigration than do elderly persons who may be fixed in their ways and unable to learn a new language or to find in new customs . Middle-clas s persons with ordinary occupations us ually handle the migration experience better than upper– and lower–social class pers ons , because employment may be easier to find. Women are confined to their homes may become socially and depres sed. E lderly family members may los e the 259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 39 of 121

prestige they once had in their country of origin as their children adopt the mentality of the hos t culture, thus creating intergenerational stress es . Acces s to s upport s ys tems depends on personal family preferences , traditional patterns, and hos t country practices and programs, such as welfare and legal aid. Immigrants often do better when they live in areas populated by others from the same country of origin. a s ituation can provide comfort and ease of trans ition first but, in the long run, may delay acculturation and even foster res entment in some segments of the host society. Marital conflicts among immigrants often on differences between gender-appropriate behaviors their old and new countries . Intergenerational conflicts may aris e over communications, becaus e children the language of their new culture more rapidly than parents and tend to los e interest in their original in addition, children are more rapidly acculturated than their parents because of the knowledge gained through socialization experiences in school. It is not uncommon immigrants, especially thos e from third world countries, develop acute ps ychotic episodes with persecutory delus ions (the s o-called aliens' paranoid reaction syndrome). T hese episodes us ually have clear-cut precipitants, may recur several times , and do not neces sarily progres s to chronic mental illnes s. In a 1998 major s tudy of 3,012 adult Mexican living in F resno C ounty, C alifornia, those born in had a prevalence rate for any mental disorder of 24.9 percent, compared to a rate of 48.1 percent among born in the United S tates. S ubs tance abus e and dependency rates were s even times higher in native260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 40 of 121

women than in immigrant women; the ratio for men 2:1. Another C alifornia study of 1,500 us ers of primary medical services found that immigrants , one-half of were born in Mexico and C entral America, had a significantly lower prevalence of depres sion and P T S D, despite their lower s ocioeconomic s tatus, than Latinos born in the United S tates. Other s tudies indicate that immigrant Mexican women, in comparis on to Mexican women born and living in the United S tates , have lower infant mortality rates , much better nutritional intake, are significantly less likely to test positive for drugs at of delivery. T hes e s omewhat shocking findings may, in part, be due to the migration of the fittes t, healthiest, most resilient Mexicans ; a more powerful explanation is that the immigrants are buffered by their clos eness to a traditional culture characterized by clos e-knit, extended families that offer s ocial support, low rates of divorce, healthier eating habits. T he generalization and sustainability of thes e negative findings on the effects acculturation to other cultural s ituations remain to be seen. A typical pattern is that each succeeding of immigrants over time more clos ely approximates the behavioral patterns and phys ical characteris tics of the majority of persons in the host country.

S egregation P ers ons may be removed from the community and in more-or-less total care ins titutions. E rving G offman five types of s egregated institutions : (1) thos e that care incapable harmless persons (orphanages and old-age homes ), (2) thos e that care for ill pers ons who pos e an unintended threat to society (mental hos pitals and lepros aria), (3) thos e that protect the community from 261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 41 of 121

persons who pos e intentional threats (pris ons and concentration camps ), (4) those established to purs ue work-like tas ks (boarding s chools and military and (5) thos e designed as retreats from the world (monas teries and convents ). Ins titutional inmates all their activities in the s ame place and are regulated the same authority. T his s ituation, incompatible with family life and the bas ic work-payment structure of is reinforced by a s trongly enforced split between and s taff with res trictions agains t social mobility the two. Until the 1950s , large s tate mental hospitals were cons idered to be a static setting within which treated patients . T hes e neatly lands caped, tightly and tranquil hospitals were thought to ins till a beneficial sens e of neatnes s, order, and tranquility to the T he impact of these hos pitals' s ociocultural on patient care became evident in 1954, when Alfred S tanton and Morris S chwartz published their study on C hes tnut Lodge, demonstrating that patients usually improved during periods of effective collaboration personnel and deteriorated during periods when s taff disagreements were not dis cuss ed openly. T his link between a hospital's adminis trative process and patient–staff therapeutic process was also by William C andill, an anthropologis t influenced by Maxwell J ones' work in establishing therapeutic communities on mental hospital wards , who admitted hims elf as a patient to the Y ale P sychiatric Institute to make around-the-clock observations about life on a T hese and other studies, combined with the growth of community mental health movement in the 1960s and 262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 42 of 121

development of effective medications , have led to the demis e of large s tate hos pitals and to the placement of patients in the leas t res trictive environment, that is , the community. T he deinstitutionalization process has fraught with difficulties, but there now exis ts a number res idential facilities, supervised apartments, day and other placements for patients with s evere and persis tent mental illness es. Unfortunately, because of shortage and inadequacy of facilities , a major P.607 of thos e patients who have been unable to live succes sfully in the community now res ide in jails and prisons.

C hanges in S oc iety Human beings have always had to deal with social induced by natural disas ters , warfare, colonization, revolutions, and new technology. However, in the past centuries , the rapidity and extent of change have been more vas t than the total previous accumulative of human existence. Many benefits, such as improved public health, better communications , and ease of transportation, have resulted, but some of the costs include degradation of the environment, homeless nes s, and the increased lethality of weapons. C hange the number of s tres sful events in people's lives; thes e events range from annoying traffic jams to disastrous loss es of jobs . P ers ons whos e mental health is already marginal may decompensate when confronted by rapid change. E ugene B rody examined rural to urban res ulting from indus trialization in B razil. He identified 263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 43 of 121

many pers ons , “the lost ones ,” who needed psychiatric care. T hey had feelings of rootless nes s from the loss of familiar cultural guidepos ts, from sadness and due to alienation from work and s eparation from and from s uspicion and dis trus t of the unknown. was a major factor in determining the mental health of “the lost ones ,” because it decisively limited their to understand and to manipulate s ymbols, to receive to integrate information, and to form relations hips with the more dominant members of s ociety. C ultural adaptation always lags behind rapid s ocial change; the more resilient the culture, the briefer the S ocieties whos e culture is unprepared for rapid change may dis integrate. S ome overwhelmed Native American tribes , for example, have died off. T he native Alaskan population in newly discovered oil-rich areas rapid s ocial upheaval. A report on the Inupiat in B arrow found that (1) 72 percent of an adult sample s cored in definite or sugges tive alcoholic range on the Michigan Alcoholis m S creening T est; (2) 42 percent had been detained or arres ted for alcoholis m at least once; (3) that had been almost free of s uicide and homicide marked increase; and (4) when the only liquor store clos ed, wides pread bootlegging ensued as an the social relations hips among family and friends. problematic behaviors have diminis hed somewhat over generation as Inupiat culture has adjusted to the on its traditional way of life.

R E L IG ION A ND S P IR ITUA L ITY T he practice of medicine, including psychiatry, is experiencing major changes as a res ult of rapid 264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 44 of 121

biotechnological advances. Diagnostic machines are replacing hands-on examinations , robots are already performing some s urgical procedures , computerized ps ychotherapy programs are being perfected, are replacing dialogue, and doctor–patient are giving way to provider–client interactions that are overs een by economically driven and faceles s organizations . One reaction to the impersonality by these changes has been the newfound alternative medicine, an approach that emphas izes traditional, folks y remedies and encourages pers ons to take a more active role in their health care. Another reaction is increas ing interest in the importance of personal religion and spirituality in medicine. In 1995, instruction in religious and s piritual is sues was made mandatory for accredited psychiatric res idency in the United S tates. T his s ection focus es on religion and spirituality. It information on religious and spiritual problems and on objective unders tanding of the human experience of B as ic material about sacred texts, es pecially the B ible the Qur'an, is pres ented because they are at the core two mos t widespread religions, C hris tianity and Is lam. reconfiguration of sin, once a central force in W estern into mental illness and criminality is dis cuss ed, as is influence of religion on problematic behaviors related to sexuality, gender, the drinking of alcohol, and healing. relations hip between religion and mental health is examined, as are differences between religion and spirituality and the psychiatrist's role in dealing with is sues.

265 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 45 of 121

R eligion T hroughout his tory, human beings have held religious beliefs and have engaged in religious practices. the divers ity of thes e beliefs and practices is s o vast is impos sible to define the word re ligion s uccinctly. It generally refers to belief in a s upernatural, creative and in the practice of rituals meant to appease, to to obey, or to relate better with this G od. F or some persons, religion is an ongoing, s elf-actualizing quest holiness , whereas , for others, it is an achievable destination. R eligions s erve the mythopoetic yearnings humankind and provide a stable orientation and moral compass . R eligious systems have greatly influenced human behavior for millennia and often underlie a society's political, legal, medical, and educational T he three great monotheistic religions —J udaism, C hris tianity, and Islam—believe in a single omnipotent G od and in a book, the B ible or the Qur'an, that reveals G od's plan for believers . B uddhis m, a religion prevalent C hina, J apan, K orea, S ri Lanka, and S outh As ia, has traditions ; T herovada B uddhis m emphasizes a s piritual quest for wisdom, whereas Mahayana B uddhis m compass ion, the divine power of the S avior B uddha, spiritual rituals . Hinduis m, prevalent on the Indian subcontinent, emphasizes the many manifestations of G od, reincarnation, a divine power that sus tains life, a dazzling array of religious s ymbols, yoga, and T he revis ed fourth edition of the Diagnos tic and Manual of Me ntal Dis orde rs (DS M-IV -T R ) now includes re ligious or s piritual proble m as an Axis I condition that be a focus of clinical attention. E xamples include over the loss or ques tioning of faith, problems 266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 46 of 121

with converting to a different faith and ques tioning of spiritual values , and the s ens e of damnation that may experienced by pers ons with P T S D. Modern times seen jolting crises of faith; many C hristians, especially C atholics , are shocked by the revelation of pederasty among clergy, whereas many Mus lims feel that have replaced traditional Is lamic values with and militaris m. DS M-IV -T R has als o reduced the us e of religious examples to illustrate psychopathology. R eligious problems have long been part of the human experience. S ome problems are due to the fact that the faith required for a belief in the s upernatural can be In the face of horrific individual tragedies , such as the death of a child or the accidental disfigurement of a guiltles s person, as well as large-scale disas ters , s uch world wars , concentration camps , ethnic cleansing, and famine, s ome people rely on their faith for s trength and turn to G od and to religion for consolation, whereas may abandon their faith and adopt the belief that beings are res ponsible for their own fate. None of the major religions is monolithic, but rather are compris ed of numerous subdivis ions that may some core beliefs but disagree dramatically in their interpretation of s acred texts and in their rituals and practices . C hristianity alone has hundreds of examples include R oman and E astern R ite C atholic, Orthodox, B aptist, P entecostal, P res byterian, C optic, Maronite, C hristian S cience, J ehovah's and C hurch of P.608 J esus C hrist of Latter-Day S aints. Among C hristians 267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 47 of 121

claim to be “born again in the Holy S pirit” and to be in C hrist,” E vangelicals recognize the authority of the and a duty to s hare their faith with others in addition to having a pers onal experience with G od; are like E vangelicals but ins ist on the absolute every word in the B ible; P entecos tals are like but place a major emphasis on an immediate with the Holy S pirit and on an exuberant s tyle of C harismatics are pers ons in mains tream C atholic and protes tant churches who practice a P entecos tal form of wors hip. A growing number of C hristians belong to nondenominational churches in which the ministers congregation as a group agree on their beliefs and practices ; extension of this trend is the formation of groups in which members do not attend any church but rather meet in individual homes to study the B ible and attempt to relate it to their lives. T he subdivis ions of the major religions often have other subdivisions bas ed on the degree of orthodoxy and the adoption of local customs . Orthodox J ews , for conform their behavior to a s trict interpretation of laws , whereas “cultural” J ews may practice their predominantly by taking part in selected rituals . In the injunction that women mus t dress modes tly in may have differing interpretations; Orthodox women fully cover their bodies except for eye s lits , whereas may s imply wear a head s carf, and s till other women disregard any special dres s code. R eligious problems believers may aris e out of dis cord between major groups , s uch as Hindus and Mus lims in India, and subdivisions, s uch as conservative and liberal B aptis ts the United S tates . E ven among groups that s hare the 268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 48 of 121

beliefs and practices, there is a uniqueness to every church, temple, mos que, and synagogue, based on the characteristics of the clergy and the congregation. R eligious problems may aris e when there is dis cord members of a congregation or when the institutional leaders behave inappropriately. Neither religious institutions nor religious leaders, like their secular counterparts, are immune from petty politics and from sexual, financial, and other scandals . R eligion may stir feelings of altruism, forgiveness , tolerance, charity, creativity, and, mos t of all, hope. However, it may be problematic when used to rationalize hatred, irrespons ible behavior, and bodily mortification: include anti-S emitism becaus e J ews were implicated in crucifixion of C hrist, prejudice agains t blacks becaus e are suppos edly cursed in the B ible, indulging in compuls ive behaviors because of s upposed demonic oppres sion, and s evere fasting. T he intens ity of feelings arous ed by religion is so prodigious as to produce a wide variety of reactions . A well-known quote from E dward G ibbon's T he Decline F all of the R oman E mpire s tates that “the various wors hip which prevailed in the R oman W orld were all cons idered by the people as equally true; by the philosopher as equally false; and by the magis trate as equally useful.” T he 16th century conflict in which was forced by church authorities to recant his that the earth moved around the sun set the s tage for modern conflict between naturalis tic and explanations of events and behavior that began with Age of R eason in 18th century E urope. Most anthropologists regard religion, or s acred culture, 269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 49 of 121

a projection of human wishes that serve to cope with anxieties . W estin La B arre, for example, des cribes as a group dream that originates in the visionary state of the s haman-originator, for example, in dreams , trances, epis odes of spirit pos sess ion, epileptic and periods of s ens ory deprivation. In another theory, sound is a link to religion; infras onic s ound waves in low hertz range can produce a high-intens ity s ound press ure in the abs ence of audible s ound. S ound perceived and proces sed in the brain, but, becaus e cannot be heard or their source identified (commonly distant thunder), they have a mystifying, uncanny, provoking effect on a person who then labels the experience as religious . Drumbeats and chants religious experience not by what can be heard but by what cannot be heard, namely subauditory, sound waves. T his theory involves process ing of the in the temporal lobe, a portion of the brain in which lesions are ass ociated with symptoms s uch as hallucinations , delus ions , illus ions, déjà vu hyperreligios ity, feelings of ecs tas y, intense and cosmological concerns, pos tseizure psychosis with religious content, and mystical states . T here is a long W estern medical tradition of conflict cooperation and religion. Once Hippocrates declared epilepsy to be a biological and not a divine illnes s, phys icians have continued to provide naturalis tic explanations for illnes ses once thought to be caus ed or influenced by the s upernatural. T he s truggle to rescue mental illness from demonology, although s till ongoing many third world countries and some W es tern groups, generally has been success ful. P erhaps this s truggle 270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 50 of 121

played a role in antipathy toward religion sometimes expres sed by ps ychiatris ts. S tudies have s hown cons istently that psychiatris ts are not as religious as general public; in s urveys done in 1975 to 1976, belief G od was endors ed by 90 percent of Americans but 43 percent of psychiatrists and 5 percent of only 27 percent of ps ychiatris ts s urveyed in London in 1993 reported a belief in G od. A study of articles in ps ychiatric journals from 1977 to 1982 found that only out of 2,348 articles contained a religious variable, a s imple listing of a patient's denomination. F reud regarded religion as an infantalizing, neurosis producing, tyrannical force, and most psychoanalysts followed his critique with the prominent exception of J ung. E ven when they s aid something pos itive about religion, they often managed to find a rankling counterbalance. E rnes t J ones , for example, wrote the “enormous civilizing influence of C hristianity” and “sublimated homosexuality” in the same s entence. Henry Mauds ley, the mos t influential E nglish of his time and certainly not a F reudian, wrote in 1918 “the corporeal or the material is the fundamental fact— mental or the spiritual only its effect.” In 1975, the outspoken ps ychologist, Albert E llis , declared that its elf is a s elf-depreciating, dehumanizing mental However, at approximately that time, ps ychiatris ts turnaround in their thinking about religion. More and more, psychiatrists are treating patients with s evere mental illness es by using new and better medications spending les s time talking with patients. In s uch an environment, psychiatrists have come to realize the importance of programs and personnel such as cas e 271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 51 of 121

managers, sheltered works hops , s upervised apartment living, and s elf-help groups in helping patients survive occasionally, pros per in the community. Ministers, and rabbis are now regarded as allies in dealing with mentally ill, and church congregations are s een as a potentially healing res ource. E zra G riffith, for example, demonstrated the psychological benefits of rituals in African-American churches. Mos t clergy now accept us efulnes s of psychiatric treatment, although a minority fundamentalists s till regard psychiatrists as agents of devil and mental illness as a moral flaw.

God and the S ac red T hroughout his tory, people have s ought an about the purpos e and meaning of life, the world, and cosmos . T his ques t invariably has led to a belief in sort of divine power or process that is called G od, the or P.609 the S acred. In 1917, the theologian, R udolph Otto, published an influential s tudy in which he cons idered Holy to be s o s pecial a category that neither it nor the human experience of it can be denied. In the pres ence the Holy, a pers on is filled with emotions that Otto in Latin mys te rium tre me ndum e t fas cinos um, that is, sublime, numinous , as tounding feelings of wonder and dread. He regarded these feelings as primary, unique, underived from anything els e, and the basic factor and impulse underlying the entire process of human P aul T illich, one of the mos t influential 20th century theologians, as serted that the sense of the numinous 272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 52 of 121

presence of the Holy is really an awarenes s of the reality of G od who is being itself and not a being. He claimed that it is jus t as atheis tic to affirm the exis tence G od as to deny it. Apart from being and exis tence, nothing and nonexis tence; psychiatrists can treat anxiety, but exis tential anxiety can be dealt with only by encountering G od, the ground of being. F or T illich, true wis dom demands a religious experience that is a transformation and an illuminating revelation not of a personal god but rather of a G od on whom everything dependent. A leading C atholic theologian, K arl R ahner, as serts G od and s elf come together in the mys ticism of life, the discovery of G od in all things, and the s ober intoxication of the Holy S pirit. In addition to everyday mys ticis m, persons may experience mys tical states which cons cious nes s is briefly altered and all things experienced as interrelated. In religious conversions or illuminations, the mystical state may be perceived as extraordinarily meaningful and coherent; the pers onal expands to a close contact with G od. Inner peace and may give ris e to a vision or s pecial mess age. B ehavioral scientis ts have offered mundane of religion and mys tical states. In 1923, F reud wrote individuals form the idea of G od by merging the image an exalted childhood father with the inherited memory traces of the primal father; thus, G od is a type of father subs titute. R omain R olland, the F rench humanist, then chided F reud for not appreciating the eternal, richly energetic, beneficent, real core of religion that an oceanic-like experience. In C ivilization and Its Dis contents , written in 1930, F reud cons idered the 273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 53 of 121

experience as the es sence of mystical states and it as an adult regress ion to the earliest undifferentiated state of infantile life in which there is a communal unity between infant and mother. T his unity recedes as the emerges, but many persons retain a connection to this primal unity, which may be experienced more as awe, wonderment, and creative insight. T he of the earliest stages of being, when infants record first experience of mother as a “proces s ” rather than an “object,” is found in the ps ychoanalytic work of C hris topher B ollas. He theorizes that thes e primal experiences are not process ed through language or mental representation but rather as bodily s ens ations emotions . An infant first knows mother existentially as recurrent experience of being. T he infant eventually transforms into a self, and mother is experienced as a proces s of this trans formation. Adults carry the memory this process as evidenced by their s earch for a person, place, event, or ideology that promises to transform the self. Humans revere objects that may transform us and may consider them to be sacred. Humans are religious beings because they carry with them the potential to be transformed and recreated. F rom this perspective, the experience of G od is ultimately bas ed on the transformative potential of creating the self, but this act creation depends on a relations hip with another human being. Although B ollas ' configuration is wholly human, poss ible to imagine a broader dependency and relations hip on what T illich called the ground of be ing namely G od. P sychiatrists W illiam Meiss ner and Ana-Maria R izzuto each propos ed a nontheological understanding of the 274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 54 of 121

human experience of G od through the life cycle. A initial image of G od is based primarily on the image of parents . T he child's G od may be loving and protective, well as fearsome, cruel, and not always available to the child's wis hes . A positive mother–child experience this s tage res ults in a bas ic sense of trust that, in later years , may lead to a trus ting faith in G od, whereas a negative, insecure experience may dis tort the of G od. As the child begins the process of s eparation of becoming an individual with some independence, it hears about s omething called G od but lacks the to understand what a s pirit or trans cendent force is. child hears that G od has made the world and, thus , G od to the most powerful person that is known, namely both parents but es pecially father, who tends to be the more forceful or aggres sive parent. Over the next few years , as the child comes to recognize that its parents neither know everything nor are all powerful, a view of a perfect, heavenly father may emerge, as well distorted view of the family. G od and parents may be idealized as totally protecting, or there may be a split a good G od and mean parents or into good parents mean G od. B etween 6 and 11 years of age, the child to appreciate symbols. T he concept of G od s hifts from of a flesh and blood pers on to a s till imperfectly unders tood s pirit whos e power mus t be revered and feared, becaus e G od exacts punis hment for every In this s tage, an immature obsess ional religios ity may emerge in conjunction with ritualis tic behaviors . During adolescence, G od becomes more personalized “my S avior” or “my F ather” and is more connected to emotions and to s ubjective attitudes , such as love, 275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 55 of 121

obedience, trust, and fear. G od is experienced as the leader and advisor who patiently and kindly lis tens to one's innermos t problems and desires. When not tempered by s ome maturity of judgment, this of G od may lead to fanatical tendencies . As become moralis ts, the burden of s infulness emerges, they may engage in the extremes of loose or behavior. R ebellion against parental authority may over to the parent's religion as well as to the G od the parents symbolically represent. As adoles cents step into adulthood, they mus t decide follow the religion of their parents, to s eek a different religion, or to avoid religion altogether. A true religious faith that is bas ed less on conflict and more on mature unders tanding probably is not acquired until 30 years age. F or some, the inner repres entation of G od solid; for others, it may change; and for still others, it be rejected or replaced. T houghts about and the of G od us ually return in old age, es pecially when death nears. A pers on may decide to embrace G od gracefully grudgingly, for reas ons that include mature acceptance the cycle of life, hope of entering a heavenly afterlife, avoidance of eternal damnation, and neurotic fear, or spurn G od's ultimate encroachment; a pers on's las t may be an inspiration or an expiration. F reud regarded belief in G od to be an illusion that fears about the dangers of life; the moral world order G od promises instills hope that justice will be served, belief in an afterlife creates an ultimate s etting for the fulfillment of wis hes . F or F reud, this illusion was because it distorted reality and promoted a state of ps ychic infantilism. However, in s ome modern thought, 276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 56 of 121

G od is a benevolent illus ion neces sary for the growth nouris hment of mental and s piritual health. G od is like baby blanket or teddy bear that is special to the infant endows it with a unique quality, cuddles it lovingly, and sometimes hates it. As the child matures , these objects are neither mourned nor forgotten but rather simply lose meaning. T hey are the s tuff of illusion and P.610 mentally somewhere between subjective and objective reality. In this formulation, G od is a s pecial transitional object who does not los e meaning totally and who is always available in religion. R izzuto concludes that a person's humanity depends on illus ion; the type of selected, be it s cience, religion, or s omething els e, our pers onal history and the trans itional space each of has created between his objects and hims elf to find a res ting place to live in.”

S ac red Texts S ome, especially tribal, religions have only an oral and tradition, whereas others have books considered authoritative; examples include the four Hindu V edas , T ibetan B uddhis t G re at L ibe ration through H earing in B ardo, and the T aois t T ao T e C hing (T he W ay and its T his s ection dis cuss es the two most globally influential sacred texts , the J udeo-C hris tian B ible and the Mus lim Qur'an.

The B ible T he B ible is a compilation of papyrus or parchment into two books: Hebrew S cripture (relabeled as the Old 277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 57 of 121

T es tament by C hris tians) and the New T estament. S cripture, written in a language that belonged to Israel never really s pread geographically, presents the s tories creation; the s election of the J ews by the one, true G od the chosen people; and the s uffering of the J ews in quest for holines s. It contains a lengthy catalogue of rituals , and commandments for the faithful to obey, as as a variety of historical recollections , ps alms, wise and prayers . T he book of the prophet Is aiah refers to as a s uffering servant, a man of s orrow who was and rejected yet who “carried our sorrows, was for our trans gres sions , was bruised for our iniquities … his wounds we are healed” (53:3–5). C hris tians claim that their New T estament completes fulfills the Old T estament. T he s uffering servant, for example, is identified as J esus C hrist, the S on of G od allowed himself to be crucified to s ave humankind. T he New T estament also speaks of the problems with starting a new religion, of healing miracles, of the res urrection of J esus , of the power of the Holy S pirit, an impending apocalypse. It was written in koiné language known throughout the cultures of the Mediterranean area and of the ancient Near E as t. J esus C hrist was born and reared as a J ew and many early followers were converted J ews , but the religion founded in his name spread to include converts from many religions. A J ew named P aul, who was a of C hristians , had a profound religious experience on road to Damascus, claimed that he directly came to J esus and G od the F ather as a result of this equated hims elf with the 12 apostles who had known C hrist. His genius and hard work were greatly 278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 58 of 121

res ponsible for the development and growth of the new religion, C hris tianity, which s uperseded the Levitical of Hebrew S cripture and promised believers and eventual res urrection. Hebrew S cripture was written from approximately 900 to 165 B C ; all the s crolls were edited over the centuries and, in approximately 150 AD, reached a form that approximates what appears in modern B ibles. T here many s crolls , each somewhat different, s o that there was a unique s et of original scrolls. Hebrew S cripture is divided into the 22 B ooks of Law (also known as the of Mos es , the P entateuch, and the T orah), the and the W ritings. B etween 150 B C and 50 AD, no religious material was written that entered into the B ible. T he C hris tian began to compile revered written documents in the second century. In 367 AD, Athanasius, the bis hop of Alexandria, elected 27 books that he considered and large, this list, which contained four G os pels, 13 of P aul's letters , and other writings, was accepted by the C hris tian community and came to be known as the T e s tament. In 50 AD, the firs t entry was written, P aul's Letter to the G alatians; the las t entry, II P eter, written in approximately 150 AD None of the G ospel writers, with the poss ible exception of J ohn, knew personally. Modern versions of Hebrew S cripture are of an idealized text and are based on an uns atisfactory century translation of the text into G reek (the B ible), S t. J erome's 4th century updated translation of S eptuagint into Latin (the V ulgate B ible), and portions from s crolls found in the 20th century in the Dead S ea 279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 59 of 121

area. T he oldes t exis ting complete copy of Hebrew S cripture was written in 1009 AD (the Masoretic B ible). K nowledge about the New T es tament text comes from few ins cribed pottery remnants ; fewer than 100 fragmentary 2nd, 3rd, and 4th century E gyptian manus cripts ; 250 incomplete 4th to 9th century parchments called uncials ; 2,500 manus cripts , called minis cule s , written from the 9th to 18th centuries; quotations from the early C hurch F athers ; nearly 5,000 G reek manus cripts , each one different than the other; translations, such as the V ulgate, from the G reek no existing trans lations of a manuscript before the 4th century). V ariants in every New T estament sentence found in the manuscript tradition. In 1966, the United B iblical S ocieties iss ued a “standard” text but noted more than 2,000 choices had to be made concerning significant alternative readings of manus cripts ; in 1975 new, improved, “standard” edition was publis hed. problems have been compounded by the difficulty of translations into nearly all the languages of the world. Hundreds of E nglis h language trans lations of the B ible available; thes e range from the magisterial K ing J ames version to a B asic E nglis h vers ion that limits its to 1,000 words to a politically correct inclusive vers ion which, for example, the opening line of the Lord's translated as “Our Mother-F ather in heaven.” In addition to varying and s ometimes confus ing of events presented in the B ible, textual and differences have influenced the interpretations and practices of believers , some of whom hold that in the B ible is literally true. S uch fundamentalists for example, that Adam and E ve were actual pers ons 280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 60 of 121

whom all human beings have descended, that the s un moves around the earth, that Noah's ark really pair of every animal, and that the earth itself was at 9 AM on October 23, 4004 B C However, most hold that the B ible was ins pired by G od but written by men who compiled their narratives in their own style; the B ible is truthful on significant s piritual matters, s uch faith and s alvation, but is not neces sarily accurate in scientific matters , such as astronomy, animal and botany; and that many biblical accounts are bes t unders tood as meaningful allegories. Although there always been s keptics about s upernatural events in the B ible, s uch as the res urrection of J es us , the truth about fundamental facts is being ques tioned by many s cholars . T here is no good evidence outs ide of B ible itself, for example, that Mos es and J es us were persons or, if they did exis t, that their lives were accurately. T he effects of thes e reports on believers undoubtedly played some role in the marked decline of religious attendance and influence in E urope; the Archdioces e of Dublin, Ireland's larges t archdiocese, example, ordained only one priest in 2001. T he United S tates presents a mixed picture in that, although mos t people profess a belief in G od, church attendance is sporadic, and the number of persons adopting a vocation has fallen dramatically. However, C hris tianity bloss oming in third world countries .

A l-Qur'an Al-Qur'an is a compilation of poetical verses divided 114 chapters ; it is the s acred text of Is lam. Mus lims that, in 610 AD, the angel G abriel confronted in a cave atop a mountain near Mecca, proclaimed him 281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 61 of 121

mess enger P.611 of the one true G od, Allah, and ordered him to read the verses from written S criptures that exis ted in heaven. experiencing doubts about this experience, cons ulted a man familiar with J ewish and C hris tian S cripture who convinced him that Mos es had seen the same angel. W hen Mohammed realized that he was , indeed, a prophet, he followed the angel's instructions and, over the next 23 years, while in trance-like s tates in many geographic locations , read and spoke aloud heavenly verses (Al-Qur'an means the R eading). His utterances were written down by various scribes. varying collections of the vers es were collected that included material from persons who claimed to have memorized s ome of Mohammed's words that had not been written down. W ithin a generation, the C aliph Uthman iss ued a s tandard vers ion that is s till us ed although there are s ome variations because the Arabic s cript neither noted vowels nor contained dots, thus complicating the parsing of a verb as active pass ive. T he Qur'an has no s tory line; the chapters with the longes t pass ages and end with the shortes t pass ages . T ranslations have been pedestrian and invariably fail to convey its augus t and lofty language. T he content of the book focus es on the necess ity of profes sing faith in the unity of one G od who was known the J ews and C hristians . T hey were the original protoMuslims, but then they suppos edly turned from the true path. T hey must become Muslims again by now Is lam (submiss ion to G od). Abraham, Is hmael, and 282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 62 of 121

were true prophets , and Muslims anticipate the return J esus in an apocalyptic time. T he book es tablis hes the of Mus lims to pray s everal times daily, to give alms to poor, to fas t during the month of R amadan, to make a pilgrimage to Mecca, and to obey certain seven of which are similar to the T en C ommandments found in the B ible. In the 8th century, Muslims solidified a belief that their behaviors and laws s hould parallel thos e of his C ompanions, and followers. T hus , collections of were gathered into books of tradition called hadith. T he literature on hadith is enormous; out of several hundred thous and hadith that have been propos ed, only s everal hundred are generally regarded as absolutely whereas the others are clas sified into numerous based on the s trength of the evidence that they can be traced back to Mohammed's time. T wo other forces have influenced Mus lim behaviors and laws are reasoning applied to similar cases and consensus by learned persons. C onsideration of all thes e factors has res ulted in a class ification of behaviors into five obligatory, recommended, indifferent, disapproved but not forbidden, and prohibited. A combined s ys tem of secular and religious law emerged, the s haría. In not covered by the s haría, highly esteemed judges may is sue an opinion called a fatwa. S hi'ite Mus lims , only to the S unnis in number, have replaced the of consensus by a belief that G od selects an infallible, authoritative leader, or Imam, who is descended from Mohammed to lead the faithful of each generation. T here are many S unni, S hi'ite, and other Muslim and s ubdivisions with differing interpretations of his tory, 283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 63 of 121

sacred texts , and s haría. Local customs , the of political states based on Islamic principles , the among fundamentalis ts , moderates , and liberals , and encroachment of W es tern ideas and attitudes have influenced behaviors and caus ed religious problems . homicide-suicide bomb attacks on Is raeli civilians have been both denounced by a majority and prais ed by a minority of differing interpreters of Is lamic principles s haría. T urkey exemplifies a Muslim nation that has adopted a secular, democratic constitution. S audi exemplifies a kingdom caught up in the battle between modernization and adherence to fundamentalist principles: Non-Muslims are not allowed to enter the of Mecca, nor are they allowed to display their own religious symbols or to be buried in S audi soil, yet clothes, fas t food, and televis ion shows are widely available.

S in One of the most profound accomplishments of the was the moral delineation of s in as a rebellion against one true G od and its characterization as wicked, evil, guilt evoking. Hebrew S cripture notes that wicked are es tranged from the womb and go astray as s oon as they are born, following the dictates of an evil heart. century B C J ewis h theologians believed that, from the moment of his creation, Adam, the firs t human, had a of evil s eed that all subs equent humans pos sess . T he penalties for trans gres sing G od's laws included death stoning, horrible diseases, financial failure, severe humiliation, and chronic s adness . However, most J ews are not Orthodox and, rather than referring to notions of innate badnes s or goodness , teach about 284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 64 of 121

personal respons ibility for one's actions . C hris tianity claims that Adam's mis us e of free will—he forbidden fruit—is the original s in that affects and that it can be removed only by baptis m in the Holy S pirit and belief in J esus C hrist, the R edemptor. rejected a majority of J ewish laws and teaches that, through confes sion and repentance, it is poss ible for to be forgiven and unrighteousness to be cleans ed. A of seven capital s ins bas ed on the T en J esus' S ermon on the Mount, and S t. P aul's writings completed by P ope G regory (1540 to 1604) and the present: pride (from which all the others derive), avarice, envy, wrath, lus t, gluttony, and sloth. elevated the role of S atan, a rebellious evil spirit, and a host of less er demons who enticed humans to s in. It perfected a concept of heaven and hell after death and predicted a cosmic apocalyptic conflict in which G od vanquish S atan and then usher in a new bless ed age the faithful. Although apocalyptic s eminars and “fire and brims tone” sermons persist, in modern times, the notions of s in, and hell have gradually withdrawn into the recess es of Wes tern cons ciousness . In 1973, W illiam Menninger in the popular pres s that s in had dropped out of daily conversation and debate. No longer were people of being s inners, nor were they expected to dis play remors e for their s ins . Indeed, attempts by s ome high profile politicians , as well as common pris oners, to their problematic behaviors as s inful are nowadays met with cynicis m and derision. C urrent s ocial morality reconfigured s in into criminal behavior, defective character, or a s ymptom of mental dis order, and mind 285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 65 of 121

replaced s oul in ps ychiatry. F ree will, a necess ary ingredient of s in, has become les s meaningful as accumulates demonstrating that much of human is determined by genetic factors, neuronal functioning, learned res ponses , peer press ure, childhood and a hos t of other naturalistic forces.

S exuality and Gender T he major monotheis tic religions reflect the patriarchal cultures in which they were founded. G od and his are masculine. W omen traditionally were valued for roles as mothers and house keepers and were duty to obey their husbands and to remain silent on mos t matters . J ewis h S cripture contains many references to prostitutes and adulteres ses ; the phras e “to play the harlot” is us ed to describe the act of abandoning one's faith. Dis trus t and fear of women's s exuality are T he book of P roverbs s tates that “the mouth of an woman is a deep pit; he who is abhorred by the Lord fall there.” Mens truating women were shunned as P.612 J esus elevated the status of women somewhat when healed a woman with chronic vaginal bleeding who had touched his robe, talked with women on the s treet, allowed women to accompany him and his male and absolutely forbade divorce (s cholars believe that, later addition to the B ible, J esus s upposedly made an exception in the case of an adulterous wife). Despite several New T estament letters encouraging husbands love their wives, S t. P aul and many of the C hurch tolerated marriage only if a person could not exercis e 286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 66 of 121

sexual s elf-control. W ith E ve as a model, women were perceived as s educers who stimulated men's lustful appetites ; to S t. B ernard (1109 to 1153) was attributed sentiment that “a beautiful woman is like a temple built over a sewer.” F emale virginity became a pathway to heaven, and, in 649, P ope Martin I officially declared perpetual virginity of Mary, the mother of J esus , a belief of the C hurch. Devotion to Mary has remained a hallmark of C atholicism, es pecially among women for whom s he is a model of comportment. T he between virginity and motherhood has been a cause of sexual confusion for some believers who dichotomize women into two types , the s o-called Madonna-whore complex, in which “good” women are like the asexual V irgin Mary, whereas “bad” women are like the biblical prostitute, Mary Magdalen. T he church's recent rehabilitation of Mary Magdalen, who is no longer cons idered a harlot but rather is revered as the firs t to see the res urrected J es us , reflects a s lowly attitude toward women. C atholicis m holds that all acts should not limit the pos sibility of achieving pregnancy, therefore prohibiting the us e of birth control devices . T he defiance of the prohibition by C atholics represents the growing challenge to ecclesiastical authority seen among many C hris tian groups ; in a survey, 75 percent of sexually active C atholic women contraceptives. B y reference to their sacred texts, J ews , C hristians , Muslims traditionally have cited the s ocial superiority of men over women. However, from a his torical the 20th century may be bes t remembered as the era which W estern women achieved a great meas ure of 287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 67 of 121

equality with men. T his revolution in gender began in earnest in 1878, when the American National Women S uffrage As sociation pass ed resolutions that religion had been used to subjugate women, that female s elf-sacrifice and obedience were s elfand that women s hould claim the right of individual cons cience and judgment that men alone claimed. E lizabeth C ady S tanton gathered together 20 learned women in the 1890s to publis h the firs t real document the revolution, T he W omen's B ible . F eminis t biblical scholars hip has blos somed since the social ferment of 1960s in an attempt to liberate the B ible from its orientation and its us e by political religious groups to women's rights and freedoms . F eminis t scholars that they are continuing the tradition of the biblical prophets who expres sed G od's will by pass ing on injustices and on the perversion of religion. Is lamic societies generally limit the freedoms of women comparis on to W estern s ocieties, although change is slowly becoming apparent. Men are s till legally allowed four wives, although each mus t be treated like the in fact, mos t Muslims today have only one wife. S ome S hi'ite Mus lims recognize mut'a marriages in which a pays a woman for her sexual services for a day or so, which the marriage automatically is diss olved. In a few areas, Muslim women can get a divorce somewhat than in the pas t, whereas men cannot get a divorce without incurring the same s ort of civil liabilities as in Wes t. In areas under F undamentalist control, women not travel alone without getting a permit, and adulterers may be s toned to death (it is eas ier to convict a es pecially if s he becomes pregnant, than a man). 288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 68 of 121

little, if any, feminist quranic scholars hip. R es is tance to change in gender relationships stems from the of patriarchal attitudes in Islamic s ocieties with high of poverty and low levels of education, from the inward looking nature of Islamic intellectual life over the past centuries , and from a strong belief in a literal and unchanging interpretation of the Qur'an. C ondemnation of homos exuality, a s ocially divis ive is often based on several biblical citations . T he B ook of Leviticus contains myriad laws, s uch as prohibitions agains t trimming one's beard, eating s hellfish or pork, wearing garments made of a mixture of linen and wool; addition, crops mus t not be planted every seventh and adulterers , fortune tellers, and male homosexuals should be put to death. Although C hristians are not obligated to follow the Levitical laws , most groups have selectively chos en to uphold the prohibition again homos exual behavior. T he book of G enesis tells the story of two angels as men who came to the city of S odom, where a man named Lot allowed them to stay in his home. A group townsmen s urrounded the home and asked about the men, s aying “bring them out to us that we may know them.” F rightened, Lot told them to leave his guests and offered his virginal daughters in their place. T he townsmen failed to break down the door and left. T he day, G od rained fire and brims tone on the city, killing inhabitants, although Lot and his children escaped. T he earliest interpretations of this s tory focus ed on the S odomites ' arrogance and rudenes s to s trangers ; G od killed them for incivility to his angels. T he theme of sexuality emerged full force in the 1s t century B C in the 289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 69 of 121

writings of P hilo of Alexandria, a J ewish his torian. R abbinical writings about S odom in the T almud and the Midras him (commentaries) generally did not mention homos exuality. Although some C hurch fathers agreed with P hilo, others did not, pointing to a parallel s tory in C hapter 19 of the B ook of J udges in which was not implicated. T he S odomite towns men wanted know” the men; the verb “to know” is us ed 943 times in J ewish S cripture, and in only 10 places does it clearly to sexual intercours e. However, over time, the interpretation won out: the K ing J ames B ible translates townsmen's request, “that we may know them whereas the New E nglish B ible says , “so that we can sexual intercourse with them.” S ome s cholars refute translations and note that Lot was not a full citizen of S odom. T he towns men were sus picious becaus e he allowed two s trangers to s tay in the city at night without as king permiss ion of the proper officials and, thus, they wanted “to know” who the two men were. J esus does not mention homos exuality. However, he link S odom with the inhos pitality that his dis ciples might encounter when preaching (Matthew 10:14–15). S t. who barely tolerated marital sexuality, s eems to have disapproved of homosexual behavior, but the exact meaning of the specific words he us ed is unclear. In I C orinthians 5:11, for example, he includes in his list of unrighteous who will not go to heaven people who are malakoi and ars enokoitai. T he translations of thes e vary widely and include effeminate, child moles ters , homos exual, masturbators, immoral, s exually immoral, depraved, and male prostitutes. In fact, sacred, cultic and female prostitution ass ociated with the god B aal 290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 70 of 121

the goddes s Ishtar are condemned in J ewish S cripture. Although homos exual behavior was practiced the ancient world, the designation of a pers on as a homos exual did not become prevalent until the 11th century AD when S t. P eter Damian coined the word s odomia, thus es tablishing an abs tract es sence: who indulged in s odomia were thereafter sodomites (homos exuals).

Alc ohol Des pite the Qur'an's clear prohibition of alcohol, many cultural Muslims drink. Although the total quantity cons umed in Muslim countries is s mall, problem is prevalent, becaus e alcohol is feared and is not integrated into daily life. J ews have drunk alcohol for thous ands of years with minimal disruptive P.613 T he basis of J ewish sobriety was es tablis hed during 200-year period after the return to Israel in 537 B C of J ews who were held captive in B abylon. B efore this, B ible contained many references to drunkennes s, but afterwards , even though J ews continued to make wine, drink it ritually and for pleasure, and to pour sacrificial libations . In addition to the banis hment of pagan gods whos e rituals demanded heavy drinking, alcohol was positively integrated into religiously oriented in the home and synagogue. Drunkennes s a s ocial problem once wine came to be regarded as a subs tance that s hould be drunk in moderation and only conjunction with food and holy rituals. E ven the fear of drunkenness vanis hed, as evidenced by a scientifically 291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 71 of 121

unsound medieval rabbinical ruling that E uropean wine was not as potent as the wine produced in biblical and therefore could be drunk undiluted. Drunkennes s alcoholism became alien to J ewis h identity; the Y iddish expres sion s kikke r vi a goy means “drunk as a However, with the increasing los s of Orthodoxy, J ewis h alcoholism rates are ris ing. No C hristian religious group condones drunkennes s, there are variations in attitudes to alcohol. T he official stance of C atholicis m, reflecting the view of S t. Aquinas , is that drinking wine is lawful, except if a takes a vow not to drink, if a pers on gets drunk easily, drinking scandalizes others. P rotes tants leave about drinking to individual dis cretion, but groups such the Lutherans and Methodists preach moderation, whereas P entecos tals and B aptists preach abs tinence regard alcohol as an invariably des tructive s ubs tance. T hese variations stem from conflicting biblical T he clearest negative comments on drinking are found the book of P roverbs 23:29–33: “Who has woe? W ho sorrow? Who has complaining? Who has rednes s of Do not look at wine when it is red, when it s parkles in cup, and goes down smoothly. At the last it bites like a serpent and s tings like an adder. Y ou will s ee s trange things , and your mind utter perverse things.” Among the Hebrew prophets, Isaiah des cribed E gypt akin to a drunken man who s taggers in his vomit and Is rael's leaders as irrespons ible, because they devote thems elves to intoxicating drinks. Hosea warned that harlotry and wine enslave the heart. J esus warned being drunk at the time of his second coming. S everal in the New T es tament cite drunkenness among the 292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 72 of 121

of thos e persons who do not walk with C hris t, who will inherit the kingdom of G od, and who live doing the of the G entiles ins tead of G od. Other biblical pas sages consider wine as a staple of a bles sing from G od. Is aac as ked G od to give his son, J acob, the dew of heaven, the fatnes s of the land, and plenty of grain and wine. In the book of Amos, G od promis ed to return the J ewis h captives to Is rael, where they s hall plant vineyards and drink their wine. notes that when the people of J udea and Is rael are res tored, then their hearts will rejoice as if with wine. J udges 9:13 refers to wine “which cheers both G od and men.” P roverbs advocates giving wine to pers ons who bitter of heart, s o that they can forget their misery and poverty. I T imothy 5:23 encourages the use of wine “for sake of your s tomach and your frequent ailments .” In the United S tates, alcohol and religion have a linked history. T he consumption of alcohol was quite after the R evolutionary W ar. Americans felt patriotic drinking liquor distilled from healthful, native corn and regarded intoxication as a freedom cons onant with hard-won independence. B enjamin R ush, one of the founders of the American P s ychiatric As sociation, cons idered whiskey and rum as the ruination of the nation, although wine and beer in moderation were the 1780s , Methodis ts and Quakers were like-minded forbidding the drinking of hard liquor, the former it interfered with religious practices and the latter it interfered with s elf-control. In 1826, a P res byterian minis ter in C onnecticut delivered six s ermons on the of liquor that became a basic text of the American T emperance S ociety. Local temperance s ocieties grew 293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 73 of 121

from 222 in 1827 to 8,500 in 1834, and antidrinking became popular. New towns were established to temperance values, the bes t known being P alo Alto, C alifornia, the s ite of S tanford Univers ity. In 1874, the Women's C hris tian T emperance Union was founded demanded the worldwide prohibition of alcohol, prostitution, child marriages , foot binding in C hina, the J apanese geisha s ys tem, and the sale of opium. frontier churches held that temperance was not enough claim s alvation; only total abs tinence would do so. In 1893, a minis ter from Ohio founded the Anti-S aloon League and s ucces sfully delivered votes for politicians supported prohibition. J ames C annon, a Methodis t from V irginia, pushed through the prohibition to the U.S . C ons titution in 1917 by demonizing alcohol the major caus e of the nation's ills. Although alcoholis m rates declined, prohibition res ulted in wides pread lawles sness and the creation of a vast criminal Ins tead of pros perity, the nation experienced a great economic depres sion. B ishop C annon was dis graced charges of war profiteering, illegal s tock deals , and corrupt political practices . T ired of austerity and nays ayers, Americans repealed prohibition in 1933.

Healing In the earlies t days of humankind, spiritually powerful and women known as s hamans healed disease and revers ed mis ery by retrieving lost souls , by pacifying exorcising malign spirits , and by providing counterT heir legacy continues today in “faith healers ” that exis t all cultures , although, especially in W estern nations, are impostors. 294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 74 of 121

Hebrew S cripture attributes mos t disease to G od's retribution against dis obedient believers ; E xodus 15:17 the definitive s tatement on G od the healer: “If you diligently heed the voice of the Lord your G od and do what is right in his sight, give ear to his and keep all his statutes, I will put none of the diseases you which I have brought on the E gyptians . F or I am Lord who heals you.” T he early Hebrews dis dained medical practice, because it diminis hed G od's position. However, by 180 B C , the book of E cclesiastes noted sick persons s hould pray to the Lord for healing but also consult phys icians who can provide medicines that heal and take away pain. T he approach of J esus to the sick, many of whom had disenfranchised from full participation in temple was revolutionary. He welcomed the sick and did not blame them for their illness es . Almos t 20 percent of the G ospels are devoted to J es us ' 41 healing encounters individuals and groups . He healed medical and spiritual and ps ychological disorders ; his mos t common was to s ay a few words and to touch the s ick person. A disproportionate number of his healings involved the exorcism of demons, and he pas sed on this power to disciples and all of his followers. T he class ic healing found in the book of J ames 5:13–16 in which sick were enjoined to call the C hurch elders to their be anointed with oil in the name of the Lord, to confes s their s ins , and to pray for one another, and “they will be healed.” In approximately 400 AD, S t. J erome the B ible into Latin; instead of “they will be healed,” J erome wrote, “they will be s aved.” B y this alteration, spiritual salvation displaced the healing of illness as the 295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 75 of 121

central focus of the text and res ulted in a neglect of phys ical healing for almost 1,500 years. In fact, suffering became a C hristian avocation that allowed a person to s hare in J esus ' suffering on the cross . W hen refused to cure P aul (he may have been epileptic) on occasions, the B ible notes that G od's grace was and that his power was made perfect in weakness . defects were no longer liabilities but rather were opportunities to receive the power of J esus. T his formulation enhanced the self-worth P.614 of dis abled and ill pers ons , but it als o contained the potential for persons to accept their infirmities with pass ivity or even to mortify thems elves in purs uit of a higher, spiritual goal. Medicine was devalued, physicians ridiculed, and healing forgotten (except for occasional exorcisms), so people turned to dead s aints for help. A cult of relics , namely, the pres erved body parts of saints who supposedly had performed miracles , prospered for millennium from the 4th century. T he church ass igned saints to specific diseases ; S t. V itus was the patron of persons with chorea, S t. Lucy was the patron of with eye disease, and S t. Dympna was the patron of mentally ill. T he many shrines that held the healing faded into obs curity when medical practice became effective. A major exception is the relatively new shrine Lourdes in F rance, where S t. B ernadette had her vis ion “the lady” in 1858. Local enthus iasts identified “the the V irgin Mary. Although S t. B ernadette died of tuberculos is at 35 years of age and never s tated that 296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 76 of 121

lady” would cure anything, the s hrine at Lourdes was promoted by merchants as a place for healing. S everal million vis itors from around the world travel there including many des perate pers ons whos e illness es not res ponded to medical treatment. Lourdes has an official medical bureau for the certification of healing; les s than 100 have been iss ued. T he Lourdes are emotionally charged and spiritually so that temporary functional improvement in some does occur despite the lack of organic changes . Interes t in religious healing in the form of “mind cures ” emerged at the end of the 19th century in New Mary B aker E ddy, for example, wrote S cience and 1875; s he declared that s ickness is a fearful belief manifest on the human body and that it can be by the divine mind. T he real rebirth of C hristian healing occurred in T opeka, K ansas , when a preacher gloss olalia, linked it to healing, and started a revival that relied on the verses found in the G os pel of Mark 16:16–18: “He who believes and is baptized will saved; but he who does not believe will be condemned. And thes e s igns will follow those who believe: In my they will cas t out demons; they will speak with tongues ; they will take up serpents ; and if they drink anything deadly, it will by no means hurt them; they will lay on the sick, and they will recover.” T he American Midwest proved to be a congenial setting for P entecostal faith healing. F rom its humble beginnings in s mall churches , faith healing ceremonies have progress ed to radio and large scale television presentations that raise millions of dollars throughout North and S outh America, E urope, and Africa. T he 297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 77 of 121

presentations us ually are s pectacular extravaganzas replete with extremely large and expectant crowds, tech lighting, fast-paced music, and continual choruses praise. T he healers have celebrity s tatus and are performers. T he healings often consist of the dramatic exorcism of illnes s—demons who have s uppos edly poss ess ed the sick pers on. S ome s ophisticated speak more about demonic oppress ion rather than poss ess ion, es pecially in pers ons with impulsivity problems , such as compulsive gamblers , alcoholics , subs tance abus ers, and self-cutters . E ven mainstream C hris tian churches have turned to healing, although in a les s s pectacular and calmer in a charismatic renewal that includes s peaking in uttering prophecies, and prayers for healing. After a of 1,600 years , the C atholic C hurch redis covered during the V atican C ouncil II in the 1960s. T he of E xtreme Unction, for example, was renamed of the S ick and is no longer reserved for the dying in private but is given publicly as soon as any of the begins to be in danger of dying from s ickness or old Many flamboyant faith healers have been exposed as charlatans , whereas others probably believe they are doing G od's work. F ollow-up studies have consistently found no evidence of cures, although many pers ons feel better briefly. A study of 71 P entecostal C hristians experienced hands -on faith healing for conditions from leukemia to peptic ulcer to warts found that all the subjects reported an ins tantaneous or gradual healing, despite the fact that the original symptoms were unchanged. T hey proclaimed thems elves to be healed because their belief in G od increased, as did their 298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 78 of 121

conviction that they were leading a proper, righteous S tudies of attempts to heal persons by prayers offered distant s ite, so that subjects have no knowledge of the prayer attempts , have shown no great advantage to prayed-for vers us control groups . An often-cited study coronary care patients did s how a slightly better cours e among prayed-for patients , but a flawed methodology cas ts doubts on the results : No was provided about the psychological characteris tics of the subjects or the treatment practices of the various health care plans ; the coordinator of the s tudy not only knew which patients were in the prayed-for and control groups , but also was responsible for record keeping on subjects ; and, when the s tudy was returned by a editor with a revision request, the author reconstructed the criteria about what establis hed a good or bad cours e after he knew which group each patient was in. E specially in times of crisis, prayers offer hope. may point to the New T estament, which states , things you ask in prayer, believing, you will receive” (Matthew 21:22), and, “whatever you as k the F ather in My name, He will give you” (J ohn 16:23). However, when a petitioner's prayers are not is us ually the cas e, theologians turn to the biblical of J es us in the garden of G eths emane before his and capture when he prayed to G od the F ather, “not will, but what Y ou will” (Matthew 31:39). Any interpretation of a s upernatural intervention, s uch as intercess ory prayer for a sick pers on, depends on the mind-set of the participants. If a prayed-for pers on is cured, the skeptical scientis t may pos it a natural, but yet unders tood, mechanism; if the pers on is not cured, 299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 79 of 121

skeptical theologian may contend that the wrong prayer or not enough prayer was offered, that G od was angry being tes ted, or that the res ult was G od's will.

R eligion and Mental Health T he complicated relationship between religion and health is due, in part, to definitions. Is mental health, for example, merely the abs ence of ps ychopathological symptoms or does it imply happines s, contentment, tranquility, s pontaneity, the capacity to love and to the maintenance of a right relations hip with G od, and fulfillment of one's intellectual potential? Is it mentally healthier to criticize or to s ubmit to authority, to be independent or to be dependent on family and friends ? it religiously healthier to focus on self-realization or to accept dogma that demands obedience? G ood data on relations hip between religion and mental health are to come by, especially in non-Wes tern countries in so-called official s tatistics are often misleading P sychiatry has a formal lis t of ps ychopathological s igns and s ymptoms, but there is no such lis t for religion. because at leas t 21 variables have been identified as components of religios ity, the selection of appropriate variables to include in scientific s tudies is problematic. most us eful delineation of religios ity is probably G ordon Allport's and J . Michael R os s' intrinsic and extrinsic T he former implies a sincere commitment to one's which are internalized and serve as a guiding behavior, whereas the latter implies the use of religion obtain status , s ecurity, s elf-justification, and s ociability. P sychiatric studies on the relationship between religion and mental health have generally treated religiosity 300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 80 of 121

superficially. R eligious P.615 studies, although numerous , tend to rely on s elfoverrepres ent churchgoers and college s tudents , exclude nonbelievers , emphasize church attendance variable, and lack longitudinal data. Mos t s tudies are correlated: A cons istent finding that elderly pers ons attend church demons trate better mental health than those who do not, for example, may s imply mean that elderly churchgoers are in good enough physical health make the trip to church. B ecause there is a pos itive relations hip between physical and mental health, attendance in this group may s ignify good physical and may have little to do with mental health. No meaningful general conclusions can be made at time about the impact of religion on mental health. A conceptually s ound s tudy of 1,902 female twins over a year period found that, except for a lower us e of and alcohol and a poss ibly lower level of depress ion, was little evidence overall for a relations hip between current ps ychiatric symptoms , lifetime and religiosity. A survey of 14,000 youths found that sort of religious commitment was related to a likelihood of s ubs tance abus e. S tudies of religious meas ures in pers ons who had experienced s tres sful events within the pas t year found that religious rituals times of crisis were helpful in 40 percent of cases and harmful in 23 percent. T hese coping meas ures were helpful to religious pers ons who had les s access to material resources and power, s uch as the elderly, the poor, the less educated, African Americans , the 301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 81 of 121

and women. R eligious beliefs may affect the express ion of ps ychopathology. S ome psychotic and manic patients proclaim thems elves to be a god, a prophet, a a s aint. P aranoia may focus on s atanic plots . may be interpreted as supernatural events. Depres sion special cas e in that its psychological torments have, recently, often been cons idered an authentic part of the religious experience; for C hris tians, it is a sharing of sufferings of the martyrs and of J es us on the cros s, whereas many S hi'ite Muslims, during the ritual remembrance of the martyrdoms of religious heroes , flagellate thems elves frenetically and recall the words Hus ain: “T rial, affliction and pains, the thicker they fall man, the better do they prepare him of his journey heavenward.” T he tribulations of Moses are an component of J ewish identity. B uddhism acknowledges the Noble T ruth that s uffering is univers al and that aging, and death are s uffering produced by a craving and repuls ion of s ense pleasure, for existence and nonexistence, and for becoming and s elf-annihilation. Indeed, the calmnes s and s eeming pas sivity of s ome B uddhis ts in dealing with their suffering may tes t the patience of W estern ps ychiatris ts who are accustomed patients s eeking rapid s ymptomatic relief with G uilt, another component of depress ion, and s in are reported by fewer patients nowadays. E ven though obses sive-compuls ive disorder (OC D) mimics the calculated rituals of s ome religions , fewer patients ruminate about right and wrong and good and evil. shifts indicate a decrease in religiosity and an increase naturalis tic, scientific beliefs and modes of express ion. 302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 82 of 121

Although conversion dis orders are s till prevalent in world countries , their decline in W es tern nations has attributed to the transparency of the s ymptoms in the of wides pread, public understanding of ps ychological principles. In fact, pers ons with conversion disorders be overrepres ented in the throngs of uns ophisticated attendees at faith healing revivals and crusades , s ome which may attract 100,000 participants, as well as a television audience. Attraction to thes e s pectacles represents a disappointment that modern medicine, despite its technological advances , s till cannot cure all diseases . T he rapid growth of C hristian groups that emphasize unabashed emotionality, mus ic, singing, gloss olalia, and a ques t to attain s piritual joy may res ponse to what seems to be a worldwide increas e in depres sion. G loss olalia or s peaking in tongues is a unders tood, nonpathological phenomenon in which a person utters a series of words that are totally unintelligible to the speaker and to listeners . It can quiet or in highly emotional s ettings , in groups or in solitary privacy, in children as well as adults , and in and lower–social class pers ons . It usually is not with an altered s tate of consciousness . It rarely is a negative experience; mos t of the time, it is mildly and s ometimes very positive. It pos sibly benefits depres sed and anxious pers ons a little bit. T he practice mentioned in the New T es tament as a minor gift of the Holy S pirit, ranking below wis dom, faith, healing, and prophecy.

S pirituality S pirituality is a somewhat nebulous concept. In 1990, David E lkins, a psychologis t, outlined the values of 303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 83 of 121

persons as belief in a “greater s elf” or pers onal G od, a sens e of purpose in life and quest for meaning, of the sacredness of nature and of all human knowledge that ultimate fulfillment is found in and not in material things , altruism, idealism, suffering and death, and leading a life that has a effect on people, nature, and whatever they consider to ultimate, trans cendent reality. S piritual and religious values overlap, but a person with extrins ic religiosity be lacking in s pirituality, whereas a nonchurchgoer who volunteers at a homeles s s helter and is active in environmental caus es may be spiritual but lacking in religiosity. T he spectrum of s pirituality is exceedingly broad. At end is religious s pirituality as exemplified by the quiet prayerful practices of monks and nuns and by the enthus ias tic, highly motoric practices of S ufi Mus lims P entecostal C hristians . At the other end is New Age spirituality, which includes ethereal mus ic, cosmic vibrations, abductions by aliens from outer space, readings, pas t-life regres sions , being touched by and near-death experiences that occur when persons in a s tate of what appears to be death but then are S ome persons later report that they were out of their bodies during the near-death period, looked down at thems elves , and felt thems elves moving through a dark tunnel peacefully. T hey reviewed their lives as in a panorama. T hey s aw a glowing light with a human cities of lights , and a border from which there is no T hey met deceased relatives and friends . T hey heard doctors or spectators who pronounced them dead, but they were res cued from death by a s pirit. R emarkable 304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 84 of 121

similarities exis t between the reports of near-death survivors and by us ers of hallucinogenic or other drugs. is likely that, when a person approaches death, there is decrease in respons e to external s timuli, a turning of attention, the releas e of old memories , and a fear of death that triggers hallucinations , dreams , and fantas ies of G od, heaven, and rescue. S hould the person survive, then the near-death experience may be interpreted as a valued s piritual phenomenon, various s tudies , as much as 22 percent of s uch have been des cribed as hellis h and terrifying. It is not s urprising that the therapeutic approach of AA centers on s pirituality because of the nature of alcohol. T he V arietie s of R eligious E xpe rie nce , written in 1902, commented on alcohol's power to s timulate the faculties of human nature, to bring drinkers to the core of life, and to make them, for the moment, one truth. Dis tilled spirits were originally called aqua vitae — water of life. T he ancient G reeks worshiped the god Dionys us , who suppos edly invented wine. At his chaste orgies , women were intoxicated with wine, danced ecstatically in the darkness of the mountains, and then ripped apart wild animals and devoured them in the P.616 that each mors el contained a bit of Dionysus hims elf. was als o revered as the Lord of S ouls, his likeness , drunken revelers to a happy afterlife, painted on sarcophagi. T he B ible calls wine “the blood of the and, in C hris tian thought, J es us ins tituted the sacrifice at the Las t S upper, when he offered his bread and wine that he declared to be his body and 305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 85 of 121

B y eating the bread-flesh and drinking the wine-blood, disciples ingested their G od, and his immortality theirs , an immortality available forevermore to believers who partake of this s acrament of Holy C ommunion. J ellinek, one of the greates t alcohol researchers , that alcoholics us ed drunkenness as a type of s hortcut higher life and higher mental state without an emotional or intellectual effort. T o be “high” is to be clos er to AA is not a religion, although s ome critics have as a religion in denial. Its roots are C hris tian; its steps and traditions unconsciously recall the 12 tribes Is rael and the 12 dis ciples of J es us . T o fulfill the s teps , members mus t believe in a power greater than thems elves , turn their lives over to G od as they him, improve their cons cious contact with G od through prayer and meditation, and experience a spiritual awakening. T he most detailed s tudy of AA dynamics is E rnest K urtz's book, Not G od: A H is tory of Alcoholics Anonymous . T he curious title refers to the fundamental mess age of AA, namely, that each alcoholic mus t claim to be more than human. R eligion's aspiration for perfection and absolute truths was too grandiose for founders of AA, who broke away from the C hristian G roup and es tablished AA's miss ion of s aving “drunks ” not the world. One of the founders noted that, before he was trying to find G od in a bottle. F or many the spiritual approach of AA is undoubtedly effective, although the organization's commitment to remain forever nonprofes sional has hampered impartial

Ps yc hiatris t's R ole P sychiatrists s hould ask all patients about the 306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 86 of 121

of religion and spirituality in their lives, the frequency intens ity of their participation in religious and spiritual practices , and the leadership s tyle and members ' behaviors of the religious and s piritual groups in which they are involved. G eneral familiarity with the beliefs behaviors of certain groups in which patients are must be joined with knowledge about s pecific local groups . S ome patients may es chew participation in congregational life—they may lack trans portation, have health problems, feel embarrass ed by their shabby or get panic attacks in crowded churches —and watch televangelis ts in the comfort of their homes . Many pray, put their trust in guardian angels , and read s acred texts daily; although their level of unders tanding may be unsophis ticated, the mere presence of the s acred text their reading of it s uffice to provide a sense of s ecurity purpos e, feelings of hope and solace, and reaffirmation a G od who pers onally cares for them. P sychiatrists s hould ass ess patients' religious and involvement in terms of mental health and social and must be alert to the misuse of religion; an example the citation of s acred texts by some C hristians , J ews, Muslims to jus tify the humiliation and physical abuse of wives. B y using pass ionately pious appeals , abusers gain the s upport of their in-laws and local groups . P sychiatrists who treat the wives of s uch persons may portrayed as evil doers who s ubvert the will of G od, they endors e the s tatus quo. However, if therapeutic efforts to ameliorate the abus ive situation fail, then must be cons idered, even though the patient may find herself es tranged from her family, her congregation, maybe even her religion. 307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 87 of 121

It is improper for a ps ychiatris t to pros elytize or to dispense s pecific s piritual advice or to pray with other than to remain res pectfully s ilent if a patient does pray. It is proper to suggest to appropriate patients that participation in religious and s piritual activities may some ps ychos ocial benefits and to respect and to encourage thos e religious and s piritual beliefs and practices being used by patients to cope with their However, it is important to know that religious organizations are not mental health providers, although the promotion of mental health may be provided such activities as caring human contacts , forums for open discus sion of values and behaviors, and material help, prayers, and moral support in times of cris is. T he ultimate purposes of religion are not mental health and euthymia but rather salvation and the quest for P sychiatrists s hould warn patients about membership cultic groups and s hould refer patients to mental health chaplains when is sues such as s alvation and dogma “B orn-again” C hris tians us ually s eek out ps ychiatris ts therapists who belong to their congregation or who publicly identify themselves as C hristians , may pray their patients , may use biblical examples in treatment, regard homosexuality as a sin, and may be loathe to cons ider divorce as an option. However, mos t C hristian ps ychiatris ts are aware of the tendency of some disguis e ps ychological problems by a religious presentation. In a study of C hristian-oriented cognitivebehavior psychotherapy, religious and nonreligious therapists were equally effective.

C UL TUR E A ND ME NTA L IL L NE S S Mental illness is the res ult of a complicated chain of 308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 88 of 121

that implicate flawed biological, psychological, s ocial, cultural process es . S ometimes, the proximal caus es of ps ychopathology are clear cut; examples include storm, drug intoxication, and the experience of a event. However, in most cas es , ps ychopathology slowly in ways not fully unders tood over the cours e of a lifetime. S cientific explanations of ps ychopathology are based on naturalistic, material findings, although the observation, determination, and interpretation of thes e findings may be incorrect and bas ed on cultural biases ; various times, psychiatrists have believed that female masturbation may res ult in mania and epileps y, that mothering may caus e children to be s chizophrenic, that homos exuality in its elf is pathological, and that one or expos ures to heroin invariably res ult in addiction. C ulture influences mental illnes s in many ways. T he content of people's delus ions, auditory hallucinations , obses sional thoughts, and phobias often reflects what significant in their culture; examples include the delus ion of being J esus, Mohammed, or B uddha; the delus ion of being persecuted by terroris ts , the C entral Intelligence Agency (C IA), or space aliens; and contamination by germs , nuclear was te, and environmental toxins. S ocial phobia, as it is known in Wes t, may be shaped by J apanese culture into a known as taijin-kyofu-s hio, an exces sive concern about interpersonal relations, body odor, and eye contact, with flushing. T he J apanes e psychiatrist, S homa developed a s pecial therapy rooted in Zen B uddhism this condition in which patients undergo res t and followed by participation in s imple tas ks , make entries diary for written comments by the therapis t, learn to 309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 89 of 121

appreciate and to accept things as they are, and their attitudes toward life. C ulture can elaborate normal behaviors , s uch as the reflex and s leep paralysis. In Malaysia and Indonesia, hypers tartling persons, called latahs , may be gleefully goaded by onlookers until they are s o flus tered that utter obscene words , obey forceful commands , and the onlookers ' behaviors. In Newfoundland, C anada, experience of s leep paralysis, which occurs when as leep or awakening P.617 and may be ass ociated with hallucinations, has been elaborated into an “old hag” syndrome. C ulture can facilitate the prevalence of disorders such as abuse and suicide, whos e rates differ depending on attitudes. T he cultural acceptance of technological advances has contributed to global obesity; the replacement of bicycles by motorized vehicles and of shovels and saws by mechanized tools has res ulted in sedentary lifes tyles . In some areas of Africa, obesity come to be valued as an indicator that a person is not infected with human immunodeficiency virus (HIV ). C ultural mating patterns may influence the prevalence ps ychopathological genes ; intermarriage on the s mall is land of B elau, Micronesia, has resulted in a high schizophrenia rate, whereas the effects of female infanticide in C hina, which has caused a surplus of 50 million single men and the ris e of cous in-marriages in “inces t villages,” remain to be s een. C ultural attitudes res ulting in s tigmatization affect the prognos is of disorders ; a positive effect of the current, albeit 310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 90 of 121

overs implified, notion that major mental illness is the res ult of a “chemical imbalance” has led to greater acceptance of the mentally ill by family, friends , and society and greater access to treatment res ources .

C ulture-R elated S yndromes T here is extreme diversity among the peoples of the concerning the recognition, class ification, and unders tanding of mental behavior s ymptoms. W es tern ps ychiatris ts class ify mental diseases according to the DS M-IV -T R and the International C lass ification of (IC D), which are thought to reflect scientific categories. P eople living in W es tern countries, in part because of economic might and military prowes s, have ass umed their world view is basic and true, whereas the world of others are variations on what is natural. However, lack of biological markers and the differing of behavior contribute to the ethnocentricity of thes e clas sifications. T he DS M-IV -T R and IC D are not applicable; ps ychopathological s yndromes exist, in non-Wes tern cultures that do not fit the scientific nomenclature unless they are placed into the “atypical” category. T hes e s yndromes are perceived to be more influenced by culture than are most W es tern and, therefore, have been labeled culture -bound, culture -re late d is a better term. S ome syndromes are in dis tinct cultural groups , whereas others are found in large cultural regions . Malgri, or intruder sicknes s, is a syndrome of s ome Aus tralian aborigines in which an offended s pirit attacks pers ons who enter the s ea or a foreign territory without performing a proper ceremony and caus es fatigue, headaches, and painful dis tended abdomens . F amily s uicide is a J apanese behavior 311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 91 of 121

which dis graced parents kill thems elves rather than live with shame; they als o may kill their children for fear their orphans would be s ocial outcas ts. K oro in and s uoyang in C hina are disorders in which men panicked and fearful of death, because they believe their penis is s hrinking into their abdomen. W estern patients with koro-like symptoms tend to be schizophrenic, brain damaged, or intoxicated with or drugs , s uch as amphetamines . Amok runners are Malaysian men who, after a period of brooding, erupt a s tate of frenzied violence and indis criminate attacks that end with exhaus tion and amnes ia. Often runners are killed by the police, although attempts are made to s ubdue them. Most s urviving amok runners been diagnos ed as s chizophrenic. Indis criminate mas s homicidal behaviors have been increasing in W estern cultures, es pecially in the United S tates , in schools and workplaces , s uch as factories and pos t offices. T hes e behaviors differ from terrorist attacks in that they are driven by political and religious motivations . P s ychiatric diagnoses have rarely been made in Wes tern cases , although, on autopsy, a s mall pineal tumor was found man who climbed a tower at the Univers ity of T exas shot at a pas sers by. F ear-of-becoming-fat anorexia appears to be a culture-related syndrome in Wes tern countries , as is diss ociative identity disorder, which to derive from a lingering notion of demon pos ses sion; well-publicized cas e in F rance in 1611 involved a girl, after being seduced by a priest, was s ent to convent at which s he and a young nun were found to be by more than 6,000 demons after developing visions of demons , and lewd behaviors with a crucifix. 312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 92 of 121

FOL K B E L IE F S A B OUT ME NTA L IL L NE S S T he distinction between cultural explanations of symptoms and true s yndromes is often problematic. beliefs about mental illnes s are rarely found in written form, fall outs ide of the s cientific tradition, and are often magical, integrative, and definitive. Although irrational, they offer explanations for life's vagaries and make the seeming capricious nes s of pathology more acceptable. S cientific and folk beliefs are ritualistic and, regard to mental illness , have s uccess es and failures . systems may function s imultaneously within a culture within a pers on. A mentally disturbed pers on may seek ps ychiatric help and, at the same time, indulge in folk therapies. F olk beliefs about the caus ation of mental illness may to naturalis tic and supernatural forces . E xamples of caus ation include heart dis tress in Iran and renal and nervous s ys tem exhaustion (neuras thenia) in Mys tical theories include fate, astronomical influences, predes tination, bad luck, ominous sensations, contact with mens trual blood or a corps e, violation of taboos , s peaking forbidden words, trespass ing, and improper conduct toward kinsmen, strangers, social superiors , or spirits . Animistic theories include s oul los s and aggres sive acts by s pirits. Magical theories ascribe illness to the use of s orcery or witchcraft; s orcerers their power by s uch means as apprenticeship, theft, whereas witches poss es s inherent powers . techniques include spells; hexes; prayers; curs es ; the supposed intrusion of objects into a pers on's body; performed over portions of a person's body (e.g., nail 313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 93 of 121

clippings and hair), excreta, or poss ess ions; of poisons that are us ually inert pharmacologically; capture of a victim's soul; sending alien spirits to victim; and rites performed over pictures and dolls thought to resemble the victim. S cientific beliefs hold that dis harmonies in the environment and in s ociety may be linked with mental phys ical disorders in individuals, whereas folk beliefs include s piritual and s upernatural dis harmonies. In traditional C hines e medicine, pathology of the human body and of emotional express ion reflects imbalances cosmic forces ; epilepsy and koro res ult from excess ive a female negative force, whereas mania res ults from yang, a masculine, pos itive force. In this system, emotions are linked to five visceral organs that are to five elements and that are affected by humidity, heat, dryness , and cold. V itality and health in this also depend on jing (vital energy) and qi (vital air). ps ychological concepts have little place in C hines e medicine in which the focus is on a holis tic balance of internal and external forces and on the prescription of herbal remedies, medications, diet, and acupuncture. T raditional Indian medicine, Ayurveda, has s ome similarities with C hinese medicine, although it pays attention to mental disorders , is somewhat more ps ychologically minded, allows for sorcery, and has a broader pharmacopeia. W es tern alternative medicine practitioners, es pecially thos e who practice in luxurious health-spa s ettings , often claim to us e traditional and Indian practices ; patients are us ually told to s top smoking, to eat a nutritious diet, to drink green tea, to relax, to meditate, to get mas sages , to practice yoga, 314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 94 of 121

to take s ome herbal “medications ” (one well-known phys ician has sold an expensive herbal mix that he described as “pure knowledge compress ed into herbal form”). P.618 F olk beliefs about mental illness are too numerous to report; however, three examples—nerves , hexing, and spirit pos sess ion—are presented.

Nerves T he E nglis h-language terms ne rvous , a cas e of the and ne rvous bre akdown are us ed commonly to mental disturbances ranging from mild anxiety to a ps ychotic epis ode. Among Latinos , the word ne rvios similar general meaning but is more frequently us ed has been elevated by cultural psychiatrists to an idiom distress . It is us ually as sociated with feeling frustrated stress ful situation. Ataque de ne rvios (nervous attack), prevalent among P uerto R icans , is characterized by sudden, dramatic, loss -of-control, anger-discharging behaviors , s uch as falling on the floor, flailing limbs , grinding teeth, and clinching fists. It may involve aggres sion toward others , in which cas e, it often is as sociated with amnesia. Attacks have been likened to adult temper tantrums and epileptic seizures. S ome persons may appear to be in a diss ociative s tate during attack but are not uncons cious . Attacks always occur in the presence of observers, and, unlike true seizures, there is no incontinence or tongue biting. T hey are attention getting and may be used for secondary gain, such as family control; persons may instill fear and guilt 315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 95 of 121

family members by threatening to have an attack if they are angered.

Hexing: The E vil E ye More than one-third of world cultures hold a belief in evil eye hex. It is widespread throughout E urope, the E as t, His panic America, the Indian subcontinent, and Africa. It is called mal occhio (Italian) and mal de ojo (S panis h). T he evil eye is generally considered to be a sudden, destructive power—sometimes unknown even to the persons who pos sess it—from the eye of a human an animal. T he victim who is hexed may develop headaches, s leepiness or fitful s leep, exhaustion, depres sion, hypochondrias is, spirit poss es sion, failure to thrive, anorexia, listles sness , diarrhea, disrupted social relations hips , and s udden death. T he supposedly can caus e the death of animals , the food, and the wilting of crops; in centuries pas t, J ews in G ermany were forbidden to look at crops for fear that glance (J ude nblick) would be damaging. P ers ons who thought most likely to pos sess the evil eye are those phys ical deformity (es pecially a hunchback), strangers, jealous kin or neighbors , marginal members of society, barren women, the poor and hungry, persons with their lot in life, children who return to their mother's breast after weaning (seen among S lovak-Americans ), most importantly, anyone who utters a word of prais e compliment. T he evil eye can strike anyone, but mos t susceptible are wealthy, handsome, and weak children; and women, es pecially when pregnant. A has been reported of a 27-year-old Italian-American 316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 96 of 121

living in P hiladelphia, who thought hims elf hexed in his community agreed with him) and s ubsequently murdered s ix people whom he believed were sorcerers res ponsible for s triking him with the evil eye. Diagnos is of the mal occhio in southern Italy reflects practices found in other cultures . A female s pecialis t three drops of oil into a bowl of water, cros ses herself, recites ritual words , calling on G od to remove the evil If the oil and water mix, the patient's s ickness is to be organic. C oagulation of the mixture is evidence of the evil eye. S ymbolically, the water repres ents and the oil repres ents evil. T he force of the Holy T rinity counterbalances the evil eye, thought, and desire. techniques are us ed to ward off evil eye attacks ; include building high, solid fences or walls around home, avoiding the dis play of one's wealth, smudging face of an infant with dirt to make it appear invoking G od's name immediately after one receives a compliment, and pos sess ing amulets in the s hape of horn or of a hunchback holding a horseshoe.

R oot Work P robably derived from hoodoo, root work is a hexing found among s ome African Americans, especially with lower social clas s, rural, S outhern backgrounds. hex is adminis tered by tampering with a victim's food or drink or by a touch or an evil glance. Other techniques include s prinkling s and, salt, or pepper on a victim's step; burying a knife with its point towards a victim's house; and magically manipulating various items — household goods , blood, excreta, and hair—in with special times, such as s unrise or the dark of the 317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 97 of 121

and s pecial days, such as F ridays, and the 13th day of month. P ers ons who believe thems elves to be hexed may emergency rooms with symptoms s uch as chest and abdominal pain, unresponsivenes s, fainting s pells, lip smacking, and epileptic seizures or ps eudoseizures . P sychiatrists may encounter s uch patients becaus e of severe anxiety, hallucinations, and persecutory or grandiose delusions . B ecause they think that might be ignorant about or disparaging of the notion of hexes , victims rarely report their belief that they have hexed. It is important to ask s pecifically about the poss ibility of root work or hoodoo.

S pirit Pos s es s ion Altered states of cons cious nes s can be induced pharmacologically, ps ychologically, and phys iologically and are experienced in many ways, s uch as s leep, concuss ion, a reaction to drugs , delirium, depers onalization and other diss ociative states , and meditation. Depers onalization is a fairly common experience and becomes pathological only when as sociated with marked dis tres s and impaired S ome of the features seen in diss ociative dis orders, in general, and depers onalization, in particular, may be interpreted in various cultures as pathological include the frenetic excitement and s eizures known as pibloktoq among Arctic native peoples and s ome forms amok), but they may also be regarded as purpos eful even des irable. T rance is the most common s ocially institutionalized altered s tate of cons cious nes s, and poss ess ion is the most common cultural explanation 318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 98 of 121

trance. In s ome belief s ys tems, s pirits are thought to permanently within a person and may even s erve as an explanation for a variety of s cientifically defined such as epileptic s eizures , s chizophrenia, and slowgrowing viral encephalopathy. It is more usual for stay within a pers on for brief periods of time. W es tern expres sions such as “What got into you? ” and “What poss ess ed you to do that? ” reflect this old belief. In the spirit pos sess ion belief probably is the most ancient prototype of many medical dis orders, s uch as an axis I ps ychiatric disorder, in which people theoretically can disposs ess ed of a dis eas e which comes on them. In situations, pos ses sed persons may be diagnos ed as ill their own culture, as is the case in s ome culture-related syndromes. A world view that allows for spirit pos ses sion can be unders tood fully only on its own terms and not scientifically; within a given culture, s pirit poss ess ion be quite logical, and the pantheon of consens ually validated spirits is unlike a projected paranoid ps eudocommunity. C ultural s ettings conducive to the occurrence of spirit pos ses sion are thos e in which an oppres sive s ocial structure s tifles pers onal protes t and weakens trust in the efficacy of social institutions and in direct actions to res olve s ocial conflicts. S ome healers make diagnoses and perform therapeutic acts while the influence of s pirits ; examples include C hris tian televangelis ts who P.619 are “moved” by the Holy S pirit and male S ufis (Mus lim), known in Morocco as the Hamads ha, who must tame 319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 99 of 121

she-demon spirit of ‘A’is ha Qandis ha. However, mos t poss ess ed persons have a low s ocial status and are B y watching others, they typically learn how to react to spirits within them; s ome s pirits have a s pecific name agenda, whereas others may be ambiguous in their character and demands . P os sess ed persons become spirit carriers and are not personally res ponsible for what the s pirits force them to or s ay, although there always are some social on their behaviors . Malevolent spirits may demean, chas tis e, and caus e their carriers mental, bodily, and interpersonal harm. During positive experiences , may improve their own social s ituation as well as make as tute diagnoses and prescribe treatments for persons seeking help. T he s pirits are us ually judgmental and speak openly about social injus tice, abus ive and flawed family dynamics . T hey may call on es teem the carriers and to fulfill the carrier's des ires for certain poss ess ions and for improved relationships. men poss es sed by female spirits act like women, and women poss es sed by male spirits act like men, the cons truct of s exual identity is publicly examined. T he intricate dynamics of spirit poss es sion vary greatly cultures, and attempts to reduce and to explain them by us ing Wes tern ps ychiatric concepts are invariably unsuccess ful. Although s ome s pirit carriers may, be paranoid, ps ychotic, or hysterical, the proces s is not pathological. Analogous ly, the psychiatric process not be invalidated just becaus e s ome ps ychiatris ts are mentally ill.

FOL K HE A L ING 320 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 100 of 121

T he number of pers ons who, to s ome extent, fall into category of folk healer is large, and they range from the ludicrous to the sublime; examples include palm and card readers , astrologers, channelers , herbalis ts, New couns elors, psychic surgeons, and shamans. S hamans persons who follow a divers e call to healing and who receive and communicate instructions from s pirits. Different types of s hamans exis t in almos t all cultural groups , s uch as Haitian hungans , Wes t Indian Obeah P uerto R ican s piritis ts, and C hris tian faith healers. P sychos ocial profiles of s hamans s how that s ome are impos tors , s ome are mentally ill, and s ome are healthy, mature individuals . T rue shamans have an ability to recognize and to organize uncons cious needs and concerns , in thems elves and in their cultural group. T hose as piring to be shamans typically undergo an initiation that includes formal didactic training and recovery from a frightening, culturally-formulated, like experience. S ome W estern observers have regarded this experience as evidence of ps ychopathology—“the crazy witch-doctor.” S hamanic therapy usually takes place in a group is a public drama in which the patient and the shaman given strong support by the group. S hamans often thems elves as extraordinary persons, becaus e supernatural world and negotiating with s pirits is harrowing, even dangerous , work. Hallucinogens may taken to facilitate contact with s pirits ; an almos t instantaneous contact may be achieved when hallucinogenic snuff is blas ted up the s haman's nos e through a blowpipe, a practice of the Y amomomo in S outh America. T he s haman's tas ks include the 321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 101 of 121

of los t s ouls, the pacification and exorcis m of demons, the provis ion of counter-magic, often by suppos edly sucking out harmful stones and animal parts from a person's body. B y demons trating objectively that has been dispelled, the s haman may effect cures suggestion. Other s hamanic treatments that may be therapeutic include herbal and other medications, surgery, bandaging, and chiropractics. F inally, prescribe steps through which patients can s tabilize cure and demonstrate their healthy s tate. P atients may told to perform acts of atonement and to adopt a new name or a new manner of dress . T he varieties and contexts of folk healing rituals are so that it is impos sible to generalize about them all, but shared commonalities can be delineated: F olk healing often is a group phenomenon, even a s ingle person is identified as sick; healer–patient relations hips are not emphasized. Healing groups are often ongoing rather than time limited. T hey occur with some regularity, and may drop in or drop out of the groups whenever desire. Healing groups may be quite large, sometimes involving hundreds of pers ons , thus enhancing support for participation, the magnificence of the ritual, and, through contagion, the manifestation of desired effects, s uch as trance states and Healing rituals are public events . Attendees include not only identified patients or troubled persons, but also family, friends , community members , and cult 322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 102 of 121

devotees . P ers ons who are healed and prove to be adept at healing others may rise through the ranks to as sistant and then primary healers with a personal following. Alterations in consciousness are central to many healing experiences . W hen in a trance, healers or patients may expres s thoughts and emotions that otherwis e might be repress ed or suppres sed. T his expres sion may be therapeutic in its elf, but it als o often s erves to call attention to interpersonal and social conflicts that are troubling the entire group. T hese conflicts have a better chance of res olution when they are brought out in the context of a controlled healing ritual, rather than in private confrontations . Als o, becaus e s uggestibility during altered states of cons cious nes s, patients res pond positively to the s ugges tion that their experience clearly indicates success ful therapy. T he concept of insight, as usually unders tood by ps ychiatris ts, does not play a role in folk healing P erhaps the most psychiatrically detailed s tudy of a healing ritual is that of the P acific Northwes t C oast G uardian S pirit ceremonial described by W olfgang 1982. T he ceremonial appears to be therapeutic for society as a whole, as well as for depres sed, alcoholic, aggres sive pers ons . Initiates are reduced to a state of infantile dependency during 10 days of seclusion in the quasi-uterine shelter of the dark longhouse. P ers onality depatterning and reorientation are accomplis hed 4 days of alternating s ens ory overload and deprivation, 323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 103 of 121

which result in rapidly alternating s tates of techniques include sleep deprivation, fasting to the of dehydration and hypoglycemia, rhythmic drumming and chants, blindfolding, restricted mobility, forced runs the woods, and s udden grabbing of initiates to stage a symbolic clubbing to death of their diseased, faulty Initiates then go through a phase of phys ical training, as s wimming in ice-cold water and dancing to the point exhaustion. T his is accompanied by intense and instruction in tribal lore. T he mythic theme of the ceremonial is death and rebirth. Initiates are “reborn” when they fully accept the wis dom of their culture, they s ee the G uardian S pirit in a dream or vis ion, and they are given new clothes and a new identity. A large number of tribal group members participate in the S uccess ful initiates who straighten out their lives may invited to return as leaders in s ubs equent ceremonials . A number of Native American tribes have the inges tion of peyote and other cons ciousnes s hallucinogens to achieve a religious and healing experience. However, the Navajo, perhaps the mos t therapeutically oriented of all cultures , focus instead on mind-numbing, ritual, group sings that may last as long P.620 1 week to treat illness es . P atients first undergo s elfpurification by bathing, sweating, and emes is. T he are invoked through specific s ongs and prayers, and healing powers are channeled onto a symbolic design then onto the patient, while tribal members work to reharmonize the patient's natural, s upernatural, and human environments . Ancient, relevant myths are 324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 104 of 121

and the gods are compelled to help, provided that the ceremony is performed s incerely and accurately. Analogous to the C hristian belief in demons is the belief in jnun (masculine singular: jinn), whims ical but potentially malevolent spirits. W hen insulted or they may pos sess a person and caus e depres sion, ps ychos is , s udden blindnes s, seizures, anorexia, or paralysis of the face and limbs. T reatment may the spirit, but sometimes, when the s pirit res ides permanently within a person, treatment is aimed at placating it by following its orders and by joining therapeutic cults . S imilar s pirits, as well as a healing are termed zar in northeast Africa and the Arabian penins ula. Zar illness often is diagnosed when us ual herbal, medical, and magical treatments fail to cure a person. V ictims, who are us ually frus trated women, elaborate healing rituals with their families, friends, and cult devotees . W hen a spirit's special s ong is played, entranced victim must dance and tell everyone what and favors her spirit wants to be appeased with to stop symptoms. T his thinly veiled attempt to get attention desirable things us ually is effective, at leas t V ictims may attend fairly regular zar rituals not only for ongoing therapy, but also as a form of entertainment.

C linic al Ps yc hiatric Prac tic e T he history of modern American ps ychiatry reveals that various s chools , each fairly certain, at the time, that held the key to unders tanding and treating mental have aris en, made contributions , and eventually have found lacking. T hus , in one period, intrapsychic conflict and the need for accurate interpretations were 325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 105 of 121

T his was followed by an emphasis on interpersonal relations hips , replete with schizophrenogenic mothers, double binds , and catch 22s . Next came s ocial embodied by the community mental health movement. T he current new s chool is biologically oriented and guilt-relieving, politically savvy, and financially reimbursable brain disease metaphor for mental Opposite to reductionis m is synthesis , the core of the cultural ps ychiatric approach. T his approach demands cons ideration of all the biological, ps ychological, and social forces that impinge on mentally ill pers ons and treatment. It broadens the biopsychosocial model by pointing out that culture overarches and provides meanings for biological, psychological, and s ocial cons tructs, such as brain dis eas e, ins ight, and trance. However, the use of this approach in everyday clinical practice is quite difficult; it is eas ier to go with the flow one's culture, becaus e it feels right and natural, and because there are incentives to do s o. T he role of culture often becomes apparent only when ps ychiatris ts as sess and treat patients whose cultural backgrounds differ from theirs . T he s pecial problems arise in s uch s ituations can be resolved only if are able to adapt their s tandard procedures . T his need adaptability in clinical practice may be regarded with skepticism by those ps ychiatris ts who have embraced certain theory or approach that they apply to all However, from a cultural perspective, no one ps ychological, or social approach can fulfill the needs patients. DS M-IV -T R provides an outline for a cultural formulation designed to ass is t in the s ys tematic and treatment of patients. T he formulation calls for data 326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 106 of 121

on (1) the cultural identity of the patients , including ethnicity, involvement with original and host cultures, language abilities; (2) the cultural explanations and of dis tres s used by patients and their community concerning their illnes s or situation; (3) the cultural impacting patients' s ocial situations , including work, religion, and kin networks; (4) the cultural and s ocial differences between the patient and clinician that may affect as ses sment and treatment, including problems communicating, negotiating a patient–clinician relations hip, and dis tinguishing between normal and pathological behaviors ; and (5) the formulation of an overall cultural ass es sment for diagnosis and care.

As s es s ment E thnic stereotyping is a problem not only for the but also for the patient and for society as a whole. T his practice is ins idious ly fostered in s cientific and popular articles, books , and polls that lump groups of people together in one category, s uch as African Americans , whites, or C atholics , and make generalizations. need to know about the various ethnic identities of patients as well as their current importance. One as sume that all Hispanics are alike; MexicanP uerto R ican Americans , for example, share as many cultural differences as they do commonalities . S ocial is a major variable. T his basic information may be through direct ques tioning and by observation of the patient's language, dres s, knowledge of social and interpersonal style. C linicians s hould not jump to conclusions bas ed on knowledge of a patient's culture. Having visited a 327 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 107 of 121

homeland or community, having read a book about it, having a pers onal friend whos e cultural heritage is to that of the patient does not make one an expert, although it may help clinicians to ask appropriate questions and alert them to poss ibilities , for example, a P uerto R ican may engage in s piritis m or that a G reek immigrant may believe in the evil eye hex. It is better to approach ethnic patients without preconceived notions even the mos t basic areas ; in s ome cultures, for sibling may include a person other than those regarded brothers or sis ters in the W es t. Attitudes and with authority figures should be determined. An upperclas s Anglo patient is apt to react negatively to an authoritarian s tance by a ps ychiatris t, but a patient another culture may regard such a stance as and helpful. S imilar attention should be given to toward s ex-related roles; male patients from a culture emphasizes machismo may have difficulty in working a female clinician and so may distort their complaints history. C linicians mus t determine whether patients' reluctance discuss certain topics is the result of pers onal s hynes s, ps ychopathology, or adherence to their s ocial group's customs and etiquette. F rank and detailed ques tions sexuality, especially in the initial evaluation, may be perceived as inappropriate and even offens ive by from cultures in which sexuality is cons idered a private matter. E thnic patients may be touchy about many such as immigration s tatus, family relationships , and finances . An Algerian man with a long history of panic disorder evaluated in an American clinic with a chief complaint 328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 108 of 121

need medicine.” He told the ps ychiatris t that he had unable to find a job in 6 months and that he depended the charity of several people at the local mos que at he was allowed to sleep. He planned to return home for week, to get married, and to return to his current When asked how he planned to s upport himself and a wife, he became angry and said, “that is none of your business .” He refused any more conversation and demanded medication. T he psychiatris t P.621 explained that the question he had asked was routine that he was concerned about the patient's welfare. T he patient was given a 1-month supply of medication but not keep his return appointment. T he case als o typifies many Muslim patients who expect only medications ps ychiatris ts; in P akistan, ps ychiatric patients usually therapy but rather demand intravenous (IV ) fluids, in to demons trate to family and friends that their illnes s is medical. In contras t, s ome Hindu patients may regard ps ychiatris t as a type of guru and accept advice and guidance, es pecially if family members can be drawn the proces s. Mains tream Americans may talk about depress ion, hallucinations , and conflicts , but persons from other cultures may talk about s omatic pains , liver problems, heavenly or s atanic visions , brain ache, and s hadowy figures . T he us e of ps ychological terms and constructs expres s distress is a relatively recent phenomenon in cours e of human his tory; it is neither s uperior nor to somatic presentations. However, ps ychiatris ts may befuddled by patients reared in cultures in which 329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 109 of 121

ps ychologizing s eems to be an odd way of selfIn fact, s omatic pres entations may be advantageous in they avoid the s tigma of mental illness . Als o, they may serve to elicit help and social s upport without directly confronting persons or institutions who might retaliate agains t the patient. It is true that adminis tration of medications labeled as antidepres sants is often us eful treating patients with s omatic presentations , but the complex pos sibilities as sociated with somatization may completely miss ed if they are regarded me rely as depres sive equivalents. V erbal and nonverbal communication patterns vary greatly among cultural groups. T seng and J ohn F . McDermott provide the following examples: T he J apanese patient nods his head and keeps saying (yes).…T he hai and the nod probably show only polite participation in the convers ation. T he Hawaiian may your eyes because he was brought up by a who taught that eye contact is rude and has an meaning.…T he S amoan's miss ed appointment may no more than a cultural-social cas ualnes s toward fixed dates and arrangements.…T he C hinese client who “My mother is always kind,” when the mother has been dead for some time is not neces sarily s uffering from unrealized, incomplete grief. T he C hines e language past tens e verb forms .…P eople of Oriental background tend to smile and laugh when they are embarras sed, anxious, or sad. Ass es sment of emotionality and motor behavior is influenced by the cultural norms of the ps ychiatris t and the patient. R es erved Anglo psychiatrists may interpret flamboyant or seemingly overs incere behavior of some 330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 110 of 121

Mediterranean area and Middle E as tern patients as histrionic, whereas the patients may judge the to be uncaring. T he diagnosis of hyperactivity in often depends on the tolerance levels of family, and ps ychiatris ts. A study involving ps ychiatris ts from Asian countries who were s hown videotapes of active children demons trated great national differences in thresholds for diagnosing hyperactivity. Hallucinations may be a symptom of psychosis, but, among some His panic groups, they may be ass ociated with milder ps ychopathology or may even be normal. A teenage girl who has vis ions of the V irgin may s imply be indicating her own purity. W hen persons may experience positive hallucinations in they receive advice and s upport from a dead parent. as sess ment of delusions can be tricky, because, by definition, a delus ion is a belief cons idered fals e by members of a society. T he exis tence of the devil verified s cientifically, yet so many people believe in the devil that such a belief cannot per se be considered delus ional. Although there is no s uch entity as the race, belief in it among G ermans in the Nazi era was widespread that it could not be regarded as delusional. V arious subcultural religious cults , political groups, and organizations , s uch as the white s upremacis t Aryan B rotherhood, may hold beliefs considered false by persons in s ociety at large, but they are probably not delus ional in a traditional ps ychiatric s ens e; exceptions include odd beliefs that may result in s uicide pacts or truly harmful behaviors. C ases involving established religions , s uch as J ehovah's W itness es and C hris tian S cience, in which pers ons may refus e certain medical 331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 111 of 121

treatments when severe bodily harm and even death ensue, are us ually handled by the legal s ys tem; courts generally have upheld the rights of adults to withhold neces sary medical treatment for thems elves but not for minors under their control. B ehaviors that may appear ps ychotic may, in fact, be normal when unders tood in their cultural context; a traditional C hines e treatment for kidney deficiency disorder requires an adult to drink the firs t morning of a young boy. C onversely, some behaviors that may appear normal may be pathological. Among the Amis h, example, symptoms of mania may include racing one's horse and buggy, driving a car, using illegal drugs, with a married person, excess ively us ing a public telephone, and treating lives tock too roughly. However, recent years, the “E nglis h” (outside) world has intruded Amish society, so that teenagers engaging in the previous ly lis ted behaviors may be acting out as to manic. P sychiatrists must not only ass ess patients vis their particular cultural groups but als o must as ses s each patient's group vis -à -vis the mainstream culture which the group is a part. W hen in doubt, the should as k members of the patient's social group if cons ider the patient's beliefs and behaviors to be T his process also allows the ps ychiatris t to ass es s, superficially, the s ocial group itself. P atients experience and des cribe their illness es , ps ychiatris ts diagnos e and treat dis eas es. E ach has her own way of comprehending the patient's condition. is extremely important for the ps ychiatris t to elucidate patient's explanatory model of the illness . What does patient think caused the illness ? How is the illness 332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 112 of 121

affecting the patient's mind and body? T hrough what mechanisms does the illnes s work? Does the illness name? What does the patient think will happen if the illness goes untreated? W hat treatment does the think may be effective? W hat treatments have already been tried? If the patient's explanatory model differs that of the psychiatrist, then as sess ment and treatment become problematic. S pecial problems arise when the psychiatris t and the patient do not s peak the s ame language. T here is a tendency to diagnos e more psychopathology when bilingual patients are interviewed in E nglis h rather than their native tongue, for example, slow speech may depres sion and grammatical errors, a thought dis order. Interpreters function best when they have s ome with and training in mental health. Wes termeyer has described three models in which interpreters may (1) as an as sistant to the ps ychiatris t who conducts the interview, (2) as a partner to the psychiatrist in a interaction with the patient, (3) as a primary interviewer the presence of and under the direct s upervis ion of the ps ychiatris t. Interpreters must be taught when to translations that are word-for-word summaries or elaborations of what the patient pres ents. It is helpful the ps ychiatris t to inquire about the trans lator's feelings about and identification with the patient, the patient's cultural group, and social clas s or caste differences might dis tort the accuracy of the translation. S imilarly, patients s hould be as ked about their level of comfort and confidence in the translator. F amily members interpreters pos e s pecial problems in that they may their trans lations to achieve a specific goal, s uch as 333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 113 of 121

ensuring hospitalization or s pecial treatment. P.622 F inally, great caution s hould be us ed in interpreting the res ults of ps ychological tes ts and rating s cales unless have been validated for the cultural group under cons ideration. More and more, such tes ts and scales , suitable for use in s pecific groups, have become C linicians s hould not attempt to us e their own because the results may be quite mis leading. In a study of 1,005 adult, low-income, primary care patients New Y ork C ity, the typical profile of a pers on among 20.9 percent of those who endorsed ps ychotic was a s eparate or divorced Hispanic who s poke a primary language. Although the rating ins truments translated from E nglis h to S panish and then backtranslated to identify and to correct translational difficulties , they were not validated for the mainly immigrant Dominican and P uerto R ican groups under study. It is likely that many of the so-called ps ychotic symptoms were really misperceptions of s timuli with depress ion and anxiety, a well-known in C aribbean cultures .

Therapy P sychiatrists are trained in what anthropologists call an approach in which scientific and presumably valid cons tructs apply to all patients, although there is a for atypicality. T he emic approach eschews cons tructs and, instead, attempts to dis cover patients' unders tandings of their illness es as experienced within context of their cultures . T he culturally s ens itive 334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 114 of 121

ps ychiatris t balances the etic and emic approaches some cases , may attempt to “convert” patients to the ps ychiatric pers pective of their condition. However, some patients' explanatory models for mental illnes s be embedded within a cultural world view that is to change by negotiation or education. In s uch cases, ps ychiatris ts mus t be flexible in their therapeutic and must respect the patients' beliefs. If ps ychotic for example, inflexibly attribute their symptoms to a work hex, psychiatris ts may support family efforts to obtain folk antidotes or protective amulets and may attribute s pecific antihex properties to the medicine that they prescribe. T his is not trickery on the part of ps ychiatris ts (patients will detect insincerity quickly) but adaptation of s cientific therapy to make it acceptable to patients. T he better the ps ychiatris ts' unders tanding of patients' explanatory models , the better they are able develop an adaptive strategy. In s ome cultures, even color of the medication may alter its effectiveness for patient. P os sible medication s ide effects , even minor ones , mus t be explained in great detail, because some ethnic patients may become noncompliant at the first inkling of a side effect, although, out of respect or deference to the ps ychiatris t, they may s tate that they still taking their medication. T he field of ethnopsychopharmacology, pioneered by K en-Ming showing that genetic and dietary ethnic differences alter responses to medication. Many Asian patients, for example, metabolize benzodiazepines slowly and to lower dos es of lithium (E skalith) and haloperidol (Haldol) than do C aucas ians. Mains tream psychotherapy often focus es on the 335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 115 of 121

achievement of independence as a result of working through conflicts . T he goal and the process us ed to it may be inappropriate for patients from many cultural groups . T herapy with a Hindu in India, for example, focus on restoration of the patient within a family and a social group that values dependence and the of angry thoughts; therapy with a Hindu Indian to the United S tates , however, may have a different Immigrant patients may be torn between maintaining values of their homeland and adopting thos e of their country. T he process of acculturation may be painful, therapeutic attempts to hasten the process may exacerbate the situation with resultant depres sion, and even acute psychotic episodes . Immigrants often best when they are able to retain some of their old and behavior patterns and to participate in ins titutions and rituals that have been transplanted from their homeland. Immigrant children through their in schools tend to acculturate rapidly and to act as socialization agents for adult family members ; the proces s may be a caus e of intergenerational s trife. P sychotherapy with patients from different ethnic and social backgrounds may require much flexibility and awarenes s of s tated and unstated is sues that must be addres sed. T rust is an is sue in a white therapis t–black patient relationship, whereas s tatus contradiction is an is sue when the s ituation is revers ed, and identity is an is sue when the patient and ps ychiatris t are black. from groups who believe thems elves to be victims of discrimination may be unwilling to engage in selfdisclos ure unless the ps ychiatris ts ans wer questions thems elves . S ome patients may present gifts or may 336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 116 of 121

their families to sess ions. P s ychiatris ts mus t be able, in these ins tances , to dis tinguish between ps ychologically and culturally motivated disorders . S ometimes , it is des irable to collaborate with folk In 1978, the W orld Health As sociation and United C hildren's F und (UNIC E F ) is sued a joint declaration on primary health care which called on clinicians to folk healing practices that were proven or considered the community to be helpful. C ollaboration is feasible when the ps ychiatrist and the folk healer are ethical practitioners who respect each other's s kills and patient, for example, may accept medication and hospitalization from a ps ychiatris t and psychological social help from a folk healer. It is not uncommon for a patient independently to seek help from ps ychiatris ts folk healers at the same time. R ecognition of the importance of culture in as sess ing treating patients is evidenced by a 2002 report of the G roup for the Advancement of P s ychiatry. It provides to-date, helpful examples of cultural formulations and culturally informed therapy on s ix patients: a middle depres sed, alcoholic, sexually troubled Irish American whos e s ymptoms subsided after he was reintroduced spirituality through AA and who then entered a to pursue a religious vocation; a middle aged, devout Muslim, P akistani housewife with severe depres sion acculturation and personality problems who believed had been hexed and was helped during a 5-year individual and couples therapy; a F ilipino-American medical student with social phobia and academic problems whos e culturally mediated distorted thoughts were helped with cognitive-behavioral therapy; a 30337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 117 of 121

old black, K enyan immigrant with major depres sion, alcohol and cocaine dependence, and religious and spiritual problems who was helped by an inpatient interdisciplinary team that he likened to a traditional, African, tribal “C ouncil of E lders ”; a 30-year-old, s ingle, dysthymic “good C atholic girl” who resolved her oedipal and rage is sues with ps ychodynamic psychotherapy; 56-year-old E cuadorian, B aptis t minis ter with many personality problems who finally trusted a S panishspeaking therapist with whom he could dis cuss is sues without fear of being criticized, denounced, or stigmatized. J ust as culture strives to organize a society into a integrated, functional, s ens e-making whole, so too cultural psychiatry s trive to make clinical psychiatry logically integrated, functional, and s ens e making. insights from cultural psychiatry are applicable to the entire spectrum of ps ychiatric practice, from ps ychoanalys is to ps ychopharmacology.

S UG G E S TE D C R OS S S ection 4.2 covers s ociology and ps ychiatry. An review of s ocioeconomic as pects of health care is contained in S ections 51.5a and 52.2. Also relevant to sociocultural iss ues in psychiatry is the discus sion of ps ychiatry (in S ection 52.1).

R E F E R E NC E S P.623 Alarcon R D, F oulks E F , V akkur M. P ers onality 338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 118 of 121

and C ulture. New Y ork: W iley; 1998. *Al-Is sa I, ed. Handbook of C ulture and Mental Inte rnational P e rs pe ctive . Madison, C T : International Univers ities P ress ; 1995. B erry J W , P oortinga Y H, P andey J , eds . Handbook C ros s C ultural P s ychology. 2nd ed. B oston: Allyn B acon; 1996. B olhenlein J K , ed. P s ychiatry and R e ligion. DC : American P s ychiatric P res s; 2000. B os well J . C hris tianity, S ocial T ole rance , and Homos e xuality. C hicago: University of C hicago 1980. B rown LB . T he P s ychology of R e ligious B e lie fs . Academic P res s; 1987. C omas-Diaz L, G riffith E E H. C linical G uide line s in C ultural Me ntal He alth. New Y ork: W iley; 1988. C rapanzano V , G arris on V , eds . C as e S tudie s in P os s e s s ion. New Y ork: W iley Inters cience; 1977. Des jarlais R , E is enberg L, G ood B , K leinman A. Me ntal H ealth: P roble ms in L ow Income C ountries . Y ork: Oxford Univers ity P res s; 1995. *F avazza A. B odies Unde r S ie ge : S e lf-Mutilation Modification in C ulture and P s ychiatry. 2nd ed. 339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 119 of 121

J ohns Hopkins University P ress ; 1996. F avazza A. P s ychoB ible: B e havior, R eligion, and B ook. C harlottes ville, V A: P itchs tone P ublis hing; F ernando S . Me ntal H ealth, R ace , and C ulture . New S t. Martin's P ress ; 1991. *G alanter M. C ults : F aith, H ealing, and C oe rcion. New Y ork: Oxford University P ress ; 1999. *G roup for the Advancement of P s ychiatry. C ultural As s es s ment in C linical P s ychiatry (F ormulate d by C ommittee on C ultural P s ychiatry, R e port No. 145). Was hington, DC : American P sychiatric P ublis hing; Hollifield M, G eppert C , J ohns on Y , F ryer C : A V ietnames e man with s elective mutism: T he of multiple interacting “cultures ” in clinical ps ychiatry. T rans cult P s ychiatry. 2003;40:329. J elek W G . Indian He aling: S hamanic C e re monialis m P acific Northwe s t. S urrey, C anada: Hancock Hous e; J ones J W . C onte mporary P s ychoanalys is and New Haven, C T : Y ale Univers ity P res s; 1991. K irmayer LJ : As klepian dreams: T he ethos of the wounded healer in the clinical encounter. T rans cult P s ychiatry. 2003;40:248–277. K leinman A. R ethinking P s ychiatry: F rom C ultural 340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 120 of 121

C ate gory to P e rs onal E xpe rie nce . New Y ork: F ree 1988. K oenig HC , ed. Handbook of R e ligion and Me ntal S an Diego: Academic P res s; 1998. K urtz E . Not G od: A H is tory of Alcoholics Wayzeta, MN: Hazeldon E ducational S ervices; Littlewood R . T he B utte rfly and the S erpe nt: E s s ays P s ychiatry, R ace , and R e ligion. London: F ree B ooks ; 2000. Mezzich J E , K leinman A, F abrega H, P arron DL. and P s ychiatric Diagnos is . W ashington, DC : P sychiatric P ress ; 1996. P arament K I. T he P s ychology of R e ligion and Y ork: G uilford P ress ; 1997. P edersen P B , Iraguns J G , Lonner W J , T rimble J E , C ouns e ling Acros s C ultures . 4th ed. T hous and S age; 1996. P odvoll E M: S elf-mutilation within a hospital setting. Me d P s ychol. 1969;42:213–221. R andi J . T he F aith He ale rs . B uffalo, NY : B ooks ; 1989. R izzuto AM. T he B irth of the L iving G od. C hicago: Univers ity of C hicago P ress ; 1979. 341 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 121 of 121

S atcher D. S urge on G e nerals ' R eport on Me ntal C ulture, R ace , and E thnicity. R ockville, MD: U. S . Department of Health and Human S ervices; 2001. S imons R C . B oo! C ulture, E xpe rience, and the R efle x. New Y ork: Oxford University P ress ; 1996. *T seng W S . Handbook of C ultural P s ychiatry. S an Academic P res s; 2001. T s eng W S , McDermott J F . C ulture, Mind and New Y ork: B runner, Mazel; 1981. Ward D, ed. C ulture and Altere d S tate s of B everly Hills, C A: S age; 1989. Warner M. Alone of All He r S e x: T he Myth and C ult V irgin Mary. New Y ork: Landon House; 1976. Wes termeyer J . P s ychiatric C are of Migrants . Was hington, DC : American P sychiatric P ress ; 1989.

342 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

01/01/2009

Page 1 of 81

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 5 - Quantitative a nd E xperimenta l Methods in P sychiatry > 5.1 E pidemiology

5.1: E pidemiology J uan E . Mezzic h M.D., Ph.D. Tevfik B edirhan Üs tün M.D., Ph.D. P art of "5 - Quantitative and E xperimental Methods in P sychiatry"

G eneral C onc epts E pidemiology is one of the fundamental sciences of health and a major approach to the unders tanding and advancement of medicine and health care. is a useful tool for clinicians to link their work to populations and complete the clinical picture. It perspective about the health of the general population, including the caus es and courses of thes e illness es . As concept of health is undergoing dis cernible expans ion, subject and methods of epidemiology require growing differentiation and refinement. C onsequently, it is important that epidemiology be understood and discuss ed in a comprehensive manner s o as to the fulfillment of its mis sion and broad objectives . In line with the above pers pectives , this chapter on ps ychiatric epidemiology, although concise, attempts to take a broad look at its subject matter. It s tarts with an examination of its definition, evolution, and context, striving for a capsular understanding of the of this burgeoning field, as well as of its his torical and 343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 2 of 81

cross -sectional contextualization. It proceeds to review methods of epidemiology, including its key cons tructs variables , the design of epidemiological s tudies (iss ues types ), and the properties , forms, and validation of epidemiological instrumentation. Next, some important epidemiological findings are pres ented and commented on as they deal with the dis tribution of mental disorders and its related factors , of disability and the burden of disease, and of the positive aspects of health social s upports , and quality of life), as well as findings concerning the application of epidemiological methods health care and the formulation and evaluation of policies . T he final section explores future perspectives, including the integration of genetic and environmental analyses , a fuller cons ideration of the social matrix and cultural frameworks , and the more active us e of informational, and communication technologies , all contributing to the broadly based development of international class ification and diagnostic systems for health and their effective us e for health restoration and health promotion at clinical and population levels.

Definitions of E pidemiology and Ps yc hiatric E pidemiology T he etymological roots of epidemiology include (diseases vis iting a community) and logos (their s tudy). and the cons ideration of the origins of epidemiology within the medical field seem to have led the R andom Hous e Dictionary of the E nglis h L anguage to define epidemiology narrowly as “the branch of medicine with epidemic diseases.” T he evolving broadening of the range of diseases 344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 3 of 81

to epidemiology and an incipient interest for its contextualization contributed in recent decades to definitions s uch as that in Maus ner & B ahn's “the study of the distribution and determinants of and injuries in human populations .” T his notion is s till quite prevalent. An emerging new concept of epidemiology pres ents discipline as the s tudy of health and dis eas e as a full spectrum across the human life s pan with a population approach, including etiological factors, comorbidities, and uses and outcomes of clinical care. line with this, Mervyn S us ser propos es cogently that epidemiology is the s tudy of the occurrence, caus es , control of health events in human populations . F urthermore, the las t 2001 edition of the Dictionary of E pidemiology, fourth edition, defines epidemiology as study of the dis tribution of health-related s tates or in specified populations and the application of this to the control of health problems. T o arrive at a reasonable definition of the specific field ps ychiatric epidemiology, it should be helpful to be cons istent with the emerging concept of epidemiology outlined above—concerned with both ill and positive as pects of health—as well as with a modern concept of ps ychiatry involving the diagnos is and treatment of mental disorders and the promotion of mental health. T hus, ps ychiatric epide miology may be defined as the of the dis tribution of mental illnes s and pos itive mental health and related factors in human populations . the principal pos itive mental health variables to be cons idered are individual s trengths , s ocial functioning participation, social s upports , and quality of life. T hes e 345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 4 of 81

positive health aspects are, of cours e, not only relevant mental health, but also to general health. Among factors , one could include contributing etiological as sociated general health conditions , and cours e characteristics , mental health s ervices, and mental health policies . E vidence-based medicine enhanced by experience and wis dom is a basic methodological approach for epidemiological study.

E volution of the C onc epts of E pidemiology and Ps yc hiatric E pidemiology T he intricacies of epidemiology in its goals and can be organized paradigmatically acros s recent in ways reflective of the prevailing cultural framework social matrix. In effect, E zra and Mervyn S us ser have propos ed an elegant s chema formulating the evolution modern epidemiology in terms of the following eras and symbols : P.657 1. T he era of s anitary statis tics (firs t half of the 19th century), emblematized by the concept of mias ma, and focus ed on foul and toxic environmental conditions. 2. T he era of infectious dis eas e epidemiology (late century through the firs t half of the 20th century), emblematized by germ theory. 3. T he era of chronic dis eas e epidemiology (second of the 20th century), allegorized with a black box, involved with a myriad of ris k factors. 346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 5 of 81

4. An emerging era of ecological epidemiology, allegorized with C hines e boxes, and concerned gene–environment interactions and the different layers of the social matrix. F urther delineation of thes e paradigms is provided in T able 5.1-1, which als o includes features of the and preventive approaches characteris tic of each era. schema is valuable not only to organize and explain complex history of epidemiology, but also to point out importance of public health as an ultimate goal in each era, transcending variations in social circums tances instrumental methodology.

Table 5.1-1 Four E ras in the E volut Modern E pidemiology E ra

Paradigm

Analytical Approac h

Preventi Approac

S anitary statis tics half of 19th century)

Mias ma: poisoning by foul emanations from s oil, and water

Demons trate clus tering of morbidity and

Draining, sewage, sanitatio

347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 6 of 81

Infectious disease epidemiology (late 19th century through firs t half of 20th century)

G erm single relate one to one to specific diseases

Laboratory is olation culture from disease experimental transmis sion, and reproduction of les ions

Interrupt transmis (vaccine is olation the affec through quarantin and feve hospitals and, ultimately antibiotic

C hronic disease epidemiology (s econd half of 20th century)

B lack box: expos ure related to outcome without neces sity for intervening factors or pathogenes is

R is k ratio of expos ure to outcome at individual level in populations

C ontrol r factors b modifyin lifes tyle (diet, exercise, etc.) or agent food, etc environm (pollution pass ive smoking, etc.)

E cological epidemiology

C hines e boxes :

Analys is of determinants

Apply bo informati

348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 7 of 81

(emerging)

relations within and between localized structures organized in a hierarchy of levels

and outcomes at different levels of organization: within and acros s contexts (us ing new information systems ) in depth (us ing new biomedical techniques)

and biomedic technolo to find leverage efficaciou levels, fr contextu to

F rom S us ser M, S us ser E : C hoosing a future for II. F rom black box to C hinese boxes and ecoJ P ublic He alth. 1996;86:674–677, with permiss ion. T he above schema is also applicable to ps ychiatric epidemiology, although the his tory of this specialized started in full force in the cours e of the 20th century— es pecially in its second half—and has now entered energetically into the 21st century. T hus, psychiatric epidemiology as a recognized dis cipline today largely corres ponds to the chronic diseas e era and, at a s tage walk into more tentatively, to the era of ecological epidemiology, the general s chema outlined earlier. 349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 8 of 81

It would be useful now to examine briefly the various phases or generations of ps ychiatric epidemiology that corres pond principally to the types of des ign and instrumentation used for epidemiological inves tigation.

F irs t-G eneration S tudies F irst-generation studies, which tended to be relatively unsystematic inquiries, often dealing with treated populations, extended typically through the mid-20th century. S ome illustrative examples follow. In 1838, J ean E tienne E s quirol documented that the number of individuals admitted to hospitals in P aris because of insanity had increased fourfold in 15 years (from 1786 to 1801). A s tudy of the prevalence of mental derangement and retardation in Mass achus etts us ing key informants (general practitioners, clergy) and hospital records 2,632 “lunatics ” and 1,087 “idiots ” that needed care. J oseph G oldberger et al. determined in the 1920s, case-control methods, that pellagra was connected to nutritional deficiency. W ithout s pecifying specific nutrients, dietary changes led to drastic reductions of pellagra in institutionalized populations . B rugger's study in 1929 attempted to es timate the prevalence of mental disorders in a defined population (T huringia, G ermany), using a census method. R obert F aris and W arren Dunham investigated the geographical distribution of all patients hos pitalized for the firs t time between 1922 and 1934 in C hicago. T hey found that the rate of schizophrenia decreas ed progres sively with distance away from the center of the 350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 9 of 81

city (from 46 to 13 percent of all admis sions ), leading to the formulation of a number of explanatory proposals.

S ec ond-G eneration S tudies S econd-generation studies were conducted after World War II, taking advantage of the extens ive interes t generated by the perceived frequency of mental in war s ettings and information and instrumentation emerging from profes sional work with such cas es and situations. T hey es tablis hed community s urveys as a tool in ps ychiatric epidemiology. T hey us ed either symptom checklists or relatively uns tructured as basic information-gathering methodology. S ome key studies of this type follow. T he Midtown Manhattan S tudy engaged s pecially social workers to conduct interviews of community res idents and collect s ymptom and other checklis t T he study as sumed that mental illnes s was distributed fundamentally as a continuum from normality and that was anchored adequately by ps ychos ocial impairment dysfunctioning). On the bas is of ps ychiatris ts ' review of collected data, it was found that 23 percent of the was severely psychiatrically impaired. T he S tirling C ounty S tudy in New Y ork ass es sed 1,010 individuals in the community via lay interviewers us ing questionnaire. Additional information was obtained general practitioners and psychiatrists in the area. R es earch ps ychiatris ts then reviewed the obtained us ing the American P sychiatric As sociation's P.658 first edition of the Diagnos tic and S tatis tical Manual of 351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 10 of 81

Me ntal Dis orde rs (DS M) as a reference and concluded prevalence of mental disorders was 20 percent. A s tudy of social clas s and mental illnes s in a treated population in New Haven, C onnecticut, was conducted August Hollings head and F rederick R edlich. T hey higher prevalence of mental dis orders in individuals of lower socioeconomic clas ses . T hey als o found that in lower socioeconomic clas ses tended to be treated electroconvuls ive treatment (E C T ) and medication, whereas thos e in higher class es tended to be treated ps ychotherapy.

Third-G eneration S tudies T hird-generation studies have characteris tically used structured interview data aimed at identifying s pecific ps ychiatric disorders, as well as more s ophis ticated statis tical techniques . F undamental to the of survey interviews that were not only more s tructured, but actually s pecific in the lis t of questions to be and s cheduled in the order in which they were was the establishment of ps ychiatric nosologies with explicit inclusion and exclus ion diagnostic criteria (as signment rules to particular categories of ps ychiatric disorders ). T he us e of operational or explicit diagnostic criteria for diagnosis of mental disorders was first proposed by E dward S tengel in his international review of clas sifications. T he earlies t set of explicit diagnostic reported in the scientific ps ychiatric literature was that published by J osé Horwitz and J uan Marconi in 1966 in Latin America for alcohol abuse and thos e by B erner in Aus tria for psychotic disorders. However, the 352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 11 of 81

criteria s ets firs t us ed for the development of fully structured and s cheduled s urvey interviews were those included in DS M-III, which were bas ed on the earlier of J ohn P . F eighner et al. and R obert S pitzer et al. In cours e, the value of psychiatric nos ology developments a new generation of epidemiological findings was reciprocated by the use of population epidemiological res ults for the refinement of psychiatric nosologies . has articulated a promis ing relationship between diagnosis and population epidemiology. Illus tratively, four major epidemiological s tudies corres ponding to this third generation are outlined from a methodological perspective. T he E pidemiological C atchment Area (E C A) s tudy trained lay workers to adminis ter the Diagnostic S chedule (DIS ), a fully s tructured and scheduled instrument aimed at identifying a s et of DS M-III categories , to individuals in several institutional and community s amples in available U.S . s ites. T he National C omorbidity S urvey (NC S ) was aimed at appraising the prevalence of a s et of ps ychiatric in as sociation or not with s ubs tance use dis orders, in a representative U.S . national household sample. It also inves tigated ris k factors for mental illness . G iven its national s cope, this study was able to explore s everal contrasts of interests, s uch as that between urban and rural areas . T his s tudy, as did the preceding one, used trained lay interviewers to administer, in this cas e, the C ompos ite International Interview S chedule (C IDI), a structured and scheduled interview. T his instrument focus ed in identifying DS M-III-R , as well as s ome and tenth revision of the Inte rnational S tatis tical 353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 12 of 81

C las s ification of Dis e as e s and R e late d He alth 10), mental disorders .

F ourth-G eneration S tudies T he firs t three generations of psychiatric studies outlined above have been characterized and differentiated from each other by design and instrumentation variables, but are all s imilar in their on mental disorders . It is pos sible now to elucidate a generation in ps ychiatric epidemiology investigations , which is characterized by a broader focus that certainly includes mental disorders but uses more frameworks, such as both ill and pos itive health, and with meaning, culture, and other interpretative T he emergence of thes e broader s tudies has , in part, heralded by what Arthur K leinman has termed the ne w wave of e thnographie s . Also dis cernible in this array of epidemiological s tudies is their subs tantial interest and involvement in the development and formulation of health policies . F or illustrative purpos es , three recent studies follow. T he B razilian Multicentric S tudy of P s ychiatric combined a highly structured epidemiological cross sectional design with an anthropological interpretation the meaning of ris k factors. A representative s ample of 6,470 adults was s creened for the pres ence of ps ychopathology, with a s ubs ample selected for diagnostic psychiatric interviews with a B razilian DS M-III. T his evolved into a nes ted cas e-control s tudy which all s ubjects positively diagnosed as having a nonps ychotic dis order were cons idered cases and compared to a random sample of thos e not having 354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 13 of 81

evidence of any disorder. T he results sugges ted that gender (and related social proces ses and roles ) has to taken as a fundamental dimens ion. T hey further that any theoretical interpretation of the findings s hould cons ider the fundamental is sue of meaning with a sociocultural matrix. T he National S urvey of Mental Health and W ell-B eing Aus tralia engaged a national population s ample with the C IDI to elicit IC D-10 mental disorders . Of relevance to its consideration as fourth generation is this Australian s tudy also investigated years of life lost, quality of life, and use of mental and general health services . Its impact on the development of national policies s eems to have been cons iderable. T he World Mental Health S urvey (W MH) is a World Health Organization (W HO) initiative that aims to examine the form and frequency, s everity, as sociated disability, and treatment of mental dis orders in more 14 countries. T he novelty of this s tudy is not only the simultaneous application of s imilar ins truments in different countries , but also the as sess ment of social cons equences, burden of disease, and service delivery comprehensive manner. T he initial report of the study edited by R onald C . K es sler and T evfik B edirhan covered a total of 60,559 community adult res pondents from general population s amples in 14 countries (s ix developed, eight developed) in different world regions . T he as sess ments were carried out within the WMH of the W HO C omposite International Diagnostic T he es timated lifetime prevalence of having any WMHdisorder (according to DS M-IV criteria) ranged widely 8.6 percent in S hanghai to 47.3 percent in the United 355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 14 of 81

S tates. At least one-third of the lifetime cas es had a month epis ode. In the United S tates, 33.7 percent of cases were mild, whereas, in Nigeria, 81.6 percent of cases were mild. S erious dis orders were as sociated in countries with substantial disabilities, such as being us ual-role in the pas t year. Although severity of a is strongly related to treatment in all countries, 30 to 53 percent in developed countries and 72 to 83 percent in less developed countries received no health care treatment. T his is not merely a matter of limited res ources , as the number of treated mild and cases s eem to exceed the number of untreated serious cases in all countries . T hese findings put in perspective many pieces regarding the need and utilization of and illness impact on the lives of people and provide us eful insights about the organization of mental health services . F or example, many mental dis orders s eem to in late childhood and adolescence and progres s into serious dis orders with significant social cons equences, which appears to reinforce the need for early clinical interventions . P.659

Purpos es and Us es of E pidemiology In a clas sic paper written in 1955, the B ritish epidemiologist J eremy N. Morris proposed a number of us es for epidemiology. Despite their relatively early formulation, they are widely acknowledged as still relevant. T hey are s ummarized and briefly commented below.

356 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 15 of 81

His torical s tudie s : T his refers to the importance of having a chronological pers pective in the s tudy of health and illness in human populations . T he preceding section on the evolution of general and ps ychiatric epidemiology illus trates the value of appraisals. Also relevant here is the longitudinal depiction of changes in patterns of disease distribution in human populations. C ommunity diagnos is : It has long been that epidemiology furnis hes crucial information on health of a community (i.e., on its diagnos is in a fundamental s ens e). E fforts to conceive community health indices are relevant here (e.g., D. F . 1966). T his application of epidemiology als o has implications for clinical care in terms of situational contextualized clinical diagnosis and of the identification of high-morbidity areas. Apprais al of an individual's health pros pe cts : T his is based on relevant population studies and made on the likelihood of life or death of an as a member of the res earched population. S uch inferences may refer to risk factors , as well as to expectation and life lived with dis abilities . Health s ervice s and ope rational re s earch: S cientific inves tigations on the organization and performance health services are becoming an area of active res earch. F or this, epidemiological methods can be quite helpful—from prevalence s tudies to the as sess ment of need for care to the evaluation of treatment coverage and outcomes. C omple ting the clinical picture : W hen initially 357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 16 of 81

by Morris , this use of epidemiology was best by determining gender and age factors ass ociated with a disease. In mental health, this purpos e is exemplified, in particular, by the of a nosological profile afforded by community surveys , which have been used for development of ps ychiatric clas sifications in IC D-10 and DS M-IV , discuss ed by T im S lade. Ide ntification of s yndrome s : T he use of for the elucidation of different types of “peptic ulcer” and for distinguishing Alzheimer's dis eas e from multiinfarct dementias is illus trative here. Models could be built to as sociate ris k and other factors to signs , s ymptoms, and course to generate nosological hypothes es. More recently, to use ethnographical approaches along with epidemiological methods for elucidating new syndromes, such as ataque de nervios and chips ychos is , that before were neglected as exotic, culture-bound syndromes have begun to emerge. C lue s to caus e s : T here are s ubs tantial indicators us e of epidemiology in clarifying the etiology of clinical problems . E xamples include the of nutritional deficiencies , indus trial cancers , smoking to lung cancer, and occupational T he searching for causes of dis eas e and protective factors for health may lead to better prevention Within the emerging multilevel paradigm, epidemiology is not a “head-counting” activity. It is systemic s cientific activity that ans wers clinical and public health questions with proper analys es of risk factors , outcomes, and other ass ociated variables. 358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 17 of 81

also offers a broader perspective of overall health and health care provision in a s ociety. policy makers and other health stakeholders can epidemiological information as a strategic input for decis ion making on priorities and res ource As epidemiology enters a new “ecological” era, concerned with understanding internal and external connections , investigations formed by a multilevel framework and cons idering a wide array of contributors may become increasingly frequent. E ach of the us es outlined above is applicable to epidemiology. It should be mentioned, however, that, in addition to these seven us es —which rather explicitly to work with illness or pathology—the emerging expansion of the concept of health to include pointedly positive health as pects (i.e., s ocial participation and supports, quality of life) suggests that the inves tigation these aspects will become a s ignificant new use of epidemiology.

ME THODS IN P S YC HIA TR IC E P IDE MIOL OG Y T his s ection reviews the conceptual and procedural that are us ed in epidemiology to fulfill its purposes and goals . F irst, the bas ic cons tructs and parameters in epidemiology and health are considered. K ey and dimensional meas ures and prototypical des igns of epidemiological s tudies are examined next. T he last subs ection outlines the types of ins truments us ed in ps ychiatric epidemiology.

B as ic C ons truc ts and S tudy 359 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 18 of 81

in E pidemiology Dis eas e, Illnes s , Dis order, and T he terms dis e as e , illne s s , dis order, and s yndrome recognized forms of pathology. Dis e as e and illne s s represent crys tallized or es tablis hed entities of severity and with definite implications for the individual and for public health. Dis e as e is often used with biomedical connotations, referring to a condition with specific etiopathogenesis , whereas illne s s is often used with experiencial and sociocultural connotations . T here however, no wide agreement on these dis tinctions . S yndrome repres ents a condition characterized by a particular symptom profile, the etiology, clinical significance or severity of which is variable. Dis orde r is term midway between a disease or illness and a in terms of cons istency, correlates, and s ignificance. the complexity, intricacy, and variable significance of ps ychiatric conditions included in standard mental and behavioral nosologies, dis order is the term that has preference at the current stage in nosological formulations. Important features of diseases or dis orders of epidemiological interest include (1) cours e of illnes s . refers to the age and mode of onset, the episodic or continuous presentation of illness , and the s table, improving, or worsening progres sion of the illnes s. (2) C omorbidity. T his is a complex and intricate term that refers to the cooccurrence or copresentation of two disorders . It has been argued that comorbidity may sometimes involve two faces of the s ame bas ic clinical condition or cons titute artifactual consequences of a 360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 19 of 81

particular nosological architecture. C omorbidity may place within the domain of mental disorders (e.g., depres sion and alcoholism) and acros s chapters of the (e.g., depres sion and arterial hypertension).

Dis ability F unctioning is an umbrella term that encompass es the bodily functions and personal activities of an individual. Dis ability refers to limitations in functioning that may place at the following different levels. P.660 





B ody level: e.g., brain and nervous s ys tem P ers onal level: e.g., limitations in personal care and daily activities S ocietal level: e.g., restrictions in s ocial and in available s ocial supports

Other Health P roblems O the r health proble ms is the term used in the current 10 to refer to conditions of clinical interes t that are not diseases s e ns o s tricto and may explain presentation to health services for evaluation and care. E xamples acce ntuated pers onality, hazardous us e of s ubs tances , burn-out s yndrome .

R is k F ac tors R is k factors are characteristics , variables, and hazards make it more likely that a given individual will develop a disorder. T hey can res ide within the individual (e.g., 361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 20 of 81

personality and temperament), with his or her family or community (e.g., life events), and with the environment (e.g., certain chemicals ). Us ually, there is an ass umed plaus ible caus al ass ociation between the ris k factor disorder or health problem.

P os itive Health P os itive health is the counterpart of ill health, which, as listed above, includes disease, illness , dis order, and related health problems . P os itive health reflects growing interest in a more comprehens ive concept of health. S uch a concept was already enshrined as “a complete phys ical, social and emotional well-being and not merely the absence of illness ” in the constitution of WHO. P res ently, pos itive health encompass es such as effective pers onal care, good interpers onal occupational functioning, social s upports, and quality of life.

C linic al C are C linical care refers to the array of actions or taking place in health s ervices. B road categories of care include the following: Diagnos is : T his is an evaluative process and formulation conducted by health profes sionals in collaboration with the patient (or cons ulting family, and pertinent members of the community. Illus trative of modern diagnostic concepts and procedures are the recent World P s ychiatric Ass ociation's International G uidelines for Ass es sment (IG DA). 362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 21 of 81

T re atme nt: T his refers to the array of profes sional interventions —in cooperation with the consulting person and family—aimed at improving the presented and restoring health. Health promotion: T his refers to a s et of actions at empowering the cons ulting pers on to raise the of his or her health. As s uch, health promotion can regarded as relevant to both public health and care.

C ontext of E pidemiology C ritical as pects of the context of epidemiology include following domains : S ocial environme nt: T his includes human as pects environment at various levels of aggregation (i.e., family, community, nations, and humankind). divers ity and political cons iderations als o play a role in this domain. P hys ical environme nt: T his includes climate, finances , transportation, and other material G e ne tic e ndowme nt: T his includes the genetic illness and health. R ecent analyses of the human genome have pointed out that the express ion of genetic factors is largely influenced by factors . T hese concepts and factors are, of cours e, interrelated. R obert E vans and G reg S toddart offer a modern perspective on thes e interrelations through an schema pres ented in F igure 5.1-1. It reflects the 363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 22 of 81

of the field and outlines the interactive influences of various individual and social factors, as well as health on the various faces of health. T he latter involves or illnes s, health and function, and a sense of well-

FIGUR E 5.1-1 R elationships among s ocial and factors , health care, and the various as pects of health. (F rom E vans R G , S toddart G L. P roducing health, health care. In: E vans R G , B arer ML, Marmor T R , S ome P e ople He althy and O thers Not? T he Health of P opulations . New Y ork: Aldine de G ruyter; with permiss ion.)

K ey C ategoric al and Dimens ional Meas ures in E pidemiology 364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 23 of 81

T he meas urement of key variables in epidemiology is guided by the s caling requirements of the type of involved (categorical vers us dimensional), as well as historical and cus tomary considerations .

Meas ures for C ategoric al Variables V ariables that are s tructured in terms of discrete or types (e.g., disorders , inpatient versus outpatient are measured through nominal scaling arrangements , as a s tandardized typology or class ification of S ome of the most frequently us ed measures in this follow: P roportion or pe rce ntage : T his is a widely us ed of frequency for all categorical variables —for percentage of emergency psychiatric evaluations res ult in inpatient admiss ions (as oppos ed to outpatient referrals). P revale nce : T his indicates the proportion of in a given population who have a dis order at a particular point or period in time. It is usually expres sed in percentages. F or point prevalence, time of meas urement is to be s pecified—for percentage of a village's inhabitants who pres ented manifestations of generalized anxiety disorder on 1, 2003. P eriod prevalence is often meas ured by 1month, 6-month, and 1-year intervals —for example, percentage of a village's inhabitants who a s chizophrenic disorder during calendar year Incide nce : T his indicates the proportion of new a dis order that emerge in a population during a specified time interval (us ually 1 year). An 365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 24 of 81

es timation of incidence may be obtained through anamnestic means , whereas a careful appraisal requires two surveys of the population involved— at the beginning and another at the end of the of P.661 interes t. A refined index, described by Olli incidence de ns ity, which deals with poss ible over time and los s at follow-up of individuals in the ris k population and is defined as an average rate over the period of interes t. O dds ratio: T his index involves a comparis on of the presence of a ris k factor for dis eas e in a s ample of diseased subjects and nondis eased controls. In words , it compares the proportion of cas es to noncases in a s ample expos ed to a given risk to proportion of cases to noncases in a nonexpos ed sample.

Meas ures for Dimens ional Variables V ariables that are meas urable with dimens ional s cales informationally more powerful (convey more detailed structured information) and mathematically and statis tically more tractable than yes or no categorical variables . In other words , although categorical are measured in terms of the pres ence or abs ence of variable, dimens ional variables are meas ured in to the extent of their presence—for example, a score of in a 100-point scale. Many variables of epidemiological interest, particularly 366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 25 of 81

those corres ponding to pos itive health (e.g., functioning and quality of life), are meas ured with dimens ional variables .

Meas ures of A s s oc iation Indices of intervariable as sociation or relations hips on the s caling of the variables involved. C ontingency tables are us ed to apprais e the interrelation between categorical variables, and their statis tical significance is expres sed through the chi-square statis tic. P roduct–moment correlation coefficients convey the degree of as sociation between dimens ional variables. can vary from –1, indicating perfectly negative or as sociation, to +1, indicating full s ame-directional as sociation, with 0 express ing no ass ociation at all between the inves tigated variables . P oint biserial correlation coefficient is an adjus ted correlation index designed to meas ure the ass ociation between a binomial variable (e.g., presence versus of a given disorder) and a dimens ional one (e.g., level occupational functioning).

Multivariate A nalys es C omplex s ituations involving several variables as contributors or predictors call for multivariate analys es . S uch analyses are facilitated when the predictor and predicted variables are dimens ionally meas ured. procedures allow the identification of the smalles t and most efficient set of predictors. W hen the predicted variable is categorical, reducible to binomial, it is to use a logistic regres sion model to elucidate a 367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 26 of 81

multivariate predictor.

Des ign of E pidemiologic al S tudies T he most important is sue in designing epidemiological studies involves its population s e tting—that is , a clinic treated population vers us a community or general population. T raditionally, a general population was regarded as always the proper s etting for C linical populations have begun to emerge as an additional proper focus of epidemiological s tudies . T his in line with the enormous significance and cost of care in today's world and with the opportunity that medical centers offer to inves tigate the relations hip between environmental and biological factors of illnes s.

C ros s -S ec tional vers us L ongitudinal P ers pec tives C ros s -sectional versus longitudinal perspectives another crucial des ign is sue in psychiatric Most studies have been cross -sectional in design, reflecting the fact that many des criptive research questions call for s uch designs and that this type of is simpler and les s expensive to conduct. Other questions , including thos e involving etiological hypothes es, the elucidation of a chain of events , and developmental cons iderations , call for longitudinal designs. Longitudinal des igns include cohort and cas e-control studies and us ually involve a time interval between and effect. C ohort s tudie s characteristically engage a sample (cohort) from a well-defined population with a particular expos ure or nonexpos ure status ), 368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 27 of 81

followed up for a specified time to determine whether a particular health outcome emerges. C ohort studies divided into prospective studies and retros pective In the pros pective type, expos ure s tatus is determined the initiation of the longitudinal s tudy; in the type, exposures are determined at a pas t point. C as e control s tudie s engage identified cases of a particular disorder and control s ubjects (thos e without the and follows them up. T his des ign is particularly s uited the study of rare disorders and for the exploration of poss ible ris k factors. C ase-control s tudies are attractive because of their convenience and relatively low cos t. A major limitation is recall bias , es pecially when corroborating information cannot be obtained.

F amily S tudies F amily s tudies represent a significant type of epidemiological s tudy s timulated by the interest aris ing about genetic contributions to the development of disorders . T hese studies examine aggregation of families that may be due to heredity or shared environmental ris k factors. F amily studies may us e population s amples or s amples of cases as certained through probands, including family case-control

Health S ervic es R es earc h Health s ervices research has become a major area of inves tigation, s timulated by the complexity of the organization of clinical s ervices and the magnitude and intricacy of its financing. C haracteris tic of this type of is a naturalis tic approach, which involves appraising proces s and outcome of s ervices in their regular 369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 28 of 81

E pidemiological methods, including descriptions of the types and extent of s ervices provided and the levels of unmet need for service, are applicable to this field. Illus tratively, health s ervices research deals with such as the following: (1) Need: W ho comes to care? C overage of service: W ho gets care? (3) How much res ources are required to meet the need for care? (4) are the outcomes of health care?

L ife S pan S tages R es earc h Life s pan stages res earch address es the complexity of human development by dividing it into three childhood and adolescence, adult development, and age. S tudies on the dis tribution of mental disorders in childhood and adolescence are challenged by the and instability of ps ychopathology during these years. Most epidemiological studies have been conducted adult samples. Attention must be paid to basic features adult development, s uch as res ilience as a protective and levers for health promotion. Old age brings new challenges to the methodology of epidemiological res earch—from meas urement of nosological to late-life risk factors to the role and needs of

C ultural and International C ultural and international frameworks are emerging as fundamental for health studies in general and epidemiology in particular. C ulture pervades and unders tanding of life and health (both ill and as pects ). T he vitality of new res earch in cultural has led to the development of practical tools, such as cultural formulation, 370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 29 of 81

P.662 which may be helpful for clinical care and may als o enhance epidemiological des criptions. T he interactive nature of today's world makes it compelling to cons ider international pers pectives in health at all its levels —governmental (e.g., WHO) and (e.g., W orld P sychiatric As sociation).

E videnc e-B as ed A pproac hes E vidence-based approaches to medicine and have attracted wide attention as efforts to upgrade the solidity and quality of information on which health care public health are bas ed. It is important to place in perspective such efforts , given the complexity of the field. As indicated by s ome of their most authoritative proponents , evidence-based medicine is about individual clinical expertis e and the best external T he need for balancing hard data with informed wis dom extensible to public health policy development.

Ins truments for E pidemiologic al S tudies Ins trument P roperties T he apprais al of the quality and relevance of for meas uring the variables of interes t in epidemiology us ually conducted in terms of their reliability, their or usefulness , and their feas ibility or administrability.

R E L IAB ILITY R eliability refers to the quality of an instrument to yield similar or cons istent results across various 371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 30 of 81

such as time (test–retest reliability) and evaluators (interrater reliability). F or categorical variables, s uch as identification of ps ychiatric dis orders, the most reliability index is the kappa coefficient (κ), the formula which follows: where p ois the proportion of observed agreement and the proportion of chance agreement. F or the not infrequent case of multiple raters multiple categorical diagnos es , an extens ion of the κ been designed and operationalized. F or the reliability or agreement among raters us ing scales, the mos t frequently us ed statis tical index is the intraclas s correlation coefficient.

VAL IDITY V alidity refers to the quality or s trength of an ins trument meas ure the variable or cons truct it is suppos ed to meas ure. In line with this , validity is thought to to the faithfulness , relevance, and usefulness of the instrument to reflect the reality of interes t. validity is regarded as the most fundamental quality of instrument. However, it is not always s imple to validity directly. T he following repres ent common approaches to the es timation of an instrument's C rite rion validity: According to this approach, the validity of a new ins trument is determined by comparing the res ults or meas urements it yields to those obtained with an ins trument of widely relevance and value. F or example, the validity of a depres sion s cale could be es timated by correlating 372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 31 of 81

res ults to those of the Hamilton Depres sion S cale. F ace or conte nt validity: T his is as sess ed by having experts in the field determine the extent to which a new instrument is relevant to its intended purpose covers the informational areas pertinent to that purpos e. Dis criminant validity: Here, an attempt is made to determine if a new instrument is well able to distinguish between s amples of populations presumed to be quite different from each other in instrument's domain or field of application. Illus tratively, the dis criminant validity of a new depres sion s cale could be indicated by the extent which it yields higher scores in a s ample of people than in another sample of healthy C ons truct validity: T his corresponds to the validity of an instrument (i.e., to the extent that it yields res ults consis tent with the theory underlying domain and design. F or example, if it is properly as sumed that an anxiety disorder is s ubs tantially caus ed by environmental s tres s, a new scale to measure the pres ence of that anxiety disorder would be expected to yield high scores among recently exposed to a s erious dis as ter.

FE AS IB IL ITY OR ADMINIS TR AB IL ITY T his evaluative parameter refers to the cas e of use of instrument, as well as low cos t and access ibility.

Ins truments for P s yc hopathologic al A s s es s ment 373 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 32 of 81

T here is a large number and variety of ins truments for evaluation of ps ychopathology and mental disorders . S ome are of a s creening nature. T hese include, first, instruments for detecting the likelihood of an individual having mental disorders (which are us ually bas ed on affective s ymptoms and, in some cas es, other such as social dysfunction). T his type of s creening instrument may be used as the firs t of a two-stage in which they are followed by a s econd in-depth instrument. S econd, s creening instruments may also represent a preliminary attempt at detecting the of a particular dis order, s uch as a depres sive or anxiety disorder. F or the full evaluation of mental disorders , including the identification of specific forms of them, structured or s emistructured interviews —often adminis tered by trained nonclinicians —have become standard in epidemiological s tudies . W ell-trained or psychiatrists , us ing adequate nosologies and criteria, can als o repres ent an adequate approach to ps ychopathological evaluation in epidemiology, the cost of s uch profes sional services and the lower explicitnes s of the proceedings may repres ent limitations and are usually restricted to validation A s election of instruments for general screening and full identification of a substantial s et of mental disorders are pres ented below.

INS TR UME NTS FOR G E NE R AL PS YC HOPATHOLOG IC AL S C R E E NING G e ne ral He alth Q ue s tionnaire (G HQ): T his is one earliest s creening instruments to have received acceptance in a variety of settings. It was 374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 33 of 81

David G oldberg and collaborators . Its complete version is compos ed of 60 items , mostly affective symptoms. S horter versions of 28 and 12 items exis t. Adequate reliability and validity have been documented. S elf-R eporting Q ues tionnaire (S R Q): T his designed as part of a W HO project to s creen for disorders in primary health care settings. It includes items —20 on depres sive and anxiety s ymptoms, on ps ychotic phenomena, one on epileps y, and five related to alcohol abuse—and has been adjusted in length for use in different world s ettings . P ers onal H ealth S cale : T his ins trument, developed J uan Mezzich and ass ociates, is bas ed on an prototypical model for the definition of psychiatric illness and includes 10 items (s ix affective ps ychological and somatic symptoms , three social dys function, and one on global s elfof illnes s and need for clinical care). It can be completed in 2 to 4 minutes and has s everal versions with documented reliability and validity. P.663

INS TR UME NTS FOR FULL PS YC HIATR IC DIS OR DE R S DIS : T his fully structured and s cheduled diagnos tic interview was originally designed to identify a set of DS M-III mental dis orders through interviews 375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 34 of 81

conducted by lay interviewers. It was most prominently applied in the E C A s tudy in five U.S . C IDI: T his structured interview was built on the DIS approach and was extended to identify sets of disorders in DS M-IV and IC D-10. It has been a number of studies, including the U.S . NC S and WMH. S tandardize d C linical As s e s s me nt for (S C AN): T his modular ins trument was built on the tenth edition of the P res ent S tate E xamination (a structured interview for ps ychiatric s ymptoms) and categorical diagnos tic algorithm (C AT E G O). It has us ed in a national s urvey of ps ychiatric morbidity in G reat B ritain. B oth P S E and S C AN were used in Longitudinal S tudies of S chizophrenia. Mini-Inte rnational Ne urops ychiatric Interview T his brief structured diagnos tic interview, recently developed by David S heehan and collaborators , at the identification of a s et of DS M-IV and IC D-10 mental disorders in multicenter clinical trials and epidemiological s tudies . It can usually be less than 30 minutes. It has been validated against C IDI and the S tructured C linical Interview for DS M-

Ins truments for the A s s es s ment of Dis ability and F unc tioning WHO PS YC HIATR IC DIS AB IL ITY AS S E S S ME NT S C HE DUL E T he WHO developed a new version of the Disability Ass es sment S chedule (W HO-DAS II) as a general 376 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 35 of 81

of functioning and disability that reflects major life domains and is sensitive to change. T his endeavor on the development of the revis ion of the International C las sification of F unctioning, Disability, and Health and aims to develop a common metric tool that is culturally applicable, psychometrically reliable and valid, and for health s ervices research, s uch as the evaluation of needs and outcomes . W HO-DAS II was conceived as a general health state ass ess ment meas ure that can be for multiple purposes , s uch as epidemiological s urveys , clinical us e, or as a potential description system to contribute to s ummary meas ure of population health. It gives a general s core as well as different profiles on cognition, mobility, s elf-care, interpers onal relations , participation in the community.

INTE R NATIONAL C L AS S IFIC ATION OF FUNC TIONING , DIS AB IL ITIE S AND (IC F) T he International C lass ification of F unctioning, and Health (IC F ) is a major revis ion of the International C las sification of Impairments , Dis abilities, and (IC IDH). T he first edition ass umed that disabilities exclusively from illnes ses. T he s econd considered that disabilities might res ult from the interaction among illness es, the pers on, and the s ocial environment. In disability is conceptualized here as involving at body, personal, and social levels —impairments , limitations , and participation restrictions. An outline of IC F is presented in T able 5.1-2. A checklis t as sess es presence and severity of various functional limitations. F igure 5.1-2 displays the interactions between the 377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 36 of 81

components of the IC F .

Table 5.1-2 An Overview of the C las s ific ation of Func tioning, Dis a (IC F)  

Part 1: Func tioning and Dis ability

 

Part 2: Fac tors

C omponents

B ody functions and structures

Activities and participation

E nvironm factors

Domains

B ody functions and structures

Life areas (tas ks , actions)

E xternal on functi disability

C ons tructs

C hange in body functions (phys iological)

C apacity, executing tas ks in a standard environment

F acilitati hindering of feature phys ical, and attitu

378 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 37 of 81

world  

C hange in body structures (anatomical)

P erformance,   executing tas ks in the current environment

P os itive as pect

F unctional and s tructural integrity

Activities, participation (function)

F acilitato

Negative as pect

Impairment

Activity limitation

B arriers/

 

 

P articipation res triction (disability)

 

F rom W orld Health Organization. Inte rnational C las s ifica and H ealth (IC F ). G eneva: World Health Organization; 2

379 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 38 of 81

FIGUR E 5.1-2 Interactions among the components of International C lass ification of F unctioning, Dis ability and Health. (F rom W orld Health Organization. Inte rnational C las s ification of F unctioning, Dis ability and H ealth G eneva: W orld Health Organization; 2001, with

GL OB AL AS S E S S ME NT OF S C AL E T he G lobal As sess ment of F unctioning S cale combination, social dys function and severity us ing a 100-point scale. It is used to ass ess of DS M-IV and DS M-IV -T R .

Ins truments to A s s es s C ontextual F ac tors : L ife E vents , S tres s ors , S upports ME AS UR ING L IFE E VE NTS 380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 39 of 81

T he apprais al of s tres sors and life experiences as contributors to the emergence of mental dis orders represents an intricate challenge. Interesting here is approach of G eorge B rown, which addres ses the definitions of life events, stress , and contextual threat. practical and s imple proposal to evaluate the presence frequent threatening experiences was offered by T erry B rugha et al.

APPR AIS AL OF A S TANDAR D S E T OF C ONTE XTUAL FAC TOR S T his may be attempted using the Z-coded categories of C hapter XXI of IC D-10. As part of the development of multiaxial system for IC D-10, a s chema was des igned the reporting of contextual factors that may influence diagnosis, treatment, and prognos is of mental

Ins truments to A s s es s Quality of Q uality of life as a notion has become increasingly with the recognition that the impacts on health and health care–seeking behavior are often determined not just by s ymptoms and s igns, dis orders , or but also by s ubjective global appraisals of health. T his es pecially important for health conditions that are either recurrent or of a long duration (as is the case with a number of mental P.664 health conditions). T he concept has also gained in the pharmacoeconomic literature. Quality of life can thus be cons idered an operational meas ure of overall health and well-being. 381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 40 of 81

T here are a growing number of procedures and tools to as sess health-related quality of life. S ome were for the evaluation of individuals experiencing specific illness es, psychiatric and nonpsychiatric. Others quality of life generically and are most appropriate as of a comprehens ive as sess ment of health status . T he Quality of Life Ins trument (W HOQoL) is noteworthy for broad international anchorage, careful development, wide range of content. T he W HOQoL was developed through an international cross -cultural collaborative to measure people's s elf-perception of their pos ition in in the context of the culture and value s ys tems in which they live and in relation to their goals , expectations , standards , and concerns . It has been extensively us ed is being currently revis ed to reflect new frameworks for meas uring health and health-related outcomes. T he item Quality of Life Index, developed by J uan Mezzich collaborators , is also wide in content (phys ical and emotional well-being, personal and social functioning, social s upports , and personal and spiritual fulfillment) also quite efficient, us ing a culture-informed rating and validated in terms of s everal language versions .

E P IDE MIOL OG IC A L F INDING S ON IL L NE S S A ND HE A L TH T his s ection presents selected recent findings on distribution and patterns of mental disorders , positive as pects of health, clinical care, and health T hese epidemiological res ults are presented principally tabular form.

Findings on Mental Dis orders 382 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 41 of 81

As an illustration of findings on distribution of mental disorders in a broad population, R onald K ess ler et al. reported on the lifetime and 12-month prevalence of III-R disorders in a U.S . national household sample 5.1-3). T he lifetime prevalence of any NC S dis order found to be 48.0 percent. Of the broad categories of disorders , substance us e dis order (26.6 percent) was most common, followed by any anxiety disorder (24.9 percent) and any mood dis order (19.3 percent). Of the specific disorders , major depress ion was most (17.1 percent), followed by alcohol dependence (14.1 percent).

Table 5.1-3 L ifetime and 12-Mont Dis orders  

Fem

Male

 

Lifetime

Dis orders

%

12-Mo

(S E )

%

Lifetime

(S E )

%

(S E )

Mood disorders

 

 

 

 

 

 

    Mania

1.6

0.3

1.4

0.3

1.7

0.3

383 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 42 of 81

    Major depres sion

12.7

0.9

7.7

0.8

21.3

0.9

    Dysthymia

4.8

0.4

2.1

0.3

8.0

0.6

    Any mood disorders

14.7

0.8

8.5

0.8

23.9

0.9

Anxiety disorders

 

 

 

 

 

 

    G eneralized anxiety disorder

3.6

0.5

2.0

0.3

6.6

0.5

    P anic disorder

2.0

0.3

1.3

0.3

5.0

1.4

    S ocial phobia

11.1

0.8

6.6

0.4

15.5

1.0

    S imple phobia

6.7

0.5

4.4

0.5

15.7

1.1

    Agoraphobia 3.5 without panic

0.4

1.7

0.3

7.0

0.6

    Any anxiety disorder

0.9

11.8

0.6

30.5

1.2

19.2

384 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 43 of 81

S ubstance disorders

 

 

 

 

 

 

    Alcohol abuse

12.5

0.8

3.4

0.4

6.4

0.6

    Alcohol dependence

20.1

1.0

10.7

0.9

8.2

0.7

    Drug abus e

5.4

0.5

1.3

0.2

3.5

0.4

    Drug dependence

9.2

0.7

3.8

0.4

5.9

0.5

    Any subs tance disorder

35.4

1.2

16.1

0.7

17.9

1.1

Other disorders

 

 

 

 

 

 

    Antis ocial personalitya

4.8

0.5

—

—

1.0

0.2

    Nonaffective 0.3 ps ychos is b

0.1

0.2

0.1

0.7

0.2

Any NC S disorder

0.2

27.7

0.9

47.3

1.5

48.7

385 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 44 of 81

NC S , National C omorbidity S tudy; S E , s tandard error. aAntisocial

personality was only as sess ed on a lifetime b

bNonaffective

psychosis : s chizophrenia, s chizophrenifor delus ional disorder, and atypical psychosis. F rom K es sler R C , McG onagle K A, Zhao S , et al.: Lifetim ps ychiatric disorders in the United S tates: results from th P s ychiatry. 1994;51:8–19, with permiss ion. Als o of high interest, the NC S found that 79 percent of ps ychiatrically ill people pres ented with comorbidity involving two or more ps ychiatric disorders . More than of all lifetime disorders occurred in 14 percent of the population. T he figures obtained in the NC S were higher than obtained in the E C A s tudy. F urthermore, lifetime prevalence of “any mental disorder” with the C IDI was found to vary greatly, from more than 40 percent in the U.S . and the Netherlands to 20 percent in Mexico and percent in T urkey. C omplementing the above-mentioned National C omorbidity S tudy in the United S tates , findings from a recent study conducted as part of the W HO World Health S urvey in 12 different settings are presented in T able 5.1-4. C onsiderable variations can be noted countries . Quite consistently, the results obtained in the United S tates tended to be highes t (e.g., 47.3 percent lifetime prevalence of any dis order investigated, and 386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 45 of 81

percent as 12-month prevalence), whereas those in S hanghai, C hina, tended to be the lowes t (e.g., 8.6 percent as lifetime prevalence of any disorder and 4.5 percent as 12-month prevalence).

Table 5.1-4 L ifetime (L T) and 12 C ompos ite Internationa  

Moodb

Anxiety

 

LT

12-Mo

LT

1

 

%

SE

%

SE

%

SE

%

Americas

 

 

 

 

 

 

 

    C olombia

19.5

1.2

9.9

0.8

13.2

0.7

6.2

    Mexico

11.9

0.7

6.9

0.5

10.0

0.7

5.

    United S tates

28.6

0.9

18.2

0.7

21.4

0.8

9.8

E urope

 

 

 

 

 

 

 

    B elgium

13.3

1.9

6.2

1.1

14.4

1.1

5.0

387 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 46 of 81

    F rance

22.0

1.5

9.7

0.9

23.3

1.3

6.4

    G ermany

14.1

1.3

5.9

0.8

10.9

0.8

3.4

    Italy

10.9

0.9

5.0

0.6

10.2

0.6

3.

    Netherlands 15.2

1.0

7.2

0.9

17.5

1.4

4.8

    S pain

10.0

1.0

5.2

0.6

11.6

0.6

4.4

    Ukraine

11.3

1.0

7.4

0.8

16.1

1.2

8.8

Middle E as t and Africa

 

 

 

 

 

 

 

    Lebanon

13.3

1.3

10.9

1.2

11.7

1.0

6.3

    Nigeria

5.8

0.7

3.3

0.4

3.2

0.3

1.0

Asia

 

 

 

 

 

 

 

    J apan

8.4

0.9

4.7

0.8

8.5

0.7

3.0

    P R C

5.9

1.2

3.4

0.7

4.6

0.6

2.7

    P R C S hanghai

3.9

1.0

2.6

0.8

3.7

0.8

1.8

388 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 47 of 81

P R C , P eople's R epublic of C hina; S E , s tandard error. aAnxiety

disorders include agoraphobia, generalized anx disorder, s ocial phobia, and specific phobia. Mood dis or Impulse-control disorders include bulimia, intermittent ex past 12 months of symptoms of three child-adoles cent d defiant disorder). S ubstance disorders include alcohol o met full criteria at some time in their life and who continu currently do not meet full criteria for the dis order. Organ were not us ed. bB ipolar

disorders were not ass ess ed in the E uropean S G ermany, Italy, the Netherlands, and S pain). 3 Intermittent dDrug

explosive dis order was not as sess ed in the

abus e and dependence were not as sess ed in the

F rom W orld Mental Health S urvey C ons ortium: P revalen Organization World Mental Health (W MH) S urveys. J AM One of the most important s ettings for appraising the prevalence of mental disorders is primary health care. David G oldberg and Y ves Lecrubier s tudied s uch prevalence with the C IDI in 15 cities acros s all and found that the prevalence of all mental dis orders varies from 53 percent in S antiago, C hile, to 7.3 S hanghai, C hina, with an average acros s sites of 24 percent. Likewise, depres sive disorder ranged from 30 percent in S antiago to 2.6 percent in Nagas aki, J apan. S ome interesting contrasts acros s continents are 389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 48 of 81

(T able 5.1-5).

Table 5.5-1 Prevalenc e of Major Dis orders in Primary Health

C ities

C urrent Alcohol Depres s ion Generalized Dependenc (%) Anxiety (%)

Ankara, T urkey

11.6

0.9

1.0

Athens , G reece

6.4

14.9

1.0

B angalore, India

9.1

8.5

1.4

B erlin, G ermany

6.1

9.0

5.3

390 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 49 of 81

G roningen, the Netherlands

15.9

6.4

3.4

Ibadan, Nigeria

4.2

2.9

0.4

Mainz, G ermany

11.2

7.9

7.2

Manches ter, 16.9 UK

7.1

2.2

Nagasaki, J apan

2.6

5.0

3.7

P aris, F rance

13.7

11.9

4.3

R io de J aneiro, B razil

15.8

22.6

4.1

S antiago, C hile

29.5

18.7

2.5

S eattle,

6.3

2.1

1.5

S hanghai, C hina

4.0

1.9

1.1

391 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 50 of 81

V erona, Italy

4.7

3.7

0.5

Total

10.4

7.9

2.7

F rom G oldberg DP , Lecrubier Y . F orm and frequency of acros s centres. In: Üs tü T B , S artorius N, eds. Me ntal Illn C are : An International S tudy. C hichester, U.K .: J ohn W i permis sion. As an example of international work with specific ps ychiatric disorders , E zra S us ser et al. reported on delineation of acute and trans ient ps ychotic dis orders C handigarh, India. On examining the dis tribution of duration of illnes s for 46 cases of nonaffective acute ps ychos is , they found a bimodal dis tribution of this variable, with 80 percent of the cases lasting less than weeks and 20 percent lasting more than a year. T his supports the nosological s eparation of acute trans ient ps ychos is from s chizophrenia. T he distribution of mental disorders in children and adoles cents in North C arolina was recently reported on E . J ane C ostello et al. Us ing the C hild and Adolescent P sychiatric Ass ess ment (C AP A) as a structured they found that by age 16, one in three adoles cents indications of having a mental disorder. A similar (30 percent) was obtained by K es sler et al. for 15-yearin the NC S . 392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 51 of 81

More broadly, the prevalence of child and adolescence disorders in recent studies across the world are comparatively in T able 5.1-6. T his prevalence varied 23 percent in S witzerland to 13 percent in India.

Table 5.1-6 Prevalenc e of C hild Adoles c ent Dis orders , S elec ted S tudies C ountry

Age

Prevalenc e (%)

E thiopia a

1–15

17.7

G ermany b

12–15

20.7

India c

1–16

12.8

J apand

12–15

15.0

S paine

8, 11, 15

21.7

S witzerlandf

1–15

22.5

US A g

1–15

21.0

393 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 52 of 81

aT ades se

B , et al.: C hildhood behavioural Ambo district, Wes tern E thiopia: I. P revalence es timates. Acta P s ychiatr S cand. 1999;100 97. bWeyerer

S , C as tell R , B iener A, et al.: treatment of ps ychiatric disorders in 3–14-yearchildren; results of a representative field study in small rural town region of T rauns tein, Upper Acta P s ychiatr S cand. 1988;77:290–96. c Indian

C ouncil of Medical R esearch (IC MR ). E pidemiological S tudy of C hild and Adole s ce nt P s ychiatric Dis orders in Urban and R ural Are as . Delhi: IC MR ; 2001.

dMorita

H, S uzuki M, S uzuki S , et al.: P s ychiatric disorders in J apanes e s econdary s chool children. C hild P s ychol P s ychiatry. 1993;34:317–322. e G omez-B eneyto

M, B onet A, C atala MA, et al.: P revalence of mental dis orders among children in V alencia, S pain. Acta P s ychiatr S cand. 357. fS teinhausen

HC , Metzke C W , Meier M, et al.: P revalence of child and adolescent ps ychiatric disorders : the Zurich E pidemiological S tudy. Acta P s ychiatr S cand. 1998;98:262–271.

394 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 53 of 81

gS haffer

D, F isher P , Dulcan MK , et al.: T he Diagnos tic Interview S chedule for C hildren 2.3 (DIS C -2.3): description acceptability, rates, and performance in the ME C A study. J Am C hild Adole s c P s ychiatry. 1996;35:865–877.

P.665

Findings on Dis abilities T he proportion of all disability-adjus ted life years attributed to neuropsychiatric disorders has been found be 12 percent in the G lobal B urden of Diseas e S tudy. 5.1-7 lists the leading caus es of disability-adjus ted life years in all ages and both s exes —unipolar depres sive disorders is in fourth place, and two other behavioral conditions (s elf-inflicted injuries and alcohol us e are included among the top 20 health conditions .

Table 5.1-7 L eading C aus es of Dis ability-Adjus ted L ife Years in Ages , B oth S exes  

Health C onditions

Perc ent

395 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 54 of 81

of Total

1.

Lower res piratory infections

6.4

2.

P erinatal conditions

6.2

3.

Human immunodeficiency virus /acquired immunodeficiency syndrome

6.1

4.

Unipolar depres sive disorders

4.4

5.

Diarrheal diseases

4.2

6.

Is chemic heart dis eas e

3.8

7.

C erebrovascular disease

3.1

8.

R oad traffic accidents

2.8

9.

Malaria

2.7

10.

T uberculos is

2.4

11.

C hronic obs tructive pulmonary disease

2.3

12.

C ongenital abnormalities

2.2

396 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 55 of 81

13.

Meas les

1.9

14.

Iron-deficiency anemia

1.8

15.

Hearing los s, adult-onset

1.7

16.

F alls

1.3

17.

S elf-inflicted injuries

1.3

18.

Alcohol us e dis orders

1.3

19.

P rotein-energy malnutrition

1.1

20.

Osteoarthritis

1.1

F rom Murray C J L, Lopez AD, eds . T he G lobal of Dis e as e . B oston: Harvard University P ress ; with permis sion. Neurops ychiatric conditions account for 31 percent of years of life lived with dis ability. T able 5.1-8 identifies leading caus es of years of life lived with dis ability in all ages and both sexes . F ive of the top 20 health are mental—unipolar depres sive dis order, alcohol us e disorders , schizophrenia, bipolar affective disorder, and Alzheimer's disease and other dementias. T . B . Üs tün as sociates have prepared an update of the initial B urden of Dis eas e S tudy, confirming and extending the 397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 56 of 81

importance of depress ion as a public health problem.

Table 5.1-8 L eading C aus es of Years of Life L ived with All Ages , B oth S exes  

Health C onditions

Perc ent of Total

1.

Unipolar depres sive disorders

11.9

2.

Hearing los s, adult-onset

4.6

3.

Iron-deficiency anemia

4.5

4.

C hronic obs tructive pulmonary disease

3.3

5.

Alcohol us e dis orders

3.1

6.

Osteoarthritis

3.0

7.

S chizophrenia

2.8

8.

F alls

2.8

9.

B ipolar affective dis order

2.5

398 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 57 of 81

10.

Asthma

2.1

11.

C ongenital abnormalities

2.1

12.

P erinatal conditions

2.0

13.

Alzheimer's disease and other dementia

2.0

14.

C ataracts

1.9

15.

R oad traffic accidents

1.8

16.

P rotein-energy malnutrition

1.7

17.

C erebrovascular disease

1.7

18.

Human immunodeficiency virus /acquired immunodeficiency syndrome

1.5

19.

Migraine

1.4

20.

Diabetes mellitus

1.4

F rom Murray C J L, Lopez AD, eds . T he G lobal of Dis e as e . B oston: Harvard University P ress ; with permis sion.

399 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 58 of 81

F urther illustration of significant epidemiological on disabilities is furnis hed by the National S urvey of Mental Health and W ell-B eing in Aus tralia. F igure 5.1-3 health conditions in Aus tralia and their as sociated disability, expres sed as years of life lost through Mental disorders exceeded all the other major health categories in this regard.

FIGUR E 5.1-3 Y ears of life lost through disability (Y LD), Aus tralia, 1996. (F rom Mathers C , V os T , S tevenson C . B urde n of Dis e as e and Injury in Aus tralia. C anberra: Aus tralian Ins titute of Health and W elfare; 1999, with permis sion.)

400 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 59 of 81

Findings on Pos itive As pec ts of T he National S urvey of Mental Health and W ell-B eing Aus tralia included meas urement of well-being at the strong request of cons umers and caregivers. W ellwas apprais ed with the s ingle-item Life S atis faction with 0 percent indicating “terrible” and 100 percent representing “delighted.” T he mean s core for the Aus tralian adult population was 70.4 percent. Men and women had very similar mean scores. W ell-being was higher in people with tertiary education and in thos e owning or purchasing their homes. It was lower in individuals with physical or mental dis orders, depres sion. It was higher in mild us ers of alcohol than was in abs tainers and heavy us ers . Of particular was the existence of a few individuals with current or depress ive disorders who reported high life Quality of life, us ing the S panish version of the Quality Life Index (QLI-S p), was s tudied in a S panis h sample by E s ther Lorente et al. T he mean scores of items of the QLI-S p and the average s core in this community sample composed of 489 men and 70 percent univers ity s tudents and 30 percent having other occupations —is presented in T able 5.1-9. W ithin framework of this 0- to 10-point scale, the average obtained in this community s ample was 6.98 (quite cons istent with the findings of K eith Dear et al. in Aus tralia). T here was not a significant difference in the average s cores of men and women. T he scale item presenting the highest loading on the s ingle factor underlying the scale was “personal fulfillment.” More recently, S aavedra and as sociates studied an adapted version of the QLI-S p on a statis tical s ample of 2,418 401 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 60 of 81

households in Lima, P eru, and found a mean average of 7.64, with no highly significant differences among or gender groups .

Table 5.1-9 Quality of L ife in a S panis h C ommunity S ample (489 Men and Women) Quality of L ife Indexa Items

Mean

S tandard Deviation

1. P hys ical well-being

6.58

1.65

2. well-being

6.48

1.74

3. S elf-care/independent functioning

7.31

1.48

4. Occupational

7.48

1.56

5. Interpers onal

7.68

1.56

6. S ocial emotional

7.46

1.81

7. C ommunity support

6.67

1.54

402 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 61 of 81

8. P ersonal fulfillment

6.78

1.76

9. S piritual fulfillment

6.04

1.95

10. G lobal perception of quality of life

7.27

1.65

Average

6.98

1.11

aS core

range: 0 (bad) to 10 (excellent).

F rom Lorente E , Ibáñez MI, Moro M, et al.: Indice calidad de vida: es tandarización y características ps icométricas en una muestra española. S alud Integral. 2002;2:45–50, with permiss ion. P.666 P.667 A s tudy of sociodemographics, self-rated health, and mortality in the United S tates was conducted by P . et al., who analyzed data from the 1987 National E xpenditure S urvey on a representative sample of U.S . civilians. S elf-reported health was measured with the Medical Outcome 20-Item S hort F orm (S F -20) (health perceptions, phys ical function, role function, mental health). P hysical function s howed the greates t 403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 62 of 81

decline with age, whereas mental health increased Women reported lower health for all s cales except role function. G reater income was as sociated with better health, least marked for mental health. C ompared P.668 with whites, blacks reported lower health, whereas reported higher health. Lower s ocioeconomic s tatus being black were factors as sociated with lower health status and higher mortality, women reported health status but exhibited lower mortality, and Latinos reported higher health s tatus and exhibited lower mortality.

Findings on C linic al C are T here is a trend worldwide to diversify the s ettings for mental health care. T he extent and patterns of this are being investigated by the W HO Atlas S urvey on Health R es ources by as king governments to complete questionnaires about mental health resources. T he distribution of ps ychiatric beds per 10,000 population WHO regions is presented in F igure 5.1-4. It shows availability rates are highest in E urope (9.3) and the Americas (3.6) (which includes North America and America) and are quite low (under 1.0) in the res t of the world.

404 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 63 of 81

FIGUR E 5.1-4 P s ychiatric beds per 10,000 population World Health Organization (W HO) regions . (F rom W orld Health Organization. Atlas of Me ntal H ealth R e s ource s W orld 2001. G eneva: World Health Organization; 2001, permis sion.) According to the previous ly mentioned Atlas S urvey, median numbers of ps ychiatris ts per 100,000 are 1.0 worldwide, 9.0 in E urope, 1.6 in the Americas , in the E astern Mediterranean, and under 0.28 in the 405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 64 of 81

the world. T he median numbers of ps ychiatric nurses 100,000 population are 2.0 worldwide, 27.5 in E urope, in the Americas, 1.1 in the W estern P acific, and under the res t of the world. T he median rates of ps ychologists working in mental health are 0.4 worldwide, 3.0 in 2.8 in the Americas , and under 0.2 in the res t of the F inally, the median rates of social workers in mental care are 0.3 worldwide, 2.35 in E urope, 1.9 in the and under 0.4 in the res t of the world. F ocus ing attention on Aus tralia, G avin Andrews et al. as certained the use of the s ervices of different types of health profess ionals for mental problems. T his s tudy documented the predominant roles of general practitioners and even other health profes sionals (including nurses, pharmacists , and welfare above that of psychiatrists , for the care of people experiencing mental disorders (even a large number of these) (T able 5.1-10).

Table 5.1-10 Us e of Profes s ional S ervic es for Mental Problems in Aus tralia, 1997 C ons ultations No Dis order for Mental (%) Problems

Any Dis order (%)

3 Dis orders (%)

406 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 65 of 81

G eneral practitioner onlya

2.2

13.2

18.1

Mental health profes sional onlyb

0.5

2.4

3.9

Other health profes sional onlyc

1.0

4.0

5.7

C ombination of health profes sionals

1.0

15.0

36.4

Any health profes sionald

4.6

34.6

64.0

aR efers

to individuals who had at leas t one cons ultation with a general practitioner in the previous 12 months but did not consult any other type of health profess ional. bR efers

to individuals who had at leas t one cons ultation with a mental health profes sional (ps ychiatris t, psychologist, mental health team) in the previous 12 months but did not consult any other type of health profes sional. 407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 66 of 81

c R efers

to persons who had at least one with another health profes sional (nurse, nonps ychiatric medical s pecialis t, pharmacist, ambulance officer, welfare worker, or counselor) the previous 12 months but did not cons ult any other type of health profes sional.

dR efers

to persons who had at least one with any health profes sional in the previous 12 months. F rom Andrews G , Henderson S , Hall W : comorbidity, dis ability and s ervice utilization: overview of the Aus tralian National Mental Health S urvey. B r J P s ychiatry. 2001;178:145–153, with permis sion. J yrki K orkeila et al. inves tigated the factors predicting readmiss ion to psychiatric hospitals in F inland during early 1990s. T he mos t prominent factors were previous admis sions , long lengths of s tay, and identification of ps ychotic or personality dis orders. T hes e P.669 findings pointed out that, des pite recent emphasis on community care, a continuing need for inpatient for some ps ychiatric patients seems to exist. Illus trating the importance of primary health care for people presenting mental disorders , M. G . R owe et al. found that one in five women and one in ten men 408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 67 of 81

their primary phys icians have been recently depress ed. B ernardo Ng et al., surveying nonpsychiatrist rural C alifornia, documented the need for enhanced postgraduate training on depres sion for primary care phys icians .

Findings on Mental Health Polic y T he WHO Atlas S urvey Minis tries of Health revealed percent of countries in the world have no mental health policies , 30 percent have no national mental health programs, 25 percent have no mental health percent have no s pecific budget for mental health, and percent have no regular mental health training for care personnel. T hese figures are preliminary, and the survey is now being enhanced in collaboration with the World P s ychiatric Ass ociation. Illus trating the value of pointed inves tigations in the complex mental health field to upgrade health and policies , T able 5.1-11 displays the relations hip between women experiencing domestic violence and then contemplating s uicide in eight developing countries in Latin America, Africa, and As ia. In all the s tudy s ites , than twice the percentages of women ever phys ical violence by an intimate partner contemplate committing suicide, as compared to women never experiencing such domestic violence.

Table 5.1-11 R elations hip Domes tic Violenc e and C ontemplation of S uic ide 409 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

01/01/2009

Page 68 of 81

 

Perc entage of Women Who E ver Thought of C ommitting S uic ide (P T able of C ontents > V olume I > 6 - T heories of P ers onality and P s ychopathology > 6.1: C las P s ychoanalys is

6.1: C las s ic Ps yc hoanalys is W. W. Meis s ner M.D., S .J . P art of "6 - T heories of P ers onality and P sychoanalysis has existed s ince before the turn of the 20th century and, in that s pan of years, has es tablished its elf as one of the fundamental dis ciplines within ps ychiatry. T he science of ps ychoanalys is is the ps ychodynamic unders tanding and forms the fundamental theoretical frame of reference for a variety forms of therapeutic intervention, embracing not only ps ychoanalys is its elf but als o various forms of ps ychoanalytically oriented psychotherapy and related forms of therapy using ps ychodynamic concepts . current efforts are being directed to connecting ps ychoanalytic unders tandings of human behavior and emotional experience with emerging findings of neuros cientific res earch. C onsequently, an informed clear understanding of the fundamental facets of ps ychoanalytic theory and orientation is es sential for student's grasp of a large and s ignificant s egment of current ps ychiatric thinking. One of the difficulties in pres enting s uch a synthetic account is that it must draw its material from more than century of thinking and theoretical development. Although there is more than one way to approach the divers ity of such material, the material in this chapter is 424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 2 of 238

organized along historical lines, tracing the emergence analytical theory or theories over time but with a good deal of overlap and s ome redundancy. B ut there is an overall pattern of gradual emergence, progress ing from early drive theory to s tructural theory to ego object relations and on to s elf-ps ychology, inters ubjectivism, and relational approaches .

R OOTS OF THINK ING P sychoanalysis was the child of S igmund F reud's He put his s tamp on it from the very beginning, and it be fairly said that, although the s cience of has advanced far beyond F reud's wildes t dreams, his influence is still strong and pervasive. In understanding origins of ps ychoanalytic thinking, it is us eful to keep in mind that F reud hims elf was an outstanding product of the scientific training and thinking of his era.

S c ientific Orientation F reud was a convinced empirical s cientis t whose early training in medicine and neurology had been in the progres sive s cientific centers of his time. He s hared the conviction of mos t of the s cientists of his day that law and order and the systematic study of phys ical and neurological process es would ultimately yield an unders tanding of the apparent chaos of mental When he began his study of hys teria, he believed that brain phys iology was the definitive scientific approach that it alone would yield a truly s cientific understanding. With his own increasing clinical experience, F reud was forced to modify that bas ic scientific credo, but it is 425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 3 of 238

significant nonetheles s that he maintained it in one or another form throughout the whole of his long career. own efforts to elaborate a scientific phys iology of phenomena were, in the end, to prove frustrating and disappointing. After abandoning that attempt, contained in the long-lost pages of the P roje ct for a S cie ntific P s ychology (1895), he continued to believe that, the clinical material he dealt with forced him to work on level of ps ychological reflection, there was a close and intimate connection between phys ical and psychical proces ses.

On A phas ia Although a good deal of attention has been paid to F reud's P roje ct as express ing his early model of the more recent attention has been drawn to his important neurological work O n Aphas ia (1891), in which F reud advanced his earliest views of the relation between structure and function in the brain. F ollowing J ohn Hughlings J acks on's emphasis on the complex between thought and language, F reud challenged the prevailing notions of brain localization of function advanced by P ierre B roca, K arl W ernicke, T heodor and others . R ather than thinking in terms of brain à la B roca's speech center, F reud related the functions speech to functional capacities in a widespread visual, acoustic, tactile, and even kines thetic reflecting generalized changes in the functioning of the brain as a whole. T hus, he viewed simple functions , s uch as perception or memory, as phys iologically complex and involving multiple brain systems . In his view, it was the dis ruption in the network that was respons ible for various forms of 426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 4 of 238

rather than des truction of s pecific centers. F ollowing J acks on's differentiation between mind and brain and his concept of functional retrogress ion from higher levels of organization to lower, F reud regarded aphas ia as reflecting retrogress ion to earlier developmental s tates of speech development. He attributed s peech functions to a “zone of language” that was independent of anatomical location, a position that res onated with his later stipulations regarding hysteria which s ymptoms were not related to anatomical lesions but had to do with meaning and symbolization related network of as sociations. In any cas e, the concepts he developed in his s tudy of aphas ia later reemerged in ps ychological theory, specifically, concepts of mental representation, cathexis , s ymbol formation, and word and object representation. T he view of from higher to lower levels of functioning seems to P.702 foreshadow his later doctrine of regress ion, and his comments on forms of paraphas ia read like a draft of the ps ychopathology of everyday life.

The P rojec t T he effort to bridge the chas m between psychological proces ses and neurological mechanis ms reached a intens ity in F reud's attempt to cons truct a “scientific ps ychology”—that is , a psychology bas ed on principles. E arnes tly dedicated to the s cientific ideals of Hermann Helmholtz's approach to phys iology and ps ychology, he conceived the s cheme of elaborating a complete ps ychology that would be bas ed on the 427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 5 of 238

phys icalis tic s upposition of the Helmholtz school. F or nearly 2 years , from 1895 to 1897, F reud s truggled these ideas. F inally, in the white heat of intens e in a period of no more than 3 weeks , he wrote out what known today as the P roje ct. W hen the intensity of his inspiration had begun to wane, F reud became discouraged with what he had written and finally, in disgust, threw it into a des k drawer where it was to for years . In 1898, he wrote in dis couragement and to his friend W ilhelm F lies s that he was “not at all to leave the psychology hanging in the air without an organic basis. B ut apart from this conviction [that there must be s uch a basis] I do not know how to go on, theoretically nor therapeutically, and therefore must behave as if only the ps ychological were under cons ideration.” It was his intention that the P roje ct be des troyed, but after his death, his papers came into hands of thos e who recognized its importance, and it finally published posthumous ly. If it brought F reud's neurological period to a brilliant clos e, it also opened way to the broad vis tas of psychoanalysis and, in important and significant ways, determined the shape ps ychoanalytic principles were to take. F reud's understanding of the principles of mental functioning traditionally formed the core of explanations of how the mental apparatus works and functions, but within the last half century, the central position of thes e principles has come into ques tion. T he P roje ct was on two principal theorems: firs t, the idea that the system was compris ed exclus ively of neurons, by “contact barriers ” (F reud's express ion for s ynaps es); second, a quantitative concept of neural excitation (Qn) 428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 6 of 238

transmitted from cell to cell in the nervous s ys tem and either s tored or discharged, thus accounting for various forms of nervous activity. T he energy in this early was simply a form of quantitative excitation within an open-system neuronal reflex model, but it quickly surplus meaning as a hypothetical substance with hydros tatic properties . Out of these simple elements , in combination with a set of regulatory principles , F reud elaborated his complex and ingenious account of functioning. T he bas ic model used in the P roje ct on a reflex apparatus whose function was withdrawal stimuli, particularly excess ive s timuli, and discharge of accumulated excitation as governed by the cons tancy principle and the neces sity of withdrawing from stimulation in accordance with the unple as ure principle . When F reud finally surrendered his effort to formulate ps ychology in terms of a physical model, he was forced shift to a more s pecifically psychological model of the mental apparatus but without completely abandoning ideas in the P roje ct. His thinking remained tied to the phys icalis tic model of energy s ys tems and their distribution. S urrender of his objective of explaining mental life in terms of phys iological and neurological proces ses was more a compromise than a s urrender. view, the mind pos sess ed certain dynamic properties that the ps ychological model had to be cons tructed according to the dynamic laws and principles inherent current physical theories of the dis tribution and of the flow of energy. Nonetheless , psychic energy was clearly distinct and different from the metabolic energy the brain and referred s pecifically to purpos eful s triving. P sychic energy became the central concept around 429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 7 of 238

F reud erected his economic model of mental P s ychic e nergy was that energy, as sumed to be the mental apparatus deriving from ins tinctual drives, related to affective experience, es pecially anxiety, and modified in various ways by ps ychic s tructures , always with a tendency toward discharge. Although it derived from instinctual drives , it had no specified relations hip phys ical energies ass umed to be operating in corres ponding neural structures. In any case, the concept prevailed that ps ychic energy represented a purely quantitative and nonqualitative capacity for work, which the ps ychic apparatus carried by the transformation, storage, discharge, or delay of discharge of psychic energy. In the clas sic theory, the instinctual drives impose this demand for work on the mind. Not only does the concept of energy as work potential divorce it from the hydros tatic model, but separating the economic principle from connections ps ychic energy removes it from the line of causal in other words , economic principles are not principles efficiency—they are principles of quantitative E fficiency (caus ality, work) belongs to energic factors . However, the regulatory principles, as ess ential to the economic perspective, were originally formulated in of the regulation of ps ychic energies and have been viewed almos t exclus ively in s uch terms ever s ince. may retain s ome validity in economic rather than terms as regulatory principles of how the mental works (T able 6.1-1). Other questions remain regarding place of the drives in relation to the capacity for work or force and whether the drives are the only guarantee of connection between the mind and the phys ical 430 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 8 of 238

Table 6.1-1 E nergic Princ iples B as ed on the P rojec t R evis ed Princ iple

E xplanation

E ntropy

S igmund F reud: T endency for energy in any physical s ys tem to flow from a region of high energy regions of lower energy; tendency of system toward homogeneity; tendency of s ys tem to spontaneously diminish the of energy available for work.

 

R evised: A revised schema the physical model for ps ychic proces ses in favor of a model bas ed on motivation and tendency of psychic s ys tems to and achieve purpos eful goals .

C ons ervation

F reud: T he s um of forces any isolated (clos ed) system remains cons tant.

 

R evised: T he psychic apparatus not a clos ed s ys tem, but open, does not operate on the bas is of 431

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 9 of 238

clos ed-system dynamics. Neuronic inertia

F reud: Neurons tend to dives t thems elves of quantities of excitation. Application of entropy and cons ervation to neuronal activity.

 

R evised: G eneral psychic to resolve s ituations of conflict, tension, affective imbalance (including anxiety, fear, guilt, shame, depres sion) in favor of greater balance and more harmonious integration with other ps ychic s ys tems.

C ons tancy

F reud: T he nervous system tends maintain its elf in a state of tension or level of excitation. to a level of constant excitation is achieved by a tendency to immediate energic discharge (through the path of leas t res is tance).

 

R evised: T endency of ps ychic functions to return to a s tate of res ting potential as contextual stimulus conditions and the 432

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 10 of 238

of feedback-regulated conditions the same and related ps ychic systems allow. Nirvana

F reud: T he dominant tendency to reduce, keep cons tant, or remove the internal ps ychic tension due to the excitation of s timuli; the tendency to reduce the level of excitation to a minimum; of constancy principle; expres sed pleas ure principle, ultimately in death ins tinct.

 

R evised: T his principle has no in an economically revised but is replaced by an oppos ite tendency to seek stimulation, to seek complex rather than stimulation.

P leasureunpleasure

F reud: T endency of mental apparatus to s eek pleas ure and avoid unpleasure. Unpleas ure is to the increas e of tension or level excitation, whereas pleas ure is to the release of tension or discharge of excitation. T he pleas ure principle thus follows the economic requirements of

433 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 11 of 238

cons tancy.  

R evised: Indicates the degree of functional satis faction/diss atis faction and efficacy derived from effective/ineffective operation of ps ychic s ys tems; pleasure succes sful transition from to actual operation of the ps ychic function(s ) and achievement of purpos eful and wis hed-for goals .

R eality

F reud: Modification or delay of energic discharge adapting pleas urable dis charge according the demands of reality.

 

R evised: Modification or delay of ps ychic functioning as mutually conditioned by the internal of intra- and inters ys temic within the mental apparatus ; limiting conditions for s pecific functions outside the mind are determined by reality factors.

R epetition

F reud: T endency of ins tinctual forces , as a result of inertial tendencies, to repeat patterns of 434

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 12 of 238

discharge even when res ulting in unpleasure.  

R evised: R ather than resulting inertial energic dynamics, may relate to stabilization of functions and s tructural integrations, thus contributing to development and the continual proces s of as similating and accommodating to reality.

F reud used ps ychic energy both as a device to observable phenomena and as a construct in his model the mind. P eople have only begun to appreciate the to which F reud used the neurological and energic terminology of Helmholtz and G ustav F echner as metaphorical devices to express his psychological cons tructs. T he use of s uch metaphors may have us efulnes s, es pecially in expres sing iss ues of conflict development dealt with by ps ychoanalys is — that lend themselves readily to verbal metaphorical hypothes es and les s readily to mathematical quantification. As F reud's viewpoint became ps ychological, his use of concepts of drive and energy became increas ingly metaphorical, as in T hre e E s s ays (1905). P robably after 1900, F reud became aware of the limitations of his theory, es pecially the system and hydraulic aspects of his model, which 435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 13 of 238

prompted further revisions . After his abandonment of P roje ct, he preferred to think of his theories as purely ps ychological, but even s o, the energic ass umptions carried over into s tructural theory.

C ritic is ms of Ps yc hic E nergy All these uncertainties and ambiguities come to roos t in contemporary criticisms of ps ychic energy. T he statements s ummarize the objections and the reas ons critics conclude that the class ic notion of ps ychic can no longer be tolerated in a contemporary ps ychoanalytic theory: P sychic energy is not measurable, so we are tes t any quantitative as sumptions of the theory. T he relationship between neural energies in the and ps ychic energy remains vague and poorly unders tood, and therefore any laws for the transformation of one to the other remain elusive. T he hydraulic analogy is outmoded, and the view of ps ychic energy was based on a simplified view of caus ality and a misleading equation of ps ychic with physiological energy as an explanatory T he model is internally contradictory P.703 and lacks cons is tency; it pres ents a logically closed system that misinterprets metaphor as fact; it tautological renaming of obs ervable ps ychological phenomena in energic terms, which mas querades explanation; it is unable to explain all the relevant data; it tends to lead to a false s ense of 436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 14 of 238

particularly to the extent that it offers ps eudoexplanations that are incons is tent with knowledge of neurophys iology. R ather than serving a bridge between ps ychoanalys is and physiology, es pecially neurophys iology, it becomes a barrier to interdisciplinary communication and integration. T he human organis m is in s ome degree tens ion seeking and maintaining, whereas the energic is based on the principle of tension reduction. P sychic energy comes in multiple forms , s uch as libidinal, aggres sive, narcis sistic, and various of neutralized energies, bound energies, and fus ed energies. T he difficulty here has not so much to do with the varying manifes tation of energies in forms but, rather, with the idea that the differences inherent in the energies themselves . T his objection focus es on the differentiation of the energy its elf, as oppos ed to the idea that various manifestations of ps ychic energy may be determined by the through which they are express ed—qualitative differences would be due to the patterned control, channeling, and mediation of intervening In the analogous cas e of physical energy, the differences of the various forms, s uch as heat and are not attributed directly to energy as s uch but, rather, to the physical channels through which the energy is express ed. B y implication, qualitative differences undercut the idea of the id as chaos cons isting only of energy and its modes of discharge. T here are also problems with the energic metaphor its elf. F reud did not clearly dis tinguis h drive and 437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 15 of 238

energy as biological, phys iological, or ps ychological and connected them almost exclusively with the sexual drive. T he terms share both physical and ps ychological reference: C athexis is both an electrochemical charge and a wish. T his opened door not only to conceptual errors but als o to the of an ess entially nonanalytical model to explain analytical material. If energy s erves as a metaphor for experience, it is merely descriptive and not explanatory; if it stands some neurophys iological function, any explanatory value res ts on dualistic mind–brain as sumptions. T he notion of psychic energy does not meet criteria of accepted scientific method. S pecifically, it internally contradictory and lacks consis tency; it presents a logically clos ed system that metaphor as fact; it involves a tautological observable and experienced psychological phenomena in energic terms that masquerade as explanations ; it is unable to explain all of the data, especially the phenomena of pleasurable tension, exploratory behavior, and s timulus hunger; tends to lead to a false s ense of explanation, particularly ins ofar as it offers ps eudoexplanations are incons is tent with current knowledge of neurophys iology; and it promotes a form of mind– body dualis m—dualistic interactionis m—that P.704 prevents integration of ps ychoanalytic concepts related sciences of the mind and behavior. T he metaphor is given s urplus meaning, which elevates 438 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 16 of 238

to an objective phenomenon and introduces circularity, vitiating any verification of drive–energy concepts . T he energic metaphor is incons istent with current neurophys iological unders tanding bas ed on of selective inhibition rather than energy depletion the all-or-none nature of the nervous impuls e rather than fluid dynamics . T he us efulnes s of the energic model for clinical purpos es has been ques tioned. Using a model for qualitative events limits both the range depth of explanation. S uch quantitative trans lation persis ts in the name of presumed objectivity and in belief that it offers a more s cientific view of clinical conceptions . T he drive-discharge model interprets in terms of discharge, thus blurring any distinction between drive and motive. B ut in the clinical libido and s exuality do as sume s ignificant connotations of meaning and motive. E ven if and motive do not exclude quantitative dimens ions , the quantitative cannot s ubstitute for the qualitative. On the basis of such s lender pos tulates , F reud complex and ingenious account of mental functions. He was unable, however, to provide a s atis factory account either defense or cons cious nes s. In both cas es , he embroiled in a continuing regres s in which he s eemed unable to stop. Des pite a variety of ingenious feedback loops that he built into the s ys tem—F reud was many decades ahead of his time in envisioning informational servomechanis ms —he was unable to complete the functioning of his s ys tem without violating the demands 439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 17 of 238

of his mechanical principles . He thus introduced into system a major concess ion to vitalis m, an observing T his obs erving ego was able to s ee danger for the mobilization of defens es and was able to s ens e the indication of quality in cons cious experiences. T he ego remained as a sort of primary “willer” and ultimate “knower,” a pers onal center within the theory that could not be reduced to the phys icalistic terms of postulates and that cons equently enjoyed a s ignificant degree of autonomy. One of the persis tent difficulties inherent in the of ps ychic energy is that, because of the original mode which F reud expres sed his economic views, the hypothes is has become overidentified with the of psychic energy. T here is little doubt that theory cannot do without a principle of economics . It is impos sible to express or unders tand matters of quantitative variation, degrees of intensity, levels and intens ity of motivation, or informational communication to explain how individual subjects are able to make choices among conflicting motivations and goals to about the resolution of conflict—or, for that matter, to explain the whole range of affective, motivational, and structural concepts that form the backbone of ps ychoanalytic unders tanding—without invoking the concepts and iss ues of quantity and intens ity that led F reud from the very beginning to postulate an point of view. T he s hifting focus on informational- and communication-based concepts does not escape the for economic governing principles.

B E G INNING S OF 440 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 18 of 238

In the decade from 1887 to 1897, F reud turned his attention to the s erious study of the disturbances of his hysterical patients , and, in this period, the beginnings ps ychoanalys is took root. T hese slender beginnings threefold aspect: emergence of ps ychoanalys is as a method of inves tigation, as a therapeutic technique, as a body of scientific knowledge bas ed on an fund of information and basic theoretical propos itions . T hese early res earches flowed out of F reud's initial collaboration with J os eph B reuer and then, from his own independent investigations and developments.

The C as e of Anna O. B reuer was an older phys ician, a distinguished and es tablis hed medical practitioner in the V iennes e community. K nowing F reud's interes ts in hysterical pathology, B reuer told him about the unusual cas e of a woman he had treated for approximately 1.5 years, December 1880 to J une 1882. T his woman became under the pseudonym F räulein Anna O., and s tudy of difficulties proved to be one of the important s timuli in development of ps ychoanalys is . Anna O. was , in reality, B ertha P appenheim, who later became independently famous as a founder of the work movement in G ermany. At the time she began to B reuer, s he was an intelligent and s trong-minded of approximately 21 years of age who had developed a number of hys terical symptoms in connection with the illness and death of her father. T hese symptoms paralysis of the limbs , contractures, anesthesias, visual disturbances , disturbances of speech, anorexia, and a 441 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 19 of 238

distress ing nervous cough. Her illness was also characterized by two distinct phases of cons cious nes s: relatively normal, but the other reflecting a second and more pathological personality. Anna was very fond of and clos e to her father and with her mother the duties of nurs ing him on his deathbed. During her altered s tates of cons cious nes s, Anna was able to recall the vivid fantasies and intens e emotions s he had experienced while caring for her It was with cons iderable amazement, both to Anna and B reuer, that when s he was able to recall, with the as sociated express ion of affect, the s cenes or circums tances under which her s ymptoms had aris en, symptoms could be made to disappear. S he vividly described this process as the “talking cure” and as “chimney sweeping.” Once the connection between talking through the circums tances of the s ymptoms and the dis appearance the symptoms themselves had been es tablis hed, Anna proceeded to deal with each of her many s ymptoms after another. S he was able to recall that, on one when her mother had been absent, s he had been her father's beds ide and had had a fantas y or which s he imagined that a snake was crawling toward father and was about to bite him. S he s truggled try to ward off the snake, but her arm, which had been draped over the back of the chair, had gone to sleep. was unable to move it. T he paralysis persisted, and unable to move the arm until, under hypnosis, s he was able to recall this s cene. It is easy to s ee how this kind material mus t have made a profound impres sion on It provided convincing demons tration of the power of 442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 20 of 238

unconscious memories and s uppress ed affects in producing hysterical s ymptoms. In the course of the s omewhat lengthy treatment, had become increasingly preoccupied with his and unusual patient and, cons equently, spent more more time with her. In the meanwhile, his wife had increasingly jealous and resentful. As soon as B reuer to realize this, the sexual connotations of it frightened and he abruptly terminated the treatment. Only a few hours later, however, he was recalled urgently to bedside. S he had never alluded to the forbidden topic sex during the cours e of her treatment, but s he was experiencing hysterical childbirth. F reud s aw that the phantom pregnancy was the logical termination of the sexual feelings she had developed toward B reuer in res ponse to his therapeutic efforts. B reuer had been unaware of this development, and the experience was quite unnerving. He was able to calm Anna down by hypnotizing her, but then he left the house in a cold and immediately s et out with his wife for V enice on a second honeymoon. P.705 According to a version that comes from F reud through E rnest J ones, the patient was far from cured and later to be hospitalized after B reuer's departure. It seems ironical that the prototype of a cathartic cure was , in far from success ful. Nevertheles s, the cas e of Anna O. provided an important starting point for F reud's thinking and a crucial juncture in the development of ps ychoanalys is. 443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 21 of 238

S tudies on Hys teria T he collaboration with B reuer brought about publication of “P reliminary C ommunication” in 1893. E s sentially, and B reuer extended J ean C harcot's concept of hysteria to a general doctrine of hys teria. Hys terical symptoms were related to psychic traumata, clearly and directly but als o s ometimes in a s ymbolic disguis e. Obs ervations bas ed on these later cas es es tablis hed a connection between pathogenesis of common hys teria and that of traumatic neurosis; in cases, trauma is not followed by sufficient reaction and thus kept out of cons cious nes s. T hey obs erved that individual hys terical symptoms seemed to disappear when the event provoking them clearly brought to life, with the patient describing the event in great detail and putting accompanying affect words . F ading of a memory or loss of its ass ociated depends on various factors, including whether there been an energetic reaction to the event that provoked affect. T hus, memories can be regarded as traumata have not been sufficiently abreacted. T hey noted that splitting of cons cious nes s, so striking in clas sic cases hysteria as “double cons cious nes s,” is present to at rudimentary degree in every hys teria. T hey des cribed basis of hys teria as a hypnoid s tate—that is , a state of diss ociated cons ciousnes s. T hey believed achieved its curative effect on hys terical s ymptoms by bringing to an end the emotional force of the idea that not been s ufficiently abreacted in the firs t ins tance. It this by allowing strangulated affect to gain dis charge through speech, thus s ubjecting it to as sociative 444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 22 of 238

correction, integrating it with normal cons cious nes s. “P reliminary C ommunication” created cons iderable interes t and was followed in 1895 by S tudie s on which B reuer and F reud reported on their clinical experience in the treatment of hysteria and proposed a theory of hys terical phenomena. F reud's cas e proved to be extremely s ignificant because they formed the original basis for much of his ps ychoanalytic F reud concluded from thes e observations that an experience that had played an important pathogenic together with its subsidiary emotional concomitants, accurately retained in the patient's memory even when apparently forgotten and unrecoverable by voluntary recall. He postulated that repres sion of an idea from cons ciousnes s and exclus ion from any modification by as sociation with other ideas was an ess ential condition development of hysteria. At this early s tage, F reud regarded repress ion as intentional and believed it as the bas is for convers ion of a s um of neural When cut off from more normal paths of ps ychic as sociation, this sum of excitation would find its way all more easily along a deviant path leading to somatic innervation. T he basis for s uch repress ion, he argued, be a feeling of unpleasure derived from the between the idea to be repres sed and the dominant of ideas constituting the ego. Moreover, as one symptom was removed, another developed to take its place. T he illnes s could be even by a person of s ound heredity as the res ult of appropriate traumatic experiences. It should be noted F reud's view was quite different from B reuer's, the origin of hys teria to hypnoid s tates. In F reud's view, 445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 23 of 238

the actual traumatic moment, the incompatibility of forces its elf on the ego so that the ego repudiates the incompatible idea. T his reaction brings into being a nucleus for crys tallization of a s eparate psychic group somehow divorced from the ego. T his process res ults the splitting of cons cious nes s characteris tic of acquired hysteria. T he therapeutic process consists in this s plit-off ps ychical group to unite once more with main mas s of cons cious ego ideas . In every cas e of based on sexual traumas , F reud believed that from the presexual period, which produce little or no on the child, can attain traumatic power at a later date memories when the girl or married woman begins to acquire an unders tanding of and exposure to adult life. On the basis of thes e cas es, F reud recons tructed the following s equence of steps in the development of hysteria: (1) T he patient had undergone a traumatic experience, by which F reud meant an experience that stirred up intense emotion and excitation and that was intens ely painful or dis agreeable to the individual; (2) traumatic experience represented to the patient s ome or ideas incompatible with the “dominant mas s of ideas cons tituting the ego”; (3) this incompatible idea was intentionally diss ociated or repres sed from (4) the excitation as sociated with the incompatible idea was converted into s omatic pathways, resulting in hysterical manifes tations and s ymptoms; (5) what was in consciousness was merely a mnemonic symbol only connected with the traumatic event by as sociative links that are frequently enough disguis ed; and (6) if the memory of the traumatic experience can be brought 446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 24 of 238

cons ciousnes s and if the patient is able to releas e the strangulated affect as sociated with it, then the affect is discharged, and s ymptoms dis appear.

Freud's Tec hnic al E volution One interesting aspect of the S tudie s on H ys te ria is the evolution in F reud's development of technical to the treatment of hys teria. R es ulting from his early interes t in hypnosis , as well as his exposure to techniques both in C harcot's clinic and later at Nancy, F reud began us ing hypnos is extens ively in treating his patients when he opened his own practice in 1887. In beginning, he us ed hypnotic s uggestion to enable patients to rid thems elves of their symptoms . It became quickly obvious, however, that, although patients res ponded to hypnotic s uggestion and tried to treat the symptoms as if they did not exist, the s ymptoms nonetheless reas serted themselves again during the patient's waking experience. B y 1889, then, F reud was s ufficiently intrigued by cathartic method to use it in conjunction with hypnotic techniques as a means of retracing the his tories of symptoms. In his early efforts , he stayed quite close to notion of the traumatic origins of hysterical s ymptoms . C ons equently, the goal of treatment was res tricted to removal of s ymptoms through recovery and of suppres sed feelings with which symptoms were as sociated. T his procedure has since been described “abreaction.” However, as in the case of hypnotic suggestion, F reud was still s omewhat diss atisfied with res ults of this treatment approach. T he beneficial hypnotic treatment s eemed to be transitory; they 447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 25 of 238

to las t, or seemed effective, only as long as the patient remained in contact with the phys ician. F reud that alleviation of s ymptoms was in fact dependent in some manner on the pers onal relations hip between patient and phys ician.

F rom Hypnos is to A nalys is F reud had begun to feel that inhibited sexuality may a role to play in production of the patient's s ymptoms. suspicion of a sexual as pect in the treatment of such patients was amply confirmed one day when a female patient awoke from a hypnotic sleep and suddenly her arms around his neck. F reud s uddenly found the same pos ition in P.706 which B reuer had found hims elf during his earlier treatment of Anna O. P erhaps bolstered by B reuer's experience and apparently able to learn from it, F reud not panic or retreat in the face of this sexual advance. R ather, the peculiar obs ervant quality of his mind was to dis engage its elf sufficiently so that this experience could be treated as a s cientific obs ervation. F rom this point on, F reud began to understand that the therapeutic effectivenes s of the patient–phys ician relations hip, which had s eemed so mys tifying and problematic to him until this time, could be attributed in fact to its erotic bas is . T hese obs ervations were to the bas is of the theory of transference that he later into an explicit theory of treatment. In any event, these experiences reinforced his dis satisfaction with hypnotic techniques. He became aware that hypnosis 448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 26 of 238

masking and concealing a number of important manifestations that seemed to be related to the cure or, in s ome cases, to the inability of the patient to achieve a definitive resolution of the neurosis. Later, diss atis faction with hypnosis became more specific in he could see that continued us e of hypnos is precluded further investigation of transference and resis tance phenomena. F reud had also dis covered that many of the patients in private practice were in fact refractory to hypnos is. gradually did he come to recognize that what seemed be his inability to hypnotize a patient might often be due to a patient's reluctance to remember traumatic events. He was able later to identify this reluctance as res is tance. T he vagaries of the hypnotic method did satis fy F reud, and he believed it necess ary to develop approach to treatment that could be us efully applied regardless of whether the patient was hypnotizable. C ons equently, although F reud continued to us e techniques as a bas ic approach to treatment of began to experiment with it and gradually succeeded in modifying the technique.

C ONC E NTR ATION ME THOD One of the patients whom F reud found to be refractory hypnotic technique was E lizabeth von R . F or the first in this cas e, F reud decided to abandon hypnosis as his primary therapeutic tool. He bas ed his decis ion to alter technique on the obs ervation of Hippolyte B ernheim although certain experiences appeared to be forgotten, they could be recalled under hypnosis and then subs equently recalled consciously if the physician were 449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 27 of 238

as k the patient leading ques tions urging reproduction these critical memories. F reud thus evolved his method concentration. T he patient was asked to lie on a couch and close her S he was then instructed to concentrate on a particular symptom and to recall any memories as sociated with it. T he method was substantially a modification of the technique of hypnotic s uggestion. F reud press ed his on the patient's forehead and urged her to recall the unavailable memories. F reud's graphic descriptions of technique carry with them the unavoidable impress ion that he was struggling agains t a force he sensed in the patient and agains t which he found himself battling, as though in hand-to-hand combat. He came slowly, by of this laborious experience, to realize that the is olation certain memory contents was a matter of the operation mental forces generating cons iderable power that kept complex of pathogenic ideas separate from the mass cons cious ideation. T his substantially provided him with the empirical notion of resistance and with the metapsychological perspective of the mind as terms of psychic forces.

FR E E AS S OC IATION T he material presented in such graphic detail in Hys teria reflects dramatically the evolution of F reud's technique in the direction of his more definitive to ps ychoanalys is . He became increas ingly convinced the late 1890s that the process of urging, press ing, questioning, and trying to defeat the resistance offered the patient—all of which were part and parcel of the “concentration” method—rather than facilitating 450 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 28 of 238

overcoming of the patient's res is tances , actually with the free flow of the patient's thoughts. P iece by then, F reud gave up the concentration method. this progress ive evolution, the basic principle of ps ychoanalys is—free as sociation—was focus ed and articulated. G radually, F reud surrendered his technique forehead press ure as well as the requirement that clos e their eyes while lying on the couch. T he only remnant of this earlier procedure persisting in the of ps ychoanalys is is the use of the couch. T he of the central principle of ps ychoanalysis was the product of F reud's evolution. T he evolution of F reud's as sociative technique to progres s until it had been perfected. T he continued with increas ing reliance on the patient's capacity to freely manifes t mental contents without suggestive interference on the part of the therapis t. B y end of the 19th century, F reud had more or les s es tablis hed his as sociative technique. He described it the following terms : T his [technique] involves some psychological of the patient. W e must aim at bringing about two changes in him: an increas e in the attention he pays to own psychical perceptions and the elimination of the criticis m by which he normally s ifts the thoughts that occur to him. In order that he may be able to his attention on his self-observation it is an advantage him to lie in a restful attitude and to s hut his eyes. It is neces sary to insis t explicitly on his renouncing all of the thoughts that he perceives . W e therefore tell him that the succes s of the ps ychoanalysis depends on his noticing and reporting whatever comes into his head 451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 29 of 238

not being mis led, for ins tance, into suppres sing an idea because it s trikes him as unimportant or irrelevant or because it s eems to him meaningles s. He must adopt completely impartial attitude to what occurs to him, it is precis ely his critical attitude which is respons ible his being unable, in the ordinary cours e of things , to achieve the des ired unraveling of his dream or idea or whatever it may be. In jus t a few years more, clos ing of the eyes was also abandoned. T hus, free ass ociation became the technique of psychoanalysis . In fact, it was this technique that opened the door to exploration of dreams , which became one of the primary sources of bolstering the nascent psychoanalytic point of view.

Theoretic al Innovations T he theoretical point of view in S tudie s on H ys te ria was relatively complex. B reuer adopted the point of view hysterical phenomena were not altogether ideogenic— that is , that they were not determined s imply by ideas. fact, the phenomena of hysteria may be determined by variety of causes, some brought about by an explicitly ps ychical mechanis m but others without it. Although called hysterical phenomena were not necess arily by ideas alone, their ideogenic as pects were described as hysterical. T he contribution of F reud and B reuer was that they focus ed on investigation of these ideogenic as pects and dis covered s ome of their origins. P articularly, the concept of neuronal excitation, conceived of as s ubject to process es of hydraulic flow discharge as in the P roje ct, was of fundamental in understanding hysteria as well as neurosis in 452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 30 of 238

A careful reading of B reuer's theoretical s ection in of Hys te ria makes it abundantly clear that what he propos ed was a P.707 reworking of the ingenious ideas of F reud's P roje ct, specific application to the explanation of hysterical phenomena. B reuer described two extreme conditions central nervous system (C NS ) excitation, namely, a waking state and the s tate of dreamles s s leep. W hen brain performs actual work, greater cons umption of energy is required than when it is merely prepared to work. T he phenomenon of s pontaneous awakening take place in conditions of complete quiet and without any external s timulus. T his demonstrates that development of ps ychic energy is based on vital of neural elements thems elves . B reuer also provided an explanation of hysterical conversion. His basic explanatory concept—originally propos ed by F rench ps ychiatris ts, particularly P ierre J anet—was the notion of hypnoid states. S uch s tates believed to resemble the basic condition of dis sociation obtaining in hypnos is . T heir importance lay in the that accompanied them and in their power to bring splitting of the mind. T he s pontaneous origin of s uch states through autohypnosis was identifiable relatively frequently in a number of fully developed hysterics. states often alternated rapidly with normal waking E xperience of the autohypnotic s tate was found to be subjected to a more or les s total amnes ia while the was in the waking s tate. Hys terical convers ion seemed take place more eas ily in such autohypnotic s tates than 453 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 31 of 238

waking states , similar to more facile realization of suggested ideas in states of artificial hypnos is . Neither hypnoid states during periods of energetic work nor unemotional twilight states were pathogenic. T he reveries, however, filled with emotion and states of arising from protracted affects did s eem to be Occurrence of s uch hypnoid s tates was important in genes is of hysterical phenomena becaus e they made convers ion easier and prevented, by way of amnes ia, the converted ideas from wearing away and losing their intensity. It mus t be said that F reud was not s ympathetic to concept of hypnoid s tates, although, at this s tage, had not been able to bring hims elf to reject it. T he concept, in fact, did not explain very much. T he state was used as an explanation for hysterical s tates, the occurrence and function of hypnoid states were in no way explained or s upported—they were postulated. T he only explanatory attempt made was in terms of a hereditary dis pos ition to such states. T his unproven postulate was one that F reud's scientific could not accept. T he spirit of F reud's treatment of the psychotherapy of hysteria was quite different from that embodied in theoretical treatment. His discus sion of the treatment of hysteria in S tudie s of H ys te ria gives one a good s ens e extent to which F reud had moved away in his own thinking from the somewhat res trictive formulations of P roje ct. He pointed out that each individual hys terical symptom seemed to disappear more or les s when the memory of the traumatic event provoking it brought into cons cious awareness along with its 454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 32 of 238

accompanying affect. It was neces sary that the patient describe such traumatic events in the greates t poss ible detail and be able to expres s verbally the affective experience connected with it. F reud believed that the basic etiology of the acquisition neuros is had to be located in s exual factors. Different sexual influences operated to produce different neurotic disorders . Us ually, the neurotic picture was and purer forms of either hysterical or obs es sional were relatively rare. F reud did not regard all hys terical symptoms as ps ychogenic in origin so that they could all be effectively treated by a ps ychotherapeutic procedure. In the context of his theory and technique at that time, he found that a significant number of patients could not be hypnotized despite an apparently certain diagnosis of hysteria. In these patients, F reud believed he had to overcome a certain ps ychic force in the force that was s et in oppos ition to any attempt to bring the pathogenic idea into cons cious nes s. In the therapy, experienced himself engaging in s ometimes forceful ps ychic work to overcome this intens e counterforce. T he pathogenic idea, however, des pite the force of res is tance, was always clos e at hand and could be by relatively easily acces sible as sociations. T he patient seemed to be able to rid himself or hers elf of s uch turning them into words and des cribing them. Nevertheles s, F reud's experience was that, even in which he was able to surmise the manner in which were connected and could tell the patient before the patient had actually uncovered it, he could not force anything on the patient about matters in which the was es sentially ignorant nor could the therapis t 455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 33 of 238

the product of the analys is by arous ing the patient's expectations .

R es is tanc e T he basic question that confronted F reud and B reuer to do with the mechanism that made pathogenic memories unconscious. T he divergence in their points view was not simply a matter of theoretical differences. F reud's own thinking underwent a definite trans ition, the transition seemed to be bas ed primarily on his experience in dealing with his patients . In the he and B reuer had agreed that their hys terical patients undergone traumatic s exual experiences. T hes e experiences were not available to cons cious T hey had als o agreed, at leas t for a time, that recovery these forgotten experiences during an induced state resulted in abreaction and cons equent improvement. F reud discovered that his patients were often quite unwilling or unable to recall the traumatic memories. defined this reluctance of his patients as re s is tance . As clinical experience expanded, he found that, in the majority of patients he treated, resis tance was not a of reluctance to cooperate—that is , the patients engaged in the treatment process and were willing to obey the fundamental rule of free as sociation. T he generally seemed to be well motivated for treatment, frequently enough, it was particularly patients who most dis tres sed by their s ymptoms who s eemed most hampered in treatment by resistance. F reud's was that res is tance was a matter of the operation of forces in the mind, of which the patients themselves 456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 34 of 238

often quite unaware, that maintained the exclus ion cons ciousnes s of painful or dis tres sing material. F reud described the active force that worked to exclude particular mental contents from cons cious awareness re pre s s ion, one of the fundamental ideas of theory.

R epres s ion T he concept of repress ion, together with its related of defens e, came to be the bas ic explanation for phenomena in F reud's thinking. T he notion of reflects one of the basic hypothes es of ps ychoanalytic theory, namely, that the human mind includes in its operation basic dynamic forces that can be s et in oppos ition and that s erve as the source of powerful motivation and defense. F reud described the of repress ion in the following terms : A traumatic experience or a s eries of experiences, us ually of a nature and often occurring in childhood, had been “forgotten” or “repress ed” because of their painful or disagreeable nature; but the excitation involved in stimulation was not extinguished, and traces of it in the uncons cious in the form of repres sed memories . T hese memories could remain without pathogenic until some contemporary event, for example, a love affair, revived them. At this juncture, the s trength the repress ive counterforce was diminis hed, and the patient experienced what F reud termed the return of re pre s s ed. T he original sexual excitement was revived found its P.708

457 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 35 of 238

way by a new path, allowing it to manifes t itself in the of a neurotic s ymptom. T hus , the s ymptom res ults from compromise between repres sed desire and the mass of ideas constituting the ego.” T he whole process repress ion and the return of the repress ed was thus conceived of as involving conflicting forces —that is , the force of the repres sed idea s truggling to expres s itself agains t the counterforce of the ego s eeking to keep the repress ed idea out of consciousness . F reud's development of the notions of repres sion and res is tance was based primarily on his studies of cases conversion hys teria. S pecifically, in s uch cases , he that impulses that were not allowed acces s to cons ciousnes s were diverted into paths of somatic innervation, resulting in such hysterical symptoms as paralysis, blindness , dis turbances of s ens ations , and manifestations. Despite this early emphas is on hysteria as the prototype of repres sion, F reud believed that the basic propos ition that s ymptoms res ulted from compromise between a repress ed impuls e and other repress ing forces could be applied to obs es sivecompuls ive phenomena and even to paranoid ideation. T he logical consequence of this hypothesis was that treatment process during this period focused primarily enabling the patient to recall repres sed sexual experiences , so that the accompanying excitation could allowed to find its way into consciousness and be discharged along with the revivified and previous ly dammed-up affects .

S educ tion Hypothes is and Infantile S exuality 458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 36 of 238

One additional aspect of psychoanalytic theory with s triking clarity from these early researches into hysteria. Invariably, when inquiring into the histories of hysterical patients , F reud found that the repres sed traumatic memories that seemed to lay at the root of pathology had to do with s exual experiences. His became increas ingly focused on the importance of early sexual experiences , us ually recalled in the form sexual s eduction occurring before puberty and often rather early in the child's experience. F reud began to that these seduction experiences were of central importance for understanding the etiology of ps ychoneurosis . Over a period of s everal years, he continued to collect clinical material that seemed to reinforce this important hypothes is . He even went so to dis tinguis h between the nature of the seductive experiences involved in hys terical manifes tations and those involved in obs ess ional neurosis. In the case of hysteria, he believed that the s eduction experience had been primarily pass ive—that is , the child had been the pass ive object of seductive activity on the part of an or older child. In obs ess ive-compuls ive neuros is , he believed the s eduction experience had been active the part of the child. T hus, the child would have actively and aggres sively pursued a precocious s exual What was significant in all of this development was that F reud had taken literally the accounts his patients had given him in the form of forgotten but revived memories of such s exual involvement. T he patients provided him with “tales of outrage” committed by s uch relatives or caretakers as fathers , nursemaids, or uncles. F reud devoted little attention to the role of the child's own 459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 37 of 238

ps ychological experience in the elaboration of thes e B ut, little by little, he began to have s ome s econd about thes e s o-called memories . S everal factors contributed to his doubt. F irs t, he had gained additional insight into the nature of pathological process es from clinical experience and his increas ing awarenes s of the of fantasy in childhood. S econd, he simply found it hard believe that there could be s o many wicked and adults in V iennes e s ociety. T he third influence, which undoubtedly was of major significance in this recons ideration, was his own s elf-analysis. As this important proces s of self-analysis progres sed, F reud began to have more and more reason to call the seduction hypothes is into question. During this time, 1893 to 1897, F reud was s till using the combined technique of pres sure and suggestion with relatively as surance. Often, he insisted that patients recall the seduction s cene s o that much of the evidence on which the seduction hypothes is was based was open to the charge of s uggestion. C ons equently, as F reud became more aware of the role of s ugges tion in his technique, doubts about the s eduction hypothesis grew apace. In S eptember 1897, his doubts came to a focus , and he to his good friend F lies s as follows: And now I want to confide in you immediately the great secret that has been slowly dawning on me in the las t months. I no longer believe in my ne urotica [theory of neuros es]. T his is probably not intelligible without an explanation, after all, you yours elf found credible what I was able to tell you. S o I will begin historically [and tell you] where the reasons for disbelief came from. T he continual disappointment in my efforts to bring a single 460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 38 of 238

analysis to a real conclusion; the running away of who for a period of time had been mos t gripped [by analysis]; the abs ence of the complete s ucces ses on I had counted; the pos sibility of explaining to mys elf the partial success es in other ways, in the us ual fas hion— was the first group. T hen the s urprise that in all cas es , father, not excluding my own, had to be accus ed of pervers e—the realization of the unexpected frequency hysteria, with precisely the s ame conditions prevailing each, whereas s urely s uch widespread perversions children are not very probable.… T hen, third, the insight that there are no indications of reality in the unconscious, s o that one cannot distinguish between and fiction that has been cathected with affect. [Accordingly, there would remain the s olution that the sexual fantasy invariably seizes upon the theme of the parents .] F ourth, the consideration that in the most reaching psychoses the unconscious memory does not break through, s o that the s ecret of childhood is not disclos ed even in the most confus ed delirium. If thus s ees that the unconscious never overcomes the res is tance of the conscious, the expectation that in treatment the oppos ite is bound to happen, to the point where the uncons cious is completely tamed by the cons cious, als o diminishes. It is obvious that at this period F reud was struggling his own great reluctance to abandon the s eduction hypothes is. T he doubts and the clarifying realization he expres sed to F liess were depress ing. After all, he put in years of effort and had compiled a significant amount of evidence to bolster this s eduction was only with reluctance that he could s urrender it. He 461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 39 of 238

sens ed, however, that, in s urrendering the s eduction hypothes is, new poss ibilities for psychological were opened up. In fact, this juncture in the of F reud's thinking was crucial. T he abandonment of seduction hypothes is , with its reliance on actual seduction, forced F reud to turn with new realization to inner fantasy life of the child. It can be s aid, in the real sens e, that this shift from an emphasis on reality factors to an attention to and an unders tanding of the influence of inner motivations and fantas y products marks the real beginning of the ps ychoanalytic movement. In this attempt to distinguish ps ychic reality and fantas y from actual external events ps ychoneurosis from perversion, ps ychoanalys is its elf on a new and highly significant dimens ion. W hat emerged from this shift in direction was a dynamic of infantile sexuality in which the child's own life played the s ignificant and dominant role. T his replaced the more static point of view in which the child represented an innocent victim whos e eroticis m was prematurely disrupted at the hands of uns crupulous adults . P.709 T he turning point was one of extreme significance for F reud hims elf. Increas ingly, he turned his attention to own self-analysis and put increasing reliance on it. He wrote to F liess , “My s elf-analysis is in fact the most es sential thing I have at present and promises to of the greatest value to me if it reaches its end.” More more, he became involved in the s tudy of dreams , all more s o as he developed the technique of free 462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 40 of 238

which provided him with a tool for exploring the as sociative content underlying the dream experience. concerned hims elf ever more s o with the nature of infantile sexuality and with the inner s ources of fantas y and dream content, namely, the uncons cious drives . In recent years, this s o-called abandonment of seduction hypothes is has been s ubjected to severe criticis m on the grounds that it tended to minimize the role of actual s eduction, which looms as a pervasive problem in our contemporary s ociety. B ut in F reud's defens e, it s hould be said that he never denied that seduction was a problem; he knew well enough that it exis ted, but it was not for him a path to deeper unders tanding of the dynamic as pects of ins tinctual infantile sexual life. B y 1897, when the hypothesis of actual s eduction had fallen in the dust at F reud's feet, he could look to a of significant accomplis hments . T he fundamental of psychic determinis m and the operation of a dynamic unconscious were es tablis hed, and concomitantly, a theory of psychoneurosis based on the idea of psychic conflict and the repress ion of disturbing childhood experiences had become clearly established. particularly in the form of childhood sexuality, had been unveiled as playing a significant but previous ly underemphasized or ignored role in the production of ps ychological s ymptoms. More s ignificantly, perhaps , F reud had arrived at a technique, a method of inves tigation, that could be exploited as a means of exploring a wide range of mental phenomena that had previous ly been poorly understood. Moreover, the horizons of psychoanalytic interest had begun to 463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 41 of 238

rapidly. F reud's attention was no longer focus ed on limited forms of ps ychopathology. It had begun to out, reflecting the wide-ranging curios ity and interes ts F reud's mind and to embrace the unders tanding of dreams , creativity, wit, and humor, the everyday experience, and a hos t of other normal and culturally s ignificant mental phenomena. had indeed come to life.

INTE R P R E TA TION OF DR E A MS C urrently, the whole area of sleep and dream activity is one of the most exciting and intens ely studied as pects ps ychological functioning. T he discovery of rapid eye movement (R E M) cycles and the definition of the stages of the sleep cycle have s timulated an intense extremely productive flurry of research activity into the neurobiology of dreaming. A whole new realm of fres h important ques tions has been opened as a result of activity, and ps ychoanalys ts are drawing much closer more comprehens ive unders tanding of the links patterns of dream activity and underlying neurophys iological and ps ychodynamic variables. As is learned about this fascinating and complex question, one comes much clos er to understanding the nature of dream process and the dream experience its elf. In this context, it is difficult to look back and to the uniqueness and originality of F reud's immersion in dream experience. Only when F reud's attention had refocused to the s ignificance of inner fantasy by reason of abandonment of the s eduction hypothesis and in the context of his developing the technique of as sociation, did the s ignificance and value of the 464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 42 of 238

inves tigation of dreams impres s on him. F reud became aware of the s ignificance of dreams in his experience his patients when he realized that, in the process of as sociation, his patients frequently reported their along with the ass ociative material that seemed with them. He dis covered little by little that dreams had definite meaning, although that meaning was often hidden and disguis ed. Moreover, when he encouraged patients to as sociate freely to the dream fragments , he found that what they frequently reported was more connected with repres sed material than ass ociations to events of their waking experience. S omehow, the content s eemed to be closer to the uncons cious and fantas ies of the repress ed material, and dream material seemed to facilitate dis clos ure of this content.

Theory of Dreaming T he rich complex of data derived from F reud's clinical exploration of his patients' dreams and the profound insights derived from his ass ociated investigation of his own dreams were distilled into the landmark publication in 1900 of T he Inte rpre tation of Dre ams . B asing his on thes e data, F reud presented a theory of the dream paralleled his analys is of psychoneurotic symptoms. viewed the dream experience as a cons cious an uncons cious fantas y or wish not readily access ible cons cious waking experience. T hus, dream activity cons idered one of the normal manifestations of unconscious process es. T he dream images represented uncons cious wis hes or thoughts disguis ed through a proces s of symbolization 465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 43 of 238

and other distorting mechanisms. T his reworking of unconscious contents constituted the dream work. postulated the exis tence of a “cens or,” pictured as guarding the border between the unconscious part of mind and the precons cious level. T he censor exclude uncons cious wis hes during conscious s tates during regres sive relaxation of sleep, allowed certain unconscious contents to pas s the border, yet only after transformation of uncons cious wishes into dis guised experienced in the dream contents by the s leeping subject. F reud as sumed that the cens or worked in the service of the ego—that is , as s erving the s elfobjectives of the ego. Although he was aware of the unconscious nature of the process es, he tended to the ego at this point in the development of his theory more restrictively as the s ource of cons cious process es reasonable control and volition. It s hould not be that, even in S tudie s on Hys teria, repres sion was s till envis ioned in intentional and volitional terms. F reud's deepened appreciation of the unconscious dimens ion these proces ses led him to view the ego as in some unconscious, one of the reasons for his formulation of structural theory in 1923.

A nalys is of Dream C ontent F reud's view of dream material was that it contained content that has been repress ed or excluded from cons ciousnes s by defens ive activities of the ego. T he dream material, as cons cious ly recalled by the simply the end result of uncons cious mental activity place during sleep. F reud believed that the ups urge of unconscious material was s o intense that it threatened interrupt s leep its elf so that he envis ioned one function 466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 44 of 238

the cens or was to act as a guardian of s leep. Ins tead of being awakened by these ideas , the s leeper dreams. F rom a more contemporary viewpoint, it is known that cognitive activity during sleep has a great deal of S ome cognitive activity follows the description that provided of dream activity, but much of it is more realistic and more consis tently organized along logical lines. T he dreaming activity that F reud analyzed and described is probably more or less as sociated with stage 1 R E M periods of the s leep–dream cycle. T he called manifes t dream that embodies the experienced content of the dream, which the s leeper may or may be able to recall after waking, is the product of dream activity. Uncons cious thoughts and wishes that in view threatened to awaken the sleeper were des cribed “latent dream content.” P.710 F reud referred to uncons cious mental operations by latent dream content was transformed into the manifes t dream as the dre am work. In the proces s of dream interpretation, he was able to move from the manifest content of the dream by way of ass ociative exploration arrive at the latent dream content that lay behind the manifest dream and that provided it with its core In F reud's view, there were a variety of s timuli that dreaming activity. T he contemporary unders tanding of dream process , however, s uggests that dreaming takes place more or les s in conjunction with the patterns of central nervous activation that characterize certain phases of the sleep cycle. What F reud believed be initiating stimuli may in fact not be initiating at all but 467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 45 of 238

may be merely incorporated into the dream content, determine to that extent the material in the dream thoughts. S timuli could aris e from various sources.

NOC TUR NAL S E NS OR Y S TIMUL I A variety of s ens ory impres sions, such as pain, hunger, thirst, or urinary urgency, may play a role in dream content. T hus, ins tead of disturbing one's s leep leaving a warm bed, a s leeper who is in a cold room who urgently needs to urinate may dream of voiding, and returning to bed. F reud's view would have been that the activity of dreaming preserved and safeguarded the continuity of sleep. It is known now, however, that the function of dreaming is cons iderably more complex and cannot be regarded simply as preserving sleep, although there is still room for this proces s to be counted among the dream functions.

DAY R E S IDUE S One of the important elements contributing to s haping the dream thoughts is the residue of thoughts and and feelings left over from experiences of the day. T hes e res idues remain active in the unconscious like sensory s timuli, can be incorporated by the s leeper into thought content of the manifest dream. T hus, day res idues could be amalgamated with unconscious drives and wis hes deriving from the level of instincts. T he amalgamation of infantile drives with elements of the day's residues effectively disguises the infantile impuls e and allows it to remain effective as the driving force behind the dream. Day res idues may in thems elves be quite s uperficial or trivial, but they 468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 46 of 238

significance as dream ins tigators through unconscious connections with deeply repress ed instinctual drives wis hes .

R E PR E S S E D INFANTILE DR IVE S Although these various elements may be determining as pects of the thought content of the dream the es sential elements of the latent dream content from one or several impulses emanating from the repress ed part of the uncons cious . In F reud's s chema, ultimate driving forces behind dream activity and dream formation were the wis hes , originating in drives , from an infantile level of ps ychic development. T hese drives took their content s pecifically from oedipal and oedipal levels of psychic integration. T hus, nocturnal sens ations and day res idues played only an indirect determining dream content. A nocturnal stimulus , however intens e, had to be as sociated with and with one or more repres sed wis hes from the to give rise to the dream content. T his point of view some revis ion because it s eems that, in s ome phas es nighttime cognitive activity, the mind is able to proces s res idues of daytime experience without much indication connection with unconscious repres sed content. in phases of cognitive activity during sleep that bear stamp of dreaming activity as F reud described and it, this ess ential link to the repres sed probably s till some validity.

S ignific anc e of Dreams Once F reud's attention had definitively shifted to the of inner process es of fantasy and dream formation, the 469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 47 of 238

study of dreams and the process of their formation became the primary route by which he gained acces s unders tanding uncons cious proces ses and their In T he Inte rpre tation of Dre ams , he maintained that dream s omehow repres ents a wish fulfillment. He bolstered this hypothes is with a cons iderable amount documentation, including exhaus tive analysis of his dreams . T here is a more general tendency today to view the activity as express ing a broader spectrum of proces ses, keeping the as pect of wish fulfillment as among the dimens ions of dream activity but not as an absolute principle, as it s eemed to be in F reud's T he manifest dream content may represent imaginary fulfillment of a wish or impulse from early childhood, before such wis hes have undergone repres sion. In childhood, and even later in adulthood, however, the acts to defend its elf agains t unacceptable instinctual demands of the unconscious. W is h fulfillment in the proces s is usually quite obs cured by the extensive distortions and disguis es brought about by the dream work so that it often cannot be readily identified on a superficial examination of the manifest content.

Dream Work T he theory of the nature of dream work became the fundamental description of the operation of proces ses —the bas ic mechanis ms and the manner of operating—that s tands even today as an unsurpas sed foundational account of uncons cious mental T he focus of F reud's analysis was on the proces s by unconscious latent dream thoughts were disguis ed and 470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 48 of 238

distorted in s uch a fashion as to permit their express ion and translation into conscious manifes t content of the dream. However, these unconscious process es , part of fruit of his inves tigation, found ready application and extrapolation not only to understanding the formation of neurotic s ymptoms but als o, more broadly, to a whole range of unconscious productivity. T he theory of dream work consequently became the basis for a wideanalysis of uncons cious operations that found in F reud's s tudy of everyday experiences, as well as creativity, jokes, and humor, and a variety of culturally based activities of the human mind. As pects of the work are as follows.

R epres entability T he basic problem of dream formation is to determine how it is that latent dream content can find a means of representation in the manifes t content. As F reud s aw it, the state of s leep brought with it relaxation of and, concomitantly, latent uncons cious wis hes and impulses were permitted to press for dis charge and gratification. B ecaus e the pathway to motor expres sion was blocked in the s leep state, thes e repres sed wis hes impulses had to find other means of representation by of mechanis ms of thought and fantasy. Activity of the dream censor provided continual res is tance to of thes e impulses, with the result that the impulses had be attached to more neutral or “innocent” images to be able to pass the scrutiny of cens orship and be allowed cons cious expres sion. T his dis placement was made poss ible by s electing apparently trivial or ins ignificant images from residues of the individual's current ps ychological experience and linking thes e trivial 471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 49 of 238

dynamically with latent uncons cious images, on the bas is of s ome res emblance that allowed links to be established. In the proces s of facilitating economic express ion of latent unconscious contents at the same time, maintaining the distortion that was es sential for uncons cious contents to es cape the repress ing action of the censor, the dream work us ed a variety of mechanisms, making it pos sible for more images to represent repres sed infantile components. T hese mechanis ms included symbolis m, dis placement, condensation, projection, and s econdary revision. P.711

S YMB OL IS M S ymbolis m is a complex process of indirect that in the ps ychoanalytic us age has the following connotations : A s ymbol is repres entative of or s ubs titute for some other idea from which it derives a secondary significance that it does not poss es s itself. A s ymbol represents this primary element by a common element that thes e ideas s hare. A s ymbol is characteris tically sensory and concrete nature, as oppos ed to the idea it repres ents , which may be relatively abs tract and complex. A s ymbol provides a more condens ed express ion of the idea represented. S ymbolic modes of thought are more primitive, both ontogenetically and phylogenetically, and repres ent 472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 50 of 238

forms of regres sion to earlier stages of mental development. C ons equently, symbolic tend to function in more primary process or regress ed conditions : in the thinking of primitive peoples, in myths, in s tates of poetic inspiration, particularly, in dreaming. A s ymbol is thus a manifes t express ion of an idea is more or less hidden or s ecret. T ypically, the us e the symbol and its meaning are unconscious. T hus , symbols tend to be used s pontaneous ly, and unconsciously. T he use of s ymbols is a sort of secret language in which instinctually determined content can be reexpress ed as other images ; for example, money can s ymbolize feces , or windows symbolize the female genitals . Many questions still pers is t about the origins of proces ses; the s tage of development in which they become organized; the extent to which they require altered states of consciousness , such as the sleep their implementation; and the degree to which symbolic expres sion is related to underlying conflicts . C urrent formulations regard the symbolic function as a uniquely human trait involved in all forms of human mental from the most primitive expres sion of infantile wishes to the most complex creative process es of literary, religious , and s cientific thinking.

DIS PL AC E ME NT T he mechanis m of dis place me nt refers to the transfer amounts of energy (cathexis ) from an original object to subs titute or symbolic representation of the object. 473 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 51 of 238

B ecaus e the s ubs titute object is relatively neutral—that less inves ted with affective energy—it is more to the dream cens or and can pass the borders of repress ion more easily. T hus, whereas s ymbolism can taken to refer to the substitution of one object for displacement facilitates dis tortion of unconscious through transfer of affective energy from one object to another. Des pite the transfer of cathectic energy, the of the uncons cious impulse remains unchanged. F or example, in a dream, the mother may be represented visually by an unknown female figure (at leas t one who less emotional significance for the dreamer), but the content of the dream nonetheless continues to derive from the dreamer's unconscious instinctual impulses toward the mother.

C ONDE NS ATION C onde ns ation is the mechanism by which s everal unconscious wis hes , impuls es, or attitudes can be combined into a single image in the manifest dream content. T hus , in a child's nightmare, an attacking may come to represent not only the dreamer's father may als o repres ent s ome aspects of the mother and some of the child's own primitive hostile impuls es as T he converse of condens ation can als o occur in the work, namely, an irradiation or diffusion of a s ingle wis h or impulse that is distributed through multiple representations in the manifest dream content. T he combination of mechanisms of condens ation and provides the dreamer with a highly flexible and device for facilitating, compress ing, and diffus ing or expanding the manifest dream content, which is 474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 52 of 238

from latent or unconscious wishes and impulses.

PR OJ E C TION T he proces s of projection allows dreamers to rid thems elves of their own unacceptable wis hes or and experience them as emanating in the dream from other people or independent sources. Not s urprisingly, figures to whom these unacceptable impuls es are in the dream often turn out to be those toward whom subject's own unconscious impulses are directed. F or example, the individual who has a s trong repres sed to be unfaithful to his wife may dream that his wife has been unfaithful to him; or a patient may dream that she has been sexually approached by her analyst, although is reluctant to acknowledge her own repress ed wishes toward the analyst. S imilarly, the child who dreams of a destructive monster may be unable to acknowledge his her own destructive impulses and the fear of the power to hurt the child. T he figure of the monster cons equently is a res ult of both projection and displacement.

S E C ONDAR Y R E VIS ION T he mechanis ms of symbolism, dis placement, condensation, and projection are all characteristic of relatively early modes of cognitive organization in a developmental s ens e. T hey reflect and expres s the operation of the primary process . In the organization of the manifest dream content, however, primary-proces s forms of organization are supplemented by a final that organizes the absurd, illogical, and bizarre aspects the dream thoughts into a more logical and coherent 475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 53 of 238

T he distorting effects of symbolis m, displacement, and condensation thus acquire a coherence and rationality are necess ary for acceptance on the part of the more mature and reasonable ego through a process of secondary revis ion. S econdary revision thus us es intellectual proces ses that more closely resemble organized thought proces ses governing rational s tates cons ciousnes s. It is through secondary revision, then, the logical mental operations characteris tic of the secondary process are introduced into and modify work.

AFFE C TS IN THE DR E AM WOR K In the process of dis placement, condens ation, or projection, as F reud hypothesized, the energic component of the ins tinctual impulses is s eparated its repres entational component and follows an independent path of expres sion in the form of affects or emotions . T he repress ed emotion may not appear in manifest dream content at all, or it may be experienced a considerably altered form. T hus , for example, hostility or hatred toward another individual may be modified into a feeling of annoyance or mild irritation in the manifest dream express ion, or it may even be represented by an awareness of not being annoyed— is , a conversion of the affect into its absence. T he affect may poss ibly be directly transformed into an oppos ite in the manifes t content, for example, as when repress ed longing might be represented by a manifes t repugnance or vice vers a. T hus, the viciss itudes of and the transformation by which latent affects are disguis ed introduce another dimens ion of dis tortion into the content of the manifes t dream. T he vicis situdes of 476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 54 of 238

affect, then, take place in addition to and in parallel proces ses of indirect repres entation that characterize viciss itudes of dream content.

R egres s ion In the seventh theoretical chapter of T he Interpre tation Dreams , F reud provided a model of the ps ychic as he understood it at the turn of the 20th century. Not only was the model a description of the functioning of dreaming mind, but it als o repres ented a broader conceptualization of the ps ychic apparatus as it in both pathological and normal human experience, P.712 as he had formulated previously in the P roje ct. It clear that the economic model, on which F reud had expended such intense effort in the 1890s and had seemingly abandoned in frus tration, had come back to reass ert itself, now in a new language and in a different setting. T he lines of continuity and parallels between model of the mind in the P roje ct and the model of the seventh chapter could not be appreciated until the manus cript of the P roje ct was rediscovered after death. T he model was an elaborate construction bas ed on a notion of a stimulus –res ponse mechanis m. In normal waking experience, s ens ory input is taken into the receptor end of the apparatus and then process ed in a number of mnemonic s ys tems of increasing degrees of elaborateness and complexity. After varying degrees of proces sing, the impuls e is s ubs equently dis charged through the motor effector apparatus . In the dream 477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 55 of 238

motor effector pathways are blocked so that, instead of discharge through motor s ys tems, excitation is forced move in a backward or regress ive direction through the mnemonic s ys tems and back toward s ens ory systems . During waking hours, the path leading from levels of the apparatus through precons cious to levels is barred to the dream thoughts by activity of the cens or. In sleep, however, this pathway is again made more available becaus e res is tance of the censor is diminis hed in s leep. C onsequently, uncons cious and their instinctual determinants could press to through the perceptual apparatus, as is particularly the case in hallucinatory dream experiences. T hus , dreams could be des cribed as having a regres sive character. C ons is ting specifically of the turning back of an idea the sensory image from which it was originally derived, regress ion is an effect of the resistance opposing of psychic energy ass ociated with the thought into cons ciousnes s along the normal path. R egress ion is contributed to by simultaneous attraction exercised on thought by the presence of ass ociated memories in the unconscious. In dreams , regress ion is further facilitated by diminution the progres sive current flowing from continuing s ensory input during waking hours. R egress ion, as F reud is es sentially a regres sion to the originating s ource of impres sion in the revers al he describes within the apparatus, but it also is a regres sion in time. F reud distinguished s everal forms of regres sion, namely, a topographical regress ion involving a regress ion in cons cious to unconscious s ys tems within the mental model; a temporal regres sion according to which the 478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 56 of 238

mental proces s refers back to older ps ychical particularly thos e deriving from an infantile level of development; and formal regress ion, in which more primitive methods of expres sion and repres entation the place of the more normal ones . “All these three of regres sion,” F reud commented, “are, however, one bottom and occur together as a rule; for what is older in time is more primitive in form and in psychical lies nearer to the perceptual end.”

P rimary and S ec ondary P roc es s P erhaps the most central aspect of the functioning of mental model, clos ely related to the formulations of the P roje ct, has to do with F reud's notions of the primary secondary process es. T o begin with, the impulses and instinctual wishes originating in infancy serve as the indis pensable nodal force for dream formation. T he energic conception of these drives follows the bas ic economic principles laid down by the P roje ct (T able T hey are elevated states of psychic tens ion in which energy is constantly s eeking discharge according to cons tancy principle and the pleas ure principle. T he tendency to discharge, however, is oppos ed by ps ychic s ys tems. T hus , F reud envisioned two fundamentally different kinds of ps ychic process es involved in the formation of dreams . One of these proces ses tends to produce a rational organization of dream thoughts , which was of no les s validity in terms contact with reality than normal thinking. However, another s ys tem—the firs t psychic s ys tem in F reud's schema—treats the dream thoughts in a bewildering irrational manner. He believed that a more normal train 479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 57 of 238

thought could only be s ubmitted to abnormal psychic treatment if an uncons cious wis h, derived from infancy and in a s tate of repres sion, had been transferred to it. res ult of the operation of the pleas ure principle, the firs t ps ychic s ys tem is incapable of bringing anything disagreeable into the context of the dream thoughts. It unable to do anything but wish. Operating in with the demands of this primary system, the system can only cathect an unconscious idea if it can inhibit any development of unpleasure that may have proceeded from the coming to awarenes s of that idea. Anything that may evade that inhibition is equivalently inacces sible to the s econd s ys tem, as well as to the because it is promptly eliminated in accordance with unpleasure principle. T he ps ychic proces s derived from the operation of the system is referred to as primary proce s s . T he process res ulting from the inhibition impos ed by the s econd system is referred to as the s e condary proce s s , and it reflects the operation of the s ys tem of inhibition and sketched in the P roje ct. T he s econdary s ys tem thus and regulates the primary s ys tem in accordance with principles of logic, rationality, and reality. Among the wis hful impulses derived from infantile impulses, there some whos e fulfillment is a contradiction of the and ideas of secondary process thinking. T he these wishes can no longer generate an affect of but is unpleasurable. T his formulation, it s hould be forms the bas is for F reud's later elaboration of the principle, as oppos ed to the reality principle. T he secondary process organization of preconscious aimed at avoiding unpleas ure, at delaying instinctual 480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 58 of 238

discharge, and at binding mental energy in accordance with the demands of external reality and the subject's moral principles or values . T hus, functioning of the secondary process is closely connected with the reality principle and is governed, for the mos t part, by the dictates of the reality principle.

Topographic al Theory B eginning with abandonment of the s eduction with the concomitant turning of F reud's interes ts to proces ses of fantas y and dream formation, and ending with publication of T he E go and the Id in 1923, in which F reud propounded his s tructural model of the psychic apparatus, F reud's thinking was cas t largely in terms of topographical theory.

B as ic As s umptions T here were a number of as sumptions underlying thinking that s erved as lines of continuity between stages of his investigations and helped him to organize thinking in terms of success ive models of the mental apparatus. T he firs t as sumption was that of determinism,” according to which all ps ychological including behaviors , feelings , thoughts, and actions, caus ed by—that is , are the end res ult of—a preceding sequence of causal events . T his ass umption derived F reud's Helmholtzian convictions and repres ented application of a bas ic natural science principle to ps ychological unders tanding; but it was also reinforced F reud's clinical observation that apparently hysterical s ymptoms , which had been previous ly attributed to s omatic etiology, could be relieved by 481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 59 of 238

relating them to past, apparently repress ed, T hus, apparently arbitrary pathological behavior could tied to a caus al psychological network. T he second ass umption is that of “unconscious ps ychological process es.” T his ass umption derived cons iderable amount of evidence gathered through the us e of hypnosis , but it was als o cons olidated by experience of the free ass ociating of his patients past experiences to awarenes s. T he uncons cious which s urvived and was able to influence present experience, was found to be governed by s pecific regulatory P.713 principles, for example, the pleas ure principle and the mechanisms of primary proces s that differed radically those of cons cious behavior and thought process es . the unconscious process es were brought within the of psychological understanding and explanation. T he third as sumption was that “unconscious conflicts ” between and among psychic forces formed basic elements at the root of ps ychoneurotic difficulties . T his ass umption related to F reud's experience of and the drive to repres sion in his patients . T he full realization of this aspect of psychic functioning came with awarenes s that the reports of patients represented not memories of actual experiences but, rather, unconscious fantas ies . T he ass umption of uncons cious forces accounted for the process that created those fantas ies and brought them into conscious ness during as sociation. It als o accounted for the agency that the coming to cons cious nes s of s uch fantasies . T his 482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 60 of 238

counterforce that clas hed with the sexual drives and diverted them into fantas ies or s ymptoms was related the function of censorship as developed in the dream theory and, later, to the operation of ego instincts that were set in opposition to the s exual ins tincts . T he final ass umption of the topographical theory was there exis ted “ps ychological energies ” that originated in instinctual drives . T his as sumption was derived from observation that recall of traumatic experiences and accompanying affect resulted in dis appearance of symptoms and anxiety. T his sugges ted, therefore, that displaceable and transformable quantity of energy was involved in the psychological process es res ponsible for symptom formation. F reud originally ass umed that this quantity was equivalent to the affect, which became dammed up or strangulated when it was not expres sed and, thus , was trans formed into anxiety or conversion s ymptoms . After he had developed his of ins tinctual drives, this quantitative factor was of as drive energy (cathexis ). As noted previous ly in discuss ion of the P roje ct, the ass umption of psychic energies s erved F reud as an important heuristic T he us efulnes s of the metaphor and its necess ity as a as sumption of analytical theory have been ques tioned found wanting.

Topographic al Model F reud's thinking about the mental apparatus at this was bas ed on the class ification of mental operations contents according to regions or s ys tems in the mind. T hese systems were des cribed neither in anatomical spatial terms but, rather, were s pecified according to 483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 61 of 238

relations hip to cons cious nes s. T he topographical has ess entially fallen into disfavor because of its limited us efulnes s as a working model of psychoanalytic largely because it has been s urpas sed and s upplanted the structural theory. T he topographical viewpoint, however, is still useful for clas sifying mental events descriptively by quality and degree of awarenes s. a tendency currently to revive aspects of the model of the mind in viewing mental process es as descriptively more or less cons cious or unconscious, than as reflecting operation of a mental structure as in systemic unconscious of clas sic metapsychology.

C ons c ious nes s T he cons cious system is that region of the mind in perceptions coming from the outside world or from the body or mind are brought into awarenes s. Internal perceptions can include intros pective observations of thought proces ses or affective states of various kinds . C ons cious nes s is, by and large, a subjective the content of which can only be communicated by language or behavior. It has also been regarded ps ychoanalytically as a s ort of superordinate s ens e which can be s timulated by perceptual data impinging the C NS . It was as sumed that the function of cons ciousnes s used a form of neutralized psychic called atte ntion cathe xis . T he nature of cons cious nes s was described in les s F reud's early theories , and certain aspects of are not yet completely unders tood and are actively debated by ps ychoanalys ts. F reud regarded the system as operating in close as sociation with the 484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 62 of 238

preconscious. T hrough attention, the s ubject can cons cious of perceptual s timuli from the outside world. F rom within the organis m, however, only elements in preconscious are allowed to enter consciousness . T he of the mind lies outside awareness in the uncons cious . B efore 1923, however, F reud als o believed that cons ciousnes s controlled motor activity and regulated qualitative distribution of psychic energy.

P rec ons c ious T he preconscious s ys tem consists of thos e mental proces ses, and contents that are, for the mos t part, capable of reaching or being brought into cons cious awarenes s by the act of focus ing attention. T he quality preconscious organizations may range from realityoriented thought s equences or problem-solving with highly elaborated secondary proces s s chemata all way to more primitive fantasies, daydreams , or dreamimages, which reflect a more primary proces s T hus, it s tands over and agains t unconscious which the trans formation to consciousness is accomplis hed only with great difficulty and by dint of expenditure of cons iderable energy in overcoming the barrier of repress ion. T he preconscious has been amplified by recent neuros cientific study of memory. An es sential between episodic memory and procedural memory. E pisodic memory deals with pas t events in the experience that are us ually autobiographical or in content. Other memories , however, have more to do with skills and habitual patterns of behavior, as, for example, riding a bike, driving a car, playing the piano, 485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 63 of 238

grammatical rules, s ocial norms of politeness and etiquette, and so forth. T hes e are as pects of normal living and behavior that people rarely, if ever, think about—people just do them, but the procedures are embedded in our memories and are readily applied without any effort to recall them. In fact, any effort to them more than likely only interferes with their T hese memory s ys tems, along with others that can be differentiated, are apparently s erved by different neural circuits and have different connections with and behavior.

Unc ons c ious Uncons cious mental events , namely, thos e not within cons cious awarenes s, can be des cribed from several viewpoints . One can think of the unconscious descriptively, that is , as referring to the s um total of all mental contents and proces ses at any given moment outside the range of cons cious awarenes s, including preconscious. One can als o think of the uncons cious dynamically, as referring to thos e mental contents and proces ses are incapable of achieving cons cious nes s becaus e of operation of a counterforce of cens ors hip or T his repres sive force or “countercathexis ” manifests in ps ychoanalytic treatment as res istance to T he unconscious mental contents in this dynamic cons ist of drive representations or wishes that are in meas ure unacceptable, threatening, or abhorrent to the intellectual or ethical s tandpoint of the individual. T his res ults in intraps ychic conflict between the repress ed forces and the repress ing forces of the mind. W hen 486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 64 of 238

repress ive countercathexis weakens, this may result in formation of neurotic s ymptoms. T he symptom is thus viewed as ess entially a compromise between forces . T hese uncons cious mental contents are als o organized on the basis of infantile P.714 wis hes or drives and strive for immediate discharge, regardless of the reality conditions . C onsequently, the dynamic unconscious is believed to be regulated by the demands of primary process and the pleas ure F inally, there is a s ys temic sense of the unconscious referring to a region or system within the organization the mental apparatus that embraces the dynamic unconscious and within which memory traces are organized by primitive modes of as sociation, as by the primary proces s. T his s ys temic view of the unconscious is cons idered, in a specifically sens e, as a component subsystem within the topographical model and in the s tructural theory is attributed to the id. C ons equently, the systemic unconscious can be described in terms of the following characteristics in F reud's view: Ordinarily, elements of the systemic unconscious inacces sible to consciousness and can only cons cious through acces s to the preconscious, excludes them by means of cens ors hip or R epress ed ideas, consequently, may only reach cons ciousnes s when the cens or is overpowered ps ychoneurotic symptom formation), relaxes (as in dream s tates), or is fooled (in jokes). 487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 65 of 238

T he unconscious s ys tem is exclusively ass ociated primary process thinking. T he primary process has its principal aim facilitation of wis h fulfillments and instinctual dis charge. C ons equently, it is intimately as sociated with—and functions in terms of—the pleas ure principle. As s uch, it disregards logical connections , permits contradictions to coexis t simultaneously, recognizes no negatives, has no conception of time, and repres ents wis hes as fulfillments . T he unconscious s ys tem als o uses primitive mental operations that F reud identified in the operation of the dream proces s. Moreover, the quality of motility, characteristic of primary process thinking and of unconscious energy, is als o linked to the capacity for creative thinking. Memories in the uncons cious have been divorced their connection with verbal s ymbols. F reud discovered in the cours e of his clinical work that repress ion of a childhood memory could occur if energy was withdrawn from it and, especially, if the verbal energy was removed. W hen the words are reconnected to the forgotten memory traits (as ps ychoanalytic treatment), it becomes recathected and can thus reach cons cious nes s once more. T he content of the uncons cious is limited to wis hes seeking fulfillment. T hes e wishes provide the force for dreams and neurotic s ymptom formation. has already been noted that this view may be overs implified. T he unconscious is clos ely related to the ins tincts . this level of theory development, the instincts are cons idered to consist of s exual and s elf488 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 66 of 238

(ego) drives. T he unconscious is believed to mental representatives and derivatives , particularly the sexual instincts.

Dynamic s of Mental Func tioning F reud conceived of the ps ychic apparatus , in the of the topographical model, as a kind of reflex arc in the various s egments have a spatial relationship. T he cons ists of a perceptual or sensory end through which impres sions are received; an intermediate region, cons isting of a s torehous e of unconscious memories ; motor end, closely ass ociated with the preconscious, through which instinctual dis charge can occur. In early childhood, perceptions are modified and s tored in the form of memories . According to this theory, in ordinary waking life, the mental energy as sociated with uncons cious ideas discharge through thought or motor activity, moving the perceptual end to the motor end of the apparatus . Under certain conditions, such as external frus tration or sleep, the direction in which energy travels along the revers ed, and it moves from the motor end to the perceptual end instead of the other way around. It tends to reanimate earlier childhood impres sions in earlier perceptual forms and res ults in dreams during or hallucinations in mental disorders . T his reversal of normal flow of energy in the ps ychic apparatus is the “topographical regress ion” discuss ed previously. F reud s ubs equently abandoned this model of the mind a reflex arc, he retained the central concept of and applied it later in s omewhat modified form in the theory of neurosis . T he theory states that libidinal 489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 67 of 238

frus tration res ults in revers ion to earlier modes of instinctual dis charge or levels of fixation, which had previous ly determined by childhood frustrations or excess ive erotic s timulations. F reud called this kind of revers ion to instinctual levels of fixation libidinal or ins tinctual re gres s ion.

Framework of Ps yc hoanalytic R epres s ed vers us R epres s ing T hroughout his long lifetime and in the course of many twis tings and turnings of the theoretical developments his thinking, F reud's mind was dominated by a to des cribe many as pects of mental functioning in contrasting polarities; s ome of the primary polarities that of subject (ego) vers us object (outer world), versus unpleas ure, and activity versus pas sivity. T he fundamental and dominant dualism is between the and contents of the mind viewed as repres sed and unconscious and those forces and mental agencies res ponsible for the act of repress ing. Although the persis tence of such bas ic dualis m in ps ychoanalytic thinking has clear advantages and undoubtedly helps unders tand some fundamental as pects of the mind, should not forget that s uch paradigms may prove to be overly res trictive. T here is real ques tion in the current of psychoanalysis as to whether s ome of these basic dimensions may not, in fact, be limiting the of ps ychoanalytic theory to grow apace with the expanding horizons of both clinical experience and experimental, es pecially neuroscientific, exploration. historical role and the present vitality of the bas ic ps ychoanalytic dualism, however, s hould not be undervalued because they provide a powerful tool for 490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 68 of 238

unders tanding and treating clinical pathology.

INS TINC TUA L THE OR Y All human beings have s imilar ins tincts . T he actual discharge of these ins tinctual impuls es is organized, directed, regulated, or even repres sed by functions of individual ego, which mediates between the organism the external world. Historically, F reud's exploration of instincts in ps ychoanalys is preceded his development structural theory and his concern with ps ychology of ego.

C onc epts of Ins tinc ts One of the firs t problems to be dealt with in considering the theory of ins tincts is what is meant by the term “instinct.” T he problem is made more complex by the variation in usage between a primarily biological and F reud's primarily psychological concept. T he difficulties are als o compounded by the complexities in F reud's own us e of the term. T he term “instinct” was introduced primarily by students of animal behavior, P.715 referring generally to a pattern of s pecies -specific based mainly on potentialities determined by heredity was therefore considered to be relatively independent learning. T he term was applied to a great variety of behavior patterns, including patterns described in such terms as a maternal ins tinct, a nes ting instinct, or a migrational instinct. S uch usage resis ted success ful phys iological explanation and tended to introduce a strong teleological connotation, thus implying some 491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 69 of 238

of purposefulness , as in the concept of a s elfinstinct. F reud adopted this us age unques tioningly, but validity has been ques tioned even by strong of ins tinctual theory among animal behaviorists , for the line between instinctual and learned behavior has become increas ingly more complex and debatable. dichotomy of nature/nurture can no longer be simplis tically or rigidly maintained. T hus , instinctually derived patterns of behavior are s een to be modifiable in the interes ts of adaptation. E thologis ts cons equently prefer to s peak s imply of s pecies -typical behavior patterns that are based on innate equipment that mature and develop or are elicited through a degree of environmental interaction. F reud, of cours e, took as the bas is of his thinking the concept of instinct, but in adopting it for his purposes, transformed it. Actually, F reud's own formulation of the notion of ins tinct underwent contextual modification s o that he actually offered a variety of definitions . P erhaps most cogent was the following: “An ‘instinct’ appears to as a concept on the frontier between the mental and somatic, as the ps ychical repres entative of the s timuli originating from within the organis m and reaching the mind, as a meas ure of the demand made upon the for work in cons equence of its connection with the It is immediately evident that the bas ic ambiguity in the concept of instinct between biological and as pects continued to influence F reud's thinking about instinctual drives and remains latent in s ubs equent ps ychoanalytic usage of the term. F reud hims elf varied the emphasis he placed on one or another aspect of concept s o that s ubsequent discus sions of the concept 492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 70 of 238

instinct in psychoanalysis have varied similarly emphasis on biological aspects and emphasis on ps ychological as pects .

Theory of the Ins tinc ts When F reud began his investigation into the nature of unconscious drives, he s trove cons is tently to base ps ychoanalytic theory on a firm biological foundation. of the mos t important of his attempts to link and biological phenomena came when he bas ed his theory of motivation on instincts. F reud viewed ins tincts a class of borderline concepts that functioned between mental and organic s pheres. C ons equently, his use of term “instinct” is not always consistent because it emphasizes either the psychic or biological aspect of term in varying degrees in varying contexts. then, libido refers to the s omatic proces s underlying the sexual instinct, and at other times , it refers to the ps ychological representation its elf. T hus , F reud's quite divergent from the Darwinian implications of the term “instinct,” which imply innate, inherited, unlearned, and biologically adaptive behavior. T he cleares t formulation of the notion of instinct is as a concept of functions between the mental and the s omatic realms ps ychic representative of stimuli, which come from the organism and exercise their influence on the mind. they are a meas ure of the demand made on the mind work as a result of its connection with the body.

C harac teris tic s of the Ins tinc ts F reud ascribed to ins tinctual drives four principal characteristics : s ource, impetus , aim, and object. In 493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 71 of 238

general, the s ource of an ins tinct refers to the part of body from which it arises, the biological substratum gives ris e to the organis mic s timuli. T he source, then, to a s omatic proces s that gives rise to s timuli, which represented in the mental life as drive repres entations affects. In the case of libido, the s timulus refers to the proces s or factors that excite a specific erotogenic T he impe tus or pre s s ure be hind the drive is a economic concept referring to the amount of force or energy or demand for work made by the instinctual stimulus . T he aim is any action directed toward or tens ion releas e. T he aim in every instinct is which can only be obtained by reducing the s tate of stimulation at the s ource of the ins tinct. T he object is person or thing that is the target for this s atis factionseeking action and that enables the instinct to gain satis faction or dis charge the tens ion and thus gain the instinctual aim of pleasure. F reud commented that the object was the mos t characteristic of the instinct becaus e it is only to the extent that its characteris tics make satis faction poss ible—a view that has been s ignificantly revised in light of object relations . At times, the s ubject's own may s erve as an object of an instinct as , for example, masturbatory activity. Although this early view of the instinctual object long held s way in ps ychoanalytic thinking, it has come under some serious criticis m C ons iderably more weight is put on the significance of objects of libidinal attachment, particularly by object relations theoris ts. Increas ingly, it has become that the ps ychoanalytic concept of instincts is unles s it includes and derives from a context of object 494 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 72 of 238

relatednes s. Moreover, it cannot be said s imply that the objects of infantile drives are the mos t variable characteristic of the instinct becaus e attachment to the primary objects , particularly the mothering object, is of utmos t s ignificance developmentally.

C ONC E P T OF L IB IDO T he ambiguity in the term ins tinctual drive is reflected in us e of the term libido. B riefly, F reud regarded the instinct as a ps ychophysiological process that had both mental and phys iological manifes tations . E ss entially, us ed the term libido to refer to “the force by which the sexual instinct is repres ented in the mind.” T hus, in its accepted sense, libido refers s pecifically to the mental manifestations of the s exual ins tinct. F reud recognized early that the sexual instinct did not originate in a or final form, as represented by the stage of genital primacy. R ather, it underwent a complex process of development at each phase of which the libido had specific aims and objects that diverged in varying from the s imple aim of genital union. T he libido theory thus came to include all of these manifestations and complicated paths they followed in the course of ps ychos exual development.

INFANT S E XUAL ITY It had long been s upposed, as one of the favored analytical lore, that F reud's belief on infantile sexuality cons tituted an as sault on the cherished ideas of 19thcentury and V ictorian thinking and that he was violently attacked for his views of the erotic life of young seems, however, that his significant contribution, the 495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 73 of 238

T hre e E s s ays on the T heory of S e xuality, came to light a revolutionary work but as part of a flood of literature dealing with s exual problems . F reud had become convinced of the relationship sexual trauma, in both childhood traumata and the of psychoneuros is, and disturbances of sexual as related to the s o-called actual neuros es —that is , hypochondriasis, neurasthenia, and anxiety neuroses. F reud originally viewed these conditions as related to misuse P.716 of sexual function. T hus , for example, he believed neuros is to be due to inadequate dis charge of s exual products, leading to the damming up of libido that was then converted into anxiety. Als o, he attributed neuras thenia to excess ive masturbation and a in available libidinal energy. In any case, these studies F reud to an awareness of the importance of s exual in the etiology of ps ychoneurotic s tates.

PAR T INS TINC TS F reud described the erotic impulses arising from the pregenital zone as compone nt or part ins tincts . T hus , kiss ing, s timulation of the area s urrounding the anus , even biting the love object in the course of lovemaking examples of activities as sociated with these part T he activity of component instincts or early genital excitement may undergo displacement, as, for the eyes in looking and being looked at (s coptophilia), may consequently be a s ource of pleas ure. Ordinarily, these component ins tincts undergo repres sion or 496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 74 of 238

a restricted fashion in s exual foreplay. More young children are characterized by a polymorphous pervers e s exual disposition. T heir total sexuality is relatively undifferentiated and encompass es all of the instincts. In the normal course of development to adult genital maturity, however, thes e part instincts are presumed to become s ubordinate to the primacy of the genital region.

A ggres s ion and E go Ins tinc ts T he aggres sive drives hold a peculiar place in F reud's theory. His thinking about aggres sion underwent a evolution. E arly in his thinking, his attention had been preoccupied by the problems posed by libidinal drives . was quite aware of the aggress ive components often expres sed in the operation of libidinal factors, but he not long avoid taking explicit account of the more destructive aspects of ins tinctual functioning. Undoubtedly, also, the horrors and des tructiveness of World W ar I made a s ignificant impres sion on him s o he began to realize more profoundly the s ignificance of destructive urges in human behavior. B y 1915, F reud arrived at a dualistic conception of the instincts as divided into sexual instincts and ego He recognized a sadis tic component of the sexual but this s till lacked a s ound theoretical basis. Oral, and phallic levels of development all had their sadis tic components. Devoid of any manifes t eroticism and covering a wide range from s exual perversions to of cruelty and des tructiveness , the s adis tic as pects certainly had different aims from the more s trictly Increasingly, F reud s aw the s adis tic component as 497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 75 of 238

independent of the libidinal and gradually segregated it from the libidinal drives. Moreover, impulses to control, tendencies toward the acquis ition and exercis e of and defens ive trends toward attacking and des troying manifested a strong element of aggres siveness . It then, that there was s adism as sociated with the ego instincts as well as with the libidinal ins tincts . F reud again followed the dualistic bent of his mind and postulated two groups of instinctual impulses, two qualitatively different and independent sources of instinctual impulses with different aims and modalities . With the publication of T he E go and the Id in 1923, gave aggress ion a s eparate s tatus as an instinct with a separate s ource, which he pos tulated to be largely the skeletomus cular s ys tem, and a separate aim of its namely, des truction. Aggres sion was no longer a component instinct nor was it a characteris tic of the instincts; it was an independently functioning instinctual system with aims of its own. T he elevation of aggress ion to the s tatus of a s eparate instinct, on a par with sexual instincts, dealt a severe to any lingering romantic notions of the es sentially or exclusively benign nature of man. Aggress ion and destructiveness were seen as inherent qualities of nature such that aggres sive impuls es were elicited whenever an individual was sufficiently thwarted or abused. F reud's new formulation als o drew attention to the specific role of aggres sion in forms of as well as to understanding of the developmental proces ses through which aggress ion could be normally integrated and controlled. It s hould be noted that aggres sion remains a problem 498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 76 of 238

ps ychoanalytic thinking even today. Although a great has been learned about the operation and vicis situdes aggres sion s ince F reud originally struggled with it, still a great deal that remains to be learned about its nature, its origins , and the conditions that produce and unleas h it as well as the developmental factors that contribute to its pathological deviations and to its more cons tructive integration in the realm of human functioning. S ome more recent revis ions of aggress ion it les s in terms of des tructive or s adistic aims but more broadly as a capacity for effective action in the face of obstacles or opposition-embracing capacities for and s elf-as sertion and as related to patterns of rather than as a biologically determined drive force.

L ife and Death Ins tinc ts When F reud introduced his final theory of life and instincts in B eyond the P le as ure P rinciple in 1920, he what can now be seen as an inevitable and logical next step in the evolution of the instinct theory he had been developing. It was nonetheles s a highly s peculative attempt to extrapolate the directions in which his theory was taking s hape to the broad realm of principles. One can recall that F reud's thinking about instincts always casts its s hadow in a dual modality. In beginning, he had dis tinguished s exual and ego T his dis tinction provided the bas ic dichotomy for the explanation of ps ychological conflict and the unders tanding of psychoneurosis. T he introduction of the life and death ins tincts must be seen in the cours e of this development and as the inherent duality of instinctual theory to the level of 499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 77 of 238

ultimate and final biological principle. F reud had not divorced his notion from the underlying economic principles derived from principles of entropy and cons tancy. T he constancy principle was extended to Nirvana principle, the objective of which was ces sation all s timuli or a state of total rest. It was only a small, subs equent s tep that led F reud from the formulation of Nirvana principle to the death ins tinct, or T hanatos. postulated that the death ins tinct was a tendency of all organisms and their component cells to return to a total quies cence—that is , to an inanimate state. In opposition to this instinct, he set the life ins tinct, or referring to tendencies of organic particles to reunite of parts to bind to one another to form greater unities, in sexual reproduction. In F reud's view, the ultimate destiny of all biological matter, driven by the inexorable tendencies of all life to follow principles of entropy and cons tancy (with the exception of the germ plasm), was return to an inanimate state. He believed that the dominant force in biological organisms had to be the death ins tinct. In this final formulation of life and death instincts, the instincts were cons idered to represent abstract biological principles, which transcended the operation of libidinal and aggres sive drives. T he life death ins tincts repres ented the forces underlying and aggres sive ins tincts . C ons equently, they general trend in all biological organis ms . Needles s to s ay, F reud's extravagant s peculation has subjected to severe criticis m. It is impos sible to argue a general biological principle exis ts merely on the basis clinical observation. If the inherent destructivenes s of some states of psychopathology can permit the 500 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 78 of 238

of P.717 destructive forces operating in the individual psyche, it no means points to the exis tence of inherent and biologically determined forces of self-destructive However one regards the argument as a biological speculation, for thes e thinkers , it has little relevance as ps ychological speculation. On the contrary, the life and death ins tincts are alive and flourishing in K leinian and F rench analytical circles . T he school of analysts the lead of Melanie K lein constitute the most significant group of ps ychoanalytic theorists who embrace the instinct. K leinian analysis bases a considerable portion its unders tanding of intrapsychic process es on the operation of the life and death ins tincts . In K lein's work with severely dis turbed children, she ascribed the manifestations of aggress ive instincts in s uch children the operation of the death instinct. T his point of view seems to collapse the intervening s teps in the of ins tinctual theory and makes almost any of des tructive aggres sion a direct expres sion of the instinct. Although contributions of K lein and her to the psychopathology of childhood dis turbances are significant, other s chools of analytical thinking have not followed their lead in this conceptualization of the instincts.

NA R C IS S IS M A ND THE DUA L THE OR Y T he concept of narcis sism holds a pivotal pos ition in development of psychoanalytic theory. It was F reud's 501 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 79 of 238

dawning realization of the importance of narcis sism led him to important modifications in his unders tanding libido and his instinct theory. At the s ame time, F reud's examination of narciss is m and its related clinical phenomena led to an increasing concern with the and functions of the ego. It mus t be said that the introduction of and focus on narcis sis m have had broad implications and reverberations in psychoanalytic since F reud's day. T he whole problem of narcis sism remains difficult and problematic for psychoanalys is . problem of pathological narcis sis m remains a focus of active interest, thinking, and clinical concern even T he problem has s pecial relevance with regard to forms of character pathology, which are relatively to therapeutic intervention. F reud observed that in cases of dementia praecox (s chizophrenia), libido appeared to have been from other people and objects and turned inward. He concluded that this detachment of libido from external objects might account for the loss of reality contact s o typical of these patients. He s peculated that the libido had then been reinves ted and attached to the patient's own ego, res ulting in megalomaniacal and s uggesting that this libidinal reinves tment found expres sion in their grandios ity and omnipotence. F reud also became aware at the same time that was not limited to these ps ychotic manifes tations . It also occur in neurotic and, to a certain extent, even in “normal” individuals under certain conditions . He noted, for example, that in s tates of phys ical illness and hypochondriasis, libidinal cathexis was frequently withdrawn from outs ide objects and from external 502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 80 of 238

activities and interests. S imilarly, he s peculated that, in sleep, libido was withdrawn from outs ide objects and reinvested in the pers on's own body. T hus, he believed could be that the hallucinatory intens ity of the dream experience and the intensity of the emotional quality of the dream might res ult from the libidinal cathexis of fantas y repres entations of the people who compos ed dream images . F reud also appealed to the basically narcis sistic form of object choice in perversions, particularly homosexuality. T he introduction of narcis sism into his theory played a significant role because it required that he reconcile his theory of libido with what now s eemed to be a libidinal force operating within the ego. F reud originally thought the reinvestment of libido as directed to the ego as T his formulation has given rise to a considerable in the understanding of narciss istic libido. A decis ive reorganization of the concept of narciss is m was by Heinz Hartmann when he pointed out that it was accurate to regard narciss is tic libido as attached not to ego as such but to the s elf. T he ego, as an intraps ychic cons truct, is oppos ed to the self as related to external objects extraps ychically. T he proper opposition, then, between object libido and narciss is tic libido is that the former is attached to object repres entations, whereas latter is attached to s elf-representations. T his important shift in the unders tanding of narcis sis m has opened an area of theoretical reconsideration that is still very flux and has introduced into psychoanalytic thinking the concept of s elf as an important, albeit as -yet-ill-defined, intraps ychic s tructural component.

503 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 81 of 238

Narc is s is m and the C hoic e of L ove Objec t R eference was made earlier to the crucial role of early object relations hips in later choice of love objects. found that a deepened unders tanding of the of narcis sis m made it eas ier to unders tand the basis for choice of certain love objects in adult life. A love object might be chos en, as F reud put it, “according to the narcis sistic type,” that is , because the object res embles subject's idealized self-image (or fantasized s elfP os sibly the choice of object might be an “anaclitic in which cas e the object might res emble someone who took care of the s ubject during the early years of life. In summary, the concept of narcis sis m occupies a and pivotal pos ition in ps ychoanalytic theory. W ith the introduction of the concept of narcis sism, it became obvious that the concept of the “individual” and the individual's “body” and “ego” could no longer be us ed interchangeably. It became clear that further unders tanding and advances in psychoanalytic theory depended on a clearer definition of the concept of self its more adequate delineation from the concept of ego. Attempts to implement s uch understanding have into focus the ambiguities in the concept of the ego and have underscored the need for the s ys tematic study of development, structure, and functions. Attention to narcis sistic phenomena has als o enlarged the unders tanding of a variety of mental disorders as well various normal psychological phenomena. T hese are dis cuss ed in relation to treatment iss ues .

S TR UC TUR A L THE OR Y A ND E G O 504 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 82 of 238

P S YC HOL OG Y T he topographical theory was ess entially a trans itional model in the development of F reud's thinking and an important function in providing a framework for development of his bas ic ins tinct theory. However, the problems inherent in the topographical theory once again, the need for a more systematic concept of ps ychic s tructure. T he main deficiency of the topographical model lies in its inability to account for extremely important characteristics of mental conflict. T he firs t important problem was that many of the mechanisms that F reud's patients us ed to avoid pain or unpleasure and that appeared in the form of res is tances during psychoanalytic treatment were thems elves not initially access ible to consciousness . drew the obvious conclus ion that the agency of repress ion, therefore, could not be identical with the preconscious because this region of the mind was , by definition, easily access ible to consciousness . T he problem was that he found that his patients frequently exhibited an uncons cious need for punis hment or an unconscious s ens e of guilt. According to the model, however, the moral agency making this demand was allied with the P.718 antiinstinctual forces available to cons cious nes s in the preconscious level of the mind.

From Topographic al to S truc tural Pers pec tive T he germination of the shifting currents of F reud's 505 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 83 of 238

thinking finally came to fruition in his abandoning the topographical model and replacing it with the structural model of the psychic apparatus in T he E go and the Id. introduction of the structural hypothesis initiated a new era in psychoanalytic thinking. T he structural model of mind, or the “tripartite theory” as it is often called, is comprised of three distinct entities or organizations the ps ychic apparatus—the id, the ego, and the T he terms have become s o familiar and the tendency hypos tas ize them so great that it is well to bear in mind their nature as scientific cons tructs. T he terms are theoretical cons tructs that have as their primary the specific groups of mental functions and operations that they are intended to organize and integrate into higher-order s ys tems. E ach refers to a particular mental functioning, and none of them expres ses or represents the sum total of mental functioning at any time. Although they are often s poken of as though they functioned as quasiindependent systems , they are, nonetheless , ultimately coordinated aspects of the operation of the mental apparatus representing mental actions of the person. Attribution of agency to any one them is a form of misplaced concretenes s because actions and functions are bas ically thos e of the thems elves . Moreover, unlike such phenomena as sexuality or object relations, id, ego, and superego are empirically demonstrable phenomena in themselves must be inferred from the observable effects of the operations of specific psychic functions .

His toric al Development of E go Ps yc hology 506 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 84 of 238

T he evolution of the concept of ego within the of the historical development of psychoanalytic theory parallels to a large extent the s hifts in F reud's view of instincts and can be divided into four phases. T he first phase ended in 1897 and coincided with the of the early ps ychoanalytic formulations . T he s econd phase extended from 1897 to 1923, thus s panning the development of psychoanalys is proper. T he third from 1923 to 1937, saw development of F reud's theory the ego and the gradual emergence to prominence of ego in the overall context of the theory. P arallel to this development was the evolution of F reud's thinking anxiety. F inally, the fourth phas e, coming after F reud's death, saw the emergence and s ys tematic a general psychology of the ego as well as a s hifting of focus from the operation of ego functions themselves the broader social and cultural contexts within which ego developed and functioned.

F irs t P has e: E arly C onc epts of the In the initial phase, the ego was not always precisely defined. R ather, it referred to the dominant mass of cons cious ideas and moral values that were dis tinct impulses and wis hes of the repress ed unconscious. ego was concerned primarily with defense, a term soon replaced with the notion of repress ion, so that repress ion and defens e were regarded as the neurophys iological jargon of the P roje ct, the ego described as “an organization… whos e presence with pas sages of quantity (of excitation).” T ranslating into the language of psychology, the ego was regarded an agent defending against certain ideas that were unacceptable to consciousness . T hese ideas were 507 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 85 of 238

be primarily sexual in nature and were initially believed have been engendered by premature s exual trauma real s eduction. P resumably, becaus e memory of s uch trauma led to arous al of unpleas ant and painful affects , they evoked a defens ive res ponse and repress ion of original thought content. T his repres sion, however, led damming up of energy and the consequent production anxiety. F unctioning of this “early ego” was to a degree because its primary purpos e was to reduce tension and thus avoid unpleas ant affects connected sexual thoughts , but in the process of repress ion, it seemed to evoke an equally unpleasant affect s tate, anxiety.

S ec ond P has e: His toric al R oots of P s yc hology During the years preceding publication of T he E go and Id, analysis of the ego as such received little direct attention becaus e F reud was concerned primarily with instinctual drives —their repres entatives and transformations. C onsequently, references to defens e defens ive functions were much les s frequent. T he clarification of these concepts required further of the ego, its functions , and the nature of its It was during this s econd phase that F reud grappled these problems and gradually approached the more definitive res olution provided by the s tructural theory. T he ego's relations hip to reality is particularly relevant this connection. As noted earlier, the concept of a secondary process implies the ability to delay instinctual drives in accordance with demands of reality. T he capacity for delay was later to be as cribed 508 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 86 of 238

the ego. T he progres sion from pleasure principle to principle in childhood involves a similar capacity to “postpone gratification” and thereby conform to the requirements of the outside world. F inally, if neither the preconscious nor the ego instincts were s olely respons ible for repress ion or cens ors hip, was repress ion to be achieved? F reud tried to ans wer question by pos tulating that ideas are maintained in the unconscious by a withdrawal of libido or energy In the manner characteristic of unconscious ideas , however, they cons tantly renew their attempt to attached to libido and thus reach cons cious nes s. C ons equently, the withdrawal of libido must be repeated. F reud described this process as “countercathexis .” Again, however, if such is to be cons is tently effective agains t uncons cious must be permanent and must its elf operate on an unconscious basis. Understanding of ps ychic s tructure, specifically of the ego, which could perform this complicated function, was clearly called for and cons tituted s till another indication of the need for the development of ego psychology. T hus , the way was pointed toward the third phas e, wherein the ego was delineated as a s tructural entity and s eparated from the instinctual drives .

Third P has e: F reud's E go With publication of T he E go and the Id, the phase of introduction and development of F reud's own theory of the ego was accomplis hed. T he ego was pres ented as structural entity, a coherent organization of mental proces ses and functions, primarily organized around 509 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 87 of 238

perceptual-cons cious system, but it also included structures res ponsible for res is tance and uncons cious defens e. T he ego at this s tage was relatively pass ive weak. Its functioning was s till a res ult of press ures from id, s uperego, and reality. T he ego was the rider on the id's hors e, more or less obliged to go the id wished to go. T he as sumption remained that the ego was not only dependent on forces of the id but was somehow genetically derived and differentiated out of id. F reud had yet to recognize any real development of ego comparable to the phases of libidinal development. During this period, the view of the ego underwent transformation. S ome of the details of this development took place in connection with F reud's theory of anxiety. Inhibitions , S ymptoms , and Anxie ty in 1926, F reud repudiated the conception of ego as subservient P.719 to the id. S ignal anxiety became an autonomous for initiating defense, and the capacity of the ego to pass ively experienced anxiety into active anticipation underlined. Here, too, the relatively rudimentary conception of the defens ive capacity of the ego was enlarged to include a variety of defens es that the ego at its dis pos al and could us e in the control and id impulses . Moreover, elaboration of F reud's of the reality principle introduced a function of that allowed the ego to curb ins tinctual drives when prompted by them led to real danger. T he effect of this trans formation of his theory of the ego was threefold. F irs t, it brought the ego into prominence a powerful regulatory force respons ible for integration 510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 88 of 238

control of behavioral res pons es . S econd, the role of was brought to center stage in the theory of ego functioning. It had been banished to the wings in the preceding quarter century, but concern with the function of the ego again brought it back to E ven s o, the conception of adaptation here was rudimentary and limited to the ego's capacity to avoid danger. T he notions that F reud was evolving during phase provided the foundation for the later concept of autonomy of the ego, as developed by later theoris ts. F inally, it was toward the end of this period that F reud finally made explicit the as sumption of independently inherited roots of the ego that were quite independent the inherited roots of the ins tinctual drives. T his formulation was taken over by Hartmann and s erved as the bas is for his notion of primary ego autonomy, which cons equently s timulated the developments of the fourth phase.

F ourth P has e: S ys tematization of P s yc hology If the third phase can be thought of as culminating in F reud's work on the defense mechanis ms of the ego, fourth phas e can be s een as taking its initiation from publication of Hartmann's work on the ego and adaptation. Hartmann's work primarily focused on two as pects of F reud's later notions of the ego, namely, the autonomy of the ego and the problem of adaptation. Dis cus sion of the apparatuses of primary autonomy the bas is for a doctrine of the genetic roots of the ego a development of the notion of epigenetic maturation. Hartmann's treatment of adaptation als o brought the adaptational point of view into focus in such a way that 511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 89 of 238

has become generally acceptable as one of the basic metapsychological as sumptions of ps ychoanalytic Although this development of thinking about the ego an important advance, many psychoanalys ts began to that it created an imbalance in the theory and that, by increasingly focus ing on the mechanical and as pects of ego functioning, it left a picture of functioning and dys functioning that s eemed relatively mechanistic and inhuman. Moreover, there developed widening s plit between the id, the vital s tratum of the mind and the dynamic s ource of ps ychic energies, and nonins tinctual, nondynamic structural apparatuses of ego. C onsequently, the id increas ingly came to be the source of ins tinctual energies —the image of the seething cauldron—without the repres entational or directional qualities that s o long characterized F reud's views of the instincts and their functions. T he other extremely important as pect of the fourth is reemergence of the importance of reality in its and most profound meanings as a significant ps ychoanalytic thinking. T his is in many ways a direct extrapolation of Hartmann's thinking about adaptation because the adaptive functioning of the organis m has directly to do with fitting in with the requirements of external reality and adaptively interacting with the environment, not only the inanimate but als o the and s ocial environment.

S truc ture of the Ps yc hic Apparatus F rom a structural viewpoint, the ps ychic apparatus is divided into three groups of functions des ignated as id, ego, and s uperego and dis tinguis hed by their different 512 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 90 of 238

functions . T he id is the locus of the instinctual drives under domination of primary process . It operates according to dictates of the pleas ure principle, without regard for the limiting demands of reality. T he ego, however, represents a coherent organization of whos e task is to avoid unpleasure or pain by oppos ing regulating the dis charge of instinctual drives to conform demands of the external world. T he regulation of id discharges is also contributed to by the third structural component of the psychic apparatus, the s uperego, contains the internalized moral values, prohibitions , standards of the parental imagoes .

Id F reud s eparated the ins tinctual drives in his tripartite theory into a separate compartment, the vital stratum of the mind, and in s o doing reached the culminating point of the evolution of his theory of ins tincts . In contrast to concept of the ego as an organized, problem-solving capacity, F reud conceived of the id as a completely unorganized, primordial reservoir of energy, derived the instincts , and under the domination of primary proces s. It was not, however, s ynonymous with the unconscious because the structural viewpoint was in that it demons trated that certain functions of the ego, specifically certain defenses against uncons cious instinctual pres sures, were unconscious; for the most the superego also operated on an uncons cious level.

E go T he cons cious and precons cious functions typically as sociated with the ego—for example, words, ideas, or 513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 91 of 238

logic—do not account entirely for its role in mental functioning. T he dis covery that certain phenomena that emerge most clearly in the psychoanalytic treatment setting, s pecifically repress ion and res is tance, both as sociated with the ego, could themselves be pointed out the need for an expanded concept of the as an organization retaining original clos e relations hip cons ciousnes s and to external reality and yet variety of unconscious operations in relationship to and their regulation. Once the s cope of the ego had thus broadened, cons cious nes s was redefined as a quality that, although exclusive to the ego, cons titutes only one of its qualities or functional as pects rather separate mental s ys tem its elf, as in the topographical model. No more comprehens ive definition of the ego is than the one F reud himself provided toward the end of career in O utline of P s ychoanalys is : Here are the principal characte ris tics of the e go. In cons equence of the pre-es tablis hed connection sens e and perception and muscular action, the ego voluntary movement at its command. It has the tas k of self-preservation. As regards external events, it that task by becoming aware of s timuli, by storing up experiences about them (in the memory), by avoiding excess ively strong s timuli (through flight), by dealing moderate s timuli (through adaptation) and finally by learning to bring about expedient changes in the world to its own advantage (through activity). As internal events, in relation to the id, it performs that by gaining control over the demands of the ins tinct, by deciding whether they are to be allowed satisfaction, by 514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 92 of 238

postponing that s atisfaction to times and circums tances favourable in the external world or by s uppress ing their excitations entirely. It is guided in its activity by cons ideration of the tension produced by stimuli, these tens ions are present in it or introduced into it. P.720 T hus, the ego controls the apparatuses of motility and perception, contact with reality, and, through of defense, inhibition of primary instinctual drives .

OR IG INS OF THE E G O If the ego is defined as a coherent s ys tem of functions mediating between ins tincts and the outs ide world, one must concede that the newly born infant has no ego or, best, the mos t rudimentary of egos. Nonetheles s, the neonate certainly has a rather complex array of intact capacities and both sensory and motor functions . however, little coherent organization of thes e s o that must say that the ego is at bes t rudimentary. Developmental ego ps ychology is then faced with the problem of explaining the process es that permit modification of the id and the concomitant genes is of ego. F reud believed that the modification of the id occurs as res ult of the impact of the external world on the drives. P res sures of external reality enable the ego to energies of the id to do its work. In the proces s of formation, the ego seeks to bring the influences of the external world to bear on the id, substitute the reality principle for the pleasure principle, and thereby to its own further development. In s ummary, F reud 515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 93 of 238

emphasized the role of ins tincts in ego development particularly, the role of conflict. At first, this conflict is between the id and the outside world, but later, it is between the id and the ego itself.

DE VE L OPME NT OF THE E G O T he proces ses by which the internal world is built up by which s tructure is consolidated within the self are referred to under the heading of internalization. F orms internalization—incorporation, introjection, and identification—are various ly connected with of the ego. Incorporation was originally conceived of as an activity derived from and based developmentally on the oral phas e and was considered as a genetic precurs or identification. However, even though incorporation fantas ies are often as sociated with internalizing they are by no means identical and may be quite independent. S ome authors envision incorporation as mechanism of primary identification, aimed at a primary union between ones elf and the maternal object. Incorporation as a mechanism of internalization seems involve a primitive oral wis h for union with an object. union has a quality of totality and globalization so that the internalization of the object, the object loses all distinction and function as object. T he external object is completely ass umed into the pers on's inner world. Incorporation is thus operative in infantile or relatively regress ive conditions. Introje ction is perhaps the mos t central process in development of the s tructural apparatus involving ego and s uperego. Introjection was originally des cribed by 516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 94 of 238

F reud in Mourning and Melancholia as a process of narcis sistic identification in which the lost object is introjected and thus retained as a part of the internal structure of the psyche. F reud later applied this mechanism to the genes is of s uperego, making introjection the primary internalizing mechanism by parental imagoes were internalized at the close of the oedipal phas e. T he child tried to retain gratifications derived from thes e object relations hips , at least in through the proces s of introjection. B y this mechanis m, qualities of the person who was the center of the gratifying relationship are internalized and as part of the organization of the s elf. F reud referred to internalized product as a pre cipitate of abandoned cathe xis . Ide ntification has often been confused with introjection, partially becaus e the two proces ses were treated in an overlapping and s omewhat interchangeable fashion by F reud. T here are, nonetheless , grounds for maintaining distinction between them. Ide ntification is , properly speaking, an active s tructuralizing proces s that takes within the s elf by which the s elf cons tructs the inner cons tituents of regulatory control on the bas is of elements derived from the model. W hat cons titutes the model of identification can vary considerably and can include introjects, structural aspects of real objects , or even value components of group structures and group cultures. T he process of identification is specifically an intras ys temic structuralizing activity attributed to the functions of the s elf, related to its synthetic function, affecting structural integration in all parts of the ps ychic apparatus, including superego. 517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 95 of 238

FUNC TIONS OF THE E G O T he ego comprises an organization of functions that in common the task of mediating between ins tincts and the outside world. T hus , the ego is a subsystem of the personality and is not s ynonymous with the s elf, the personality, or character. Any attempt to compile a complete list of ego functions has to be relatively Invariably, the list of basic ego functions s uggested by various authors differs in varying degrees. T his is limited to s everal functions generally conceded to be fundamental to ego operation.

C ontrol and R egulation of Ins tinc tual Development of the capacity to delay immediate discharge of urgent wis hes and impulses is ess ential if ego is to ass ure the integrity of the individual and fulfill role as mediator between id and outside world. Development of the capacity to delay or pos tpone instinctual dis charge, like the capacity to tes t reality, is clos ely related to the progres sion in early childhood pleas ure principle to reality principle.

R elation to R eality F reud always regarded the ego's capacity for relations hip to the external world among its principal functions . T he character of its relationship to the world may be divided into three components : (1) the of reality, (2) reality testing, and (3) the adaptation to reality.

S ens e of R eality T he sens e of reality originates simultaneous ly with the 518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 96 of 238

development of the ego. Infants firs t become aware of reality of their own bodily s ens ations . Only gradually do they develop the capacity to dis tinguis h a reality their own bodies .

R eality Tes ting R eality te s ting refers to the ego's capacity for objective evaluation and judgment of the external world, which depends first on primary autonomous functions of the ego, s uch as memory and perception, but then also on relative integrity of internal structures of s econdary autonomy. Under conditions of internal s tres s, in which regress ive pulls are effectively operating, introjective as pects of inner psychic structure can tend to dominate and, thus, become s usceptible to projective dis tortions that color the individual's perception and interpretation the outside world. B ecause of the fundamental of reality tes ting for “negotiating” with the outside world, its impairment may be ass ociated with severe mental disorder.

A daptation to R eality Adaptation to re ality refers to the capacity of the ego to the individual's resources to form adequate solutions based on previously tested judgments of reality. It is poss ible for the ego to develop not only good reality tes ting, with perception and grasp, but als o to develop adequate capacity to accommodate the individual's res ources to the s ituation thus perceived. Adaptation is clos ely allied to the concept of mastery, both in res pect external tasks and to the instincts. It should be distinguished from adjustment, which may entail 519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 97 of 238

accommodation to reality at the expense of certain res ources or potentialities of the individual. T he adaptation to reality is closely related to P.721 the defens ive functions of the ego. T he mechanism may s erve defensive purposes from one point of view simultaneously s erve adaptive purposes when viewed from another perspective. T hus, in the obs ess ivecompuls ive person, intellectualization may s erve important inner needs to control drive impulses, but by the same token, from another perspective, the activity its elf may s erve highly adaptive functions in dealing with the complexities of external reality.

Objec t R elations hips T he capacity for mutually s atisfying relations hips is one the fundamental functions to which the ego contributes , although s elf–other relations hips are more properly a function of the whole person, the s elf, of which the ego functional component. S ignificance of object and their disturbance—for normal psychological development and a variety of ps ychopathological were fully appreciated relatively late in the clas sic ps ychoanalys is . T he evolution in the child's for relations hips with others , progres sing from to social relations hips within the family and then to relations hips within the larger community, is related to capacity. Development of object relations hip may be disturbed by retarded development, regress ion, or conceivably by inherent genetic defects or limitations in the capacity to develop object relations hips or 520 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 98 of 238

impairments and deficiencies in early caretaking relations hips . T he development of object relations hips clos ely related to the concomitant evolution of drive components and the phas e-appropriate defens es that accompany them.

Defens ive F unc tions of the E go As was pointed out previous ly, in his initial formulations and for a long time thereafter, F reud cons idered repres sion to be virtually s ynonymous with defens e. More specifically, repres sion was directed primarily agains t the impulses, drives, or drive representations and, particularly, agains t direct of the sexual instinct. Defense was thus mobilized to instinctual demands into conformity with demands of external reality. W ith development of the structural view the mind, the function of defens e was ascribed to the Only after F reud had formulated his final theory of however, was it poss ible to study the operation of the various defense mechanis ms in light of their in res pons e to danger s ignals . T hus, a s ys tematic and comprehensive study of ego defens es was only presented for the first time by Anna F reud. In her class ic monograph T he E go and the Me chanis ms of De fe ns e , s he maintained that whether normal or neurotic, uses a characteris tic repertoire of defens e mechanisms but to varying On the basis of her extensive clinical s tudies of she described their ess ential inability to tolerate instinctual stimulation and discus sed proces ses the primacy of s uch drives at various developmental stages evoked anxiety in the ego. T his anxiety, in turn, 521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 99 of 238

produced a variety of defens es. W ith regard to adults, ps ychoanalytic investigations led her to conclude that, although res is tance was an obstacle to progress in treatment to the extent that it impeded the emergence unconscious material, it als o cons tituted a us eful information concerning the ego's defensive operations.

G enes is of Defens e Mec hanis ms In the early s tages of development, defens es emerge res ult of the ego's s truggles to mediate press ures of and the requirements and s trictures of outs ide reality. each phas e of libidinal development, as sociated drive components evoke characteris tic ego defens es . T hus, example, introjection, denial, and projection are mechanisms as sociated with oral-incorporative or oralsadis tic impulses, whereas reaction formations, s uch shame and disgust, us ually develop in relation to anal impulses and pleas ures . Defens e mechanisms from phases of development pers is t side by s ide with thos e later periods. W hen defens es ass ociated with phases of development tend to predominate in adult over more mature mechanisms, such as s ublimation repress ion, the personality retains an infantile cast.

C las s ific ation of Defens es T he defens es used by the ego can be categorized according to a variety of clas sifications, none of which inclusive or takes into account all of the relevant Defenses may be class ified developmentally, for in terms of the libidinal phase in which they aris e. T hus, denial, projection, and distortion are as signed to the stage of development and to the correlative narciss is tic 522 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 100 of 238

stage of object relations hips. C ertain defens es , such as magical thinking and regres sion, cannot be categorized in this way. Moreover, certain bas ic developmental process es , such as introjection and projection, may als o s erve defens ive functions under certain s pecifiable conditions. T he defens es have also been clas sified on the bas is of particular form of psychopathology with which they are commonly ass ociated. T hus, the obs es sional defens es include isolation, rationalization, intellectualization, and denial; however, defens ive operations are not limited to pathological conditions. F inally, the defens es have clas sified as to whether they are simple mechanisms or complex, in which a single defens e involves a or compos ite of s imple mechanis ms . T able 6.1-2 gives brief clas sification and description of s ome of the bas ic defens e mechanisms mos t frequently us ed and mos t thoroughly inves tigated by ps ychoanalys ts.

Table 6.1-2 C las s ific ation of Defens e Mec hanis ms Narcis s is tic Defens es P rojection

P erceiving and reacting to unacceptable inner impulses and their derivatives as they were outside the s elf. On 523

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 101 of 238

ps ychotic level, this takes the form of frank delus ions about external reality, usually persecutory, and includes perception of one's own feelings in another with subs equent acting on the perception (ps ychotic delus ions). Impuls es may from id or s uperego (hallucinated recriminations). Denial

P sychotic denial of external reality, unlike repres sion, perception of external reality more than perception of internal reality. S eeing, but refusing to acknowledge what one s ees , or hearing, and negating what is actually are examples of denial and exemplify the clos e of denial to s ens ory Not all denial, however, is neces sarily ps ychotic. Like projection, denial may in the service of more or even adaptive objectives. Denial avoids becoming of some painful aspect of

524 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 102 of 238

reality. At the psychotic level, the denied reality may be replaced by a fantas y or delus ion. Dis tortion

G ross ly res haping external reality to suit inner needs , including unrealistic megalomaniacal beliefs, hallucinations , wis h-fulfilling delus ions, and using feelings of delus ional superiority or entitlement.

Immature Defens es Acting out

T he direct expres sion of an unconscious wis h or impulse action to avoid being of the accompanying affect. T he unconscious fantas y, involving objects , is lived out impulsively in behavior, thus gratifying the impulse more than the prohibition against it. On a chronic level, acting out involves giving in to impulses to avoid the tens ion that 525

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 103 of 238

from postponement of expres sion. B locking

An inhibition, usually temporary in nature, of affects es pecially, but pos sibly also thinking and impuls es . It is clos e to repress ion in its but has a component of arising from the inhibition of the impulse, affect, or

Hypochondrias is

T ransformation of reproach toward others aris ing from bereavement, lonelines s, or unacceptable aggres sive impulses into s elf-reproach somatic complaints of pain, illness , and so forth. R eal may als o be overemphasized exaggerated for its evas ive regress ive poss ibilities . T hus, res ponsibility may be guilt may be circumvented, instinctual impuls es may be warded off.

Introjection

In addition to the developmental functions of proces s of introjection, it als o

526 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 104 of 238

serves s pecific defensive functions . T he introjection of loved object involves the internalization of of the object with the goal of clos enes s to and cons tant presence of the object. cons equent to separation or tension arising out of ambivalence toward the is thus diminished. If the is a los t object, introjection nullifies or negates the los s taking on characteristics of object, thus, in a sens e, internally preserving the E ven if the object is not los t, internalization usually a s hift of cathexis , reflecting a significant alteration in the object relations hips . Introjection of a feared object serves to avoid anxiety internalizing the aggres sive characteristic of the object thereby putting the under one's own control. T he aggres sion is no longer felt as coming from outs ide but is taken within and us ed

527 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 105 of 238

defens ively, thus turning the subject's weak, pass ive into an active, s trong one. clas sic example is “identification with the aggres sor.” Introjection can also be out of a s ens e of guilt which the s elf-punis hing introject is attributable to the hostile, destructive of an ambivalent tie to an object. T hus, the s elf-punitive qualities of the object are over and establis hed within one's s elf as a s ymptom or character trait, which represents both the and the preservation of the object. T his is als o called ide ntification with the victim. P as siveaggres sive behavior

Aggress ion toward an object expres sed indirectly and ineffectively through pass ivity, masochism, and turning agains t the s elf.

P rojection

Attributing one's own unacknowledged feelings to others ; it includes severe

528 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 106 of 238

prejudice, rejection of through s uspicious ness , hypervigilance to external danger, and injus tice P rojection operates correlatively to introjection, such that the material of the projection is derived from the internalized configuration of the introjects . At higher levels of function, projection may the form of misattributing or misinterpreting motives , attitudes, feelings, or of others. R egress ion

A return to a previous s tage development or functioning to avoid the anxieties or involved in later s tages. A return to earlier points of fixation embodying modes of behavior previous ly given up. T his is often the res ult of a disruption of equilibrium at a later phas e of development. T his reflects a basic tendency achieve ins tinctual or to es cape ins tinctual by returning to earlier modes

529 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 107 of 238

and levels of gratification later and more differentiated modes fail. S chizoid fantasy

T he tendency to use fantasy and to indulge in autis tic retreat for the purpos e of conflict res olution and gratification.

S omatization

T he defens ive conversion of ps ychic derivatives into bodily symptoms; tendency to react with somatic rather than ps ychic manifes tations . Infantile s omatic responses replaced by thought and during development (desomatization); regress ion earlier somatic forms or res ponse (resomatization) res ult from unres olved and may play an important in ps ychophysiological reactions .

Neurotic Defens es

530 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 108 of 238

C ontrolling

T he excess ive attempt to manage or regulate events or objects in the environment in the interes t of minimizing anxiety and s olving internal conflicts.

Dis placement

Involves a purposeful, unconscious s hifting from one object to another in the of solving a conflict. Although the object is changed, the instinctual nature of the impulse and its aim remain unchanged.

Dis sociation

A temporary but dras tic modification of character or sens e of pers onal identity to avoid emotional dis tres s; it includes fugue states and hysterical convers ion

E xternalization

A general term, correlative to internalization, referring to the tendency to perceive in the external world and in external objects components of one's own pers onality, including instinctual impuls es , conflicts,

531 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 109 of 238

moods , attitudes , and s tyles thinking. It is a more general term than projection, which is defined by its derivation from and correlation with specific introjects . Inhibition

T he unconscious ly limitation or renunciation of specific ego functions , s ingly in combination, to avoid anxiety aris ing out of conflict with ins tinctual impuls es , superego, or environmental forces or figures.

Intellectualization

T he control of affects and impulses by way of thinking about them instead of experiencing them. It is a systematic excess of thinking, deprived of its affect, to agains t anxiety caused by unacceptable impulses.

Is olation

T he intraps ychic s plitting or separation of affect from content res ulting in of either idea or affect or the displacement of affect to a

532 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 110 of 238

different or substitute content. R ationalization

A justification of attitudes, beliefs, or behavior that might otherwis e be unacceptable by an incorrect application of justifying reasons or the invention of a convincing fallacy.

R eaction formation

T he management of unacceptable impulses by permitting express ion of the impulse in antithetical form. T his is equivalently an expres sion of the impulse in negative. W here instinctual conflict is pers is tent, reaction formation can become a character trait on a basis , usually as an aspect of obses sional character.

R epress ion

C ons is ts of the expelling and withholding from cons cious awarenes s of an idea or It may operate either by excluding from awareness was once experienced on a cons cious level (s econdary

533 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 111 of 238

repress ion) or by curbing and feelings before they have reached cons cious nes s (primary repres sion). T he “forgetting” of repress ion is unique in that it is often accompanied by highly symbolic behavior, which suggests that the repress ed not really forgotten. T he important dis crimination between repres sion and the more general concept of defens e has been discus sed. S exualization

T he endowing of an object or function with s exual significance that it did not previous ly have, or a less er degree, to ward off anxieties connected with prohibited impulses.

Mature Defens es Altruis m

T he vicarious but cons tructive and instinctually gratifying service to others . T his mus t 534

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 112 of 238

distinguished from altruistic surrender, which involves a surrender of direct or of instinctual needs in favor of fulfilling the needs of others to the detriment of the self, with vicarious s atis faction being gained through introjection. Anticipation

T he realis tic anticipation of or planning for future inner discomfort: implies overly concerned planning, and anticipation of dire and dreadful poss ible outcomes .

Asceticism

T he elimination of directly pleas urable affects to an experience. T he moral element is implicit in s etting values on s pecific pleas ures . Asceticism is directed against all “base” pleas ures cons ciously, and gratification derived from the renunciation.

Humor

T he overt express ion of without pers onal discomfort immobilization and without

535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 113 of 238

unpleasant effect on others . Humor allows one to bear, yet focus on, what is too terrible to be borne, in to wit, which always involves distraction or dis placement away from the affective is sue. S ublimation

T he gratification of an whos e goal is retained but whos e aim or object is from a socially objectionable one to a s ocially valued one. Libidinal sublimation involves desexualization of drive impulses and the placing of a value judgment that subs titutes what is valued by the superego or s ociety. S ublimation of aggres sive impulses takes place through pleas urable games and Unlike neurotic defens es , sublimation allows instincts to be channeled rather than dammed up or diverted. in sublimation, feelings are acknowledged, modified, and directed toward a relatively significant pers on or goal s o

536 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 114 of 238

that modest ins tinctual satis faction res ults. S uppres sion

T he cons cious or decis ion to pos tpone attention to a cons cious impuls e or conflict.

Adapted from V aillant G E . Adaptation to L ife . Little, B rown; 1977; S emrad E . T he operation of defens es in object los s. In: Moriarity DM, ed. T he of L ove d O nes . S pringfield, IL: C harles C . 1967; and B ibring G L, Dwyer T F , Huntington DS , V alens tein AA: A s tudy of the ps ychological principles in pregnancy and of the earlies t child relationship: Methodological cons iderations . P s ychoanal S tud C hild. 1961;16:25.

S ynthetic F unc tion T he s ynthetic function of the ego refers to the ego's capacity to integrate various aspects of its functioning. involves the capacity of the ego to unite, organize, and bind together various drives, tendencies , and functions within the personality, enabling the individual to think, feel, and act in an organized and directed manner. the synthetic function is concerned with the overall organization and functioning of the ego in the selfand cons equently mus t enlis t the cooperation of other 537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 115 of 238

and nonego functions in its operation. Although the synthetic function subserves adaptive functioning in the ego, it may als o bring together forces in a way that, although not completely adaptive, an optimal s olution for the individual in a particular at a given moment or period of time. T hus , the of a s ymptom that repres ents a compromis e of tendencies, although unpleasant in some degree, is nonetheless preferable to yielding to a dangerous instinctual impuls e or, conversely, trying to s tifle the impulse completely. Hysterical convers ion, for combines a forbidden wis h and the punis hment for it a physical s ymptom. On examination, the s ymptom turns out to be the only poss ible compromise under the circums tances .

A utonomy of the E go Although F reud only referred to “primal, congenital ego variations ” as early as 1937, this concept was greatly expanded and clarified by Hartmann. Hartmann a bas ic formulation about development that the ego id differentiate from a common matrix, the so-called undifferentiated phase, in which the ego's precurs ors inborn apparatuses of primary autonomy. T hese apparatuses are rudimentary in nature, pres ent at birth, and develop outs ide the area of conflict with the id. area Hartmann referred to as a “conflict-free” area of functioning. He included perception, intuition, comprehension, thinking, language, certain phases of motor development, learning, and intelligence among functions in this conflict-free sphere. E ach of these functions , 538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 116 of 238

P.722 P.723 however, might als o become involved in conflict secondarily in the course of development. F or example, aggres sive, competitive impulses intrude on the impuls e learn, they may evoke inhibitory defens ive reactions on part of the ego, thus interfering with the conflict-free operation of these functions .

P rimary A utonomy With the introduction of the primary autonomous functions , Hartmann provided an independent genetic derivation for at leas t part of the ego, thus es tablis hing it an independent realm of psychic organization that was totally dependent on and derived from the instincts . T his was an ins ight of major importance because it laid the foundations for the emerging doctrine of ego autonomy and meant that the analys is of ego development would have to cons ider an entirely new set of variables quite separate from thos e involved in instinctual

S ec ondary A utonomy Hartmann obs erved that the conflict-free sphere derived from s tructures of primary autonomy can be enlarged that further functions could be withdrawn from the domination of drive influences . T his was Hartmann's concept of s econdary autonomy. T hus, a mechanism arose originally in the s ervice of defense agains t drives may in time become an independent s tructure, that the drive impuls e merely triggers the automatized 539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 117 of 238

apparatus. T hus, the apparatus may come to serve functions than the original defensive function, for example, adaptation or s ynthes is . Hartmann referred to this removal of s pecific mechanis ms from drive as a process of change of function.

S uperego T he origins and functions of the superego are related those of the ego, but they reflect different viciss itudes . B riefly, the s uperego is the las t of the structural components to develop, resulting in F reud's analysis from resolution of the oedipal complex. It is concerned with moral behavior based on uncons cious behavioral patterns learned at early pregenital stages development. F requently, the superego participates in neurotic conflict by allying its elf with the ego and thus impos ing demands in the form of conscience or guilt feelings. Occasionally, however, the superego may be allied with the id agains t the ego. T his happens in severely regres sed reaction, in which functions of the superego may become s exualized once more or may become permeated P.724 by aggres sion, taking on a quality of primitive (us ually anal) destructivenes s.

HIS TOR IC AL DE VE L OPME NT In a paper written in 1896, F reud described ideas as “s e lf-re proaches which have re-emerged from re pre s s ion and which always relate to some s e xual act was performed with pleas ure in childhood.” T he activity 540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 118 of 238

a s elf-criticizing agency was also implicit in F reud's discuss ions of dreams, which pos tulated existence of a “cens or” that did not permit unacceptable ideas to enter cons ciousnes s on moral grounds . He first dis cuss ed concept of a special s elf-critical agency in 1914, that a hypothetical s tate of narcis sis tic perfection in early childhood; at this stage, the child was his or her own ideal. As the child grew up, admonitions of others self-criticis m combined to destroy this perfect image. compens ate for this los t narciss ism or to recover it, the child “projects before him” a new ideal or ego-ideal. It at this point that F reud s ugges ted that the psychic apparatus might have still another structural special agency whos e task it was to watch over the make s ure it was measuring up to the ego-ideal. T he concept of the superego evolved from thes e of an ego-ideal and a s econd monitoring agency to its preservation. Again in 1917, in Mourning and Me lancholia, F reud of “one part of the ego” that “judges it critically and, as were, takes it as its object.” He s uggested that this which is s plit off from the res t of the ego, was what is commonly called cons cie nce . He further s tated that this self-evaluating agency could act independently, could become “diseased” on its own account, and s hould be regarded as a major institution of the self. In 1921, referred to this self-critical agency as the ego-ide al and held it res ponsible for the s ens e of guilt and for the reproaches typical in melancholia and depres sion. At point, he had dropped his earlier distinction between ego-ideal, or ideal s elf, and a s elf-critical agency, or cons cience. 541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 119 of 238

In 1923, however, in T he E go and the Id, F reud's the superego again included both these functions—that the s uperego repres ented the ego-ideal as well as cons cience. He als o demonstrated that operations of superego were mainly uncons cious . T hus, patients were dominated by a deep sense of guilt lacerated thems elves far more hars hly on an unconscious level they did conscious ly. T he fact that guilt engendered by superego might be eas ed by suffering or punishment apparent in the case of neurotics who demonstrated an unconscious need for punis hment. In later works, elaborated on the relations hip between ego and superego. G uilt feelings were ascribed to tens ion these two agencies , and the need for punis hment was expres sion of this tens ion.

OR IG INS OF THE S UPE R E G O In F reud's view, the s uperego comes into being with res olution of the Oedipus complex. During the oedipal period, the little boy wishes to poss es s his mother, and little girl wis hes to pos ses s her father. E ach must, contend with a substantial rival, the parent of the same sex. T he frustration of the child's pos itive oedipal this parent evokes intense hostility, which finds not only in overt antagonistic behavior but also in thoughts of killing the parent who stands in the way with any brothers or sisters who may also compete for love of the desired parent. Quite unders tandably, this hos tility on the part of the is unacceptable to parents and, in fact, eventually unacceptable to the child as well. In addition, the boy's sexual explorations and masturbatory activities may 542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 120 of 238

thems elves meet with parental disfavor, which may be unders cored by real or implied threats of castration. T hese threats and, above all, the boy's obs ervations women and girls lack a penis convince him of the castration. C onsequently, he turns away from the situation and its emotional involvements and enters the latency period of ps ychosexual development. He renounces the sexual express ions of the infantile G irls , when they become aware of the fact that they penis (in F reud's terms , they have “come off badly”), to redeem the los s by obtaining a penis or a baby from father. F reud pointed out that, although the anxiety surrounding castration brings the Oedipus complex to end in boys, in girls it is the major precipitating factor. renounce their oedipal s trivings, first, because they fear the loss of the mother's love and, second, because of disappointment over the father's failure to gratify their wis h. T he latency phas e, however, is not s o well girls as it is in boys , and their pers istent interest in relations is expres sed in their play; throughout grade school, for example, girls “act out” the roles of wife and mother in games that boys s crupulous ly avoid. T his the bas ic outline of F reud's theory of the superego.

E VOL UTION OF THE S UPE R E G O What, indeed, is the fate of the object attachments up with res olution of the Oedipus complex? F reud's formulation of the mechanis m of introjection came into play here. During the oral phase, the child is entirely dependent on the parents. Advancing beyond this the child must abandon these earlies t s ymbiotic ties the parents and form initial introjections of them, which, 543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 121 of 238

however, follow the anaclitic model—that is , they are characterized by dependence on the parents . T hus, diss olution of the Oedipus complex and the abandonment of object ties led to rapid acceleration of introjection process . T hese introjections from both parents became united formed a kind of precipitate within the self, which then confronted other contents of the ps yche as the T his identification with the parents was based on the child's s truggles to repres s ins tinctual aims that were directed toward them, and it was this effort of that gave the s uperego its prohibiting character. It is for this reas on, too, that the s uperego res ults, to such a extent, from introjection of the parents' own s uperegos. Y et, becaus e the s uperego evolved as a result of of ins tinctual desires, it had a clos er relation to the id did the ego itself. Its origins were more internal; the originated to a greater extent in relation to the external world and was its internal repres entative. F inally, throughout the latency period and thereafter, child (and later the adult) continues to build on these identifications through contact with teachers , heroic figures , and admired people, who form the s ources of child's moral standards, values , and ultimate and ideals. T he child moves into the latency period endowed with a superego that is, as F reud put it, “the to the Oedipus complex.” Its structures at firs t might be compared to the imperative nature of demands of the before it developed. T he child's conflicts with the continue, of cours e, but now they are largely internal, between his or her own ego and superego. In other the s tandards , res trictions , commands, and 544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 122 of 238

impos ed previously by the parents from without are internalized in the child's s uperego, which now judges guides behavior from within, even in the abs ence of the parents .

C UR R E NT INVE S TIGATIONS OF THE S UPE R E GO E xploration of the s uperego and its functions did not with F reud, and such s tudies remain of current active interes t. R ecent interes t has focus ed on the between superego and ego-ideal, a distinction that periodically revived and abandoned. At pres ent, the s upe re go refers primarily to a self-critical, prohibiting agency bearing a close relationship to aggres sion and aggres sive identifications . T he ego-ideal, however, is a kinder function, bas ed on a transformation of the abandoned perfect state of narcis sism, or s elf-love, exis ted in early childhood and has been integrated with positive elements P.725 of identifications with the parents . In addition, the of an ideal object—that is , the idealized object choice— has been advanced as dis tinct from the ideal self. theoris ts regard the ego-ideal as an aspect of s uperego organization derived from good parental imagoes . A s econd focus of recent interes t has been the contribution of the drives and object attachments in the pre-oedipal period to the development of the superego. T hes e pregenital (es pecially anal) the superego are generally believed to provide s ome of the very rigid, strict, and aggres sive qualities of the 545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 123 of 238

superego. T hes e qualities s tem from projection of the child's own sadis tic drives and primitive concept of based on retaliation, which is attributed to the parents during this period. T he hars h emphasis on absolute cleanliness and propriety that is sometimes found in rigid individuals and in obsess ional neurotics is based some extent on this s phincter morality of the anal One result of these developments is that the between oedipal dynamics and s uperego development have been s ignificantly diluted in the s ense that preoedipal s uperego precurs ors and pre-oedipal s uperego functions are better unders tood on one hand, and postoedipal adaptive integrations, especially with ego functions , on the other hand, have modified the unders tanding of s uperego functions .

P S YC HIC DE VE L OP ME NT— INTE G R A TION OF P HA S E S A ND OB J E C T As his clinical experience increased, F reud was able to recons truct to a certain degree the early s exual experiences and fantasies of his patients . T hese data provided the framework for a developmental theory of childhood s exuality, which, in the subs equent cours e of ps ychoanalytic developmental exploration based on observation of childhood behavior, has been widely corroborated, accepted, and elaborated by theoris ts . T hese views have been s ubjected to cons iderable revis ion and development, as well as and rejection, in ens uing years . P erhaps an even more important source of information that contributed to F reud's thinking about infantile s exuality was his own analysis, begun in 1897. He was gradually able to 546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 124 of 238

memories of his own erotic longings in childhood and conflicts in relations hip to his parents, related to his oedipal involvement. R ealization of the operation such infantile s exual longings in his own experience suggested to F reud that these phenomena might not res tricted only to the pathological development of neuros es, but that es sentially normal individuals might undergo similar developmental experiences. T he progres sive integration of psychos exual developments and object relations has been further elaborated in phases of instinctual development, Margaret Mahler's separation-individuation process , and E rik E rikson's epigenetic s equence.

Phas es of Ps yc hos exual T he earlies t manifes tations of infantile s exuality aros e relation to bodily functions that were bas ically such as feeding and development of bowel and bladder control. T herefore, F reud divided these stages of ps ychos exual development into a s ucces sion of developmental phas es, each of which was believed to build on and s ubsume accomplis hments of the phases —namely, the oral, anal, and phallic phases . oral phase occupied the first 12 to 18 months of the infant's life; next, the anal phas e, until approximately 3 years of age; and, finally, the phallic phase, from approximately 3 to 5 years of age. F reud postulated that, in boys , phallic erotic activity es sentially a preliminary stage for adult genital activity. contrast to the male, whos e principal s exual organ remained the penis throughout the course of ps ychos exual development, the female had two 547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 125 of 238

erotogenic zones , the clitoris and the vagina. F reud believed that the clitoris was preeminent during the infantile genital period but that erotic primacy after puberty was transpos ed to the vagina. R ecent sexual inves tigations have cas t some doubt on a s upposed transition from clitoral to vaginal primacy, but many analysts retain this view on the basis of their clinical experience. T he ques tion for the time being remains unresolved. F reud's basic s chema of the psychosexual s tages was modified and refined by K arl Abraham, who further subdivided the phas es of libido development, dividing oral period into a s ucking and biting phas e and the anal phase into a des tructive-expulsive (anal sadis tic) and a mastering-retaining (anal erotic) phase. F inally, he hypothes ized that the phallic period cons is ted of an phase of partial genital love, which was designated as true phallic phas e, and a later, more mature genital F or each of the stages of psychosexual development, F reud delineated s pecific erotogenic zones that gave to erotic gratification. T able 6.1-3 provides an overview current, more or les s tentative, views on ps ychosexual development.

Table 6.1-3 S tages of Development Oral S tage 548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 126 of 238

Definition

E arlies t s tage of development in which the infant's needs , perceptions, and modes of expres sion are primarily centered mouth, lips, tongue, and other organs related to the oral zone.

Des cription

Oral zone maintains dominance in ps ychic organization through approximately the first 18 mos of Oral s ensations include thirs t, hunger, pleasurable tactile stimulations evoked by the nipple its s ubs titute, and s ensations to swallowing and s atiation. Oral drives cons is t of two components: libidinal and aggres sive. S tates of oral tension lead to s eeking for gratification, as in quiescence at of nurs ing. Oral triad cons is ts of to eat, sleep, and reach that relaxation that occurs at the end of sucking jus t before ons et of s leep. Libidinal needs (oral erotis m) predominate in early oral phase, whereas they are mixed with more aggres sive components later (oral sadis m). Oral aggres sion biting, chewing, s pitting, or crying. Oral aggres sion connected with

549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 127 of 238

primitive wis hes and fantas ies of biting, devouring, and destroying. Objectives

E stablish a trusting dependence nursing and s ustaining objects , es tablis h comfortable express ion and gratification of oral libidinal needs without excess ive conflict or ambivalence from oral s adistic wis hes .

P athological traits

E xces sive oral gratifications or deprivation can res ult in libidinal fixations contributing to traits. S uch traits can include excess ive optimism, narciss ism, pess imism (as in depres sive or demandingness . E nvy and jealousy often as sociated with oral traits.

C haracter traits

S uccess ful resolution of oral phas e res ults in capacities to give to and receive from others without excess ive dependence or envy, capacity to rely on others with a sens e of trus t as well as with a of self-reliance and self-trus t. Oral characters are often excess ively dependent and require others to

550 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 128 of 238

give to them and look after them are often extremely dependent on others for maintaining self-es teem.

Anal S tage Definition

S tage of ps ychos exual prompted by maturation of neuromuscular control over sphincters, particularly anal sphincters, permitting more voluntary control over retention or expulsion of feces .

Des cription

P eriod extends roughly from 1–3 of age, marked by recognizable intens ification of aggress ive drives mixed with libidinal components in sadis tic impulses. Acquisition of voluntary s phincter control as sociated with increas ing shift pass ivity to activity. C onflicts over anal control and s truggles with parents over retaining or expelling feces in toilet training give rise to increased ambivalence together struggle over separation, individuation, and independence. 551

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 129 of 238

Anal e rotis m refers to s exual in anal functioning, both in precious feces and presenting as a precious gift to the parent. s adis m refers to express ion of aggres sive wishes connected with discharging feces as powerful and destructive weapons. T hes e often displayed in fantasies of bombing or explosions . Objectives

Anal period is marked by striving independence and s eparation from dependence on and control of parents . Objectives of sphincter control without overcontrol (fecal retention) or los s of control (mess ing) are matched by to achieve autonomy and independence without excess ive shame or self-doubt from los s of control.

P athological traits

Maladaptive character traits , often apparently inconsistent, derive anal erotis m and defenses against Orderliness , obs tinacy, willfulnes s, frugality, and are features of anal character. defens es agains t anal traits are

552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 130 of 238

effective, anal character reveals of heightened ambivalence, lack of tidiness , mess iness , defiance, and s adomas ochis tic tendencies. Anal characteristics and defens es typically s een in obs es sivecompuls ive neuros es. C haracter traits

S uccess ful resolution of anal provides bas is for development of personal autonomy, a capacity for independence and personal without guilt, a capacity for s elfdetermining behavior without a sens e of shame or s elf-doubt, a of ambivalence and a capacity for willing cooperation without either excess ive willfulnes s or selfdiminution or defeat.

Urethral S tage Definition

T his s tage not explicitly treated by S igmund F reud but s erves as transitional s tage between anal phallic stages . It s hares s ome characteristics of anal phase and some from subs equent phallic 553

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 131 of 238

Des cription

C haracteris tics of the urethral often s ubs umed under phallic Urethral e rotis m, however, refers pleas ure in urination as well as pleas ure in urethral retention analogous to anal retention. is sues of performance and control are related to urethral functioning. Urethral functioning may als o have sadis tic quality, often reflecting persis tence of anal s adistic urges . Loss of urethral control, as in enures is , may frequently have regress ive s ignificance that reactivates anal conflicts.

Objectives

Is sues of control and urethral performance and loss of control. clear whether or to what extent objectives of urethral functioning differ from thos e of anal period.

P athological traits

P redominant urethral trait is competitivenes s and ambition, probably related to compens ation for shame due to loss of urethral control. T his may be start for development of penis envy, related to feminine s ens e of shame and inadequacy in being unable to

554 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 132 of 238

male urethral performance. Als o related to iss ues of control and shaming. C haracter traits

B es ides healthy effects analogous those from anal period, urethral competence provides s ens e of and s elf-competence bas ed on performance. Urethral is area in which s mall boy can and try to match his father's more adult performance. R esolution of urethral conflicts s ets stage for budding gender identity and subs equent identifications .

Phallic S tage Definition

P hallic s tage begins s ometime during 3rd yr and continues until approximately end of 5th yr.

Des cription

P hallic phas e characterized by primary focus of s exual interests, stimulation, and excitement in genital area. P enis becomes organ principal interes t to children of both sexes, with lack of penis in 555

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 133 of 238

being considered as evidence of castration. P hallic phas e with increase in genital accompanied by predominantly unconscious fantas ies of sexual involvement with opposite-sex parent. T hreat of cas tration and related anxiety connected with over mas turbation and oedipal wis hes . During this phase, oedipal involvement and conflict are es tablis hed and consolidated. Objectives

T o focus erotic interest in genital area and genital functions . T his foundation for gender identity and serves to integrate residues of previous stages into predominantly genital-sexual orientation. E stablishing oedipal s ituation es sential for furtherance of subs equent identifications s erving basis for important and enduring dimensions of character organization.

P athological traits

Derivation of pathological traits phallic-oedipal involvement are sufficiently complex and subject to such a variety of modifications so

556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 134 of 238

that it encompas ses nearly the of neurotic development. Iss ues, however, focus on cas tration in males and penis envy in females . P atterns of identification from res olution of oedipal complex provide another important focus of developmental distortions . of castration anxiety and penis defens es agains t them, and of identification are primary determinants of the development human character. T hey also and integrate res idues of previous ps ychos exual stages so that or conflicts deriving from preceding stages can contaminate and oedipal resolution. C haracter traits

P hallic s tage provides foundations for emerging s ens e of sexual of a s ens e of curios ity without embarrass ment, of initiative guilt, as well as a s ens e of mastery not only over objects and people in environment but also over internal proces ses and impuls es. of the oedipal conflict gives rise to internal s tructural capacities for regulation of drive impulses and

557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 135 of 238

their direction to constructive ends . T his internal s ource of regulation is the superego, bas ed on identifications derived primarily parental figures.

Latency S tage Definition

S tage of ins tinctual relative quies cence or inactivity of s exual drive during period from res olution of the Oedipus complex until pubes cence (from approximately yrs of age until approximately 11– yrs of age).

Des cription

Ins titution of superego at close of oedipal period and further maturation of ego functions allow cons iderably greater degree of control of ins tinctual impuls es. S exual interes ts generally believed be quiescent. P eriod of primarily homos exual affiliations for both and girls as well as a sublimation libidinal and aggres sive energies energetic learning and play exploring environment, and 558

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 136 of 238

becoming more proficient in with world of things and people around them. P eriod for development of important skills. R elative s trength of regulatory elements often gives rise to of behavior that are somewhat obses sive and hypercontrolling. Objectives

P rimary objective is further integration of oedipal and cons olidation of sex-role and s ex roles . R elative quies cence and control of ins tinctual impuls es allow for development of ego apparatuses and mas tery of s kills . F urther identificatory components may be added to the oedipal ones basis of broadening contacts with other s ignificant figures outside family (e.g., teachers , coaches , other adult figures ).

P athological traits

Danger in latency period can aris e either from lack of development of inner controls or excess of them. Lack of control can lead to inability to sufficiently sublimate energies in interes t of learning and of skills; exces s of inner control,

559 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 137 of 238

however, can lead to premature clos ure of personality development and precocious elaboration of obses sive character traits . C haracter traits

Latency period frequently regarded as period of relatively unimportant inactivity in the developmental schema. More recently, greater res pect has been gained for developmental process es in this period. Important cons olidations additions are made to basic postoedipal identifications and to proces ses of integrating and cons olidating previous attainments in ps ychos exual development and es tablis hing decis ive patterns of adaptive functioning. T he child can develop a sense of industry and capacity for mastery of objects and concepts that allows autonomous function and a sense of initiative without risk of failure or defeat or a sens e of inferiority. T hes e are all important attainments that need to be further integrated, ultimately as the es sential basis for a mature life of satis faction in work and love.

560 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 138 of 238

Genital S tage Definition

G enital or adoles cent phas e from onset of puberty from 11–13 of age until young adulthood. C urrent thinking tends to s ubdivide this s tage into preadoles cent, early adoles cent, middle adoles cent, adoles cent, and even periods.

Des cription

P hysiological maturation of of genital (s exual) functioning and attendant hormonal systems leads intens ification of drives, particularly libidinal drives . T his produces a regress ion in pers onality organization, which reopens of previous s tages of development and provides opportunity for reres olution of conflicts in context of achieving a mature sexual and adult identity. Often referred to as a s e cond individuation.

Objectives

P rimary objectives are ultimate separation from dependence on attachment to parents and es tablis hment of mature, 561

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 139 of 238

noninces tuous, heterosexual relations . R elated are achievement mature sense of personal identity and acceptance and integration of adult roles and functions that new adaptive integrations with expectations and cultural values . P athological traits

P athological deviations due to inability to achieve s ucces sful res olution of this s tage of development are multiple and complex. Defects can arise from whole s pectrum of psychosexual res idues becaus e developmental tas k of adolescence is in a s ense a partial reopening and reworking reintegrating of all of thes e as pects of development. P revious unsuccess ful resolutions and fixations in various phas es or of psychosexual development produce pathological defects in the emerging adult personality.

C haracter traits

S uccess ful resolution and reintegration of previous ps ychos exual stages in adoles cent genital phas e set s tage normally fully mature pers onality with

562 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 140 of 238

capacity for full and satis fying potency and a self-integrated and cons istent s ense of identity. T his provides bas is for capacity for s elfrealization and meaningful participation in areas of work, love, and in creative and productive application to s atis fying and meaningful goals and values.

Development and Objec t R elations C urrent theories in ps ychoanalytic psychiatry have increasingly on the importance for later of early disturbances in object relationships —that is , a disturbance in the relations hip between the child's and the significant objects in the environment, the mothering object. F rom the very beginning of the child's development, F reud regarded the s exual instinct “anaclitic” in the sense that the child's attachment to feeding and mothering figure was based on the child's utter phys iological dependence on the object. T his view the child's earliest attachment s eems consis tent with F reud's understanding of infantile libido developed on basis of his insight, acquired early in his clinical that s exual fantasies of even adult patients typically centered on early relationships with their parents . In event, throughout his descriptions of libidinal phases of development, F reud made constant reference to the significance of children's relationships with crucial 563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 141 of 238

in their environment. S pecifically, he pos tulated that the choice of a love object in adult life, the love relationship its elf, and object relations hips in other s pheres of and activity depend largely on the nature and quality of the child's object relations hips during the earliest years life.

Objec t R elations during P regenital P has es At birth, the infant's respons es to external stimulation relatively diffus e and dis organized. E ven so, as recent experimental res earch on neonates has indicated, the infant is quite responsive to external stimulation, and patterns of res pons e are quite complex and relatively organized, even s hortly after birth. E ven neonates of a hours of age respond s electively to novel s timuli and demonstrate remarkable preferences for complex, as compared with simple, patterns of s timulation. T he res ponses to noxious and pleas urable stimuli are also relatively undifferentiated. E ven so, sensations of cold, and pain give ris e to tens ion and a corresponding need to seek relief from painful s timuli. At the life, however, the infant does not res pond s pecifically to objects as objects . A certain degree of development of perceptual and cognitive apparatus es is required, as as a greater degree of differentiation of s ens ory P.726 P.727 impres sions and integration of cognitive patterns, babies are able to differentiate between impres sions 564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 142 of 238

belonging to thems elves and thos e derived from objects. C ons equently, observations and inferences on data derived from the first 6 months of life mus t be interpreted in the context of the child's cognitive functioning before self–object differentiation. In thes e first months of life, human infants are cons iderably more helpless than any other young mammals . T heir helples snes s continues for a longer than in any other s pecies. T hey cannot survive unless are cared for, and they cannot achieve relief from the painful disequilibrium of inner phys iological states help of external caretaking objects . Object relations hips the most primitive kind only begin to be established an P.728 infant firs t begins to gras p this fact of experience. In the beginning, an infant cannot dis tinguis h between its own lips and its mother's breas ts, nor does an infant initially as sociate s atiation of painful hunger pangs with presentation of the extrins ic breast. B ecaus e the infant aware only of its own inner tension and relaxation and unaware of the external object, longing for the object exis ts only to the degree that the disturbing s timuli and longing for satiation remains unsatis fied in the absence of the object. W hen the s atisfying object appears , and the infant's needs are gratified, longing disappears. G radually, but als o rather quickly, the becomes aware of the mother herself, in addition to her breast, as a need-satis fying object.

OR AL PHAS E AND OB J E C TS 565 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 143 of 238

T his experience of unsatis fied need, together with the experience of frus tration in the absence of the breas t need-satis fying release of tension in the presence of breast, forms the bas is of the infant's firs t awarenes s of external objects . T his firs t awarenes s of an object, the ps ychological s ens e, comes from longing for something that is already familiar and for something actually gratified needs in the pas t but is not available in the pres ent. T hus, it is basically the infant's hunger in this view that in the beginning compels recognition of the outside world. T he first primitive reaction to objects, putting them into the mouth, then becomes unders tandable. T his reaction is consistent the modality of the infant's first recognition of reality, judging reality by oral gratification, that is, whether something will provide relaxation of inner tens ion and satis faction (and s hould thereby be incorporated, swallowed) or whether it will create inner tens ion and diss atis faction (and cons equently s hould be s pit out). E arly in this interaction, the mother s erves an important function, that of empathically res ponding to the infant's inner needs in such a manner as to become involved in proces s of mutual regulation, which maintains the homeostatic balance of the infant's physiological needs and proces ses within tolerable limits . Not only does this proces s keep the child alive, but it sets a rudimentary pattern of experience within which the child can build elements of a basic trust that promote reliance on the benevolence and availability of caretaking objects . C ons equently, the mother's administrations and res ponsiveness to the child help to lay the mos t rudimentary and es sential foundation for subsequent 566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 144 of 238

development of object relations and the capacity for entering the community of human beings. As differentiation between the limits of self and object gradually es tablis hed in the child's experience, the becomes acknowledged and recognized as the s ource gratifying nouris hment and, in addition, as s ource of erotogenic pleas ure the infant derives from sucking on breast. In this s ens e, s he becomes the first love object. quality of the child's attachment to this primary object is the utmos t importance, as developmental and theoris ts have demonstrated. F rom the oral phas e the whole progress ion in psychosexual development, its focus on success ive erotogenic zones and as sociated component ins tincts , reflects the quality of child's attachment to the crucial figures in the environment as well as the strength of feelings of love hate, or both, toward these important people. If a fundamentally warm, trusting, secure, and affectionate relations hip has been es tablis hed between mother and child during the earlies t s tages of the child's career, least theoretically, the stage is s et for development of trus ting and affectionate relationships with other human objects during the course of life.

ANAL PHAS E AND OB J E C TS During the oral s tage of development, the infant's role not altogether pas sive becaus e, caught up as it is in a proces s of mutual interaction, the infant makes its own contribution to eliciting certain res ponses from the mother. T he activity, however, is more or les s and dependent on such phys iological factors as level of activity, irritability, or res ponsivenes s to stimuli. 567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 145 of 238

speaking, however, the infant's control over the feeding res ponses is relatively limited. C ons equently, primary onus remains on the mother to gratify or the demands of the infant. In the trans ition to the anal period, however, this changes s ignificantly. T he child acquires a greater of control over behavior and particularly over sphincter function. Moreover, for the firs t time during this period, demands are placed on the child to relinquish some of freedom by reason of expectations to accede to parental demands to use the toilet for evacuation of and urine. However, the primary aim of anal eroticis m enjoyment of the pleasurable s ens ations of excretion. S omewhat later, s timulation of the anal mucos a retention of the fecal mas s may become a s ource of more intense pleasure. Nonetheles s, at this stage of development, the demand is placed on the child to regulate gratification, to surrender some portion of the gratification at the parent's wis h, or to delay according to a s chedule es tablis hed by the parent's It can be readily s een that one of the important as pects the anal period, therefore, is that it s ets the stage for a contest of wills over when, how, and on what terms the child achieves gratification.

PHAL L IC PHAS E AND OB J E C TS T he pass age from anal to phallic phas e marks not only transition from pre-oedipal to beginnings of the oedipal level of development but also marks completion of the work of s eparation individuation and, in the normal of development, achievement of object cons tancy. T he oedipal s ituation evolves during the period extending 568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 146 of 238

from the third to the fifth year in children of both s exes.

Oedipus C omplex In the normal course of development, the so-called pregenital phas es are regarded as primarily autoerotic. P rimary gratification derives from s timulation of erotogenic zones , whereas the object serves a although s econdary and ins trumental, role. A shift begins to take place in the phallic phas e in which phallus becomes the primary erotogenous zone for sexes, thus laying a foundation for and initiating a s hift libidinal motivation and intention in the direction of objects. T he phallic phas e sets the s tage for the fundamental task of finding a love object, a dynamic moves to another level of progres sion in establis hing relations of the oedipal period and beyond to more mature adult object choices and love relationships . T he phallic period is also a critical phase of development for the budding formation of the child's own sense of identity—as decis ively male or female—based on the child's discovery and realization of the significance of anatomical s exual differences . T he events as sociated the phallic phas e also set the stage for the predis pos ition to later psychoneuroses. F reud used the term O e dipus complex to refer to the intense love relations hips , together with their as sociated rivalries, hostilities , and emerging identifications , formed during this period between the child and parents.

C as tration C omplex T here is s ome differentiation between the s exes in the pattern of development. F reud explained the nature of 569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 147 of 238

discrepancy in terms of genital differences. Under circums tances , he believed that, for boys , the oedipal situation was resolved by the castration complex. S pecifically, the boy had to give up his strivings for his mother becaus e of the threat of castration—castration anxiety. In contrast, the Oedipus complex in girls was evoked by reason of the cas tration complex, but unlike boy, the little girl was already cas trated, and as a turned to her father as bearer of the penis out of a disappointment over her own lack of a penis . T he little was thus more threatened by a los s of love than by castration fears. P.729

The B oy's S ituation In boys, development of object relations is relatively complex than for girls becaus e the boy remains to his firs t love object, the mother. T he primitive object choice of the primary love object, which develops in res ponse to the mother's gratification of the infant's needs , takes the s ame direction as the pattern of choice in res ponse to opposite-sex objects in later life experience. In the phallic period, in addition to the attachment to and interes t in the mother as a source of nouris hment, he develops a strong erotic interes t in her and a concomitant desire to pos sess her exclus ively sexually. T hes e feelings us ually become manifest at approximately 3 years of age and reach a climax at 4 years of age. With appearance of the oedipal involvement, the boy begins to show his loving attachment to his mother 570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 148 of 238

as a little lover might—wanting to touch her, trying to in bed with her, proposing marriage, expres sing wis hes replace his father, and devis ing opportunities to s ee naked or undres sed. C ompetition from s iblings for mother's affection and attention is intolerable. Above however, the little lover wants to eliminate his arch mother's husband. His wishes may involve not merely displacing or s upers eding father in mother's affection eliminating him altogether. T he child understandably anticipates retaliation for his aggress ive wis hes toward father, and thes e expectations in turn give rise to a anxiety in the form of the “castration complex.” T his s omewhat simplified picture of the res olution of Oedipus complex is cons iderably more complex in the actual cours e of development. Usually, the boy's love his mother remains a dominant force during the period infantile sexual development. It is known, however, that love is not free of some admixture of hostility and that child's relations hip with both parents is to some degree ambivalent. T he boy als o loves his father, and at times when he has been frustrated by his mother, he may her and turn from her to seek affection from his father. Undoubtedly, to some degree, he loves and hates both parents at the same time. In addition, F reud's of an es sentially bisexual basis of the nature of the complicates matters further. On the one hand, the boy wants to pos sess his mother and kill the hated father On the other hand, he als o loves his father and seeks approval and affection from him, whereas he often to his mother with hos tility, particularly when her demands on her husband interfere with the of the father–son relations hip. T he ne gative O e dipus 571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 149 of 238

complex refers to those situations in which the boy's for his father predominates over the love for the and the mother is relatively hated as a dis turbing in this relations hip.

The G irl's S ituation Understanding of the little girl's more complex oedipal involvement was a later development. B ecause it could be regarded as equivalent to the boy's development, it raised a number of questions that proved to be more difficult. F reud could not get beyond viewing female sexual development as a variant of male development. S imilar to the little boy, the little girl forms an initial attachment to the mother as a primary love object and source of fulfillment for vital needs . F or the little boy, mother remains the love object throughout his development, but the little girl is faced with the tas k of shifting this primary attachment from the mother to the father to prepare herself for her future sexual role. was bas ically concerned with elucidating the factors influenced the little girl to give up her pre-oedipal attachment to the mother and to form the normal attachment to the father. A s econdary ques tion had to with the factors that led to the diss olution and of the Oedipus complex in the girl s o that paternal attachment and maternal identification would be the for adult s exual adjus tment. T he girl's renunciation of her pre-oedipal attachment to the mother could not be satisfactorily explained as res ulting from ambivalent or aggress ive characteristics the mother–child relationship, for s imilar elements influenced the relations hip between boys and the 572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 150 of 238

figure. F reud attributed the crucial precipitating factor to anatomical differences between the s exes—specifically the girl's discovery of her lack of a penis during the period. Up to this point, exclusive of cons titutional differences and depending on variations in parental attitudes in relating to a daughter in comparis on to a the little girl's development parallels that of the little F undamental differences , however, emerge when s he discovers during the phallic period that her clitoris is inferior to the male counterpart, the penis . T he typical reaction of the little girl to this dis covery is an intens e sens e of los s, narcis sis tic injury, and envy of the male At this point, the little girl's attitude to the mother changes. T he mother had previous ly been the object of love, but now s he is held res ponsible for bringing the girl into the world with inferior genital equipment. T he hostility can be s o intens e that it may persist and color future relations hip to the mother. W ith the further discovery that the mother also lacks the vital penis, the child's hatred and devaluation of the mother becomes even more profound. In a desperate attempt to compens ate for her “inadequacy,” the little girl then to her father in the vain hope that he will give her a or a baby in place of the mis sing penis . Obvious ly, the F reudian model of feminine development has undergone, and is currently cons iderable revis ion. T he charge has been made, and justifiably so, that masculine phallic-oedipal was the primary model in F reud's thinking and that feminine development was viewed as defective by comparis on. F reud saw women as basically weak, dependent, and lacking in conviction, s trength of 573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 151 of 238

character, and moral fiber. He believed thes e defects the res ult of failure in the oedipal identification with the phallic father because of female castration. T he internalization of aggres sion was both cons titutionally determined and culturally reinforced. T hese concepts must now be regarded as obs olete. hypothes es of a pass ive female libido, arrest in ego development, incapacity for s ublimation, and s uperego deficiencies in women are outdated and inadequate. Differences in male and female ego and s uperego development may be defined, but there are no grounds for judging one to be s uperior or inferior to the other. are simply different. As Harold B lum obs erved: development cannot be des cribed in a s imple reductionism and overgeneralization. F emininity cannot be predominantly derived from a primary masculinity, disappointed maleness , masochistic resignation to fantas ied inferiority, or compens ation for fantas ied castration and narcis sistic injury. C astration reactions penis envy contribute to feminine character, but penis envy is not the major determinant of femininity.” T he adequate conceptualization and unders tanding of feminine ps ychology and its development are still very much in process . T here is much that is poorly and much more that is hardly unders tood at all. C urrent res earch has given partial s upport to and convincing refutation of F reud's ideas. C urrent views emphasize role of primary femininity and conflicts in identification with the mother as determining the course of development of feminine gender identity rather than the outmoded views of castration anxiety and penis envy. It clear in all this that F reud was s imply wrong about 574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 152 of 238

this whole area, but much of what he des cribed may simply expres sed what he was able to observe in the women of his time and reflected the influence of toward women in his society and culture. T imes however, and the culture and the place of women in it have changed and are changing. T o that extent, are different, and much of their ps ychology is different, too. P s ychoanalytic unders tanding must inevitably lag behind these changing patterns of ps ychological experience, but a new view of feminine development functioning is gradually emerging.

Mahler's S eparation–Individuation Proc es s A utis tic P has e Mahler has conceptualized the proces s of development terms of phas es of s eparation and individuation. T he phase of development s he describes is the autis tic P.730 “During the first few weeks of extrauterine life, a s tage absolute primary narcis sism, marked by the infant's awarenes s of a mothering agent, prevails. T his is the we have termed normal autism. It is followed by a dim awareness that need s atis faction cannot be by oneself, but comes from somewhere outside the T he tas k of the autis tic phas e is the achievement of homeostatic equilibrium of the organis m within the new extramural environment, by predominantly phys iological mechanisms.” T o the external obs erver, newborn infants s eem to 575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 153 of 238

to their mothers in a condition of unique dependence res ponsiveness . T his relations hip is , however, at leas t first, purely biological bas ed on phys iological reflexes ordered to the fulfillment of basic biological needs. It is only as babies ' egos begin to develop, along with the organization of perceptual capacities and memory which allow for the initial differentiation of self and that infants can be s aid to experience s omething of themselves, to which they can relate, as satis fying inner needs. T his dawning awareness of the external object is a mos t s ignificant s tate in the psychological development of children and involves not only cognitive and perceptual developments but also goes hand in with the organization of rudimentary infantile drives and affects in relation to emerging object experiences . T he emergence of the psychological need-satis fying relations hip to the object or part-object occurs during oral phase of libidinal development. It should be noted, however, that the notion of the oral phas e of and the concepts of need-satis fying relationships are equivalent. T he oral phas e is primarily concerned with libidinal development and stress es predominance of oral zone as the main erotogenic zone. T he concept of need-satis fying relationship, however, is not concerned directly with iss ues of drive development but, rather, the characteristics of object involvement and object relations hip.

S ymbiotic P has e T his awareness signals the beginning of normal “in which the infant behaves and functions as though and his mother were an omnipotent s ys tem—a dual 576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 154 of 238

within one common boundary.” T he symbiotic phas e is described as a “hallucinatory or delusional omnipotent fusion with the representation of the mother and, in particular, the delusion of a common boundary between two phys ically s eparate individuals.” T hese boundaries become temporarily differentiated only in state of “affect hunger” but disappear again as a result need gratification. Only gradually does the child form more s table part-images of the mother such as breas ts, face, or hands . C ons equently, the object is recognized separate from the s elf only at moments of need so that, once the need is satis fied, the object ceases to exis t— the infant's (s ubjective) point of view—until a need arises . Moreover, from the infant's perspective, the relations hip is not to a specific object (or part-object) rather to a function of the object s atisfying the need the pleas ure accompanying that function. It is only the specific object—that is , the whole object—becomes important to the child as the need-satis fying function it performs that one can regard the child's development moving beyond the level of need-satis fying toward the attainment of object constancy. T hus, it is useful to distinguish between need as a s tage of development in object relations hips , to but not s ynonymous with the oral phas e of libidinal development, and need s atisfaction as a determinant in object relations hips at every level of development. T he satis faction of various kinds of psychological needs continues to play a role at all levels of object but the satis faction of s uch needs cannot be used as a distinguishing characteris tic of the specific stage of satis fying object relations hips. As objects become 577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 155 of 238

increasingly differentiated in the child's experience, representations achieve increasing ps ychological complexity and value in a context of increasingly and s ubtle needs for a variety of input from objects. Development of object constancy implies a constant relations hip to a specific object, but within that relations hip, the wish for s atis faction of needs and the actual s atis faction of thos e needs may still be a component of the object relationship.

S eparation and Individuation HATC HING During this period, the child with effort gradually differentiates out of the symbiotic matrix. T he first behavioral s igns of such differentiation s eem to aris e at approximately 4 or 5 months of age at the high point of the s ymbiotic period. T he firs t stage of this proces s of differentiation is described as “hatching” from the symbiotic orbit: In other words , the infant's attention, which during the months of symbios is was in large part inwardly focus ed in a coenesthetic vague way within the orbit, gradually expands through the coming into being outwardly directed perceptual activity during the child's increasing periods of wakefulnes s. T his is a change of degree rather than of kind, for during the s ymbiotic the child has certainly been highly attentive to the mothering figure. B ut gradually that attention is with a growing s tore of memories of mother's comings and goings, of “good” and “bad” experiences ; the latter were altogether unrelievable by the self, but could be 578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 156 of 238

“confidently expected” to be relieved by mother's minis trations.

PR AC TIC ING As the child's differentiation and separation from the mother gradually increase, there is a move to the or “practicing” subphase of s eparation–individuation. practicing period can be us efully divided into an early practicing period and a practicing period proper. T he practicing phas e begins with the infant's earlies t ability move physically away from the mother by locomotion, that is , crawling, creeping, climbing, and ass uming an upright sitting position. Moving away from the s afe protective orbit of the mother has its risks and uncertainties , however. In the early practicing phas e, is frequently a pattern of vis ually “checking back to mother” or even crawling or paddling back to her to or hold on as a form of “emotional refueling.” T he practicing period proper is characterized by the attainment of free upright locomotion. It is marked by three interrelated developments that contribute to the continuing process of s eparation and individuation. are (1) rapid bodily differentiation from the mother, (2) es tablis hment of a s pecific bond with her, and (3) and functioning of autonomous ego-apparatuses in connection and dependence on the mothering figure.

R APPR OC HE ME NT As this testing of the freedom of individuation by approximately the middle of the s econd year of life, child enters the third s ubphas e of rapprochement: He now becomes more and more aware, and makes 579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 157 of 238

greater and greater us e, of his physical separatenes s. However, s ide by side with the growth of his cognitive faculties and the increasing differentiation of his life, there is als o a noticeable waning of his previous imperviousness to frus tration, as well as a diminution of what has been a relative obliviousness to his mother's presence. Increas ed separation anxiety can be first this cons is ts mainly of fear of object loss , which is be inferred from many of the child's P.731 behaviors . T he relative lack of concern about the presence that was characteris tic of the practicing subphase is now replaced by s eemingly constant with the mother's whereabouts, as well as by active approach behavior. As the toddler's awareness of separateness grows —stimulated by his maturationally acquired ability to move away phys ically from his and by his cognitive growth—he seems to have an increased need, a wish for mother to share with him one of his new skills and experiences , as well as a need for the object's love. T he crisis in the rapprochement phase is particularly of s eparation anxiety. T he child's wishes and des ires to separate, autonomous , and omnipotent are tempered an increas ing awarenes s of the need for and on the mother. Ambivalence is characteris tic of the phase of the rapprochement subphase. T here is a between the child's need to use the mother as a extension, as having her magically fulfill wis hes , and realization that, with the child's increas ing the mother becomes less available and more distant. 580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 158 of 238

the mother's availability and the reass urance of her continuing love and support become all the more important.

OB J E C T C ONS TANC Y As developments of the rapprochement phase are gradually realized, the child enters the fourth and final phase of s eparation and individuation, namely, the of consolidation of individuality and the beginnings of emotional object cons tancy. At this s tage, there are significant developments in the s tructuralization and integration of the ego as well as definite signs of internalization of parental demands reflecting the development of s uperego precursors . Attainment of object cons tancy marks a transition from the stage of need-satis fying relationships to a more ps ychological involvement with objects . Object implies a capacity to differentiate between objects and maintain a meaningful relations hip with one specific object regardless of whether needs are being satis fied. S uch object cons tancy als o implies s tability of object cathexis and, s pecifically, the capacity to maintain emotional attachments to a particular object in the face frus tration of needs and wis hes in regard to that object. T his achievement als o implies the capacity to tolerate ambivalent feelings toward the object and the capacity value that object for qualities that it pos ses ses over beyond the functions that it may s erve in satis fying and in gratifying drives . T o summarize, it can be said that the notion of object cons tancy implies involvement of a number of s pecific elements that are central to further emergence of the 581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 159 of 238

meaningful capacity for relationships with objects. elements include perceptual object cons tancy; the capacity to maintain drive attachment to a s pecific regardless of whether it is pres ent; the capacity to both loving and hostile feelings toward the s ame object to maintain a loving relationship with the object in the face of hostile and destructive impuls es ; the capacity to maintain significant emotional attachment to a s ingle specific object; and, finally, the capacity to value the for qualities and attributes that it pos ses ses in itself, in virtue of its own uniqueness as individually and exis ting, and as independent of any need-satis fying function it may serve.

E riks on's E pigenetic S equenc e: Ins tinc tual Zones and Modes of E go Development E rikson made a major contribution to the concept of development in his study of the relations hip between ins tinctual zones and the development of modalities of ego functioning. E rikson's theory links as pects of ego development with the epigenetic timetable of instinctual ps ychos exual development by postulating a parallel relations hip between specific of ego or ps ychos ocial development and specific libidinal development. During libidinal development, particular erotogenic zones become loci of stimulation development of particular modalities of ego functioning. T he relationship between zones of ins tinctual and their corres ponding modalities of ego functioning is easily s pecifiable in pregenital levels of development, E rikson projects this basic modality of relationship, 582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 160 of 238

extending it to the limits of the life cycle. T he firs t modality of development is related to the oral phase, s pecifically to s timulus qualities of the oral T his early s tage is called the oral-re s piratory-s e ns ory and it is dominated by the firs t oral-incorporative mode, which involves the modality of “taking in.” Other modes are als o operative, including a second oralincorporative (biting) mode, an oral-retentive mode, an oral-eliminative mode, and, finally, an oral-intrus ive T hese modes become variably important according to individual temperament but remain subordinated to the first incorporative mode unless the mutual regulation of the oral zone with the providing breast of the mother is disturbed, either by a los s of inner control in the infant defect in reciprocal and res pons ive nurturing behavior the part of the mother. T he emphas is in this stage of development is placed on the modalities of “getting” “getting what is given,” thus laying the necess ary ego groundwork for eventually “getting to be a giver.” T he second s tage, also focus ed on the oral zone, is marked biting modality becaus e of the development of teeth. phase is marked by development of interpersonal patterns, centered in the s ocial modality of “taking” and “holding” onto things. S imilarly, with the advent of the anal-urethral-muscular stage, the “retentive” and “eliminative” modes become es tablis hed. E xtens ion and generalization of these over the whole of the developing mus cular s ys tem the 18- to 24-month-old child to gain some form of selfcontrol in the matter of conflicting impulses s uch as “letting go” and “holding on.” When this control is disturbed by developmental defects in the anal-urethral 583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 161 of 238

sphere, a fixation on modalities of retention or can be es tablis hed that can lead to a variety of disturbances in the zone itself (s pas tic), in the muscle system (flabbiness or rigidity), in obses sional fantas y (paranoid fears ), and in s ocial spheres (attempts at controlling the environment by compulsive E rikson laid out a program of ego development that reached from birth to death: T he individual pass es the phases of the life cycle by meeting and resolving a series of developmental ps ychos ocial crises . T hese phases of the life cycle and their respective accomplis h s everal things. F irs t, they make it clear that development is open ended and never finished. T he capacity to success fully resolve any one crisis depends on the degree of resolution of the preceding cris es. One can form a mature and integral sens e of identity only to the extent that one has meaningful s ens e of trus t, autonomy, initiative, and indus try. S ucces sful resolution at any level lays the foundation for engaging in the next developmental S econd, they clarify the relation between the various phases of development and earlier phas es of libidinal development. T he latter had been the bas ic of earlier efforts of ps ychoanalysis, but E rikson's developmental s chema gave a better unders tanding of way in which earlier libidinal developmental residues carried along in the cours e of growth and were built later developmental efforts of the ego. P s ychoanalysis not previously had the conceptual tools to deal with this problem, particularly in regard to the pos tadoles cent phases of the life cycle. F inally, E rikson's treatment of crises as s pecifically ps ychos ocial brought into focus 584 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 162 of 238

fact that the development of the ego was not merely a matter of intrapsychic vicis situdes dealing with the economics of inner psychic energies. It was that, but it was also a matter of the interaction and “mutual regulation” between the developing human organis m significant people in its environment. E ven more it is a matter of mutual regulation evolving between the growing child and the culture and traditions P.732 of society. E riks on has made the s ociocultural integral part of the developmental matrix out of which personality emerges .

Trus t vers us Mis trus t T he crisis of trus t vers us mis trus t is the first crisis the infant must face. It takes place in the context the intimate relations hip between infant and mother. infant's primary orientation to reality is erotic and on the mouth. T he primary locus for s ignificant contact with reality, therefore, is oral. T he typical situation in the infant experiences oral eroticism is the feeding relations hip. Depending on the quality of experience feeding contacts , the child learns to accept what is by the warm and loving mother, to depend on that mother, and to expect that what she provides will be satis fying. T he importance of the child–mother here s hould not be underes timated. T he child's oral orientation is largely biologically determined; the mother's feeding orientation is not only a product of biological factors but als o of a complex proces s of development in which her sense of identity as a female 585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 163 of 238

and as a mother plays a vital part. Any defect in her identity, thus , has important cons equences for the of the interaction between herself and her child. S uccess ful resolution of this initial phase of interaction entails a dis pos ition to trus t others , basic trust in capacity to receive from others and to depend on them entrus t oneself), and a sense of s elf-confidence. Uns ucces sful res olution of this cris is results in the these same qualities and relative dominance of such oppos ite qualities as mis trust and lack of confidence. C ons equently, the des ignations “basic trust” and “basic mistrust” stand for a complex of personality factors characterizing s ucces sful or uns ucces sful resolution of first cris is .

A utonomy vers us S hame and S elfT he second s tage of psychosexual development is eroticism. B iologically, this stage is marked by a fuller s tool and maturation of the neuromuscular to a point sufficient to allow control of s phincter governing retention and releas e of waste materials . Likewise, the anal zone becomes a source of erotic stimulation through pleasurable sensations of retaining releas ing. P sychos ocially, this period is marked by emergence in the child of self-awarenes s as a separate independent unit. G rowing mus cular control is accompanied by increasing capacity for autonomous expres sion and s elf-regulation, which typically centers problems of s phincter control of the s o-called anal T he ego thus enters into interactions of ass ertivenes s other wills in the s ocial environment, particularly with parents . S uccess fully resolved, the cris is of autonomy 586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 164 of 238

the foundation for a mature capacity for self-as sertion self-expres sion, a capacity to res pect the autonomy of others , an ability to maintain s elf-control without los s of self-es teem, and a capacity for rewarding and effective cooperation with others . T he corres ponding defect lays the foundation of fals e autonomy that must feed on the autonomy of others by domination and excess ive demands or of an exces sive rigidity that can be in the fragile autonomy of the compuls ive (anal) personality. Inability to achieve bas ic autonomy implies the lack of s elf-es teem reflected in a sense of shame the lack of s elf-confidence implied in s elf-doubt.

Initiative vers us G uilt When the child enters the play age, the maturing reaches a developmental s tage in which the serving functions of locomotion and language are sufficiently organized to permit facile use. T he motor equipment has reached a sufficient level of to permit not merely performance of motions but a ranging experimentation in locomotion. T he child to “tes t the limits ” of this new-found capability. T he activity becomes vigorous and intrusive. A s imilar crys tallization of function occurs in the us e of language, which becomes an exciting new toy calling for experimentation and the s atis faction of curios ity. T he child's mode of activity is marked by intrus ion: intrus ion into other bodies by physical attack, into other's by activity and aggres sive talking, into s pace by locomotion, and into the unknown by active curiosity. this activity is accompanied by a growing sexual and a development of the prerequisites of s pecifically masculine or feminine initiative, which are conditioned 587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 165 of 238

development of a phallic eroticism. If the cris is of initiative is success fully resolved, positive res idues are provided for development of conscience, sens e of respons ibility and dependability, s elfand a certain independence in the mature personality. stage is therefore crucial for the formation of the based on the introjection of authoritative, and parental, prohibitions . T he uns ucces sful resolution provides the bas is for the harsh, rigid, moralistic, and punis hing s uperego that serves as the dynamic source basic s ens e of guilt.

Indus try vers us Inferiority T he period of infantile (phallic) s exuality and the period adult s exuality (puberty) are s eparated by the so-called latency period in which the child's interest is generally diverted to other matters. T he child takes a step up the level of imaginative exploration and play to a level which participation in the adult world is foreshadowed. Wes tern culture, children are sent to school, where begin to learn skills that will equip them to take their places one day in adult society. T heir interests turn to doing and making things; in general, they become involved in developing the neces sary technology for living. T hey are drawn away from home and its close as sociations and plunged into the matrix of the s chool system. T hey learn the reward s ys tems of the school society and as similate the values of application and diligence. T hey als o ass imilate the implicit cultural of work and productivity. T hey achieve a sense of the pleas ure of work, of the satisfaction of a task accomplis hed, and of the merit of pers everance in 588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 166 of 238

enterprises . In other words, normally developing add to their evolving personality a s ens e of industry. danger at this stage is that a lack of s ucces s in meeting demands of the s chool society and inability to res olve ps ychos ocial crisis produce a sense of inadequacy and inferiority.

Identity vers us Identity C onfus ion T he pass age to adolescent years is marked by an period of phys iological growth and sudden maturation genital organs . T he ps ychos exual phas e of puberty is accompanied on the psychos ocial level by a kind of organization or crys tallization of the residues of the preceding formative phas es. T he developmental preparations for participation in adult life mus t now to take a more or less definitive s hape, s o the must begin to experiment with es tablis hing a future role and function within adult s ociety. T he adolescent mus t develop a confident sense of s elf-awarenes s the ability to maintain inner samenes s and continuity on the confidence that this awareness is matched by samenes s and continuity of his or her meaning to T his particular ps ychosocial crisis is therefore vulnerable and s ens itive to s ocial and cultural T he context of the cris is is specifically interpersonal, such, its s ucces sful res olution becomes all the more tenuous and problematic. In a s pecial sense, achieving sens e of pers onal identity requires an awareness of the context of relations to reality within which the self forms and maintains its own proper identity. P.733 589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 167 of 238

Intimac y vers us Is olation T he status of adulthood is marked on the ps ychos exual level by achievement of genital maturity. On the ps ychos ocial level, this development is paralleled by es tablis hment of s ignificant interpers onal relations hips that complement the previously formed identity in the social s phere. T ypically, the emerging sexual drive on another individual of the opposite s ex as its object. elements of s exual identification, which are ess ential as pects of personal identity, are naturally expres sed as es tablis hed by the standards of inters ex behavior of the society and culture. T he intimate ass ociation of male female in a clos e interpers onal union is thus an of their own identities as well as a culturally approved institution (marriage). T his fact does not mean that the sexual act is the only path to a s ens e of intimacy. F rom point of view of pers onality development, the crucial element is the capacity to relate intimately and meaningfully with others in mutually s atis fying and productive interactions . T he pattern of s uch selfrelations depends in large meas ure on the identity one accepted as his or her own. T he inability to achieve a success ful res olution of this ps ychos ocial crisis res ults in a sense of personal T he incapacity to es tablis h warm and rewarding relations hips with others is but a reflection of the to realize a s ecure and mature s elf-acceptance. Interpersonal relations hips become strained, s tiff, or formal. E ven if a façade of pers onal warmth can be there is a rigidly maintained inner wall that is never breached, a wall defended by intellectualization, 590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 168 of 238

distancing, and s elf-absorption.

G enerativity vers us S tagnation “G enerativity” points to a primary concern with es tablis hing and guiding the s ucceeding generation (through genes and genitality). In E riks on's terms , “G enerativity, as the instinctual power behind various forms of s elfles s ‘caring,’ potentially extends to man generates and leaves behind, creates and (or helps to produce).” It mus t also be recognized, however, that other areas of altruistic effort cannot be excluded. P erhaps “productivity” or “creativity” are terms. S uch creativity can as sume a myriad of forms , on the native endowment of the person; but realized generativity is als o determined to a large extent by the identity the individual has accepted and by the extent which one is capable of interacting maturely and cooperatively with others . C onsequently, success ful res olution of this crisis depends closely on the degree succes s achieved in the res olution of the preceding of identity and intimacy. Moreover, true generativity has its goal enrichment of the lives of others ; it involves a direct concern with the welfare of others, exclusive of concern over self-interes t.

Integrity vers us Des pair Integrity marks the culmination of development of the personality in E rikson's s chema. It means acceptance oneself and all aspects of life and integration of thes e elements into a stable pattern of living. It implies the experience of and adjus tment to the trials and troubles 591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 169 of 238

life as well as to its rewards and joys. C ons equently, exis tence holds no fear; the ego has res igned its elf to acceptance of life itself and to acceptance of the end of that life in death. Integrity thus repres ents the fully developed personality in its mos t mature selfT he inability to achieve ego integration res ults often in kind of despair and an unconscious fear of death: T he life cycle, given to every human as his or her own, has been accepted. T he person who does not achieve is doomed to live in basic s elf-contempt. T he parallel lines of development and their interrelation are indicated in T able 6.1-4.

Table 6.1-4 Parallel L ines of Dev Ins tinc tual Phas es

S eparation– Individuation

Objec t R elations

Ps yc hos

Oral

Autism, symbios is

P rimary narcis sism, needsatis fying

T rus t/mi

Anal

Differentiation, practicing, rapprochement

Needsatis fying, object cons tancy

Autonom doubt

592 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 170 of 238

P hallic

Object cons tancy, Oedipal complex

Object cons tancy, ambivalence

Initiative

Latency

—

—

Indus try/

Adoles cence G enitality, secondary individuation

Object love

Identity/i confusio

Adulthood

—

Intimacy generati integrity/

Mature genitality

C urrent C ons iderations In recent years , a fres h current has entered the of analytical developmental theory. In s ome degree reacting to the work of F reud and Mahler, on the bas is observational s tudies of very young infants , the view of infant emerged as active, s urprisingly well organized at the very beginning of life, and as attuned to and interactive with the mothering figure in complicated and quite sophis ticated ways. P articular objections to approach to s eparation–individuation focus ed on her of pathological terms (autism, s ymbiosis) to des cribe developmental phas es of normal infants and the fact her extens ive observations were often too overlaid with 593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 171 of 238

metapsychological terms that obs cured the boundary between fact and theory. T he work of Daniel S tern particularly pres ented a different view of the infant and focus ed attention on other important aspects of development that had been treated only tangentially in previous studies. S tern's observations brought into clearer focus the affective and interactional matrix between mother and child and directed attention more specifically to the emergence of a s ens e of self than had previous ly been available. T o begin with, S tern's baby was calm, alert, cognitively well organized, and highly res ponsive to interactive with the mother. T he extent to which the was preadapted to s timuli from the mother and active eliciting certain res ponses from the mother, whether caretaking or affective, cast a different light on early of development. T he relation between mother and child proved to be more active and interactive than had previous ly been appreciated. Also following in the wake Heinz K ohut's s elf–selfobject views and the developments that arose from them, much of the of mother–child interaction was cast in terms of the relational and intersubjective models of relating. S tern centered his interest on study of a subjective sense of separately from s tudy of the ego, which had held stage in Mahler's view. Whether such a separate s elf is neces sary or whether the s eparation–individuation proces s and object relations theory already covered ground remain debatable ques tions. C ertainly, Mahler's concentration on the sense of identity and selfcannot be P.734 594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 172 of 238

discounted, but S tern emphas ized inters ubjective relatednes s, sugges ting “a deliberately s ought s haring experiences about events and things.” All these interactions, including the highly intimate bodily interchanges between mother and child, are steeped in affective res onances. S tern carefully traced the of a core s ens e of s elf out of increasingly complex and s elf–other experiences , es pecially with the mother, taking place within an intens ely affective ambiance leading to development of an affective core in self-experience. T his proces s leads ultimately to es tablis hing a degree of libidinal self-cons tancy sens e of self as relatively integrated and independent, relatively durable and s table, as differentiated from but involved in complex relationships , and as an active agent capable of causing effects and influencing the surrounding environment. Whether and to what extent this approach to development of the s elf and its affective resonances is contradictory to the Mahlerian s chema or is open to eventual integration remains a s ubject of debate. the at times oppos itional s tance that advocates of one the other view ass ume, the potential exists for these pers pectives in the hope of deepening the unders tanding of the complexities of human development. C ritics have pointed out that these approaches may be looking at children in different contexts of obs ervation—the S tern baby in periods of relatively calm and unconflicted interaction with the mother, Mahler's baby in contexts of greater conflict separation. It may be that the obs ervations of both 595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 173 of 238

are valid enough and need to be brought together to accomplis h a more complete view of the developing infant. C ertainly S tern's focus on the emergence of the adds a fres h direction of inquiry more congruent with evolving theoretical concepts of the self in

OB J E C T R E L A TIONS THE OR Y One of the important developments in psychoanalysis , which emerged more or less in parallel to the evolution ps ychoanalytic ego psychology, is object relations Only gradually over the years have these parallel and somewhat independent courses of theoretical development converged into complementary rather oppos itional pers pectives . T he development of class ic ps ychoanalytic theory through elaboration of a ego ps ychology has led inexorably in the direction of better understanding of the adaptive functions of the particularly the close involvement between the ego and reality in its functioning and development. One dimension of the problem of reality in ps ychoanalytic theory is the whole question of object relations . T he integration of thes e complementary currents of thinking provides a more comprehens ive basis for about the mind as it functions not only intrapsychically interpersonally in its relation to others as important sources of the s ocial environment of the human

Origins T he origins of the object relations view can bes t be from the contribution of K lein. K lein's theorizing based its elf on F reud's later instinct theory, primarily on the death ins tinct as the main theoretical prop of her 596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 174 of 238

metapsychology. W orking primarily with very young children, she des cribed instinctual dynamics in the firs t years of life. Driven by the death ins tinct, the child was compelled to rid him- or hers elf of intolerable, impulses (predominantly oral) and to project them externally. T he earliest recipient of thes e projected impulses was the mother's breast, which provided satis fying nourishment and satiation (good breas t) but often deprived and did not s atis fy (bad breast). At this stage, the images of the breast are part-objects that infant had yet to combine into a single whole object, mother. E arly frustration of oral needs, even in the firs t of life, reinforced these trends s o that the bad breas t became a pers ecutory object that was hated, feared, envied. E xperience of the bad breas t and its ass ociated persecutory anxiety formed the earlies t developmental stage in K lein's theory: the paranoid-schizoid position. bad breast withheld gratification and thus stimulated child's primitive oral envy, provoking s adistic wis hes to penetrate and destroy the mother's breasts and body. boys , these primitive des tructive impulses gave rise to fear of retaliation (bas ed in part on projection) in the of castration anxiety; in girls, the primitive envy was expres sed in envy of the mother's breast during the developmental phas e and later was transformed into envy during the genital phas e. K lein held that by the of weaning, the child was capable of recognizing the mother as a whole object poss es sing good and bad qualities . B ut the combination of good and bad qualities a s ingle object—previous ly separated in part-objects— created a dilemma: Des tructive attacks on the bad 597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 175 of 238

also des troyed the good and needed object. T his prevented the child from unleas hing aggres sive agains t the object and lay the basis for the depres sive position, in which aggres sion was turned against the rather than against the object. T he guilt ass ociated with destructive wishes against the object was the precursor cons cience. K lein's emphas is in the child's developmental fell on the proces ses of introjection and projection, from basic instinctual drives, and their interactions with the important and primary objects of the child's early experience. P rojection of des tructive s uperego permitted acceptance of good introjects (internalization good objects ), thus alleviating the underlying paranoid anxiety. T he projected s uperego elements were later reintrojected to become the agency of guilt and early forms of obsess ional behavior. T he K leinian emphasis good and bad introjects concentrated on vital relations hips to objects at the earlies t level of child development, and the delineation of the internal structuring of the child's inner fantasy world in terms of the viciss itudes of these introjects , or internal objects , provided the basis and the rudimentary content for an object relations view of development. T hus K lein's “inner world” was peopled by internal that were either good or bad and with whom the individual was involved in intrapsychic interactions and struggles that were in many ways as real as thos e on with the real objects outside the person. In fact, saw external object relations as derived from and influenced by projective content derived from the object relations . K lein has been generously criticized 598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 176 of 238

her almost blind interpretation of all forms of destructive intent as manifes tations of the death for her inability to distinguish among the various kinds intraps ychic content (lumping object representations , representations, internal objects , fantas ies, and structures of various kinds together indiscriminately treating them in a unitary fas hion), for her tendency to subs titute theoretical inferences for observations , and, finally, for her marked tendency to predate the of intraps ychic organizations that are generally thought other theorists to be achieved only in later stages, for example, locating the origin of the superego the firs t year of life rather than in resolution of the situation in latency. In any case, K lein's observations and formulations had tremendous impact, particularly in bringing into prominence the role of aggres sion in pathological development, in making theoris ts of development much more aware of the early developmental precurs ors of structural entities, and particularly in providing the rudiments and foundations for an emergent theory of object relations . Wilfred B ion extended and applied K lein's ideas, developing the ramifications of the notion of projective identification—a process , originally described by K lein, which a subject dis places a part of the s elf into an and then identifies with that object or elicits a res ponse the object corres ponding to qualities of the projection. B ion applied this notion to a wide range of psychotic cognitive operations . He developed the metaphor of “container” P.735 599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 177 of 238

and the “contained” to expres s the manner in which projective identification occurs , es pecially in the of mother–child and analyst–patient interaction. T he child/patient projects toxic or des tructive contents onto the mother/analys t, who, in turn, absorbs, modifies , or “contains ” it so that it becomes available in more form for s ubs equent reinternalization by the res ulting in a healthier modification of the child/patient's pathogenic introjects. B ion als o contributed s ignificantly to the understanding of group process es by demonstrating the “basic as sumptions ” that operate on unconscious emotional level in therapeutic groups and expres sed in patterns of fight-flight, pairing, and dependence.

E G O A ND OB J E C TS B eginning around 1931, R onald F airbairn s hifted the emphasis in his thinking specifically to the problem of analysis. F airbairn's contribution was to bring personal object relations into the center of the theory. Whereas ego in F reudian theory had been regarded as a modification of the id, developed s pecifically for the purpos e of impulse control and adaptation to the demands of reality, F airbairn conceived of the ego as core phenomenon of the psyche. R ather than an organization of functions , he conceived of it more specifically as embodying a real s elf—that is , as the dynamic center or core of the personality. Ins tead of basing his theory on the ins tinctual drives as the basic concept, F airbairn shifted the emphasis to the ego and everything in human ps ychology as specifically an 600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 178 of 238

ego functioning. With this reorientation, there came a parallel of the instinctual pers pective. T he libido or instincts in general, rather than mechanisms for energic discharge, were regarded as ess entially object seeking. zones were not the primary determinants of libidinal but, rather, channels that mediated the primary relations hips with objects, particularly with relationships with objects that had been internalized during early life under the press ure of deprivation and frustration. E go development itself was characterized by a process whereby an original state of infantile dependence, on a s ymbiotic union with the maternal object, was abandoned in favor of a s tate of adult or mature dependence based on differentiation between self and object. T hus, F airbairn conceptualized the proces s in terms of the vicis situdes of relations with objects rather than the viciss itudes of ins tinctual T he basis for much of F airbairn's theorizing is his experience with s chizoid patients . He contrasted the dilemma of the s chizoid with that of neurotic patients whom he felt clas sic ps ychoanalytic theory was bas ed. saw that the schizoid was not primarily concerned with control of threatening impulses toward s ignificant but that the is sue for this kind of patient was es sentially that of having an ego capable of forming object at all. T he relations hip to objects presented a difficulty, because of dangerous impulses arising in connection them, but becaus e the ego was weak, undeveloped, infantile, and fragile. In the s truggle to overcome this weaknes s, the schizoid's impulses became antisocial. T hus, object relations theory in its bare es sentials 601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 179 of 238

a number of bas ic points that differentiate it from theory. F irs t, the ego is conceived of as whole or total birth, becoming s plit or los ing inner unity as a result of early bad experiences in object relations hips, in relation to the mothering object. T his point differs radically from the clas sic theory, according to which the ego begins as undifferentiated and unintegrated and achieves unity through the course of development. S econd, libido is regarded as a primary life drive of the ps yche, the energic source of the ego's s earch for relatednes s with good objects , which is ess ential for growth. T hird, aggress ion is regarded as a natural defens ive reaction to frustration of the libidinal drive rather than s pecifically as an independent instinct. the structural ego pattern that emerges when the ego unity is lost involves a pattern of ego s plitting and formation of internal ego–object relations . T he shift in emphas is toward the primacy of the environment and the influence of objects on the cours e development has es tablis hed a definite trend in ps ychoanalytic thinking and has been advanced in the work of B ritish theoris ts, among whom the work Michael B alint and Donald W innicott stands out. particularly has emphas ized the importance of early interactions between mother and child as determining factors in the laying down of important components of ego development. C urrently, there is ample room for overlap and integration in the approaches and formulations of both object relations theorists and more clas sic ps ychoanalytic ego theorists . S uch integration advanced to the point that they are generally regarded forming at least complementary as pects of a common 602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 180 of 238

theory, if not a more comprehens ive and unified theory such. B oth B alint and W innicott were concerned with levels early developmental failure that were es sentially preoedipal, were manifested in forms of pers onality that are more primitive and more difficult to treat than us ual neurotic disorders , and s eemed to involve critical as pects of the relationships with objects early in the of development and corres pondingly do not fit well with clas sic ps ychoanalytic s tructural theory with its basic on is sues of intraps ychic conflict. B alint envisioned s everal layers of psychological functioning in analysis. T he first is the familiar genital centering on triadic relations hips and concerned specifically with intrapsychic conflicts . T hese conflicts quality of relationships were usual and familiar material most analytical proces ses and could be treated by use adult language in verbal interpretations . T here was, however, a s econd, deeper level in which the meaning of words no longer had the same impact, and interpretations were no longer perceived as meaningful the patient. T his was the level of preverbal experience. referred to this level of impairment in object relations as the bas ic fault. B alint recognized that at this level of preverbal experience any attempt to address or the child's experience in adult language is bound to fail. P roblems arose in analysis when efforts were made to interpret events from this preverbal level in adult or secondary process terms. B alint dis tinguis hed between forms of regress ion that described as benign and malignant. T he benign was more or les s an extension of the basic notion of 603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 181 of 238

us ual analytic regress ion to a level of primitive with primary objects. S uch a regres sion was gradual, tempered, and modulated according to the patient's capacity to tolerate and productively integrate the res ulting anxiety. During this regress ion, the analyst's empathic res ponsivenes s and recognition made it for the patient to withstand this uns tructured and to keep the anxiety within manageable limits . At level of the bas ic fault, the lost infantile objects can be mourned, and the quality of the relationship with them was open to reworking so that the patient's basic as sumptions governing his or her interaction with the internal and external object world could be reformed. During phas es of benign regres sion to this preverbal pregenital level of object relationship in the analysis, analyst could usually provide an adequate degree of empathic acceptance and recognition, rather than verbalized interpretations, of this level of the patient's unstructured and regres sive experience, without any need to es cape or subvert this level of experience through interpretation. B alint felt that the dynamics at level are more primitive than can be adequately in terms of conflict because they derive from the bas ic form of dual relations hip involved in early mother–child interaction—that is , the basic fault. In contras t, malignant regres sion tends to be and extreme; the ego is prematurely overwhelmed by traumatic and unmanageable anxiety. P.736 T his anxiety prevented any effective reworking of fundamental disturbances in object relations hips, re604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 182 of 238

creating and reinforcing the basic fault, rather than creating the conditions for its therapeutic revis ion. At even deeper level, beyond the reach of analytic lay the area of creativity; that is, an idiosyncratic, uncommunicable, and objectless area that lies beyond conventional express ion. R egress ion to the level of the bas ic fault was a quite different and distinct phenomenon than the more usual oedipal regres sions experienced in the analysis of neurotics . In the oedipal regress ion, the aim was gratification of infantile instinctual wishes. R egres sion the level of the basic fault, however, sought a basic recognition by the therapist, as well as protective and cons ent to express the inner core of creativity that at the heart of the patient's being and accounts for the capacity to become ill or well. B alint used the notion of primary love at this deepes t level to describe libido from a frus trating object in the effort to certain inner harmony in which it becomes pos sible to recover the conditions of early care and tranquility. He referred to a “harmonious interpenetrating mix-up” to describe this early, almos t undifferentiated interaction the infant and environment. T he analogy he used was of breathing air; the organism cannot exis t without air, air and the organis m are seemingly ins eparable, but cutting off the supply of air reveals both the organism's need for it and the dis tinction between air and the organism. In terms of primary love as it came to bear in analysis, then, the patient would s eek a basic form of recognition from the analys t, as he had from significant objects in the patient's early life experience. Winnicott als o was concerned with the earlies t phase 605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 183 of 238

the mother–child relationship and the importance of he des cribed as “good-enough mothering” for the personality development. T he cours e of development involved movement from an early stage of total or absolute dependence toward a more adult phase of relative independence. As he saw it, the inherited potential for growth was s trongly influenced by the of maternal care. T his potential for development is affected even from the moment of conception. E ven before birth, the child becomes inves ted by a strong narcis sistic cathexis that allows the mother to identify the child and to become empathically attuned to the child's inner needs, as if the child were—and indeed extension of her own s elf. W innicott called this early prenatal involvement of mother and child in the womb a primary mate rnal preoccupation. T his set the stage for development of a holding relations hip in which the mother becomes sensitively attuned to the infant's and s ens itivities and is both phys ically and emotionally res ponsive to them, thus providing a phys ical, phys iological, and emotional ambiance, protection, and security for the absolutely dependent infant. As the infant moves from this early stage of absolute dependence toward a more relative dependence, awarenes s of personal needs and of the exis tence of mother as a caretaking object grows. T he optimal relations hip at this s tage involves a continuation of protective holding, along with an optimal titration of gratification and frus tration. As a result of this optimally attuned relationship between the patterning of infantile drives and initiatives and their harmonious fitting in with maternal s ens itivities and res ponsivenes s, there is a 606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 184 of 238

developing s ens e of reliable expectation that the needs will be satisfied without the threat of excess ive withdrawal of the mothering object and without the threatening, overwhelming, and s hort-circuiting of the infant's initiatives as a res ult of excess ive maternal impingements. In the course of normal development, this allowed for emergence of a certain omnipotence from which the gradually retreats with the experiences of tolerable degrees of frus tration by and s eparatenes s of the object. Although the mother continues her holding at phase, she must yet allow enough s eparation between herself and the developing infant to permit expres sion the baby's needs and initiatives that form the rudiments an emerging s ens e of self. If she is too distant, too unrespons ive, or not s ufficiently present, anxiety arises is accompanied by the fading of the infant's internal representations of her. T he transition from a phas e of abs olute dependence to one of relative dependence represents a crucial development in the capacity for object relations . It is accompanied by a critical transition from total to the capacity for objectivity in the perception of and relation to objects. T he transition from s ubjectivity to objectivity is accomplished by development of transitional phenomenon, expres sed in the firs t the emergence of trans itional objects . T hese objects the child's first object poss es sions that are perceived separate from the emerging self—the firs t “not me” poss ess ions. F rom the study of infant behavior, argued that the transitional object was a substitute for maternal breas t, the first and mos t s ignificant object in 607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 185 of 238

environment to which the infant related. T he object exis ts in an intermediate realm contributed to by the external reality of the object (the mother's and by the child's own s ubjectivity. T his intermediate realm is at once both subjective and objective without being exclusively either. Winnicott referred to this realm as the re alm of illus ion, intermediate area of experience that embraced both and external reality and may be retained in areas of functioning having to do with such imaginative as creativity, religious experience, and art. In its form, however, the transitional object commonly experienced in childhood development may take the of a particular object, a blanket, a pillow, or a favorite or teddy bear to which the child becomes intens ely attached and from which it cannot be s eparated without stirring up severe anxiety and dis tres s. Attachment to object is an immediate displacement from the figure of mother and represented an important developmental step, insofar as it allows the child to tolerate increasing degrees of separation from the mother, us ing the transitional object as a substitute. T he mother participates in this intermediate transitional realm of illus ion by her res pons iveness to the infant's to continually create her as a good mother. In her sens itivity and res ponsiveness , s he functions as a enough mother. However, her inability to provide such adequate mothering, either by exces sive withdrawal or excess ive intrusion and control, may result in of a false self in the child bas ed on compliance with the demands of the external environment, a condition that reflects a developmental failure and results in a variety 608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 186 of 238

often s evere character pathologies. When s uch patients are s een as adults , they are neurotic nor ps ychotic but s eem to relate to the world through a compliant s hell that is not quite real to them to the analys t. T hey are often mistrustful without being specifically paranoid, they appear withdrawn and disengaged and s eem able to relate only by means of protective s hell, which s eems apparently obsess ive compliant but which s eparates and isolates them from meaningful contacts with their fellows , even as it their only bas is for relations hip. T hese dis turbed personality types reflect a bas ic impairment in very object relations , particularly in the mutuality and res ponsiveness of very early mother–child interaction. Infants who developed in the direction of a false self have not experienced the security and mutual of such a relationship. S uch mothers are empathically of contact with the child and react largely on the basis their own inner fantas ies, narciss is tic needs, or conflicts. T he child's s urvival depends on the capacity adapt to this pattern of the mother's respons e, which is gross ly out of phase with the child's needs . T his es tablis hed a pattern of gradual training in compliance with whatever the mother was capable of offering, than s eeking out and finding what is needed and C ons equently, the child's needs, ins tinctual impulses, wis hes , and initiatives , instead of becoming a guide to s atis fying growth experiences and enlarging capacities to interact meaningfully with objects, from the very beginning a threat to the harmony of the relations hip with the mother, who remains to effective feedback from the child. 609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 187 of 238

Winnicott's attempts to formulate principles of for such basically impaired patients built on the model good-enough mothering. T his called for a capacity for holding, for empathic res ponsiveness , and for a P.737 capacity for creatively playful exchange that allowed patient's capacities for growth to emerge and flouris h, permitting expansion of the patient's authentic sense of self, which remains hidden behind the external facade false-self compliance.

A TTA C HME NT THE OR Y Another more recent development in the study of relations hips with objects has taken the form of attachment theory. Attachment theory takes its origin in the work of J ohn B owlby. In his s tudies of infant attachment and s eparation, B owlby pointed out that attachment cons tituted a central motivational force and that mother–child attachment was an ess ential medium human interaction that had important consequences for later development and personality functioning. Attachment theoris ts have s tudied patterns of early attachment and related them to patterns of adult interaction with s ignificant objects. Us ing the Adult Attachment Interview (AAI), developed by Mary Main others , they document the nature of internal working models of early attachment relations. B oth attachment theoris ts and object relations theorists emphasize the significance of the mother's empathic respons ivity to infant needs for s elf-development and relatedness , the importance of the mother–child involvement for 610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 188 of 238

personality development, and the role of the mother as catalys t for age-appropriate development. S tudy of infant respons es in the S tranger S ituation, an arrangement for obs erving the quality of parent–child interaction and the effects of s eparation, led to of four categories of infant behavior: secure, avoidant, res is tant, and disorganized-disoriented. T hes e patterns could be related to attachment attitudes in adults on basis of the AAI. S ecure infants were related to s ecure relatively autonomous patterns of attachment and interaction in adults , avoidant infants were ass ociated an adult pattern of dis mis sing relationships as or s ignificant, resis tant infants connected with a preoccupied adult s tance in which s ubjects were preoccupied with past attachments often with angry or fearful emotions, and the disorganized-disoriented related to an unres olved and dis organized pattern in adults s uggesting more severe dis turbance in self– relations . T hese findings provide an extension and specification of an object relations approach as well as providing specific empirical and observational methods more detailed study of the development of object relations from childhood to adulthood.

P S YC HOL OG Y OF THE S E L F Over the las t two s core and more of years , the concept the self has been emerging with increasing emphasis definition as a central notion in the deepening ps ychoanalytic unders tanding of the organization and functioning of the human psyche. Although the regarding the unders tanding of the s elf are s till very in flux, and the place of the notion of the s elf in 611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 189 of 238

ps ychoanalytic theory remains tentative and uncertain, is sues address ed by the ps ychology of the self seem to of sufficient significance and to have gained a more or permanent place in psychoanalytic thinking s o that a cons ideration of thes e iss ues is warranted in this presentation. T he is sues to which a self-ps ychology addres ses itself by no means new to psychoanalys is . P art of the stems from the ambiguity in F reud's use of the term standing ambiguous ly both for the ego as part of the mental apparatus, a s tructural agency, and for the experiential subjective and personal sense of s elf. T he decis ion of the editors of the E nglish S tandard E dition translate Ich to the term “ego” tended to s hift the of the term toward the more impersonal structural of agency and away from the more s ubjective implications. T here are pas sages where it is quite clear F reud uses the G erman term s e lbs t as s ynonymous the term Ich, referring to the s ubjectively experienced self—the person as such. T his unres olved ambiguity and the progres sive s hift in implications of the term ego have left a certain vacuum ps ychoanalytic metapsychology. T his deficit has been attacked by a number of thinkers as reflecting a lack of personal ego or a s ens e of s elf-as -agent in theory. P artly in an attempt to deal with this is sue, the notion of the self has been focused by various analytic thinkers in a variety of contexts . K ohut's development self psychology has been a major s timulus to renewed interes t in the self. T he self psychology movement came into prominence largely as the res ult of K ohut's efforts in the late 1960s, 612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 190 of 238

there was a his tory of development of a self-concept in ps ychoanalys is well before that. Development of a of the self in the context of the structural theory was stimulated by Hartmann's distinction between ego and self, terms that had been left ambiguous by F reud: T he was an intrapsychic organization of functions , whereas self was cas t in terms of a s elf-representation that then became the object of narciss istic libido but als o was specifically connected with object relations . In these the ego was related to and interactive with other intraps ychic s tructures , for example, superego, and the was concerned with object relations and self–object interactions. T his distinction also clarified the differentiation of object-libido and narciss istic libido because the self was the repository for secondary narcis sism and, as s uch, distinct from the ego. Hartmann's distinction between the ego and the s elf the self in representational terms . T he s elf was conceptualized either as a complex repres entation, organized and synthesized as a function of the ego or, later theorists , in structural terms as a more complex supraordinate integration of the tripartite structures is , embracing the tripartite entities as s ubordinate subs tructures ). T he former view regarded the self as the repres entational world, whereas the latter ass igned to the realm of internal ps ychic s tructure. T he of emphas is and formulation regarding these two perspectives remain a pers istent problem in developing cons istent concept of the self.

K ohutian S elf Ps yc hology S elf ps ychology, as a s eparate movement within 613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 191 of 238

ps ychoanalys is, takes its origin from contributions of and his followers. K ohut linked the origin of the s elf to narcis sism, viewing the s elf as the result of a s eparate of narcis sis tic development that progres ses through a series of archaic narciss istic structures toward a mature and cohesive s elf-organization. K ohut argued that narcis sism went through a separate of development independent from object libido and object relations . In his view, the original primary differentiates in the course of development and in res ponse to laps es in parental empathy into two configurations, the grandiose self and the idealized parental imago. T he grandios e s e lf involves an and exhibitionis tic image of the self that becomes the repository for infantile perfection; the ide alize d parental imago, in contrast, trans fers the previous perfection to admired omnipotent object or objects. F urther normal development of the grandios e self leads to more forms of ambition, s elf-es teem, s elf-confidence, and pleas ure in accomplis hment. T he idealized parental likewise becomes integrated into the ego ideal with the mature values, ideals , and s tandards it repres ents. P athological pers istence of the grandiose self results in intens ification of grandios ity, exhibitionis m, shame, depres sion, hypochondriacal concerns, and of P.738 self-es teem. Loss of the idealized object or the object's love can res ult in narcis sis tic imbalance, the individual vulnerable to depress ion, depletion, poor self-es teem, failure of ideals and values , and even 614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 192 of 238

fragmentation. K ohut bases his s elf ps ychology on the need, both the cours e of development and during the cours e of for empathic interaction with s e lfobje cts . T he original selfobject is the mother or caretaking person who empathic res ponse to s elfobject needs in the infant in form of love, admiration, acceptance, joyful warmth, and respons ivenes s, communicating a sense valued and cherished exis tence to the child. Human continue to s eek objects to fulfill these basic s elfobject needs throughout life. F ailures to fulfill such needs can res ult in the formation of pathological psychic and patterns of behavior during development and pathological character s tructures during adult life. (T his analysis comes close to W innicott's views on goodmothering.)

E volving C onc epts of the S elf T he direct line of development of the notion of the s elf ps ychoanalys is, as previously discus sed, is best traced to Hartmann's effort to clarify the ambiguity latent in F reud's use of the term Ich. Hartmann distinguis hed from the s elf by ass igning the res pective terms to frames of explanatory reference. T he ego referred to specific intraps ychic agency whose frame of reference action was within the intrapsychic s tructure and in to other intraps ychic entities , for example, s uperego id. T he self, in contrast, had its proper frame of relations hip to objects . T hus formulated, the notion of self came to be regarded as roughly equivalent to the concept of the person as s uch. In an effort to clarify the theoretical implications of the 615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 193 of 238

early thinkers , following Hartmann's lead, came to the self in repres entational terms —that is , as referring the self-representation, which was then regarded as a subordinate function of the ego. Another point of view, however, sees the s elf as a s tructural organization, envis ioned as a fourth focus of organization in addition the tripartite entities or as a s upraordinate organization, including the tripartite s tructures and perhaps structural as pects. P art of the difficulty is that the notion of the self can be looked at from a variety of perspectives. T he s elf can seen as agent, or as object, or even in locational terms res pect to questions of what is inside or outside of the mind or the ps ychic s tructure and what it might mean parts of the s elf to be internalized or externalized. T he representational view of the s elf seems to lend its elf clearly to a view of the s elf as object, that is , as what cognitively and experientially gras ped of the s elf as an object of inner experience. S uch an experienced s elfobject must have repres entational qualities to be cognitively relevant. B y the s ame token, the s tructural perspective seems to be mos t congruent with the view the s elf-as -agent, as a s ource of psychic integration activity, and as s ynonymous with the originating s ource personal action and awareness . T he s tructural as pect the self-as -agent, with particular reference to its of conscious s ubjectivity, comes clos est to s atisfying demand for a “personal ego” in the theory. T he theory of the s elf remains at this juncture uncertain and very much in flux. However the ultimate conceptualization may be res olved, it s eems apparent the ps ychology of the s elf will continue to gain a 616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 194 of 238

permanent place in ps ychoanalytic thinking and theory. is poss ible to specify s ome of the theoretical gains of emerging role of the s elf-concept: T he self as a theoretical construct provides a focus formulating and unders tanding the complex integrations of functional process es that involve combinations of functions of the respective component agencies . T his has specific application such complex activities as affects, in which all of ps ychic s ys tems s eem to be in one way or other represented; complex s uperego integrations in such formations as value s ys tems; and other complex interactions of ps ychic s ys tems that fantas y production, drive-motor integration, or cognitive-affective proces ses. T here is room here cons iderable reworking and refocusing of traditional ps ychoanalytic ways of looking at and ps ychic phenomena in terms of the s elf as a system. T he self-concept provides a more specific and less ambiguous frame of reference for the articulation of self–object interrelations hips and interactions , including the complex areas of object relations and internalizations . T he emergence of a self-concept provides a locus the theory for articulating the experience of the personal s elf, either as gras ped intros pectively and reflectively or experienced as the originating source personal activity. T his s ens e of the self-as -subject provides a place within the theory for an account of subjectivity and s ubjective meaning. 617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 195 of 238

T his approach raises an important metapsychological is sue; namely, the relations hip between the organization of the s elf and the tripartite entities . T he organization of the s elf and the organization of tripartite entities cannot be s imply identified. T he s elforganization operates at a different level of psychic organization than do the s tructural entities; moreover, structural entities in the strict theoretical s ens e are unders tood to be organizations of specific functions . concept applies not only to the ego as such but als o to superego and the id. Although the theory at various attributes more or les s personalized, metaphors to the operation of thes e s tructures , their theoretical intelligibility is nonetheles s given in terms of the organization of s pecific functions attributed to the res pective s tructures.

R elational and Inters ubjec tive Approac hes T hese more recent approaches to understanding the analytical interaction derive from a form of epistemology in which transference was regarded as res ulting from the interaction of analys t and patient. cons tructivist view contras ts with the more objectivist view of ego ps ychology and object relations . T he attention is focused on the here-and-now interaction the patient rather than on the inner dynamics of the patient's mental life and experience. T his effects a s hift from a one-person to a two-person ps ychology in which the ongoing interactions , whether cons cious or unconscious, between the participants are central, and transference and countertransference are regarded as 618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 196 of 238

mutually cocreated by both. T his approach was further developed into a view of analytical interaction in inters ubjective and relational terms. T he self ps ychological emphasis on s elf– transference has encouraged movement away from cons iderations of the analyst's stance as neutral or observational, ques tioning the analyst's subjectivity, authority, and capacity to know any objective reality the patient. On these terms, pers onality development is dependent on the interpersonal field insofar as ps ychic is continually being remodeled in terms of both past present relations hips and not determined by fixed patterns deriving from pas t unconscious conflicts . T he concept of personality as developing within a relational matrix calls for a central focus on the intersubjective within the relations hip between analys t and patient. It is this aspect of the analytical situation that is explored interpreted in the interest of bringing about personal growth in the patient. T he analyst's technical neutrality and objectivity are rejected in this approach as illus ory little more than express ions of the analys t's position. Within a s elf–selfobject or intersubjective relation, neutrality is precluded as P.739 potentially traumatizing and destructive to potential cons olidation of the self. An inevitable cons equence of these approaches is that they do away with the notion of the unconscious and undercut any sense of transference as reflecting unconscious aspects of the patient's inner psychic life because trans ference is anew in the pres ent analytical interaction. 619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 197 of 238

Ps yc hology of C harac ter T he development of the concept of character in ps ychoanalys is has drawn increasingly clos er to the that are latent in a ps ychology of the s elf. C haracter come to s tand for a unique combination of the components of the individual's psychic organization reflects the basic elements of that person's personality organization and style. T he implications of the concept character, then, lie much clos er to the framework of the personality functioning as a whole, rather than to ps ychic agencies . T he concept of character can vary widely in meaning, depending on whether it is us ed in a moralistic, sociological, or general s ens e. Application of the in ps ychoanalysis has remained res trictive despite the that theoretical propos itions concerning the meaning of character have undergone an evolution that parallels evolution in ps ychoanalytic theory, particularly in the theory of the ego. During the period when F reud was developing his ego theory, he noted the relations hip between certain character traits and particular ps ychos exual components. F or example, he that obstinacy, orderlines s, and pars imonious nes s as sociated with anality. He noted that ambition was related to urethral eroticis m and that generos ity was related to orality. He concluded, in his paper on and Anal E roticism,” that permanent character traits represented “unchanged prolongations of the original instincts, or sublimation of thos e instincts, or reactionformations against them.” In 1913, F reud made an important distinction between 620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 198 of 238

neurotic s ymptoms and character traits : Neurotic symptoms come into being as a result of failure of repress ion, the return of the repress ed; character traits their exis tence to the succes s of repress ion or, more accurately, of the defens e s ys tem, which achieves its through a persistent pattern of reaction formation and sublimation. Later, in 1923, with increas ed of the phenomenon of identification and the formulation of the ego as a coherent s ys tem of functions , the relations hip of character to ego development came into sharper focus . At this point, F reud obs erved that the replacement of object attachment by identification (introjection), which s et up the los t object inside the also made a significant contribution to character formation. A decade later, in 1932, F reud emphasized particular importance of identification (introjection) with the parents for the construction of character, with reference to superego formation. S everal of F reud's disciples made important to the concept of character during this period. A major share of K arl Abraham's efforts were devoted to the inves tigation and elucidation of the relations hip oral, anal, and genital eroticism and various character traits. Wilhelm R eich made an important contribution to the ps ychoanalytic unders tanding of character when he described the intimate relations hip between resistance treatment and character traits of the patient's R eich's obs ervation that res is tance typically appeared the form of thes e s pecific traits anticipated Anna later formulation concerning the relationship between res is tances and typical ego defens es. T he development of psychoanalytic ego psychology 621 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 199 of 238

led to an increasing tendency to include character traits among the properties of the ego, s uperego, and egoIt s hould be noted, however, that character is not synonymous with any of these properties . the emphasis has been extended from an interes t in specific character traits to a cons ideration of character its formation in general. P sychoanalys is has come to regard character as the pattern of adaptation to and environmental forces , which is typical or habitual given individual. T he character of a person is from the ego by virtue of the fact that it refers largely to directly obs ervable behavior and s tyles of defense, as as of acting, thinking, and feeling. T he clinical value of concept of character has been recognized by and ps ychoanalys ts and has become a meeting ground the two disciplines. T he formation of character and character traits res ults the interplay of multiple factors. Innate biological predis pos itions play a role in character formation in its instinctual and ego fundaments . T he interactions of forces with early ego defenses and with environmental influences, particularly the parents, constitute the major determinants in the development of character. V arious early identifications and imitations of objects leave their lasting s tamp on character formation. T he degree to which the ego has developed a capacity tolerate delay in drive dis charge and to neutralize instinctual energies , as a result of early identifications defens e formation, determines the later emergence of such character traits as impulsiveness . F inally, a authors have s tres sed the particularly clos e ass ociation between character traits and the development of the 622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 200 of 238

ideal. T he development of the ego-ideal must be unders tood in the context of the developmental viciss itudes of narciss is m. It is in this respect that the ps ychoanalytic concept of character begins to parallel more common us e of the term characte r in a s omewhat moral sense. T he exaggerated development of certain character traits at the expense of others may lead to character dis orders later in life. At other times , s uch distortions in the development of character traits can produce a vulnerability in personality organization or a predis pos ition to ps ychotic decompensation.

C L A S S IC P S YC HOA NA L YTIC TR E A TME NT C ertain aspects of the therapeutic technique that F reud developed and that were later expanded by his are closely related with ps ychoanalytic theory. One of distinctive as pects of the ps ychoanalytic approach to treatment in general is its cons is tent attempt to therapeutic us ages and approaches with the unders tanding of psychic functioning available from ps ychoanalytic theory. In its origins and clinical application, ps ychoanalys is is uniquely a theory of

Analys is vers us Analytic al Ps yc hotherapy One of the chronically recurring is sues among analys ts whether and to what extent psychoanalys is is distinguishable from ps ychotherapy. T here are distinguishing features between them as more or les s forms: the us e of couch in analysis, not in therapy; free as sociation as a primary method in analysis, not in 623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 201 of 238

intens ive and long-term s cheduling in analys is , not in therapy; emphasis on neutrality, abstinence, and interpretation on the part of the analyst in analys is, not therapy; and the central focus on transference and countertransference in analysis , not in therapy. Over years , however, forms of psychotherapy have evolved modifying all of these criteria and res ulting in a of psychotherapeutic interventions , ranging from ps ychoanalys is at one end to diluted forms of ps ychotherapy at the other. T he dis tinction between explorative vers us supportive therapy parallels this continuum s o that many variants of the analytical have aris en in which both components are us ed in degrees . S ome of this variation has come about by of the expans ion of P.740 analytical techniques to the widening scope of ps ychopathology and the corres ponding challenge of adapting analytical techniques to these patient needs. Another factor, however, has been the rejection of traditional analytical approaches and methods accompanying rejection of more traditional analytical theories. One conclus ion is that better means for determining what patients are better served by what forms of therapy needs to be developed.

Analytic al Proc es s S ome of the origins of F reud's approach to treatment been cons idered, particularly in the development of his basic techniques of free as sociation and in his growing awarenes s and interpretation of the trans ference. In 624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 202 of 238

es sence, modern ps ychoanalytic treatment procedures differ from thos e that F reud originally developed in one fundamental respect. E arly in his approach to therapy, F reud believed that recognition by the phys ician of the patient's unconscious motivations, the communication this knowledge to the patient, and its comprehens ion the patient would of its elf effect a cure. T his was his doctrine of therapeutic insight. F urther clinical however, has demonstrated the fallacy of these expectations . S pecifically, F reud found that his discovery of the unconscious wis hes and his ability to impart thes e to the patient s o that they were accepted and were ins ufficient. S uch ins ight might permit clarification the patient's intellectual apprais al of problems , but the emotional tensions for which the patient sought were not effectively alleviated in this way. T his led to a s ignificant breakthrough. F reud began to that the succes s of treatment depended on the ability to unders tand the emotional significance of an experience on an emotional level and depended on the patient's capacity to retain and use that insight. In that event, if the experience recurred, it elicited another reaction; it was longer repress ed, and the patient would have undergone a ps ychic economic change. F reud's formula for this process was: “Where id was , there ego be.” F reud thus elaborated a treatment method that minimal importance to the immediate relief of to moral s upport from the therapist, or to guidance. T he goal of ps ychoanalys is was to pull the neuros is out by roots, rather than to prune off the top. T o accomplis h 625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 203 of 238

it was necess ary to break down the pregenital, deep crys tallization of id, ego, and s uperego and bring underlying material near enough to the surface of cons ciousnes s s o that it could be modified and reevaluated in light of reality. T his method the clas sic ps ychological treatment from more ps ychodynamic forms of psychotherapy. T he patient is unaware of the repress ion of the forces conflict and the ps ychic mechanisms of defens e the us es . B y isolating the bas ic problem, the patient has protected her- or himself against what s eems, from the patient's view, to be unbearable suffering. No matter it may impair functioning, the neurosis s eems preferable to the emergence of unacceptable wis hes ideas . All the forces that permitted the original are thus mobilized once again in the analys is as a res is tance to this threatened encroachment on territory. No matter how much the patient may cons ciously with the therapist in the analys is, and no matter how painful the neurotic symptoms may be, the patient automatically defends agains t reopening of old wounds with every s ubtle resource of defense and res is tance available. In dis cuss ing the analytical proces s, one must clarify basic distinction between the analytical proces s and analytical s ituation. T he analytical proce s s refers to the regress ive emergence, working through, interpretation, and res olution of the trans ference neurosis. T he s ituation, however, refers to the s etting in which the analytical process takes place, specifically the relations hip between patient and analyst bas ed on the therapeutic alliance. 626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 204 of 238

T he regress ion induced by the analytical situation (instinctual regres sion) allows for a reemergence of infantile conflicts and thus induces formation of a transference neuros is . In the class ic transference the original infantile conflicts and wishes become on the pers on of the analyst and are thus and relived. In the analytical regres sion, earlier infantile conflicts are revived and can be s een as a the repetition compulsion. R egres sion has a dual from one point of view, it is an attempt to return to an earlier state of real or fantasy gratification, but from another point of view, it can be seen as an attempt to master previous traumatic experience. T he regres sion the analytical s ituation and the development of transference are preliminary conditions for the mas tery unresolved conflicts. T hey can also represent and unconscious wis hes to return to an earlier s tate of narcis sistic gratification. T he analytical process must its elf out in the face of this dual potentiality and tension. If the analytical regress ion has a des tructive potentiality (ego regres sion) that mus t be recognized and guarded agains t, it also has a progres sive potentiality for and reworking infantile conflicts and for achieving a reorganization and consolidation of the pers onality on a more mature and healthier level. As in any crisis, the risk of regres sive deterioration mus t be agains t the promise of progres sive growth and T he therapeutic importance of the criteria of can be easily recognized becaus e patients who are to achieve the progres sive potentiality of the analytical regress ion cannot be expected to realize a good therapeutic res ult. T he determining element within the 627 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 205 of 238

analytical s ituation against which the regress ion must balanced and by which the destructive or cons tructive potential of the regres sion can be meas ured is the therapeutic alliance. A firm and stable alliance offers a buffer against exces sive (ego) regres sion and also basis for pos itive growth.

The A nalytic al R elation T he analytical or therapeutic relation is compounded of least three components that are coexistent, mutually interacting and influencing, and intermingled at all in the analytical process . Although cons tantly to influence the patterns of interaction between analyst and patient and determining the cours e of the proces s, they can be us efully distinguished in that they point to differentiable is sues and aspects of the therapeutic proces s and call for different therapeutic res ponses and interventions . T hey are the trans ference and countertransference, the therapeutic alliance, and real relation.

TR ANS FE R E NC E T hrough free as sociation, hidden patterns of the mental organization that may be fixated at immature levels and refer to events or fantas ies in the patient's private experience are brought to life and activated in relation with the analyst. In the s imples t model of transference, the analyst is gradually invested with emotions us ually ass ociated with significant figures in past. T he patient dis places or projects feelings directed toward thes e earlier objects onto the analys t, then becomes alternately a friend or enemy, one who 628 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 206 of 238

nice or frustrates needs and punishes, or one who is or hated as the original objects were loved or hated. Moreover, this tendency pers is ts so that, to an extent, the patient's feelings toward the analys t feelings toward the specific people being talked about more accurately, those about whom the patient's unconscious is talking. T his transference object acts as lens through which the patient views the analyst, him or her in the image of the trans ference As unresolved childhood attitudes and feelings emerge and begin to function as fantasized projections toward analyst, he P.741 or s he becomes for the patient a phantom compos ite figure repres enting various important people in the patient's early environment or objects represented in or her inner world. T hos e earlier relations hips are reactivated with s ome of their original affective vigor, expos ing in some degree the roots of the patient's disturbance. T he concept of transference has cons iderable elaboration over time, res ulting in multiple variants, broadening its connotations to include every emotional connection to the analyst, and extending the transference model to encompas s the widening range ps ychopathology addres sed by ps ychoanalys is . in transference and their des criptions are contained in T able 6.1-5. Unders tanding trans ferences requires exploration of mechanisms involved in their formation their dynamic interactions . T he bas ic mechanisms by which trans ferences are effected—displacement, projection, and projective identification—are des cribed 629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 207 of 238

T able 6.1-6.

Table 6.1-5 Trans ferenc e Libidinal transferences    F ollow the class ic model and us ually in milder forms as pos itive trans fe rence re actions but can the form of more intens e and disturbing erotic trans fe rences . T hey are derivatives of phalliclibidinal impulses and may be permeated by pregenital influences. T hey may occur with varying degrees of intens ity and in mild forms not even require interpretation if they contribute and s upport the therapeutic relation. S igmund recommended that they call for interpretation only when they begin to serve as a res is tance. Aggress ive transferences    T ake the form either of negative or more pathological paranoid transferences . Negative trans fe rences are seen at all levels of ps ychopathology but may predominate in s ome borderline patients who tend to s ee the relations hip in terms of power and victimization, regarding the therapist as omnipotent and whereas the patient experiences him- or hers elf helpless , weak, and vulnerable. However, 630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 208 of 238

transferences are identifiable in varying degrees all analyses and usually require specific and interpretation. T ransferences of defense    Oppos ed to trans fe rences of impuls e ; defense agains t impuls es finds its way into the rather than the impuls es themselves. In this form transference, attention shifts from drives to the defens ive functioning so that trans ference is no longer merely repetition of instinctual cathexes includes as pects of ego functioning as well. T ransference neuros is    Involves the re-creation or more ample of the patient's neurosis enacted anew within the analytical relation and at leas t theoretically as pects of the infantile neurosis. T he neuros is usually develops in the middle phase of analysis, when the patient, at firs t eager for improved mental health, no longer cons is tently displays s uch motivation but engages in a continuing battle with the analys t over the desire attain some kind of emotional satisfaction from analyst so that this becomes the most compelling reason for continuing analys is. At this point of the treatment, the transference emotions become important to the patient than alleviation of dis tress 631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 209 of 238

sought initially, and the major, unresolved, unconscious problems of childhood begin to dominate the patient's behavior. T hey are now reproduced in the trans ference, with all their pentup emotion.    T he trans ference neurosis is governed by three outstanding characteris tics of ins tinctual life in childhood: the pleas ure principle (before effective reality testing), ambivalence, and repetition compuls ion. E mergence of the transference is us ually a s low and gradual process , although in certain patients with a propens ity for trans fe rence re gre s s ion, particularly more hysterical patients , elements of transference and trans ference may manifes t thems elves relatively early in the analytical process . One situation after another in life of the patient is analyzed and progress ively interpreted until the original infantile conflict is sufficiently revealed. Only then does the transference neuros is begin to s ubs ide. At that termination begins to emerge as a more central concern.    C ontemporary opinion is divided as to its importance and centrality, whether it forms to the extent F reud believed, and whether it is for success ful analysis —for some, it remains an es sential vehicle for analytical interpretation and therapeutic effectivenes s; for others , it may never

632 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 210 of 238

develop or, to the extent that it does , may play a central role in the proces s of cure. T ransference psychosis    Occurs when failure of reality testing leads to of self–object differentiation and diffus ion of self object boundaries . T his may reflect an attempt to fus e with an omnipotent object, investing the s elf with omnipotent powers as defense agains t underlying fears of vulnerability and T ransference psychosis may als o include transference elements in which fusion carries the threat of engulfment and loss of self that may precipitate a paranoid trans fe rence re action. Narciss is tic transferences    C larified by Heinz K ohut (1971) as variations of patterns of projection of archaic narcis sistic configurations onto the therapist. T hey are based projections of narciss istic introjective both s uperior and inferior—the superior form reflecting narcis sistic s uperiority, grandiosity, and enhanced self-es teem, and the inferior oppos ite qualities of inferiority, self-depletion, and self-es teem. T he therapist comes to represent, in K ohut's terms , either the grandios e s elf in mirror trans fe rences or the idealized parental imago in ide alizing trans fere nce s . In idealizing 633 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 211 of 238

all power and s trength are attributed to the object, leaving the subject feeling empty and powerles s when s eparated from that object. with the idealized object enables the subject to regain narcis sis tic equilibrium. Idealizing transferences may reflect developmental disturbances in the idealized parent imago, particularly at the time of formation of the ego by introjection of the idealized object. In some individuals , narciss istic fixation leads to development of the grandiose self. R eactivation analysis of the grandiose s elf provides the bas is formation of mirror trans ferences, which occur in three forms : archaic merge r trans fe rence , a les s archaic alter-ego or twins hip trans fe rence , and trans fe rence in the narrow s e ns e . In the most merger trans ference, the analyst is experienced as an extension of the subject's grandios e s elf thus, becomes the repos itory of the patient's grandiosity and exhibitionism. In the alter-ego or twinship transference, activation of the grandios e self leads to experience of the narciss is tic object similar to the grandiose self. In the most mature of mirror transference, the analyst is experienced a s eparate pers on but, nonetheles s, one who becomes important to the patient and is accepted by him or her only to the degree that he or s he is res ponsive to the narcis sistic needs of the reactivated grandios e s elf.

634 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 212 of 238

S elfobject transferences    R epres ent extens ions of the s elf-ps ychology paradigm beyond merely narcis sis tic T he selfobject involves investment of the s elf in object s o that the object comes to serve a s elfsustaining function that the self cannot perform its elf—either in maintaining fragile s elf-cohes ion in regulating self-es teem. T he other is, thus , not experienced as an autonomous and separate or agency in its own right but as pres ent only to serve the needs of the self. T ransference in this reflects a continuing developmental need that satis faction in the analytical relation.    S elfobject trans ferences reflect the underlying need s tructure the patient brings to the relations hip bas ed on the predominant pattern of selfobject deprivation or frus tration and the corres ponding seeking for the appropriate form of selfobject involvement. T hes e configurations been described as the unders timulated s e lf, the overs timulate d s elf, the overburdene d s elf, and fragme nting s e lf. Other des criptions of s elfobject need translate patterns of trans ference based on narciss is tic dynamics into the of the relationship between self and s elfobject, as mirror-hungry pers onalities and ideal-hungry personalities . V ariations on the mirroring transference theme include the alter-ego–hungry

635 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 213 of 238

personality, the merger-hungry personality, and, contrast, the contact-shunning pers onality. In transferences derived from s uch pers onality configurations, the clas sic meaning of has undergone radical modification. R ather than displacements or projections from earlier object relational contexts, the patient brings to bear a based in his or her own currently deficient and defective character s tructure—a need to the object in a dependent relationship to or s tabilize his or her own ps ychic integration. T ransitional relatedness    T his transference model is based on Donald Winnicott's notion of the trans itional object. T ransference in more primitive character is regarded as a form of trans itional obje ct which the therapist is perceived as outside the but is inves ted with qualities from the patient's archaic s elf-image. T he transference field in this is envis ioned as a transitional s pace in which the transference illus ion is allowed to play itself out. T ransference as psychic reality    R eflects the need of each participant in analysis draw the other into a s tance corres ponding to his her own intrapsychic configuration and needs as reflection of the individual subject's psychic 636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 214 of 238

T his regards the clas sic view of transference, on dis placement or projection from past objects, inadequate, res ulting in further diffus ion of of trans ference as equivalent to the individual's capacity to create a meaningful world or to inform the world with meaning. In this rendition, transference becomes equivalent to the patient's ps ychic reality s o that any dis tinction between the meanings given to reality and the meanings inherent in transference are lost. T ransference in these terms becomes all-encompas sing, and whatever dis tinguishing and dynamic s ignificance may have had fades into obscurity. In this form of transference, there does not s eem to be any definable mechanis m at work other than involved in the subject's psychic reality. T he view of his or her environment and his or her impres sion of objects of his or her experience, including the analytical object, are from ordinary cognitive and affective proces ses characterizing his or her involvement and res ponsiveness to the world about him or her. T ransference as relational or intersubjective    T he relational or intersubjective view of transference as emerging from or cocreated by subjective interaction between analyst and analysand transforms transference into an interactive phenomenon in which individual

637 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 215 of 238

intraps ychic contributions from either participant are obs cured. T rans ference in this sense is not anything individual to or intrapsychically derived from the patient but is based on the pres ent ongoing interaction between analys t and patient coconstructing trans ference. On these terms , analysis of transference has little to do with past derivatives and everything to do with the ongoing relation with the analyst, primarily in the form of interpersonal enactments . T ransference in this is no longer a one-person phenomenon but a two-person transference–countertransference interaction. T he s upposition is that there is no thing as trans ference without countertrans ference and no such thing as countertransference without transference. T he patient is thus relieved of any burden of a pers onal dynamic unconscious reflecting developmental viciss itudes and of a life history. T ransference is created anew in immediacy of present analytical interaction as the product of mutual influence and communication between analys t and analysand, probably relying some form of mutual projective identification to sustain the interactive connotation.

Table 6.1-6 Trans ferenc e Mec hanis ms 638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 216 of 238

Dis placement    T he basic mechanis m of class ic transference paradigms in which an object representation from any level or combination of levels of the subject's developmental experience is dis placed the representation of the new object, namely, the analyst, in the therapeutic relations hip. Dis placement is the bas ic mechanis m for based transferences , both positive and erotic, as as for aggress ive and es pecially negative transferences . B y and large, displacement transferences tend to play a more dominant role neurotic disorders in which phallic-oedipal (and to less er degree pre-oedipal) dynamics tend to play dominant, although not exclus ive, role. P rojection    P rocess by which qualities or characteristics of self-as -object, us ually involving introjections or representations, are attributed to an external and the subs equent interaction with the object is determined by the projected characteris tics. the analyst/object may be s een as sadis tic—that as poss ess ing the sadis tic character of the analysand/s ubject, an aspect of the s ubject's s elf is denied or dis owned by the subject. P rojection tends to play a more prominent, although again 639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 217 of 238

exclusive, role in formation of transferences in primitive character dis orders but can be found in variously modified forms throughout the s pectrum of neuroses. B ecause projections derive primarily from the configuration of introjects cons tituting patient's s elf-as -object, the effect of projective or externalizing transferences is that the image of therapist comes to repres ent part of the patient's own s elf-organization rather than simply an object representation.    P rojections derived from destructive introjects provide the basis for both negative and paranoid transference reactions . T hos e based on the victim/introject res ult in the patient relating to the therapist as his or her victim and him- or hers elf as suming a hos tile or s adistic pos ition as a destructive aggress or or victimizer to the victim. T hen again, projection based on the aggres sor/introject results in the patient relating the therapist as an aggres sor and him- or herself as suming a weak, vulnerable, or mas ochis tic in which he or she becomes a pass ive and victim to the therapist's des tructive aggress ion. S imilar patterns can take place around is sues involving introjective configurations of narcis sistic s uperiority and inferiority.    However, projective dynamics in s elfobject transferences seem to involve more than

640 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 218 of 238

projections becaus e these forms of transference tend to draw the analyst into meeting the pathological needs of the s elf. If anything is projected, it is an infantile wis hed-for imago, one lacking earlier in the patient's experience, as , for example, an empathic and idealized parental On the other hand, trans itional transferences , despite their considerable overlap with s elfobject phenomena, tend to involve a more explicit projective element as the s elf-related contribution the transitional experience. P rojective identification    T he concept of projective identification was first propos ed by Melanie K lein, arguing that the projection of impuls es or feelings into another person brought about an identification with that person bas ed on attribution of one's own qualities that other. T his attribution served as the bas is for sens e of empathy and connection with the other. these terms, projective identification was a taking place solely in the mind of the one    P rojective identification is often appealed to as mechanism of trans ference, or more exactly transference–countertransference interactions , particularly in K leinian usage. C onfus ion arises the failure to clearly distinguish between and projective identification. T he notion of

641 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 219 of 238

projective identification added to the bas ic of projection the notes of diffusion of ego boundaries , a los s or diminis hing of self–object differentiation, and inclusion of the object as part the self.    Later elaborations of the notion of projective identification transformed it from a one-body to a two-body phenomenon, describing interaction between two s ubjects , one of whom projects something onto or into the other, whereon the introjects or internalizes what has been projected. Ins tead of the projection and introjection taking place in the same s ubject, the projection now place in one and the internalization in the other. latter usage has led to extensive extrapolation of concept of projective identification to apply to object relations of all s orts , including T he emphasis in K leinian transference is les s on influence of the pas t on the pres ent but rather the influence of the internal world on the external in here-and-now interaction with the analys t.

P.742

C OUNTE R TR ANS FE R E NC E If the patient is capable of trans ference in the analytical interaction, the analyst is correspondingly capable of 642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 220 of 238

countertransference, meaning that the analys t engages the interaction with his or her own burden of elements coming from his or her own developmental past or elements that may be activated in the course of his or interaction with the patient, es pecially in res pons e to patient's transference. Originally, countertransference a matter of a res ponse in the analys t's unconscious affecting his or her view of and reaction to the patient, recent views tend to see it as encompas sing the total affective res ponse of the analyst to the patient, whether cons cious or unconscious, and as reflecting more res ponses arous ed in the present interaction with the patient than influences coming from the analyst's pas t experience or uncons cious . When patient transference and analys t countertransference are caught up in an interaction, res ult is a transference–countertransference E arly views of countertrans ference saw it as interfering the work of the analys is , as it may often do, but recent revis ions have emphas ized the contributions to more effective analytical work arising from attention to and of countertrans ference res pons es in the course of an analysis. C ountertrans ference has thus become as inevitable and not necess arily destructive to the analytical process . T he author's opinion is that it is insofar as it reveals unconscious factors that would otherwis e remain hidden but that therapeutic and effect cannot be achieved through countertransference as s uch but only through the us e made of it from the vantage point provided through the therapeutic alliance. If the therapis t finds him- or herself annoyed at a patient, it is not therapeutically 643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 221 of 238

to express or act out the annoyance on the patient. it is useful to analyze the s ources of the anger in his or past experience and find a cons tructive way to deal in relation to the patient.

THE R APE UTIC AL L IANC E T he therapeutic alliance is bas ed on the one-to-one collaborative relations hip that the patient establishes in interaction with the analyst. T his interaction deals with those aspects of the therapeutic relation that enable patient and analyst to engage meaningfully and productively in the analytical process with the objective achieving therapeutic benefit for the patient. T he terms the alliance are negotiated between analyst and obviously, not any terms of their working together do only thos e that can predictably contribute to or s et the stage for their effectively working together. T he alliance these terms includes at least the following elements : empathy, trust, autonomy, respons ibility, authority, freedom, hones ty, and neutrality. All these elements pertinent to the role of the patient in analysis as to the analyst. T he therapeutic alliance allows a s plit to take place in patient's ego—that is , the observing part of the ego can ally its elf with the analyst in a working relations hip, which allows it to gradually identify with the analys t in analyzing and modifying defens es put up by the defensive ego against internal danger situations . Maintenance of this therapeutic s plit, well as the relationship to the analyst involved in the therapeutic alliance, requires maintenance of s elf– differentiation, tolerance and mastery of ambivalence, 644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 222 of 238

the capacity to dis tinguish fantasy from reality in the relations hip. In many analyses, consequently, the requires work and effort to es tablis h and can thus one of the objectives of the analytical work. In no cas e the alliance be taken for granted P.743 or ass umed because the propens ity of all patients to various s ubtle forms of misalliance is pervas ive. If they not carefully looked for and attuned to, s uch can easily dis tort the cours e of an analys is and only become apparent when they reach a point of cris is or impas se. In more severely dis turbed pers onalities, a greater tendency to dis ruptions of the alliance rather than mis alliances , which can destroy an analytical and often require extreme efforts to salvage the Maintenance of the therapeutic alliance requires that patient be able to differentiate between the more and the more infantile as pects of the experience in relations hip to the analyst. T he therapeutic alliance a double function. On one hand, it acts as a s ignificant barrier to excess ive regress ion of the ego in the proces s; on the other hand, it s erves as a fundamental as pect of the analytical s ituation, against which the feelings, and fantas ies evoked by the transference can be evaluated, meas ured, and interpreted. In many pathological conditions —some character neuroses, borderline pers onalities , and more s evere neurotic disorders —it may be difficult to maintain a clinical distinction between therapeutic alliance and the transference neuros is . T he therapeutic alliance derives from the mobilization 645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 223 of 238

specific ego resources relating to the capacity for relations and reality tes ting. T he analyst mus t direct attention toward eliciting the patient's capacity to es tablis h s uch a relations hip that is able to withstand inevitable distortions and regres sive as pects of the transference neuros is . It is inevitable that the features of the therapeutic alliance be carefully and unders tood and ultimately integrated with the analysis of the trans ference neuros is. T his point is particularly and graphically displayed in the analysis of hysterical patients . T he initial transference neuros is of patients tends to pres ent primarily oedipal material, but analysts have learned to appreciate the importance of underlying oral factors in the genes is of many disorders . In the terminal stages of analys is of these patients, it becomes increasingly clear that res olution oedipal conflicts depends on the s uccess ful analys is of earlier conflicts stemming from the pregenital level of development. S pecifically involved are conflicts , us ually an oral level, that are related to achieving early object relations and the acceptance of reality and its T hese elements, however, are s pecifically thos e that the developmental basis of the therapeutic alliance.

R E AL R E L ATION R eality pervades the analytical relationship. On one there is the reality of the pers onalities and of analys t and analysand; on the other, there are the realities of time, place, and circums tance external to analytical s etting but constantly influencing the course the analytical relation. T hese include realities of the location of the analyst's office, the phys ical the furniture and decorations in the room, the 646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 224 of 238

geographical location itself, and even how the analys t dress es; they all have their effects in the analytical and influence how the P.744 patient experiences the pers on of the analyst. T he surrounding circums tances that create the framework the analytical effort—the patient's financial s ituation, marital s tatus, and job demands ; arrangements for payment of the fee; whether the patient has ins urance what kind; what kinds of press ures are pus hing the into treatment; accidental factors such as illness , interfering obligations —are reality factors extrinsic to analysis but exercis ing significant influence on the analytical relations hip and how it is es tablis hed and maintained. T he most important and central reality for the patient is the person of the analys t. E very analys t has his or her cons tellation of personal characteris tics, including manneris ms , style of behavior and speech, habits of gender, way of going about the task of managing the therapeutic s ituation, attitudes toward the patient as a human being, prejudices , moral and political views , and personal beliefs and values. T hes e are all relevant of one's real exis tence and personality as a human T hey are realities that play a role in the therapeutic relations hip and are entirely dis tinct from transference countertransference. In terms of the analytical process , none of this is lost on the patient who is observant of and s ensitive to the smallest details of the analyst's real pers on. T he same considerations operate from the s ide of the analyst in relation to the patient. 647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 225 of 238

Tec hnic al A s pec ts T he analytical technique is always adapted to the idios yncras ies of the patient's developmental needs , and defens ive cons tellation. Analytical do not stand in is olation but are part of a living, proces s that is intended to induce and achieve internal ps ychic growth.

FR E E AS S OC IATION T he corners tone of the psychoanalytic technique is free as sociation. T he patient is encouraged to use this as far as pos sible throughout the treatment. T he function of free as sociation, besides obvious ly content for the analys is , is to help to induce the regress ion and relatively pass ive dependence with es tablishing and working through the trans ference neuros is . T hus, free ass ociation is conjoined with the techniques that induce such regres sion, namely, lying the couch, not being able to see the analyst, and conducting the analysis in an atmos phere of quiet and res tful tranquility. One als o cannot simply regard the proces s of free as sociation as s omething that takes place in is olation the patient. In fact, the proces s is more complex, more difficult to conceptualize, and increasingly mus t be the context of and in reference to the more relations hip between analyst and patient. T he patient's free as sociating is a function of the more basic relations hip. Moreover, it is increasingly clear from a contemporary perspective that much more is required patient than s imply free as sociating. It is not enough for 648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 226 of 238

the patient to lay back and allow s elf-surrender to a position of pass ive dependency within the analytical relations hip without at the same time being able to mobilize basic ego res ources in the service of mastery, gaining insight, mobilizing executive and synthetic capacities, and, ultimately, being able to as sume a less pass ive and more active and autonomous function the analytical relations hip. Obviously, there is a in the mobilization of thes e capacities in the patient, varies from phas e to phase of the analytical process .

R E S IS TANC E T he most conscientious efforts on the part of the say everything that comes to mind are never succes sful. No matter how willing and cooperative the patient may be in attempting to free ass ociate, the res is tance are apparent throughout the course of every analysis. T he patient paus es abruptly, corrects him- or herself, makes a slip of the tongue, s tammers , remains silent, fidgets with s ome part of clothing, asks irrelevant questions , intellectualizes , arrives late for finds excus es for not keeping them, offers critical evaluations of the rationale underlying the treatment method, s imply cannot think of anything to s ay, or even cens ors thoughts that do occur and decides that they banal or uninteres ting or irrelevant and not worth mentioning. T he development of resis tance in the analysis is quite automatic and independent of the patient's will as the development of the transference itself. T he s ources of res is tance are just as uncons cious as sources of transference. T he emotional forces, however, that give 649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 227 of 238

to resistance us ually are defending against thos e producing the trans ference. T hus, res is tances tend to emerge more in the middle phase of the analys is, in regress ive emergence of the trans ference is a central concern. T he analys is becomes a recurring field of between the tendencies toward transference and those toward res is tance, manifes ted by the involuntary inhibition of the patient's efforts to ass ociate freely. T his inhibition may las t for moments or days or may pers is t through the whole course of the analys is . R es istance may take place in all phases of the its quality and significance are different depending on analytical task at hand. In any case, the patient's enables the analys t to evaluate and become familiar the defens ive organization of the patient's ego. In this the pattern of resistance not only offers valuable information to the analys t but also offers a channel by which the patient can be approached therapeutically. T he significance of this basic conflict is clear. It is a repetition of the very same s exuality–guilt conflict that originally produced the neuros is its elf. T ransference may be a form of resistance, in that the wis h for gratification in the analys is can circumvent and es sential goals of treatment. C onsequently, the res is tance, particularly trans ference res is tance, is one the analyst's primary functions . It als o accounts in cases for the extended time period required for ps ychoanalytic treatment. No matter how s killful the analyst, res is tance is never absent. In the light of relational and intersubjective on the analytical proces s, the concept of resistance fallen out of favor in that any s uch phenomenon is a 650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 228 of 238

byproduct of the interaction between analyst and T here is, then, no resistance coming from the patient rather is contributed by both participants . R es is tance only be dealt with by examining the interaction caus ing and not by interpretation of the patient's defens es . T his point of view remains highly controvers ial.

INTE R PR E TATION Interpretation is the chief tool of the analys t in efforts to reduce uncons cious res is tance. As mentioned earlier, the early stages of the development of psychoanalytic therapeutic techniques, the sole purpos e of was to inform the patient of his or her unconscious Later, it was des igned to help the patient understand res is tance to s pontaneous self-awarenes s. In current ps ychoanalytic practice, the analyst's function as interpreter is not limited to s imply paraphrasing the patient's verbal reports but, rather, to indicating at appropriate moments what is not reported or is implicit what is reported. C ons equently, as a general rule, analytical interpretation does not produce immediate symptomatic relief. On the contrary, there may be a heightening of anxiety and an emergence of further res is tance. If a correct interpretation is given at the proper time (mutative interpretation), the patient may react either immediately or after a period of emotional s truggle which new as sociations are offered. T hese new as sociations often confirm the validity of previous interpretations and add s ignificant additional data, thus disclos ing motivations and experiences of the patient of which the analys t could not previously have been 651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 229 of 238

G enerally s peaking, P.745 it is not so much the analyst's insight into the patient's ps ychodynamics that produces progress in the analys is it is the patient's ability to gain this insight the analyst can facilitate this proces s by reducing unconscious resis tance to s uch self-awarenes s appropriate, carefully timed interpretation. T he most effective interpretation is timed so that it is given by the analyst in s uch a way as to meet the emerging, if and half formed, awarenes s of the patient. T hus , the analyst mus t gauge the capacity of the patient at any given moment to hear, as similate, and integrate the content of a given interpretation. Another important as pect of interpretations is that they cannot be s een in isolation from the total context of the analytic situation and the analytic proces s. An interpretation, both as given by the analys t and as received by the patient—and that includes elements of both transference neurosis and therapeutic alliance— takes place within the context of the therapeutic relations hip. T hus, the giving and receiving of interpretations are cloaked with a series of meanings unavoidably influence both the capacity of the patient accept and integrate interpretations and the analys t's sens e of offering and providing such interpretations. E xperience has s hown that, at best, the therapeutic benefits produced by virtue of the analyst's unilaterally provided insights are only temporary. T hose interpretations are most effective and of lasting therapeutic value that are arrived at by the delicate 652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 230 of 238

dialectic arising from the mutually facilitated and awarenes s of both patient and analyst.

MODIFIC ATIONS IN TE C HNIQUE S T here are no shortcuts in psychoanalytic treatment. P sychoanalytic treatment typically extends over a of years and requires interminable patience on the part both analyst and patient. R igid adherence, however, to fundamental principles of psychoanalytic technique is impos sibility. F or example, the immediate situation may be s o serious for the patient that the must pay commons ens e attention to its practical implications. T hose patients whose early childhood extraordinarily deficient in love and affection so that have a basic developmental defect in their capacity for one-to-one relations hip and, consequently, in their capacity to sus tain a therapeutic alliance must be given more s upport and encouragement than usually by strict ps ychoanalytic technique. T he analyst's role in the early s tages of analysis in to es tablis h the therapeutic alliance is of particular importance. As noted, with the primitive patients, the es tablis hing of a therapeutic alliance can be the more significant aspect of the treatment proces s and can persis t as a problem through most of the analys is. es tablis hing the therapeutic alliance for mos t patients is significant aspect of the analytic process . T he nature and the degree of the analys t's active intervention in the opening hours of analys is are s till matters of considerable dis cuss ion and controversy. transference neuros is us ually develops only gradually, that attempts at premature interpretation in the early 653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 231 of 238

hours may not be productive and may even be counterproductive. T his has tended to foster the us e of prolonged silences , lack of responsivenes s, rigidity, relative lack of participation in the analys is on the part the analyst, as if any reference to the analytic situation to the pers on of the analyst or to the patient's feelings about the analys t was to be taken as contrary to developing a transference interpretation and, thus, to avoided. Often, however, s erious problems in the subs equent s tages of analysis of the transference can due to a failure to es tablis h a meaningful alliance in the initial s tages of treatment. T hus, suitable interventions the analyst in the early stages of treatment can help patient in es tablishing such a meaningful therapeutic alliance. P atients who are more borderline or very narciss is tic es tablis h a strong personal tie and strong feelings of attachment and relations hip with the analys t before can develop sufficient interes t and motivation for treatment. Moreover, s uch a s trong object tie with the analyst for these more primitive patients is an absolute neces sity if the destructive effects of excess ive are to be avoided. Development of sufficient trust is es sential for these patients if they are to establish any meaningful alliance. T hes e are difficult problems, because experience also sugges ts that every deviation from analytic technique that such special conditions compel tends to prolong the length of treatment and to cons iderably increase its viciss itudes and problems. S uch modifications in analytical technique us ually go under the heading of “parameters ,” and they remain a cons iderable source of dis cus sion and controversy 654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 232 of 238

analytical therapis ts. A significant trend today is the increasing tendency of analys ts to treat more difficult complex cases ; thus , the neces sity for introducing modifications in various aspects of the treatment corres pondingly increas es . As a res ult, what might previous ly have been thought of as parameters are increasingly accepted as valid technical practices . T he res olution of such difficulties in as sess ing and modifications of techniques mus t ultimately rest on the basis of clinical experience.

R es ults of Treatment T he therapeutic effectivenes s of ps ychoanalys is problems in its evaluation. Impartial and objective are handicapped in attempts to apprais e therapeutic res ults by the fact that s o many patients state that they have been analyzed when no s uch procedure was, in undertaken or when it was undertaken by s omeone us ed the title of analys t and who had little of analytical s cience and technique. Other patients been in analysis only for a very short time and then discontinued treatment on their own initiative or were advis ed that they were not suitable candidates for analytical treatment. E xcept for ps ychoanalys ts thems elves , profes sionals, as well as lay people, demonstrate varying degrees of confusion as to what ps ychoanalys is is and what it is not. No analyst can ever eliminate all the personality and neurotic factors in a given patient, no matter how thorough or success ful the treatment. Mitigation of the rigors of a punitive s uperego, however, is an es sential criterion of the effectivenes s of treatment. 655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 233 of 238

do not us ually regard alleviation of s ymptoms as the significant aspect in evaluating therapeutic change. absence of a recurrence of the illnes s or a further need ps ychotherapy is perhaps a more important index of value of ps ychoanalys is . T he chief bas is of evaluation, however, remains the patient's general adjus tment to life—that is , the capacity for attaining reas onable happines s, for contributing to the happines s of others, ability to deal adequately with the normal viciss itudes stress es of life, and the capacity to enter into and mutually gratifying and rewarding relationships with people in the patient's life. More s pecific criteria of the effectivenes s of treatment include the reduction of the patient's uncons cious; neurotic need for s uffering; reduction of neurotic inhibitions; decreas e of infantile dependency needs ; an increas ed capacity for respons ibility and for relations hips in marriage, work, and social relations. important criteria are the capacity for pleas urable and rewarding sublimation and for creative and adaptive application of the patient's own potentialities . T he most important criterion of the s ucces s of treatment, the releas e of the patient's normal potentiality, which been blocked by neurotic conflicts, for further internal growth, development, and maturation to mature personality functioning. Des pite the methodological difficulties and complexities outcome s tudies , extens ive empirical evaluations from number of centers P.746 have demons trated the effectivenes s and relative 656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 234 of 238

of psychoanalysis and ps ychoanalytic therapy for appropriately s elected cases in the ps ychoneurotic conditions, pers onality disorders , and forms of s elfpathology. T herapeutic outcomes have been more guarded in cas es of ps ychosomatic illness , more levels of personality dis order, and ps ychoses .

S UG G E S TE D C R OS S T he ps ychoanalytic perspective is relevant to virtually every chapter of this book. Of particular interes t are the discuss ion of E riks on in S ection 6.2, other schools in S ection 6.3, and approaches derived from ps ychology and philosophy in S ection 6.4. Neurodevelopmental theory of s chizophrenia is S ection 12.5. P s ychological treatments of mood are covered in S ection 13.9; anxiety dis orders in 14; personality dis orders in C hapter 23; psychoanalys is ps ychoanalytic ps ychotherapy in S ection 30.1; of psychotherapy in S ection 30.11; and psychotherapy with the elderly in S ection 51.4h.

R E F E R E NC E S B alint M. P rimary L ove and P s ycho-Analytic New Y ork: Liveright; 1965. B lum HP : Mas ochis m, the ego ideal, and the of women. J Am P s ychoanal As s oc. 1976;24 Diamond D, B latt S J : Attachment res earch and ps ychoanalys is. 1. T heoretical considerations . 2. implications. P s ychoanal Inquiry. 1999;19:4–5. 657 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 235 of 238

Diamond D, B latt S J , Lichtenberg J : Attachment res earch and ps ychoanalys is . 3. F urther reflections theory and clinical experience. P s ychoanal Inquiry. 23(1). E rikson E H. C hildhood and S ocie ty. New Y ork: 1963. E rle J B , G oldberg DA: T he cours e of 253 analyses selection to outcome. J Am P s ychoanal As s oc. 2003;51:257. F airbairn W R D. P s ychoanalytic S tudies of the London: R outledge and K egan P aul; 1972. *F enichel O. T he P s ychoanalytic T he ory of Y ork: Norton; 1945. F reud A. T he ego and the mechanisms of defense. T he W ritings of Anna F re ud. V ol II. 1936. New Y ork: International Universities P res s; 1975. F reud S . O n Aphas ia: A C ritical S tudy. New Y ork: International Universities P res s; 1953. *F reud S . T he S tandard E dition of the C omple te P s ychological W orks of S igmund F re ud. 24 V ols. Hogarth P ress ; 1953–1974. *G reenberg J R , Mitchell S A. O bje ct R e lations in P s ychoanalytic T he ory. C ambridge, MA: Harvard 658 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 236 of 238

Univers ity P res s; 1983. Hartmann H. E s s ays on E go P s ychology. New Y ork: International Universities P res s; 1954. Hartmann H. E go P s ychology and the P roble m of Adaptation. New Y ork: International Univers ities 1958. Hins helwood R D. A Dictionary of K leinian T hought. London: F ree Ass ociation B ooks; 1991. K ohut HS . T he Analys is of the S e lf. New Y ork: International Universities P res s; 1971. K ohut HS . T he R es toration of the S e lf. New Y ork: International Universities P res s; 1977. K ohut HS . How Doe s Analys is C ure ? C hicago: of C hicago P ress ; 1984. Levin F M. P s yche and B rain: T he B iology of T alking Madis on, C T : International Universities P res s; 2003. Loewald HW . P ape rs on P s ychoanalys is . New Y ale Univers ity P res s; 1980. Mahler MS , P ine F , B ergman A. T he P s ychological the Human Infant. New Y ork: B asic B ooks ; 1975. Mass on J M. T he C omple te L e tte rs of S igmund W ilhe lm F lie s s 1887–1904. C ambridge, MA: 659 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 237 of 238

Univers ity P res s; 1985. Meis sner WW . Inte rnalization in P s ychoanalys is . Y ork: International Universities P res s; 1981. *Meiss ner W W. T he T he rape utic Alliance . New Y ale Univers ity P res s; 1996. Meis sner WW . T he E thical Dile mma of Dialogue . Albany, NY : S tate University of New Y ork P res s; 2003. Mitchell S A. R elational C once pts in P s ychoanalys is . C ambridge, MA: Harvard Univers ity P ress ; 1988. *Moore B E , F ine B D. P s ychoanalys is : T he Major New Haven, C T : Y ale Univers ity P res s; 1995. R ichards AD, T ys on P : T he psychology of women: P sychoanalytic perspectives. J Am P s ychoanal 1996;44. R izzuto AM, Meis sner WW , B uie DH. T he Dynamics Human Aggres s ion: T heore tical F oundations , Applications . New Y ork: B runner-R outledge; 2004. S chafer R . As pects of Inte rnalization. New Y ork: International Universities P res s; 1968. S hapiro T , E mde R N: R esearch in psychoanalys is : P roces s, development, outcome. J Am P s ychoanal 1993;41[S uppl]. 660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 238 of 238

S tern D. T he Inte rpe rs onal W orld of the Infant. New B as ic B ooks; 1985. S tolorow R , Atwood G . C onte xts of B eing: T he Inte rs ubje ctive F oundations of P s ychological L ife. Hillsdale, NJ : Analytic P res s; 1992. T yson P , T yson R L. P s ychoanalytic T he orie s of Deve lopme nt. New Haven, C T : Y ale Univers ity 1990. Winnicott DW . P laying and R e ality. New Y ork: B as ic B ooks ; 1971.

661 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

01/01/2009

Page 1 of 154

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 7 - Diagnosis and P s ychiatry: E xamination of the P s ychiatric P s ychiatric Interview, H is tory, and Mental S ta tus E xa mination

7.1: Ps yc hiatric Interview, His tory, and Mental S tatus E xamination E kkehard Othmer M.D., Ph.D. S ieglinde C . Othmer Ph.D. J ohann Philipp Othmer M.D. P art of "7 - Diagnos is and P s ychiatry: E xamination of P sychiatric P atient"

INTR ODUC TION Goal of the C linic al Ps yc hiatric Interview T he goal of the initial diagnostic clinical psychiatric interview is to collect s pecific, detailed information 15 topics . T hese topics cons titute the ps ychiatric evaluation. Acquiring the databas e of information for these 15 topics enables the interviewer to make compatible with the revis ed fourth edition of Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV five axes and to develop a treatment plan acceptable to the patient: I. Identifying data. T he patient's name, s ex, age, marital s tatus, and vital s igns. 662 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 2 of 154

II. C hief complaint. T he chief complaint in the patient's own words . Alternatively, signs of dis ordered functioning observed by the interviewer. III. Informants . A list of all informants, their reliability, level of cooperation; also previous hospital records , available. S uch informants are es sential in circums tances that prevent the patient from adequate information. C hoos ing the right s et of informants is more important than having a great number of informants. IV . R eas on for admiss ion or cons ultation. T he referral source; in case of hos pitalization, statement of status —voluntary versus involuntary—and the why hos pitalization is the safest and least environment for treatment. V . His tory of pres ent illnes s. E arly manifestations and recent exacerbations of all ps ychiatric disorders present (Axis I and II); review of diagnoses and treatments given by other providers. V I. P sychiatric dis orders in remis sion. P s ychiatric presently in remiss ion, es pecially substance abus e disorders ; ps ychiatric disorders firs t diagnosed in childhood and adolescence and their treatments . V II. Medical his tory. All medical dis orders past and and their treatments and childhood disorders that involve the central nervous system (C NS ). F or pregnancy status —es pecially if on psychotropics or expecting the us e of ps ychotropics and precautions agains t pregnancy and concomitant treatment. On all patients, but particularly in liais on work, the medical history includes the 663 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 3 of 154

interrelation of medical and ps ychiatric conditions. V III. S ocial history and premorbid pers onality. E arly developmental history. Description of premorbid personality as baseline for patient's best level of functioning. Impact of Axis I and II dis orders on patient's life. T he patient's psychosocial and environmental conditions predisposing to, precipitating, perpetuating, and protecting against ps ychiatric disorders. P remorbid vers us morbid functioning. P resent s upport s ys tem. IX. F amily history. P sychiatric history of first-degree relatives , including treatment respons e as a genetic predisposition for the patient. X. Mental s tatus examination. Appearance, cons ciousnes s, psychomotor functions , s peech, thinking, affect, mood, s ugges tibility, and thought content; cognitive functions, such as orientation, memory, intelligence, and executive functions; and judgment. XI. Diagnos tic formulation. S ummary of biological, ps ychological, and s ocial factors contributing to the patient's ps ychiatric disorder. XII. Differential diagnos is . Dis cuss ion of diagnos tic based on overlapping symptomatology. XIII. Multiaxial psychiatric diagnos is . Information on all axes . XIV . Ass ets and s trengths . Inventory of patient's knowledge, interes ts , aptitudes, education, and employment status to be us ed in the treatment XV . T reatment plan and prognos is . Account of 664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 4 of 154

ps ychopharmacological, ps ychological, and s ocial treatment modalities planned, frequency of visits, list of providers ; discharge criteria if inpatient. How does the interviewer get comprehensive, clinically significant, reliable, and valid information to cover points in a restricted time frame of 20 to 90 minutes? acquire the communication skills needed for this task, interviewer has to mas ter the range between disordercentered and patient-centered interviewing s tyles and apply them to the four components of the interview: rapport, techniques , mental s tatus, and diagnos ing.

Dis order-C entered vers us P atientC entered Interviewing S tyles P sychiatric interviewing is a s pecial form of human communication. T he interviewer asks the patient to disclos e complaints , s hare problems, and reveal According to the difficulties that the patient experiences with this reques t, the interviewer shifts the focus disorder-centered and patient-centered interviewing. Dis order-centered interviewing is bas ed on a atheoretical model of ps ychiatric dis orders called the me dical P .795 mode l, which is the official model s upported by the American P s ychiatric Ass ociation (AP A) and the W orld Health Organization (W HO) codified in DS M-IV -T R and the International C lass ification of Dis eas es (IC DT his framework views ps ychiatric disorders as s imilar medical dis orders, using criteria for diagnos is as 665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 5 of 154

identifiable clus ters of occurrences from a res tricted of symptoms , s igns, and behaviors that caus e and mortality. E ach disorder can be differentiated from other psychiatric disorders ; each has a typical natural history, often occurs in increased frequency in firs trelatives , with specific comorbidities, and with predictable treatment respons es . Whereas the an infectious dis order is established by tests that determine the pres ence or absence of a specific agent, tes ts confirming the etiology of a diagnosis in ps ychiatric disorders are not available. E xcept for the presence of es tablis hed or s us pected genetic etiology is incomplete. S pecific genetic les ions or susceptibilities, perhaps arising through multifactorial genetic factors, which form the basis of the current paradigm of the etiology of psychiatric disorders , to be determined. T he triggers for ps ychiatric disorders remain a mys tery, as do the triggers for the onset of infectious diseas es and medical conditions . R is k present in more people than actually develop the T o establish a psychiatric diagnosis based on this descriptive medical model, the interviewer chooses proven, s ymptom-oriented, open-ended ques tions with relatively narrow s cope followed up by closed-ended, nonleading ques tions centering on the dis order. P rerequisites for this style are the knowledge of the IV -T R criteria and the 15 topics to be covered. T his disorder-centered interview style works for mos t cooperative patients , patients whose communication are not impaired by their Axis I and II dis orders or their defens e mechanisms. Disorder-centered interviewing driven by the patient's help-seeking behavior. 666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 6 of 154

for dis order-centered interviewing can be acquired the firs t few years of training. In contras t, patient-centered interviewing is bas ed on intros pective model, which emphas izes the individuality the patient's experience. T his model attends to the intraps ychic battle of conflicts . It is s ens itive to the patient's educational, emotional, intellectual, and social background, the personality, and the individual cons tellations tracing their arrival to individual circums tances and the individual's unique respons e (cognitive-behavioral model). One example of the intros pective model is the ps ychodynamic model. Interviewing based on the psychodynamic model uses nonstructured, open-ended ques tions with a broad encouraging free as sociation. T he ps ychodynamic posits the etiology of psychiatric s ymptoms as to often unconscious inter- and intrapersonal conflicts . explores and interprets behaviors and s equences of answers . In this model, the interviewer strives to help patient overcome self-defeating intra- and interpersonal conflicts. T he prerequis ite for s uch an interview is the interviewer's experience and unders tanding of coping styles, the knowledge of how Axis I and II disorders interfere with the doctor–patient interaction (transference), and how to manage such interference. S witching to the patient-centered s tyle may become neces sary if the patient puts up res is tance and and becomes difficult to interview. T o acquire in patient-centered interviewing is a lifelong endeavor, training for excellence in most s ports. T he disorder-centered and patient-centered styles do not exclude each other. T hey are end points 667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 7 of 154

continuum. T he interviewer's mobility and flexibility in gliding between the two extremes determine the efficiency, reliability, validity, and quality of data T he degree of the patient's impairment determines to which extent the disorder-centered interview has to be augmented by patient-centered s trategies.

Five Phas es of the Ps yc hiatric and Four C omponents T he ps ychiatric interview progres ses over time, which be arbitrarily subdivided into five phas es. T hes e cover sequentially the 15 (I to XV ) topics of the evaluation. P hase 1: W arm-up and C hief C omplaint (I to IV ) P hase 2: T he Diagnos tic Decision Loop (V ) P hase 3: His tory and Databas e (V I to X ) P hase 4: Diagnos ing and F eedback (XI to XIV ) P hase 5: T reatment P lan and P rognosis (XV ) T he five phas es divide the ps ychiatric interview longitudinally. C ros s -sectionally, the interview cons is ts four components, which the interviewer must continuously monitor and propel throughout. R apport focus es on the doctor–patient relations hip; a rapport is a prerequisite for an effective interview. is es tablis hed in the opening; with a cooperative and insightful patient, there is often little problem in es tablis hing and maintaining a good rapport. However, patients who are uncooperative or s how poor ins ight, es tablis hing a workable rapport with the patient 668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 8 of 154

a central iss ue. T e chnique refers to the approaches the interviewer keep an interview “on track.” It includes s kills to appropriately select questions to arrive at a diagnosis. G ood technique is necess ary to therapeutically engage and work with difficult patients . Me ntal s tatus as sess ment captures the patient's experiences , symptoms, signs, behaviors , thought cognitive level of functioning, insight, and judgment during the actual time of the interview. F ormal testing mental s tatus may take place late in the interview; however, in a patient with a s ignificantly altered mental status —whether it be a bois terous, irritable, and uninterruptible manic patient, a minimally responsive depres sed patient, or a paranoid patient—his or her mental s tatus plays a s ignificant role in the interview. Diagnos ing pursues a progres sion in the diagnostic decis ion proces s from chief complaint to final

R A P P OR T Interviewing relies on rapport, from the F rench verb rapporte r, to bring back—that is , to bring back the res ponse to the sender. C reating this feedback interviewer and patient is the es sence of It is rooted in a s tream of nonverbal signals. Language adds precision and complexity. If the patient's mental status interferes with this interaction, the interviewer from as sess ing a disorder to managing the patient's mental s tatus —that is , the disorder-centered interview becomes patient centered.

Dis order-C entered vers us P atient669 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 9 of 154

C entered Interviewing and R apport With a cooperative patient, the interviewer starts out in disorder-centered mode, checking whether DS M-IV -T R criteria for ps ychiatric disorders are met. He or she that the patient seeks help voluntarily and will answer questions . As the interviewer acts in a profes sional manner; does not P.796 insult or offend the patient; and asks clear, unders tandable, and relevant ques tions ; the expects the patient will res pond. R apport follows . In contras t, with a difficult patient, the interviewer shifts a patient-centered mode. T o obtain a comprehensive diagnosis and to judge the patient's capacity for staying treatment, the interviewer explicitly focuses on es tablis hing a cooperative relationship with the patient. E ight elements determine the quality of this relations hip (T able 7.1-1).

Table 7.1-1 R apport in Dis orderC entered and Patient-C entered Interviewing S tyles Dis orderE lements C entered R elations hip Interview

PatientC entered Interview

670 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 10 of 154

P ers pective

T he interviewer is in charge, knows diagnostic criteria of the disorder.

P atient holds the key to the symptoms; without the patient's genuine contributions , a valid diagnosis cannot be made.

C omfort

Most patients quickly become comfortable with the interview situation; no special attention needed. Minor discomfort by the patient may be

T he patient and interviewer need to experience comfort. T he interviewer has to address tension, es pecially with anxious and suspicious patients.

E mpathy

T he interviewer as sess es symptoms and expres ses unders tanding.

T he interviewer as sess es suffering and expres ses empathy.

671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 11 of 154

Ins ight

Most patients know they a dis order.

T he patient not accept having a disorder. T he interviewer has to decreas e the distance between the patient's and the view of the patient's ps ychiatric problems .

Alliance

T he interviewer cannot diagnose or treat the illness if the patient does not tell what is wrong. the patient becomes uncooperative, the interviewer may remind the patient of that fact.

S triving for alliance sets tone of the interview. T he interviewer identifies the patient's illness as the common enemy us ing the patient's level of ins ight.

672 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 12 of 154

E xpertise

T he interviewer us es a s et of DS M-IV -T R — derived generic questions to as sess ps ychiatric disorders .

T he interviewer individualizes questions the s pecific manifestations of the patient's disorders . T he patient contributes the knowledge about his or her problems . T he interviewer contributes his or her knowledge about ps ychiatric disorders and their treatment.

G uidance

Usually at the end of the interview, the interviewer discuss es the treatment plan and obtains verbal acceptance

T hroughout, interviewer defines the cooperative roles of interviewer and patient in the treatment proces s.

673 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 13 of 154

from the patient. T rus t

E xpected byproduct of thorough, detailed interviewing.

R es ult of purpos eful development of several levels relating, i.e., providing comfort, empathy, insight, expertise, and guidance.

Pers pec tive Depending on the patient's behavior, the interviewer focus es his or her attention either on the diagnos tic proces s (i.e., the dis orders to be explored) or on the patient's immediate emotions and needs without the interview to turn into an ad hoc ps ychotherapy sess ion. Although the knowledge of the diagnos tic is es sential for the interviewer, their implementation requires that the patient provide genuine, detailed answers . A patient who states , “Y ou are the doctor, decide,” tries to s kirt his or her part. R ecognizing dependency needs, the interviewer corrects the view by making him or her aware of the expected input. 674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 14 of 154

C omfort Many patients quickly become comfortable with the interview s ituation. However, if the patient appears anxious, is trembling, or has a moist hands hake or a pulse, the interviewer may addres s s uch discomfort indirectly: “Have you s een a psychiatrist or couns elor before? ” or directly: “Y our pulse is over 100. Is there problem with your heart? ” T he interviewer may give the patient time to calm down by offering something to or by as sess ing demographics : “Do you live in this neighborhood? ” T he interviewer als o s hould pay to his or her own comfort if the patient is intimidatingly aggres sive or demanding, offens ively flirtatious , or and addres s this problem. A 42-year-old, red-faced, married Iris hman who was accused by his wife of drinking too much entered the office accompanied by his dog, a mixed breed of wolf G erman s hepherd. T he dog circled through the interviewer's office inces santly. Interviewer (I): Mr. M., your dog distracts me from with you. C an you have the dog sit? P atient (P ): (G leaming) Are you scared? I: (T he dog keeps circling in the room and s taring at the interviewer) I know neither you nor your dog. W ould like me to be s cared? P : It depends what you will tell me. I: W hat are you scared of that I would tell you? P : T hat I'm an alcoholic and s hould s top drinking. I: (Laughing) And if I don't, you have the wolf eat me? 675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 15 of 154

P : (Also laughing) I: B ut you really have to tell me. Do you want to stop drinking? P : No. I don't. I: W hat did you want to accomplis h when you came P : My wife s ays s he'll divorce me if I don't s top. I: S o you don't want to s top? Y ou jus t want to hide your drinking better? P : I gues s that's right. I: I appreciate your hones ty. Mos t people who are for drinking too much and get threatened with divorce job loss try to con me and poss ibly themselves by they want to stop. Y ou don't. If you ever want to s top, I believe you can do it becaus e you are hones t with P : (T o the dog who is s till circling the room) Molly, here. S it! (Molly obeys) I: T hank you.

E mpathy F or a s ymptom to be counted, it has to caus e the impairment or dis tres s. W hen a patient describes his or P.797 her symptoms, the interviewer can follow up by getting precis e description of duration and frequency of symptoms or, alternatively, especially if the interviewer encounters denial (“otherwis e, I'm healthy”), by as king about the impairment and dis tres s that the s ymptom caus es and express ing empathy. A 74-year-old, white, married, former chief executive 676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 16 of 154

officer of a large company. P : I can't sleep. Otherwis e, I'm healthy. I wake up at 4 and can't go back to s leep. I: Do you also have problems falling as leep? P : Off and on. B ut I can handle that. I: W hat about waking up in the middle of the night? P : Once or twice. I may have to go to the bathroom. I: B esides your early morning insomnia, do you have other problems ? P : No. I'm really pretty healthy. I: Do you feel depres sed? P : No. I: Do you have any hobbies? P : I do volunteer work. I: C an you s till do it? P : Y es. I think it s erves a good purpos e. I help young entrepreneurs through the ZZZ foundation. Alternative: P : I can't sleep. Otherwis e I'm healthy. I wake up at 4 and can't go back to s leep. I: W hat does your ins omnia do to you? P : It wrecks my life. I tos s and turn in my bed. I'm tired during the day and worried about my s leep. W hen come over, I'm bored. T hey s ound so trivial. I: (Mirroring the patient's facial expres sion, frowning, lips, then bending forward) W e have to put our heads together and find a way to get rid of your problem. T he empathic, patient-centered approach invites the patient to express his or her thoughts and feelings 677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 17 of 154

his or her symptoms and describe his or her actions. approach breaks through the patient's denial of being depres sed, which the descriptive, s trictly symptomgathering approach does not do. T he interviewer's res ponse reflects the patient's affect and propos es a counteraction more convincing and genuine than a statement such as, “I unders tand your s uffering.” T he empathic res ponse follows the golden rule: Imagine thinking and feeling from the patient's level of ins ight. the patient know that you can understand his or her of view and initiate caring.

Ins ight A conflict about the nature of psychiatric s ymptoms and disorders can aris e between the interviewer and the patient. Undetected or unres olved, s uch a conflict of may lead to a breakup of the doctor–patient T herefore, the interviewer has to be aware of such differences and s trive for congruency. If the patient with the interviewer's view, the therapist calls this congruency full ins ight. W ith res pect to the acute hallucinations , delus ions , and manic s ymptoms , agree that the patient has very limited ins ight into the pathological nature of these perceptions, beliefs , and behaviors . T o change the patient's view, confrontation logical arguments are ineffective. Initially, the has to emulate the patient's view and intervene at the of the patient's unders tanding. A 38-year-old, divorced, male railroad worker. P : It's coming up again, even after 20 years . T hey can't go of it. 678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 18 of 154

I: Of what? P : Y ou know what, [expletive]! I: C an you help me out? P : (W ith a suspicious look) T hat I jacked off in the that hunting trip. At work, they are making digs again. I: W hat are you doing about it? P : I try to ignore it but it's getting hard. I: W ell, you are doing the right thing. don't do or say anything. don't let them know that they get to you. I will give you some medication that will make it eas ier to get over it. P : Okay. R ather than taking a dis order-centered view and telling the patient that he has a pers ecutory delus ion, which to be treated with medication, the interviewer the delus ion from the patient's viewpoint that “real” is happening to him. T his patient-centered does not challenge the patient's fals e fixed perception works on his level of ins ight, s till providing effective therapeutic intervention, a neuroleptic, and support for behavior—namely, to keep his persecutory perceptions hims elf. P atients with a pers onality dis order may recognize that certain behaviors caus e distress to family members but feel the family s hould change and be more tolerant than having to change. A 46-year-old, male, fundamental Lutheran minister. P : My wife wants a legal separation and that tears me As a minister, I s hould be able to s et an example for 679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 19 of 154

congregation. I can't have that s eparation. I: W hy does s he want that s eparation? P : S he s ays I get s o angry and critical with her and the S he can't take my anger outbursts any more. I: Do you think you get angry as s he says? P : Y es. It's my job. If I feel I get excus es or my kids or wife violate commandments of C hris tian conduct, I become like G od's hot s word cutting into butter. I: Do you feel your anger is too much and out of proportion? P : No. I think it's jus tified. I: C an you not get angry if you wanted to? P : T hat's hard to do. Maybe I carry my profes sion too into my family. I: W ould it be of advantage to you if you had more of a choice to become angry or not? If you increas ed your degree of freedom? P : I probably could live with that. I: W e both have to put our minds to work on increas ing power of free will. T he interviewer dis cus ses the patient's anger outburs ts as a res ult of a narcis sistic perfectionis tic personality disorder but as a challenge congruent with the patient's needs . S uccess ful anger control can increase the narcis sistic pride and his choices while helping the relations hip at the s ame time. R apport is strengthened identifying the patient's level of ins ight and interviewing him from the patient's perspective.

Allianc e 680 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 20 of 154

After the interviewer unders tands which s ymptoms, and behaviors the patient identifies as disordered, he she P.798 can explicitly split this part off as sick. T he interviewer explore with the patient what both can contribute to repair the s ick. B ecause the patient guards the box of his or her broken functions , he or she has to be willing to open it so that the interviewer can examine contents and dis cuss with the patient options for repair. T he interviewer stress es the need for an alliance. the patient says , “Y ou are the doctor, I do what you the interviewer may reply: “Y ou are the patient, and we both have to put our heads together to come up with best plan to s ucceed. I need your input and consent.”

E xpertis e S ome patients feel they can receive empathy and from family members and friends . S o what is the interviewer's edge? T he interviewer can provide at four things for the patient and may make him or her of that fact implicitly or explicitly. T he ps ychiatris t can acknowledge that he or she unders tands the disorder. or s he can emphasize that the patient is not alone, that others share the s ame disorder. T he interviewer can out that the patient's personality to deal with the is unique and can contribute to improve the disordered functions . He or she can appreciate the s ymptoms and signs of the dis order and the dis tres s that it caus es . He she may demons trate s uch knowledge by asking for specific s ymptoms that the patient tried to keep a 681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 21 of 154

such as : I: W hom in your family have you trusted enough to your obsess ions ? P : Nobody. How do you know that I feel embarrass ed talk about it to my family? T he interviewer may give the patient feedback about is known about the dis order. P atients who read about condition in books and on the Internet may evaluate interviewer more in terms of how much he or s he than by how much he or she cares . If the interviewer not know the ans wer to a patient's question, he or she clearly s tate that he or s he does not know but, “Let's out.” S ome patients are s us picious about the interviewer's expertise but do not want to offend him or her with their distrust. If the interviewer senses reluctance, he or she explore the nature of the doubts rather than ignoring them and hoping that the patient learns to trus t him or her. T he interviewer may pass over positive feedback the patient but, as a rule, should address negative even though he or she may feel uncomfortable in doing so. T he interviewer ins tills hope. R elated to providing a perspective and giving an outlook is the interviewer's ability to emphasize the positive factors regarding the patient's disorder, such as treatability, and the patient's personality, such as intelligence, resilience, and ability self-criticize.

Guidanc e 682 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 22 of 154

P atients rank the therapis t's leadership third after and empathy. F rom the beginning of the interview, the interviewer sets milestones for the progress ion of the encounter. T he interviewer can reach s ubgoals , s uch es tablis hing rapport and collecting information for the diagnostic process with the patient's agreement and cooperation. T hus , if the interviewer reads the patient's expectations for the interview and makes his or her congruent to these expectations , he or s he steers the interview with an invis ible hand. T he more the is willing to explain his or her ques tions and and their rationale and give options , the eas ier it to guide the patient through the interview with little conflict. S pecial s ituations may arise. Dependent may s hy from res ponsibility and des ire to be nurtured the “strong, all-powerful protector.” T he oppos itional patient or the patient with persecutory feelings may get irritated by any hint of rule s etting and may rebel the interviewer. P : W hat do you ask me for? I'm paying you to s olve my problems . It really does not make me feel good that always have to as k me for my view. don't you know enough that you can do it on your own? Or is this one those ps ychobabble tricks to pretend that you need my input? With s uch a difficult patient, the interviewer may have tes t different approaches to s ecure cooperation. I: It's your problem that we are dis cuss ing. It's your to get help. It's your information that we need to make plan. S o you are part of the s olution. I can't do anything without having you on my side s o that we can both face 683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 23 of 154

your problems and find out what works best to resolve them. R ight now your problem is that you can't come to agreement with me on how to tackle your problems . discuss why that is and what your thinking is . A patient's negative res ponse to the interviewer's cooperative approach may have deep-rooted of becoming dependent. S uch fear may reach far the present interview s ituation. Not all interpers onal conflicts, s uch as negative trans ference and countertransference, can be s olved in a time-efficient manner. T he patient may need medication or referral to different provider.

Trus t F rom the beginning, the interviewer shows s ens itivity to the patient's needs and comforts the patient. If the accepts such caring, the interviewer can forge a therapeutic alliance. B uilding on it, the interviewer's targeted questions prove his or her unders tanding and expertise, which qualify him or her as a guide for the patient's care. T he interviewer's res pect for the dignity allows the patient to trus t him or her. T rus t is rapport's summit.

TE C HNIQUE T he patient interacts on one of three levels with the interviewer: F irst, the patient cooperates. He or she complains about different areas of malfunctioning and suffering and seeks help. S econd, he or s he res ists, cautious , anxious, or s us picious and holding back embarrass ing, painful information. T hird, he or s he defens ive s trategies and obstructs the interviewing 684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 24 of 154

proces s.

Interviewing Tec hniques for the C ooperative Patient T he majority of outpatients and voluntarily admitted inpatients cooperate. As a general principle, even with cooperative patients , the interviewer should formulate questions from the patient's vantage point and us e familiar language. T he interviewer relies on five to achieve a crisp, well-flowing dialogue: openers, clarifications, covering a topic, steering, and transitions.

Openers T o initiate the interview or to explore a new topic, the interviewer chooses ques tions of s pecific target and T he patient's res ponses s hape the follow-up questions . Opening ques tions or s tatements target a problem of varying s cope. Narrow s cope: “What troubles bring you here to see me? ” T he interviewer expects a prioritized list of difficulties . P roblem: T he patient rambles. P.799 S olution: T he interviewer narrows the s cope of the question or curbs the res pons e. F or instance: P : (R es ponds with a long lis t of events that went wrong his or her life). I: J us t tell me what problem has troubled you most the last 3 days. P : T hat I can't sleep. B road s cope: “G ive me a s ens e of how your life is 685 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 25 of 154

T he interviewer expects the patient to put problems symptoms into a life perspective. S uch a broad works well for an intelligent, educated patient who can condense, abstract, and prioritize his or her life experiences . It fails with a patient with obsess ivecompuls ive disorder (OC D) by confusing the patient increasing indecis iveness and anxiety. It puts a patient with bipolar dis order into overdrive. He or she may the interviewer with circumstantial details and loosely connected thoughts. B road ques tions also fail for a who gives literal ans wers. A 23-year-old, white, s ingle medical s tudent. I: W hat brought you here? P : My mother's car. A patient with ps ychotic s ymptoms or low intelligence may give s uch concrete ans wers. Inability of the interviewer to adjus t the s cope of the ques tions can disrupt the flow of the interview and threaten rapport. A s upervis ed interview (supervis or [S ]) by a res ident with a white, newlywed woman (P ) in her early thirties. (1) R : W hat's going on in your life? P : (Looking around helples sly, s hrugging s houlders , blushing) I don't know. (2) R : W ell, for ins tance, have you felt depress ed? P : Is that what you think? (3) R : No. T his is jus t an example. I wanted to know could help you. P : I don't know whether you can help me. (4) R : W hy don't you tell me what has been happening 686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 26 of 154

lately in your life. P : (Hunching down in her chair) My hus band got promoted. W e bought a new hous e. (5) R : T hat's not really what I meant. P : (After a paus e) I don't really know what you mean. T he supervis or intervenes: (6) S : Well, you jus t said your hus band got promoted you are moving into a new house. Has that caused any stress for you? P : Oh yes . (7) S : Help me understand what s tres ses you out about move into a new hous e. P : I can't help him enough. I feel s o bad. (8) S : What kind of help can you not give him? P : I should be able to go out and buy things for the new house. B ut I can't. I get all choked up when I go to a (9) S : I can s ens e your frus tration. W hat bothers you the s tores ? P : T here are s o many people. When the interviewer noticed that question 1 (Q1) was broad, he or she went to the oppos ite extreme and clos ed-ended ques tion (Q2). Noticing the confusion, interviewer returned to an open-ended approach (Q3), the patient became s o anxious that she could not read intent of the ques tion. T he interviewer noticed her and reformulated Q1 but mis sed her clue in A4. After res ident voiced his frus tration (Q5), s he responded with frus tration of her own (A5). T he s upervis or intervened linking the content the patient had provided (A4) to her stress —that is , her anxiety level. T he patient's 687 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 27 of 154

showed the effectiveness of this intervention. An experienced interviewer monitors the effectivenes s his or her ques tions by how closely the ans wers match intent of the ques tions and adjus ts the scope of the questions .

C larific ation T o clarify an ans wer, the interviewer usually asks for specifics, probes the patient's reasoning, or offers leads .

S PE C IFIC ATION P roblem: T he patient's complaint is vague. S olution: interviewer uses s pecifying questions that focus on the Ws of interviewing: W hat? W hen? W here? W ho? Why? Alternatively, the interviewer may as k for general or examples or focus on the lates t s pecific occurrence then generalize the occurrence. A 26-year-old, white, unemployed, s ingle woman. (1) I: What kind of problems make you seek my help? P : I have many problems. (2) I: Is there any one problem that has troubled you P : (After a long hes itation) I wake up in the middle of night. (3) I: How does that trouble you? P : I really don't know. I can't explain. (4) I: What do you feel like when you wake up? P : K ind of leery. (5) I: Did you wake up las t night? 688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 28 of 154

P : Y es. (6) I: What time was that? P : 3:30 AM (7) I: What did you feel? P : I don't know. J ust leery. (8) I: Did you see anything? P : (P uzzled) My cat's hair s tood up straight. (9) I: What did you hear? P : A nois e in the kitchen. (10) I: W hat is making that noise? P : I don't know. (11) I: W hat did you feel? P : A breeze. (12) I: Does this happen every night? P : J us t about. (13) I: Y ou wake up and the cat's fur stands up on end, hear the noise in the kitchen, and you feel a breeze? P : T hat's right. (14) I: S omething that makes you leery is going on and means (raising his voice) there is … ? P : A s pirit. A spirit lives in my place. P.800 T he set of specifying ques tions adds up to a which the interviewer summarizes in Q13. When the patient accepts that summary (A13), the interviewer induces the patient to complete a s entence designed to capture the patient's interpretation of her leeriness . 689 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 29 of 154

PR OB ING P roblem: T he patient denies recurrence of past and s tres ses emphatically that he or she is healthy. emphasis alerts the interviewer to the presence of S olution: T he interviewer as ks for recent changes —not problems —and for the patient's interpretation. A 47-year-old, white, married woman who had recently moved to town reports that she has been treated in the past for major depress ion. S he emphasizes that s he is doing jus t fine and that s he only wants checkups of her past problems. S he works in her husband's law answering the phone, filing, and typing. I: Is there anything new going on in your life s ince you moved here? P : Y ou know, I'm glad that you asked. I've always had problems getting up. B ut now I'm wide awake at 5:30 I: W hy do you think that is? P : My s is ter is a nun, and at that time, s he goes to New Orleans . And that's when she communicates with I: How does s he do that? Does she call you? P : Oh no. W e've been close. It's with telepathy. T he patient's s trong intention was to be certified as healthy and as ymptomatic. T his emphas is alerted the interviewer to s crutinize the patient's recent history, discovering a delus ion that, as the interviewer learned later, was an early indicator of relapse for this patient.

LE ADING P roblem: A male patient, when as ked how he feels , 690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 30 of 154

answers : I don't know. S olution: (1) T he interviewer how the patient dealt with others las t week. T hus , behaviors may have to take the place of a mood (2) T he interviewer asks the patient to try to remember how he recently felt. W hile the patient tries to his posture and facial express ion may change. T he interviewer reads that emotion and feeds his or her reading back to the patient for his confirmation. T his technique, however, is suggestive and leads the res ponse. T he interviewer has to remain cognizant of poss ibly distorting input. A 28-year-old, white, married man knocks holes in the of his kitchen with his fis ts. He also reports problems sleeping. I: C an you tell me how you feel mos t of the time? P : I don't know. I: T ry to remember how you felt yes terday. P : (Looks down, closes his eyes , makes a fis t, then I: Y ou get a frown on your face. Y our knuckles turn Y ou appear tense… angry… anxious. P : Angry! Y eah. I: T hen a brief grin ran over your face. W hat were you thinking just now? P : T hes e Mexicans … when they buy one tire from me, bring their kids … they come with all their family. Like them. I: Y ou get angry… then you s mile… your feelings quickly. P : (P uzzled) I guess . I: Mixed up… up and down… bouncing around? 691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 31 of 154

P : My wife s ays I'm up and down. T he patient can reexperience some feelings but cannot read and express them hims elf.

C overing a Topic After opening a topic and clarifying the answers, the interviewer collects information linked to this topic to draw the big picture. Helpful techniques include as king events that are as sociated in time or are logically interrelated. T he interviewer may finally s ummarize he or s he has learned.

AS S OC IATING When ass ess ing clinical symptomatology, the us ually encounters one major symptom (i.e., the chief complaint). However, ps ychiatric disorders occur as syndromes rather than single symptoms. T herefore, interviewer asks what other s ymptoms concurred in with the chief complaint: “What else happened during time of your crying s pells ? ” or “What else happened your crying s pells were worst? ” or “What else when you had your s pell the last time? ” If the patient only a few s ymptoms , the interviewer may actively ask disturbances in sleep, appetite, s ex drive, ability to ability to relate to others .

INTE R R E L ATING T he interviewer uses interrelating when referring to the same theme, s uch as medical his tory, ps ychiatric history, or work or marital history. S uch interrelating represents logical connections. P roblem: A patient an illogical interrelations hip. S olution: T he interviewer 692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 32 of 154

addres ses the illogical connection. A 38-year-old, married, black, male airline engineer. I: W hat brought you here? P : My wife wanted me to have a s econd opinion. I: About what? P : About Alicia and the televis ion. T he pain in my groin should have stopped by now. I: F ill me in. W hat do Alicia and the televis ion have to with your groin pain? P : Man, don't you unders tand? I felt it most when I watched televis ion. I: W hat does that have to do with Alicia? P : Alicia knows about witchcraft. S he's a medium. S he my new televis ion set is bewitched. I have to bring it to her hous e. I: Did you take it over there? P : Of cours e. B ut my pain is still there. I: B esides your groin pain, was the television doing anything els e to you? P : It gave me mes sages. I: W hat kind? P : I noticed it mainly with politicians. T hey hold their with the fingers pointing down, and I unders tand immediately what they mean. I: W hat do they mean? P : Is n't it obvious? T hat my life is going down. I: W hat does your wife think about all that? P : Oh, she's mad with me. S he thinks that Alicia ripped 693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 33 of 154

off and that I need to s ee a ps ychiatris t.

S UMMAR IZING S ummarization should be informal, s upportive, and interactive. P roblem: T he patient gets eas ily While the interviewer as sess es the history of present illness , the patient mentions that her mother had s imilar problems . When talking about the medical his tory, the patient adds that her only s ibling, her older brother, admitted for detoxification. W hen reviewing the s ocial history, the patient mentions that her father is the only person in the immediate family who did not have any ps ychiatric problems. T o give clos ure to the topic of history, the interviewer pulls together P.801 and s ummarizes informally the data that belong to this topic but were collected at different parts of the “Let me make sure I'm keeping up with what you told about your family history.” P roblem: T he patient's answers are vague, and it takes interviewer several specifying ques tions to collect information. S olution: T he interviewer supportively summarizes the topic intermittently, “We are getting there,” to nudge the patient to complete the topic. P roblem: A patient describes a good relations hip but her facial expres sion contradicts the words . S olution: interviewer gives an interactive summary and confronts the patient with incons is tencies to provoke his or her protes t and to probe his or her true convictions . A 19-year-old, s ingle, white woman. 694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 34 of 154

I: Y ou described to me some of the conflicts that you with your s tepfather, right? (P atient nods .) B ut you said they were really minor. Y ou learned to tolerate each did I catch that? (P atient looks down.) B ut while you saying “tolerate,” some spit came out of your mouth. P : (T hrowing her head back and rolling up her eyes) I be unders tanding because of my mother. He really me a lot.

S teering Ins ide a topic and between topics , the interviewer the flow of information. T he main choices are to encourage the patient to continue or to redirect the of attention.

C ONTINUATION T he interviewer tends to the patient's talk by raising eyebrows or uttering hmmms to signal to the patient nonverbally to continue. He or she may use short phrases, such as “And? ” “T hen what? ” “How is that? ” if or her nonverbal signals get ignored. T he interviewer also use phrases s uch as “T hat's interesting,” “What a surpris e!” “R eally? ” “Oh, no!” to reward the patient with or her attention and to encourage the patient to

E C HOING T he interviewer may echo a part of what the patient said. He or s he may intend to prod the patient to or to s hift the emphasis.

R E DIR E C TION P roblem: T he patient introduces a new productive 695 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 35 of 154

S olution: T he interviewer follows the new lead. Alternatively, the interviewer may delay the transition: “What you are s aying is very important. W e will come to this topic. B ut before we do, let's finis h up on… (old topic).” P roblem: T he patient introduces all irrelevant topics, s uch as the problems of other people or political opinions about current events. S olution: T he us es redirection. He or s he interrupts the patient and to return to the previous topic. If the patient repeatedly gets dis tracted by irrelevant s ubjects , the interviewer overtly educate the patient, saying: “We have to cover several topics. Let's not get dis tracted. Let's continue we were talking about before.” If the patient remains overtalkative, a request to make the patient just ans wer series of yes -or-no questions or multiple-choice may help. If the interviewer is not vers atile and s killful us ing redirection, the entire interview may derail.

Trans itions T o cover the 15 s ections of the clinical interview, the interviewer has to transition from a completed topic to a new one. T hese trans itions can be s mooth, abrupt.

S MOOTH TR ANS ITIONS S mooth trans itions connect topics without the s eam becoming apparent. P roblem: T he patient s tartles new topics get introduced. S olution: (1) T he patient introduces a change in topic and the interviewer follows the new lead. (2) T he interviewer portrays different as part of a larger theme. F or example: I: B oth of your parents had problems with drinking. 696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 36 of 154

did this affect your relations hip with them? P : W ell, it was rough. T here was a lot of fighting going T hus, the interviewer has trans itioned effectively from topic of family history to social his tory. T he interviewer address es a caus e-and-effect that also leads to smooth transition. (3) T he interviewer references a point in time to s moothly link events that occurred together. Interviewers often have problems in transitioning to the testing of orientation and recent memory. T hey may introduce this topic with a such as , “P sychiatrists routinely as k s ome s trange questions , s uch as what is today's date? ” T o create a smooth transition, the interviewer may link questions about orientation to the problems that the patient has reported. I: Y ou s aid you have felt down in the dumps and could sleep well for the las t 3 weeks . S uch moods can affect memory and s ometimes the ability to track time. Have encountered those problems? P : I don't think s o. I: S o you had no problems with tracking time? P : Hmmm. Not really. I: C an we test it? P : G o right ahead. I: W hat's the date today?

AC C E NTUATE D TR ANS ITIONS An accentuated transition emphas izes the start of a topic. P roblem: T he patient loses attention and interes t 697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 37 of 154

the interview. S olution: T he interviewer announces a topic and fres hens the patient's interest.

AB R UPT TR ANS ITIONS T he interviewer jumps into a new topic without the patient. P roblem: T he patient's his tory shows many contradictions. T he patient s eems to be lying. S olution: T he interviewer jumps back and forth among different elements of the patient's story. T he patient cannot quickly enough the true events of his or her s tory with invented ones .

Interviewing the R es is ting Patient F or the initial interview, a patient may decide not to talk about certain s ubjects. He or s he may overtly express her refusal: “I don't want to talk about this .” the patient may divert his or her answer to a different topic. T he reas on for s uch refusal is often a fear of los s face. S ix techniques help to overcome res istance.

S haring C onc ern P roblem: T he patient refuses to dis clos e details of an because he or she is not certain about legal S olution: T he interviewer shares the patient's concern points out the negative cons equences that secrecy have for the unders tanding of the problem. A 57-year-old, white, retired man has a problem with rage. P : I've done s ome bad things in my life. P.802

698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 38 of 154

I: S uch as… ? P : (P ause) S uch as bumping off two people. Do you report that if I tell you? I: W e could discuss the circums tances in general I have to document it. If you talk about it, it would help to understand your rage attacks better. I understand concern. Y ou may want to cons ult your lawyer.

E xpres s ing A c c eptanc e P roblem: A patient with OC D fears that the interviewer may think he or she is “crazy” and therefore gives and misleading ans wers. S olution: R eass uring the and s howing unders tanding and acceptance of his or symptoms help to reveal the “ridiculous” symptoms. Accepting certain symptoms as normal often reduces patient's embarrass ment.

C onfrontation P roblem: B y the patient's behavior and open refus al, a patient res is ts dis cuss ing a topic. S olution: C onfronting patient repeatedly with his or her refus al or pointing out his or her evasive s trategies or exploring the reasons the res is tance and describing the consequences for diagnosis and treatment may convince the patient to be more open.

S hifting F oc us P roblem: A patient res is ts a particular line of questions he or she dreads . S olution: S hifting the approach losing s ight of the topic, the interviewer often secures answers that he or s he desires . T he interviewer may neutral ground or to a different angle to find a new 699 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 39 of 154

point. A 57-year-old white man. I: W hen did you s tart having problems with your mental health? P : Oh that's all a thing of the past. I've forgotten most And I'd rather talk about my future. I: Okay. Y ou are divorced now. W ould you like to get married again? P : Oh, yes . I: W hat went wrong with your first marriage? P : My wife got mean with me when I firs t got sick when was 23 years old. I: I'm s orry to hear that. S o she did not really support S he did not believe in the phras e “for better, for P : T hat's right. I: W hat was it that bothered her? P : T hat I as ked the same ques tions over and over that I felt s o bad, checked things , and was hed my S he said I leave 30 dirty towels a day. S he dumped me when I was 28. T he patient did not want to recall the s ymptoms that him s o much trouble in the pas t but was ready to his past his tory in connection with his s till unresolved, painful divorce.

E xaggeration P roblem: A patient experiences a minor failure as a infraction and feels that he or she will lose the interviewer's support if he or s he admits to it. S olution: 700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 40 of 154

interviewer exaggerates the patient's actions to make them fit s uch inflated guilt feelings. S uch exaggeration may help the patient to regain pers pective and give up or her resis tance. A 49-year-old man refus ed to discuss his s hortcomings bank teller. I: S o you must have cleaned out the vault and got with it. P : (W ith a thin s mile) No, not quite that bad. I: Not that bad? B ut you s aid it is s o bad that you could talk about it. P : I made a private long-distance call without reporting And I've worried about it ever since. Do you think I still report it?

Induc tion to B ragging P roblem: A patient hides his or her true motives for reques t of a s ick leave to remain in good standing with interviewer. S olution: T he interviewer challenges the patient's cleverness and induces bragging to uncover patient's motives . A 47-year-old man, 290 lbs , reques ting sick leave from job because of s tres s on his delivery s ervice job. I: S o you deliver all thes e advertis ing brochures. P : (W ith a broad grin) Y es, and I'm doing a good job that, but I'm stress ed out now. T hat's the first time I try route getting disability. I: Y ou look quite content to me. Maybe you need a vacation rather than a sick leave. 701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 41 of 154

P : I've us ed up all my vacation at the beginning of the Now I need s hort-term disability. I: Y ou s aid this is the first time you tried this route. W hy don't you tell me why you really want the s ick leave? P : I'm telling you. T hes e 7 years at the job have really a toll on me. I feel I need time off. I: I wonder whether you have learned how to work the system. P : I've been at it for 7 years. (W ith a grin) I should be at it. I: How is that? What do you mean being good at it? P : I have that quiet spot clos e to the cemetery where I look at a lake. T hat's where I take a break from all that driving. (S heepishly) I just dump some of the printings . I: Y ou wouldn't have enough miles on your car if you that. P : don't you think I know that? I run out to my place grab s ome lunch. T hat gives me the miles. Induction to bragging revealed the patient's antis ocial features behind his request for s tres s relief and sick

Interviewing the Defens ive Patient Defense mechanis ms may dis rupt the interviewing proces s. Nevertheles s, the interviewer has to deal with them. T he DS M-IV -T R groups 31 defens e mechanisms seven levels of adaptation. T he interviewer can spot a defense mechanis m by its observable, characteristic behavior (T able 7.1-2). T he interviewer may identify the emotional conflicts , and the proces ses that activate the defens e if the 702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 42 of 154

interferes with the interview. If the interviewer identifies defens e mechanism, he or s he may determine its levels. F or each of the levels, a general s trategy is that may help the interviewer to address the defens e.

Table 7.1-2 Defens e Mec hanis ms on (DS M-IV-TR ) Defens e Mechanis m

Obs ervable B ehavior or S ymptom

E motional C onflic t and S tres s ors

High adaptive level

 

 

Affiliation

F ormation of work and troubleshooting teams ; s triving for cooperation

Is olation, imperfection, res ponsibility

Altruis m

Unconditional offer of help

Defeat in competition

Anticipation

P redicting

S udden,

703 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 43 of 154

probable events overwhelming and planning threats countermeasures Humor

Highlighting amus ing of threat

F ailure, loss , destruction

S elf-as sertion

E xpres sion of impulses in socially acceptable form

F ear, anxiety, and anger

S elf-observation

R eflection on own feelings, impulses, and thoughts

F ear, anxiety, failures, aggres sion

S ublimation

S ocially acceptable behavior

Unacceptable feelings or impulses

S uppres sion

Avoidance of discuss ing

P ainful event, sadis tic or

704 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 44 of 154

painful problems , wis hes , or feelings

sexual

Mental inhibitions level

 

 

Dis placement

P hobias

F ear and threat by an object or love and hate for an object

Dis sociation

Multiple personality, fugue, amnes ia

P romis cuous , hostile, or irrespons ible behavior, painful events

Intellectualization

Abs tract thinking, doubting, indecis ivenes s, generalizations

Dis turbing feelings and thoughts

Is olation of

Obsess ions, talking about emotional

P ainful emotions and memories

705 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 45 of 154

without feeling R eaction formation

Devotion, s elfsacrificing behavior, correctnes s, cleanliness

F eelings of hostility and disinterest

R epress ion

G aps in

T hreatening memories , feelings, wis hes

Undoing

C ompulsive behavior

S adistic wis hes , unacceptable impulses

Minor image distortion level

 

 

Devaluation

Derogatory statements about others or self, “sour grapes ” about a goal

P os itive qualities of others , unattainable goal

Idealization

E xaggerated praising of s elf

Negative qualities of

706 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 46 of 154

others

or s ignificant others

Omnipotence

S elfpresumption, entitlement

Inferiority feelings, failure, low self-es teem

Dis avowal level

 

 

Denial

S tubborn and angry negation of some reality obvious to others

P ainful reality

P rojection

Ideas of reference, prejudice, suspicious nes s, injus tice

Hos tility, unacceptable attitudes, wis hes ,

R ationalization

S elf-serving explanations justification of behavior

S ocially unacceptable impulses, low self-es teem

707 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 47 of 154

Major image distortion level

 

 

Autistic fantasy

Daydreaming

Uns atis fied impulses and wis hes

P rojective identification

Accus ing others of causing distress , and anger

Hate, anger, and hostility

S plitting of selfimage or image of others

Idealization alternating with devaluation of self or others

E xperience of negative and positive qualities of or others

Action level

 

 

Acting out

V iolent acts, stealing, lying, rape

S exual and aggres sive impulses

Apathetic withdrawal

Decreas ed emotions , activity, and social

Needs, impulses, wis hes

708 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 48 of 154

interactions Help-rejecting complaining

Depicting oneself with pity as victim

Hos tility and reproach toward others

P as sive aggres sion

P rocras tination, lack of followthrough

Aggress ive, hostile impulses, res entment

Level of defens ive dysregulation

 

 

Delusional projection

P ers ecutory delus ions

Overpowering, unacceptable and uncontrollable impulses

P sychotic denial

Negation of obvious reality

Overpowering, painful reality

P sychotic distortion

Obvious ly unrealistic statements and claims and

Overpowering, unacceptable impulses and reality

709 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 49 of 154

irrational

F rom Othmer E , Othmer S C . T he C linical Interview Us in American P s ychiatric P res s; 2002:82–85, with permiss io

High A daptive L evel T hese eight defense mechanis ms can be viewed as for the patient. I: I admire your sens e of humor. It will help you to deal better with your depres sion. Y ou are able to take the V iennes e approach and say, “T he s ituation is hopeless not serious.”

Mental Inhibitions L evel T he seven defens e mechanisms on this level deprive patient of s ome degrees of freedom in P.803 P.804 decis ion making. Us ually, the patient has insight into pathological nature of phobias, obs ess ive-compuls ive behavior, and diss ociative identity disorders without aware of the underlying process . In the cas e of intellectualization, is olation of affect, reaction formation, 710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 50 of 154

and repress ion, the patient miss es that a defense mechanism inhibits his or her ability to recognize his or true feelings. C onfrontation with the observable may allow the patient to recognize his or her true I: W hat value do you attach to life? P : I feel as a C hristian it is a sin to even think about G od gave us our life and he is the one who s hould take I: Y ou mentioned s uicide when I just wanted to know you think about life. P : don't you think s uicide is a s in? I: I'm more concerned about your generic answer. It your feelings . What are your feelings about your life? P : (S tarts crying) It's awful. I would not care if I didn't up in the morning.

Minor Image Dis tortion L evel A patient may idealize an interviewer at the beginning the interview and s ubs equently devaluate the because of a minor perceived failure, s uch as as king embarrass ing question. W hen idealization, devaluation, omnipotence interfere with the interview, the overt behavior itself may have to be address ed. I: How quickly I end up in the doghous e! Let's find out what got me there.

Dis avowal L evel F rom the three defense mechanis ms on the dis avowal level, projection is the most dis ruptive during an 711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 51 of 154

A patient accuses the interviewer of not liking her. as ked whether she hers elf dis likes the interviewer, she answers , “How could I like you if you don't like me? ” he as ks her whether there is anything that she does like about him s he ans wers: “T he way how you make feel. I don't like s ex.” S olution: T he interviewer has to the patient aware that her feelings and not his actions caus e her difficulties. He may accept her feelings as and repeatedly discuss them with her to neutralize

Major Image Dis tortion L evel T he three defens e mechanisms on this level have to be identified and addres sed but not interpreted. A 45-year-old, white, married truck driver avoided his mother for s everal years because he believed s he him s ick. He then quit his job because his coworkers rejected him. He felt hate and anger toward them. In interview, he told his psychiatrist that his questions making him sick. T he interviewer pointed out to him he had felt the same way about his mother and later his coworkers . Avoiding his mother and quitting his job not give him peace of mind. T herefore, he and the interviewer had to find new ways of dealing with the patient's s ocial dis comfort other than accusing people next to him. “Let's work on your anger and distrust of and others . With your help, we can find out what and medications make you less sensitive to other remarks.” T he interviewer recognized the accus ations as identification. Instead of an interpretation that is usually not effective, the interviewer offered s upport and 712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 52 of 154

medication.

A c tion L evel P roblem: A patient acts out his or her anger. S olution: interviewer sets limits rather than trying to interpret the behavior. T he diagnosis helps to decide which combination of behavioral and medical intervention is neces sary to manage this patient.

L evel of Defens ive Dys regulation T he three defens e mechanisms on this level produce ps ychotic s ymptoms. If, for instance, the interviewer challenges a delus ion as nons ens ical, the patient may angry and dis trus tful and break off the interview. T herefore, the interviewer has to adopt the patient's vantage point and offer s upport accordingly. A 43-year-old, white, s ingle farmer claims that night caus e his headaches. I: I will protect you agains t these spacemen. I'll put you the hospital, and I will give you medication that will you immune to their attacks . P : S o you believe me that s pacemen cause my I: I can't tell you that. B ut I know that you feel this, and I know that the medication may help. R ecognizing the behaviors that, according to a ps ychodynamic view, repres ent an unconscious mechanism is in the realm of des criptive ps ychiatry. However, descriptively oriented ps ychiatris ts doubt the validity of the underlying ps ychological mechanisms therefore prefer behavioral and medical management 713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 53 of 154

interpretation.

ME NTA L S TA TUS T he third component of ps ychiatric interviewing is the online monitoring of the patient's mental status . T he interviewer screens the mental s tatus to detect signs symptoms of mental disorders (T ables 7.1-3 and 7.1-4) four as sess ment methods: observation, conversation, exploration, and testing.

Table 7.1-3 Quantitative C hange Frequenc y, Duration, and Intens ity o S tatus Func tions S ec ondary to S o and II Dis orders Func tion As s es s ment Method

C ategory

Inc reas ed In

Appearance (O)

Apparent vs . stated age

AD, MDD, S chiz with chronic cours e, S R D, precocious puberty

MA

 

G rooming and

OC -P D,

AD,

Dec In

714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 54 of 154

clothing

His trP D, narcis sistic (mint condition),

SRD

 

E ye contact

DelD (hos tile)

GA MA

 

Nutritional status

SRD (antihistamine us e), MDD atypical, S D; us e of medication: olanzapine, valproic sodium, clozapine, lithium, mirtazapine

SRD (s tim AN, (cac

Attitude toward interviewer E , T)

C ooperation

Dependent P D, His trP D, MA

Ds ps y feat MA into MD AsP con

715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 55 of 154

C ons cious nes s Alertnes s (O, C , T )

SRD (s timulants), G AD, posttraumatic stress paranoid D

SRD (alc sed

P sychomotor (O, C , T )

P os ture

MA

MD dem

 

Movements

 

 

 

   R eactive

MA, G AD,

MD (cat

 

   G rooming

S ocP h, G AD

MD

 

   S ymbolic

MA, cluster B PD

MD (cat

 

   Illustrative

MA, S D

MD (cat

 

   E xpress ive

MA, G AD, His trP D

MD (cat

 

   G oal directed

MA, ADD

MD

S peech (C ,

Articulation

—

SRD

716 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 56 of 154

T)

neu Ds

 

F low

MA

P D,

 

S peed

MA, G AD

P D,

 

V olume

MA

MD

 

Latency of res ponse

MDD

MA

 

Inflection

MA

MD

T hinking (C , T)

S peed

MA, S R D

MD AD, P ar dise

 

Abs traction

—

Men reta S ch fron dem

 

T ightness of as sociation

OC D, OC -P D

MA SRD

 

G oal directedness

—

MA OC

717 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 57 of 154

SRD Affect (O, C , T)

Quality

MA

MD AN, nerv inte exp

 

R eactivity

MA, S D, AD, retarded MDD, OC D

AD, OC

 

 

MA, S D, His trP D

MD S ch

 

Intens ity

MA, AnxD, E atD

MD

 

R ange

MA

S ch GA

 

Appropriateness

—

S ch with ps y feat

Mood (E , T )

Quality

MA, S R D

MD E at

 

S tability

MDD

AsP

718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 58 of 154

mix SD  

Intens ity

MA, OC D

MD

 

Duration

OC D, OC MDD

B ID cyc

T hought content (C ,

C ongruency of delus ions and hallucinations to mood; pathological content (s ee T able 7.1-4)

S chizoaffective — D (s ee T able 7.1-4)

C ognition (C , E , T)

S ee T ables and 7.1-6

—

S ee 7.17.1-

Ins ight (C , E )

B eing s ick, needing help

—

AD, MA P ick

J udgment (C , E)

F uture plans, dealing with friends and money

—

MA S ch P ick

719 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 59 of 154

AD, dementia of Alzheimer's type; ADHD, attentiondeficit/hyperactivity dis order; AN, anorexia nervosa; Anx disorder; As P D, antis ocial pers onality disorder; B ID, bip C , convers ation; D, dis order; DelD, delusional disorder; exploration; E atD, eating dis orders; G AD, generalized a disorder; HistrP D, histrionic pers onality disorder; MA, m major depress ive disorder and depress ion; O, observati obses sive-compuls ive disorder; OC -P D, obsess ive-com personality dis order; P D, personality dis order; P ick's , P i S chiz, schizophrenia; S D, somatization disorder; S ocP h phobia; S R D, s ubs tance-related dis orders; T , testing.

Table 7.1-4 Qualitative C hanges in Mental S tatus Func tions to S ome Axis I and II Ps yc hiatric Dis orders and S yndromes Func tion As s es s ment Method

S ymptom, S ign

Dis order, S yndrome

Appearance (O)

Needle marks

SRD

 

S cars on

MDD, B ID,

720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 60 of 154

and wris t

borderline P D, Cl B PD

 

Inappropriate attire

MA, P sychD

 

Miss ing eyelashes, eyebrows, hair

ID, trichotillomania

 

B itten-off nails

ID, AnxD, P sychD

 

R eddened, chapped hands

OC D

 

E xces sive or tattoos

Cl B PD

C ons cious nes s Hyperalertness (O, T )

S R D (sedative withdrawal or stimulant

 

S R D sedation (Intox), ps ychiatric D due to a medical condition

Lethargy, s tupor, coma

721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 61 of 154

P sychomotor (O, C , T )

R igidity

P arkD, neuroleptic malignant syndrome, extrapyramidal symptoms

 

T remor

Idiopathic, S induced, S withdrawal, P arkD

 

T ics (motor,

T OUR , other D

 

R es tles s squirming, overflow

ADHD

 

C horeatic, athetotic movements

TD

 

B uccolingual movements

TD

 

C ataleps y

S chiz, D with ps ychotic features, AD, F LD

722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 62 of 154

 

G egenhalten (oppos ing movement)

S chiz

 

E chopraxia

S chiz

 

P seudoaphonia, ps eudoparalysis, ps eudoseizures

C onvers ion D

 

Avoidance of touching

OC D

 

Apraxia

F LD, AD, NeurolD

 

S eizures

S R D (sedative withdrawal)

 

C ataplexy

Narcolepsy

 

Micrographia

P arkD

 

S tereotypical movements

P ervas ive developmental D

S peech (C , T)

S tuttering, stammering

AnxD, generalized anxiety D,

723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 63 of 154

NeurolD  

V ocal tics

T OUR

 

Aphasias

F LD, AD, NeurolD

 

P us h of speech

MA

T hinking (C , T)

B locking and derailment

P sychD

 

C ircumstantiality

OC D

 

F light of ideas

MA

 

Loose as sociations

MA, P sychD, S chiz

 

P ers everation

F LD

 

V erbigeration

P sychD (catatonia), NeurolD

 

P alilalia

NeurolD

 

C lang

S chiz, MA

 

Nons equitur

S chiz

724 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 64 of 154

 

F ragmentation

S chiz

 

R ambling

Delirium, S R D

 

Driveling

Aphasia (W ernicke's ), S chiz

 

Word salad

P sychD, Aphasia (global)

 

T angentiality

S chiz, D with ps ychotic features

Affect (O, C , T)

Lability

B ID, S R D,

 

Inappropriateness D with ps ychotic features

T hought content (C ,

S uicidality, homicidality

MDD, S R D, S chiz, B ID

 

Hallucinations, delus ions

B ID, MDD, S chiz, S R D,

725 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 65 of 154

 

Obsess ions, compuls ions

OC D

 

P anic attacks

MDD, panic D

 

Medically unexplained pain

S omatization

 

Derealization, depers onalization

Dis sD

C ognition (C , E , T ; see 7.1-6)

C onfabulation

Amnes tic D

 

Dis sociative amnes ia

Dis sD

AD, dementia of Alzheimer's type; ADHD, deficit/hyperactivity dis order; AnxD, anxiety B ID, bipolar disorder; B P D, borderline pers onality disorder; C , convers ation; C l, cluster; C onvD, conversion dis order; D, disorder; Dis sD, disorder; E , exploration; F LD, frontal lobe impulse-control disorder; Intox, intoxication; MA, mania; MDD, major depres sive dis order and depres sion; NeurolD, neurological disorders; O, observation; OC D, obsess ive-compuls ive disorder; P arkD, P arkins on's dis eas e; P D, pers onality 726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 66 of 154

P sychD, ps ychotic dis orders ; S , substance; S chiz, schizophrenia; S R D, s ubs tance-related dis orders; tes ting; T D, tardive dyskinesia; T OUR , T ourette's disorder.

Obs ervation F or obs ervation, the interviewer does not need the patient's cooperation. B esides sex and race, the interviewer obs erves appearance, level of ps ychomotor functions , body language, and affect. T hrough the power of obs ervation, S herlock Holmes deduce a pers on's life his tory and occupation. the as tute interviewer, obs ervation can give clues to diagnosis.

C onvers ation E ven if the patient refuses to speak about him- or his or her s ymptoms or s uffering, the interviewer can conclus ions from convers ation about the patient's thinking, affect, thought content, concentration, intelligence, insight, and judgment. P.805 P.806

727 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 67 of 154

P.807

E xploration E xploration requires the patient's willingness to disclose information about mood; content of thinking, such as obses sions , compuls ions, s uicidal ideation, delus ions , hallucinations , panic attacks, avoidance behaviors , and “spells;” amnes ias; personality changes; and pain sens ations. T o verify his or her impres sion, the may feed back to the patient his or her reading of symptoms and s igns ass es sed during the interview. the patient's mental s tatus becomes the object of exploration.

Tes ting T es ting of the patient's mental functions , whether intact impaired, demands the highest degree of cooperation. T es ting adds a quantitative component to the interview. C ombining obs ervation, convers ation, exploration, and tes ting, the interviewer screens at least 12 mental functions often affected by ps ychiatric disorders . T able 3 lists the mental s tatus function and the method of its as sess ment, the categories that are as sess ed for the individual functions, the mental dis orders that may show an increas e, and the mental disorders that may s how a decrease in the s pecific category. T he interviewer signs and s ymptoms of disorders in thes e mental s tatus functions . T able 7.1-4 lists mental s tatus functions and as sess ment methods, symptoms and s igns, and the disorders and syndromes in which the s ymptoms and are frequently encountered. T he mental status functions 728 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 68 of 154

T ables 7.1-3 and 7.1-4 are discus sed subsequently. In T ables 7.1-3, 7.1-4, 7.1-5, and 7.1-6 the term MDD to des ignate major depres sive dis order as well as depres sion due to other disorders , such as dys thymia, bereavement, or adjus tment dis order, substance us e, general medical condition.

Table 7.1-5 C hange in E motional R e Indic ator of S ome Ps yc hiatric A Dis orders E motion

E vent

Action

S urprise

Unexpected E valuation, stimulus integration

P T S D, MA, G AD, P anD,

Interes t

Need reducing stimulus

MA, ADHD

E xploration

Inc reas e

729 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 69 of 154

E lation

E xpected satis faction of need

S atisfaction of need

MA

C ontentment

C ompleted need satis faction

R elaxation

—

Anger

Obstacle

Des truction of obs tacle

MA, delus ional disorder, ADHD clus ter B intermittent explosive disorder, subs tancerelated disorder, P anD,

Dis gus t

Intrusion

E xpuls ion withdrawal

Anorexia nervos a, bulimia nervos a, OC D, S pecP H, S ocP H

Anxiety

T hreat

Avoidance

S ocP H,

730 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 70 of 154

agoraphob S pecP H, P T S D, OC D S adnes s

Loss

Undoing, MDD, replacement histrionic

G uilt

V iolation of code

R emorse, selfpunis hment

MDD, borderline PD

ADHD, attention-deficit/hyperactivity disorder; AsP D, an disorder; G AD, generalized anxiety dis order; ID, impuls e MA, mania; MDD, major depress ive disorder and depres obses sive-compuls ive disorder; P anD, panic disorder; P disorder; P T S D, posttraumatic s tres s disorder; S chiz, sc social phobia; S pecP H, s pecific phobia.

Appearanc e T able 7.1-3 lists quantitative and T able 7.1-4 qualitative changes in appearance that may be due to a disorder. T he onset of some disorders is age related 7.1-3). G ender is ass ociated with certain diagnoses . instance, anorexia and bulimia nervos a, somatization disorder, and major depres sion are more common in women, whereas antis ocial pers onality disorder and alcohol abus e predominate in men. 731 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 71 of 154

R ace and ethnic background are important: F irs t, acros s racial and ethnic boundaries may be impeded. S econd, the attitude toward mental illness varies from culture to culture and may delay cons ultation. T hird, and ethnicity affect the incidence of some psychiatric disorders .

Attitude T he patient's attitude reflects his or her disorder and her evaluation of the doctor–patient relationship. A patient may hide his or her uncooperative attitude vaguenes s, memory los s, or one-word ans wers or it openly. He or she may refus e to ans wer ques tions or refuse to be tested.

C ons c ious nes s Most common disturbances of consciousness are due intoxication or substance withdrawal res ulting in or decreas ed reactivity. More s evere disturbances of cons ciousnes s (T able 7.1-4) can be as sess ed by tes ts (T able 7.1-6).

Ps yc homotor Func tion B es ides posture, humans dis play types of movements differ in their purpose (T able 7.1-3). R eactive are directed toward a new stimulus , such as respons es phone ringing or door knocking. G rooming movements control appearance, s uch as straightening out clothes , or mus tache. S uch movements frequently indicate discomfort with the s ituation. S ymbolic movements are culture s pecific and can replace language. Instead of saying, “We will win,” a pres idential candidate, for 732 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 72 of 154

may form a V with his or her arms . During an interview, patient may s ometimes make an unintended symbolic gesture that reveals hidden thoughts . Illus trative movements duplicate what is s aid—they are E xpres sive movements reflect in a rudimentary form motor action that a patient would like to undertake in res ponse to an emotion-provoking stimulus ; for an angry patient who says he or she will take on his or employer ass umes an erect posture and makes a fis t anticipating a fight. G oal-directed movements occur as part of a phys ical action, s uch as reaching for a coffee P sychiatric dis orders can affect frequency P.808 P.809 P.810 and intens ity of such movements (T able 7.1-3), but can also induce qualitative changes , s uch as movements specific to psychiatric or neurological disorders (T able 7.1-4).

S peec h S pe e ch is a motor function driven by the patient's proces ses. T herefore, mos t disorders that affect motor functions in frequency and intensity affect s peech as R apid s peech is seen in mania and in anxiety disorders (T able 7.1-3). A cons tant rapid flow of speech that can interrupted is called pus h of s pee ch. If it is difficult to interrupt, it is called pre s s ure of s pee ch. B oth forms are in mania (T able 7.1-4). Qualitative changes of s peech 733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 73 of 154

us ually of diagnos tic significance (T able 7.1-4). If centers in the brain are damaged, specific forms of (inability to s peak) occur. B edside tests help to which type of aphasia is pres ent (T able 7.1-6). Developmental disorders affect s peech. S peech is noticeably impaired in patients with low intelligence quotient (IQ) or with dementias .

Thinking T he interviewer judges thinking according to the categories listed in T able 7.1-3. T he interviewer's impres sion and a patient's report may conflict. S ome patients report racing thoughts but talk with a normal or even s lowly. S uch a mismatch may be more anxiety disorders , ps ychotic dis orders, or hypomania; mania, racing thoughts are us ually accompanied by increased rate of speech. T he ability to unders tand the abstract meaning of words varies with the level of intelligence and is not pathognomonic for T he ability to abstract can be tested by as king for communality of categories and proverb interpretation (T able 7.1-6). C oncreteness of thinking in firs t-episode ps ychos is may be as sociated with lack of insight. Ass ociation between s entences can be loos ened by ps ychiatric disorders (T ables 7.1-3 and 7.1-4). seem to jump from topic to topic and their goal gets phenomenon called flight of ideas (T able 7.1-4). T he as sociations between thoughts can become very clos e, and the patient may be unable to omit irrelevant making his or her thinking circumstantial. S ome lose the goal of their ans wer but touch on the general topic, called tange ntial thinking (T able 7.1-4). 734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 74 of 154

Affec t Affect communicates to the interviewer the emotional value that the patient puts on his or her experience. interviewer sees affect expres sed in the patient's face, and body movements. He or she hears it in the patient's voice. E xternal events and internal such as thoughts , ideas , and memory, evoke affect. interviewer has to explore to what extent immediate circums tances , s uch as being press ured by a family member to see a ps ychiatris t, contribute to the pres ent affect. T he nine basic emotions that C arroll Izard and others have identified are transcultural, innate (T able 7.1-5). E ach is triggered by a s pecific event and urges the individual to take a s pecific action (T able 7.1T he quality of the firs t four emotions —surpris e, elation, and contentment—is positive; the last five have negative quality—anger, dis gus t, anxiety, sadness , and guilt. Most psychiatric dis orders influence affect and mood (T able 7.1-5). T hey shift a patient's emotional res ponse toward a dominating affect and mood, thus increas ing intens ity of that specific affect but at the s ame time res tricting the range of res ponsiveness . F or instance, mania and some substance-related dis orders, elation dominates . In depres sion, sadnes s and guilt are In eating dis orders , disgust is prominent, and in anxiety disorders , anxiousness is of course prevalent. the interviewer gets significant clues about ps ychiatric disorders by noticing the shift in quality and intensity of affect (T ables 7.1-3 and 7.1-5). F urthermore, disorders influence the reactivity of affect. F or instance, patients with bipolar disorder may dis play dramatic, 735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 75 of 154

changes in quality and intens ity of affect in respons e to changing thought content (T able 7.1-3). T he then observes a labile affect (T able 7.1-4). P s ychiatric disorders with psychotic features often affect the appropriatenes s of affect to thought content. A patient may report and s how elation but have delus ions of forced to commit suicide, thus showing thought content incongruent to mood. F or instance, a patient may while describing her mother's funeral (T able 7.1-4). Without being sad or depres sed, s ome patients may an affective res ponse, which is often des cribed as flat bland affect in contrast to full affect. T o evaluate affect, interviewer may explore the patient's res ponse to listed in T able 7.1-5. F or instance, he or she may ask a sales man, “How does it make you feel when you P.811 meet a representative of a competing company in your territory? ” T he mixture of anger about the obs tacle, about the intrus ion, and anxiety about the threat may valuable clues of the patient's emotional second method to as sess mood is by brief tests (T able 6). W ith respect to affect, the interviewer can as k the patient to enact the nine bas ic affects (T able 7.1-6). As these areas, patients may exhibit situationally driven res ponses due to recent s tres sors or external circums tances of the interview.

Mood Mood refers to the predominant, longer-lasting quality experienced emotion. T herefore, if the interviewer to evaluate the patient's mood, he or s he has to ask. 736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 76 of 154

interviewer can judge to what extent the observed and the reported mood corres pond to each other. A patient with high s ocial skills can often dis play an affect inconsistent with the mood. T his apparent discrepancy between affect and mood occurs more frequently when the patient speaks. W hen the patient lis tens and feels unobs erved, the happy mask may drop. P rolonged of depress ion, as s een in major depres sive dis order, pathological stability and duration of mood. A patient OC D or obses sive-compuls ive personality dis order also report that his or her dysphoric mood las ts for a time, yet it may be unstable becaus e of his or her outburs ts . Depending on the severity of a ps ychiatric disorder, the predominant mood can be intens e.

Thought C ontent During exploration, the interviewer s earches the past for the occurrence of pathological thought content (T able 7.1-4). T o as sess suicidality, the interviewer discuss the patient's quality of life, thus getting a better reading of suicide risk than with direct ques tioning. F ollow-up questions for s uicide risk include past immediate intent, lethal plan, availability of means, history of suicide, and perceived outcome. C oncurrent presence of psychotic features , s uch as command hallucinations , as well as depress ion, s ubs tance recent los s of s ocial support, male gender, white race, middle age or older, may increas e the ris k of s uicide. comorbidity of major depres sion and s ubs tance use disorder leads to the highes t ris k of s uicide. A for risk factors of s uicide is helpful: S AD P E R S ONS . S ex: W omen are more likely to be attempters , men 737 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 77 of 154

more likely to be committers. Age: Highest rate of s uicide is in teenagers and the elderly. Depress ion: 15 percent commit s uicide. Previous attempts : 10 percent of previous finally s ucceed. E thanol abuse: 15 percent of alcoholics commit suicide. R ational thinking los s, ps ychos is. 10 percent of schizophrenics commit suicide. S ocial support is lacking. Organized plan increases the suicide risk. No s pouse increas es the suicide risk. S ickness . C hronic illness increas es the risk. Homicidality may become apparent if the interviewer discuss es the patient's enemies . As in the ass es sment suicidality, previous homicidal attempts or completions , intent, lethality of plan, and available means have to be as sess ed. P atients at risk for homicide are those with persecutory delusions, antis ocial pers onality disorder, subs tance-related dis orders. T o increas e the likelihood a patient admits to homicidal ideas or plans , us e the golden rule: Approach the s ubject from the patient's of view as understandable. Use questions s uch as “Are there people in your life who have harmed you and deserve to die for what they have done? ” “Are there people whom you wis h to be dead? ” If the patient an intent to harm s uch foes, introduce the s ubject of 738 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 78 of 154

management, including warning of identified victims , which is the interviewer's duty. C ontrary to expectation, tell the patient about the duty to warn has only minimal impact on the alliance with the patient. When asked about experiences with extrasensory perception (E S P ), the patient may report hallucinations and delus ions. Hallucinations and delus ions can be according to the patient's level of insight (T able 7.1-6). Hallucinations and delus ions are also evaluated by mood congruency. B ecaus e the patient usually has insight into obsess ions , compuls ions, panic attacks, unexplained pain, derealization, and depers onalization, the interviewer can explore these thought contents and experiences with targeted ques tions. However, the may consider s ome obsess ions and compuls ions as embarrass ing and may attempt to hide them.

C ognition T he interviewer judges cognition by the patient's ability comprehend ques tions and express the res pons es . the interviewer finds no evidence of a cognitive disturbance during conversation and exploration, he or she s till may select a few brief tes ts that as ses s attention, recent memory, remote memory, abs traction, and intelligence (T able 7.1-6).

Ins ight T he interviewer asks the patient to what extent he or feels s ick. Us ually, a patient with schizophrenia, mania, dementia, or s ubs tance-related dis orders may deny sick, yet s ome s uch patients have partial insight. T hey acknowledge being depres sed but explain that the 739 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 79 of 154

depres sion is a res pons e to the scolding voices. A may acknowledge that he or s he needs help but deny being sick. S uch a patient may accuse other people factors —the employer, the spous e, the lack of as being the cause of his or her problems . Insight is reported as being good, fair, or poor. A more technique is to des cribe to what extent the patient recognizes being s ick.

J udgment R eview of significant life events , money management, personal relations hips reflects a history of the patient's judgment. J udgment often varies in accordance with patient's s tate of illness . In patients with bipolar judgment may deteriorate during mania but may be intact during euthymic or even depres sed states . a patient's current judgment in comparis on with his or historical judgment may provide a meas ure of the of a disorder. If a patient's judgment is not apparent or inconsistent with the diagnosis , judgment can be more formally ass es sed. S ome psychiatrists us e ques tions the Wechs ler Intelligence T est to as sess judgment. E xample: W hat do you do when you first detect a fire in crowded theater? S uch questions do not involve the patient's affect, mood, and motivation and, therefore, fail to meas ure the appropriatenes s of judgment. A powerful question is to as k about future plans. If these plans appear consis tent with the educational and res ources , the patient appears to have appropriate judgment.

Tes ting 740 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 80 of 154

T es ting is a highly structured form of exploration. T o valid res ults, the patient has to be fully compliant. T he majority of the brief tests that a psychiatric interviewer us es at the beds ide or office meas ure s ome as pect of cognitive function (T able 7.1-6). Interviewers s elect bedside tests according to the patient's complaints or demonstrated P.812 cognitive deficits apparent during the interview. T able 6 s hows the function to be tested, the test, the of abnormal res ponse, the clinical evaluation, and key examples of dis orders that may tes t positive. T able 7.1covers 15 cognitive and three noncognitive functions — affect, suggestibility, and abnormal perception. T he of two of the noncognitive functions and the s taging of hallucinations as part of abnormal perception are discuss ed above. S ugges tibility may be tes ted if the patient shows dis sociative s ymptoms. A high degree of suggestibility need not be a weakness but can be a strength us ed for therapeutic purpos es . T hus, suggestibility is not a s ymptom of a ps ychiatric However, high sugges tibility is a prerequisite for diss ociative disorders and conversion disorder, in patient nearly automatically convinces him- or hers elf being amnes tic of a particular traumatic event amnes ia) or feels , for ins tance, that he or she is (conversion dis order). T he interviewer uses s ome of the cognitive tes ts in diagnostic interviews —that is , vigilance or short- and long-term memory, orientation, abstract thinking, and intelligence. S evere anxiety, major 741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 81 of 154

depres sion with ps ychomotor retardation, and deficit/hyperactivity disorder (ADHD) may interfere with concentration and lead to the impres sion of an recent memory. If the interviewer evidences poor concentration, he or she should make an effort to error-free immediate recall. Major depres sion and other noncognitive ps ychiatric disorders may interfere only retrieval of information and not with storage. Hints or multiple-choice options may help to overcome the retrieval block. If s torage of information is impaired, as in dementia of Alzheimer's type, this help fails . T he interviewer may focus on evaluating abstract thinking (T able 7.1-6) and intelligence testing if the quality of patient's answers during the interview s ugges ts that concentration, orientation, and memory are intact. T he interviewer selects any one of the other tests in T able when he or s he believes that a particular function may impaired and needs documentation. If not already ass es sed, at the end of the mental s tatus examination, the interviewer evaluates four risk factors the patient's and others ' safety, summarized by the acronym S OAP . T he interviewer explores which of the major psychiatric dis orders is responsible for thes e key factors and makes plans for their immediate S uicidality, homicidality, phys ically as saultive, unpredictable, explosive, and self-injurious and implied or overt threats . Organic disturbances of cognitive functions : disorientation, memory dis turbances, decline of executive functions , aphas ias and apraxias that prevent the patient from exercising the activities of 742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 82 of 154

daily living (ADL). Alcohol and other s ubstance abuse, ranging from occasional social us e to uncontrollable addictive behavior and dependency that may endanger the patient's and others ' safety on the road and in legal, marital, occupational, and financial s tatus. Psychotic features, such as delus ions, es pecially delus ions of control, and hallucinations , es pecially command hallucinations , and their dangerous nes s the patient's obedience to thes e experiences . here are illogical thinking and speech and catatonic behavior. T he interviewer compares the patient's psychiatric with the patient's mental s tatus to confirm the impres sion. Incons is tencies have to be explored. S uch inconsistencies may raise the pos sibility of incomplete as sess ment by the interviewer or of factitious lying, or malingering on the patient's part.

DIA G NOS IS F or the treatment plan, the interviewer verifies one or more Axis I or II, or both, ps ychiatric diagnoses and excludes others . T he interviewing s tyle matches the patient's res ponses. Us ually, a s trategy that strikes a balance between a dis order- and a patient-centered approach is appropriate. T he diagnostic process can arbitrarily divided into five phases.

Phas e 1: As s es s ing the C hief T o choos e an opening for the chief complaint is the beginning of a chain of eight decisions (A to H) in a 743 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 83 of 154

diagnostic loop (F ig. 7.1-1). T he interviewer may link decis ions in an order s uggested by the clues that the patient offers.

FIGUR E 7.1-1 Diagnos tic decision loop for ps ychiatric disorders . C C , chief complaint; Dx, diagnos is ; Hx, 744 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 84 of 154

N, no; NOS , not otherwise specified; S xs, symptoms ;

Openings for C hief C omplaint T he interviewer s elects one out of several poss ible openings that leads to the patient's genuine chief complaint (B ox A in F ig. 7.1-1). B elow are s ome

DIR E C T QUE S TIONING “What brought you here? ” “What kind of problems do have? ” “What's going on in your life? ” S uch ques tions target the patient's chief complaint and may lead to the history of the pres ent illnes s.

C ONFR ONTATION WITH A S IG N T he interviewer confronts the patient with a poss ible of a mental illness , s uch as wearing dark glass es walking with a cane, exuding the smell of alcohol, or having s lurred s peech, cold and clammy hands , ataxic or bruis es on the face. I: I notice you are wearing dark glass es. P : (Looking behind the interviewer at the door, Y es , I don't like people to s ee my eyes. T hey can look through me and read my mind. I: Is this fear the reas on why you came? P : My colleagues at work really look at me. T hey want get into my head, but I won't let them. S uch an entry leads the interviewer to the chief the history of present illness , and the mental status 745 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 85 of 154

evaluation.

ME DIC AL HIS TOR Y P : (Obviously anxious ; her hands make wet imprints on interviewer's des k) I: Have you ever been to a psychiatrist's office before? P : Never. I'm s o as hamed. Why do you have C enter” written above your door? I had a hard time because of that. I: W ell, have you had the same feeling at your family doctor's office? P : Of cours e not. I: W hat did you see the general practitioner for? P : Oh, I have a thyroid condition. I'm on S ynthroid. I: Any other medicines you take? Here, the interviewer s hows sensitivity to the patient's anxiety. T o give the patient time to calm down, the interviewer ass es ses the P.813 medical his tory first before returning to the ps ychiatric chief complaint, which may center on anxiety and persecutory thoughts.

FAMILY HIS TOR Y P : (After the greeting ceremony) I never thought I have to s ee a ps ychiatris t myself. I: Oh? Who had to s ee a ps ychiatris t before you? P : My mother did. S he was in and out of psychiatric 746 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 86 of 154

hospitals . I: T ell me about it. It may give us some clues about own problem. F amily history provides a link to the chief complaint.

S OC IAL HIS TOR Y P : (Looking around, anxious) I didn't expect Monet and Degas prints at a doctor's office. I: Do you have any art background? P : W ell, not really, but I'm a profess ional fundrais er, sometimes we run into some interes ting pieces . I have developed an eye for it. And art really interests me. I: How long have you been into fundraising? P : F or 12 years now. And it has n't always been easy. T he interviewer picks up on the patient's clue and with the s ocial his tory, which leads to stress ors in the patient's life and offers an entry for the chief complaint. P.814 After the interviewer has s olicited a chief complaint, he she clarifies the chief complaint and translates it into a DS M-IV -T R criterion if poss ible (s ee the s ection

Phas e 2: Diagnos tic Dec is ion L oop T he chief complaint leads to a diagnostic decision loop, which as sists the interviewer in including and excluding DS M-IV -T R Axis I and II disorders and in ass es sing history.

C linic al S ignific anc e: Morbidity— 747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 87 of 154

Mortality T he firs t s tep is to determine whether the elicited chief complaint caus es increas ed ris k of mortality or morbidity—that is , interferes with the patient's life, or health or requires treatment or hos pitalization (B ox B F ig. 7.1-1). T his concept of a psychiatric disorder is on the pres ence of dysfunction that causes the patient handicap. A 27-year-old white hous ewife, Ms . C heryl X. I: Y ou s ay that for the last 3 weeks you have been so that you cannot go to the mailbox. W hat other have you experienced? P : I startle when the phone rings. I don't want to leave house. My husband has to do the s hopping. It all weeks ago in church. I had to run out of the service. My husband came after me, and then I felt like a knife was rammed into my chest. I could not breathe. I: W hat did you do? P : I thought I had a heart attack and had to die. B ut in emergency room, they took an electrocardiogram and drew blood and told me after a few hours that my heart okay. And they told me to make an appointment with I: Did you use any alcohol or drugs at that time? P : No. Drugs never. As a teenager, I drank beer. It me to talk to the boys . B ut that was many years ago. In the cas e of C heryl X., the symptoms led to an department visit and interfered with the patient's ability leave the house. Morbidity was obvious. Its degree can as sess ed with the G lobal As sess ment of F unctioning S cale. C heryl X. may be rated G AF 35 becaus e s he is 748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 88 of 154

able to leave the hous e. If the interviewer cannot clinical s ignificance, the option is to diagnos e no ps ychiatric disorder (a “no” res ponse to B ox B in F ig.

S ymptoms A s s oc iated and Not A s s oc iated with the C hief C omplaint T he interviewer gathers s ymptoms that occur approximately at the s ame time as the chief complaint (B ox C in F ig. 7.1-1). E xcluded should be symptoms , or laboratory res ults that the chief complaint s uggests cannot be verified. In the cas e of C heryl X., the interviewer found symptoms ass ociated with the chief complaint. At the same time, the interviewer excluded cardiac dis orders drug and alcohol abus e as ass ociated conditions. Infrequently, the interviewer may elicit a chief complaint without being able to identify ass ociated s ymptoms . In case, he or s he cons iders a ps ychiatric disorder not otherwis e s pecified (NOS ), or, if clinical significance is lacking, he or s he may not diagnose a ps ychiatric at all (a “no” res ponse to B ox C in F ig. 7.1-1).

C riteria for A xis I or II Met? After the interviewer has elicited with open-ended questions a lis t of symptoms ass ociated with the chief complaint, he or she checks whether s ufficient criteria an Axis I or II dis order are met (B ox D in F ig. 7.1-1). If the diagnosis can be made (B ox E ). If no, additional questions have to be as ked to satisfy the s et of criteria needed for a diagnos is . An incomplete set of criteria only allow a diagnos is NOS (a “no” res ponse to B ox D F ig. 7.1-1). 749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 89 of 154

Ms. C heryl X.'s initial ans wers s ugges t the ons et of panic disorder with agoraphobia. At this point, the interviewer may as k whether an attack like the one church s ervice had occurred before and, if s o, how F urthermore, the interviewer may elicit other symptoms that have occurred during the panic attack but were not spontaneously mentioned by the patient.

L ongitudinal His tory vers us C ros s S ec tional C omorbidity After the interviewer has established a psychiatric the interviewer reaches a major decision point in the diagnostic process . He or she has to decide whether to as sess other comorbid psychiatric dis orders or purs ue history of the already es tablis hed dis order (B ox F in 7.1-1). In the cas e of C heryl X., the interviewer could either the presence of other anxiety disorders , s uch as social phobia, s pecial phobias, OC D, and generalized anxiety disorder, mood disorders, or s ubs tance-related or follow up on historical symptoms of panic dis order agoraphobia (B ox F in F ig. 7.1-1). I: T he attack that you had in church is called a panic If you think back, have you ever experienced any type spell like this ? P : No. I don't think so. Wait… Y ou know, when I was in high s chool, we had to jog, and then we had to work on the high bar. All of a s udden, I felt I could not breathe, had to lie down. B ut I never had anything like that I: Have you ever had the feeling you could not leave house? 750 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 90 of 154

P : W hen I was 12, I did not want to go back to s chool the s ummer vacation. How does the interviewer decide whether to pursue comorbid disorders or the history of the already disorder? F irst, if the patient provides a clue, the interviewer may follow the lead. F or instance, if C heryl X. had said, had the attack, I s tarted drinking again,” the interviewer would follow this lead and explore this comorbidity of alcohol abus e. If C heryl X. had said, “Now that you ask all these questions about my attack, I think I've had mild ones before,” the interviewer would take the of the panic dis order. S econd, the interviewer may follow up on comorbidity if the chief complaint or as sociated s ymptoms suggest presence of a more serious ps ychiatric disorder. F or instance, if C heryl X. mentions s he cannot go to the mailbox becaus e the neighbors do not like her, the interviewer may want to explore the presence of ideas reference or pers ecutory delus ions. S uch exploration lead to disorders with psychotic features and reveal poss ible homicidal and suicidal tendencies . T hird, the clinical s ignificance of the disorder may the interviewer: If the disorder is s evere, the interviewer may purs ue its his tory; if the dis order is mild, the interviewer may explore comorbidity to exclude a more severe disorder. F ourth, if the patient is circums tantial or has difficulties focus ing or abstracting, the interviewer may complete history of the disorder already diagnos ed to avoid 751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 91 of 154

confusing the patient. F inally, if leads are lacking, the interviewer is left with arbitrary decision. P.815

S earc h for an A dditional C hief C omplaint If the interviewer screens for comorbidity (a “yes ” to B ox E in F ig. 7.1-1), he or she searches for an chief complaint. Ms. C heryl X. I: B esides your panic attacks and your difficulty with leaving your home, do you have any other problems? If C heryl X. mentions a second chief complaint, the interviewer loops back to B ox B , ass es sing clinical significance and ass ociated symptoms (B ox C ), the decis ion whether the s ymptoms fulfill sufficient for an Axis I or II ps ychiatric disorder (B ox D). Depending on the symptomatology, the interviewer complete the diagnostic decis ion loop B through H times . W ith each newly made diagnosis, the lengthens the lis t of es tablis hed Axis I and II disorders , shortens the lis t of unexplored dis orders, and may add the list of excluded disorders .

S c reening for A dditional Diagnos es If the interviewer runs dry of new chief complaints or significant ps ychiatric s ymptoms, he or she may switch from open-ended to clos ed-ended ques tions and 752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 92 of 154

screen for all those psychiatric dis orders that have not been covered yet (B ox H in F ig. 7.1-1). C losed-ended screening questions , mos t well res earched, are in T able 7.1-7. F or each pos itive answer, the may es tablis h clinical s ignificance. T he S tandardized Ass es sment of P ers onality–Abbreviated S cale example, may be a helpful screening tool for disorders .

Table 7.1-7 S c reen for Dis orders (Axis I and II) Dis order

Ques tions

C ognitive disorders

Use tes ts of memory, aphas ia, and apraxia in T able 6.

Mental retardation

While you were in s chool, did anyone ever s ay that you were very s low learner?

 

Did you ever have to go into a special education clas s when were in s chool?

S ubstance-

Has heavy drug or alcohol us e 753

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 93 of 154

related disorders

ever caus ed you problems in life?

 

Have you ever used pot, s peed, crack, heroin, ice, or any other drugs to make yours elf feel

P sychos is

Have you ever heard voices or seen things that no one else hear or see?

 

Have you ever felt your mind or body was being s ecretly controlled or controlled agains t your will?

 

Have you ever felt others to hurt you or really get you for some special reas on, maybe because you had s ecrets or powers of s ome sort?

 

Have you ever had any other strange, odd, or very peculiar things happen to you?

 

If yes to any of the above: Did happen even when you were drinking or taking drugs?

754 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 94 of 154

B ipolar disorder, manic

Have there ever been times you felt unus ually high, charged up, excited, or res tless for 1 at a time?

 

Have there ever been times other people s aid that you were too high, too charged up, too excited, or too talkative?

 

Have these high, excitable ever s tayed with you most of the time for at least 1 week?

Major depres sive disorder

Have there ever been times you felt unus ually depres sed, empty, s ad, or hopeless for days or weeks at a time?

 

Have there ever been times you felt very irritable or tired of the time for hardly any reas on at all?

 

Have these feelings ever stayed with you most of the time for as long as 2 weeks?

P anic dis order

Have you ever had sudden or attacks of nervousness , 755

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 95 of 154

or a strong fear that jus t s eems come over you all of a sudden, of the blue, for no particular reason?  

If yes : Did you have thes e even though a doctor said that there was nothing s eriously wrong with your heart?

P hobic disorders

Have you ever been much more afraid of things the average person is not afraid of? Like heights, animals, needles, thunder, lightning, the sight of blood, or things like that?

 

Have you ever been so afraid to leave home by yours elf that you would not go out, even though you knew it was really s afe?

 

Have you ever been afraid to go into places like s upermarkets , tunnels, or elevators becaus e were afraid of not getting out?

 

Have you ever been so afraid of embarrass ing yourself in public that you would not do certain 756

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 96 of 154

things most people do? Like eating in a res taurant, using a public restroom, or s peaking out in a room full of people?  

If yes to any of the above: W hen your fears were the s tronges t, you try to avoid or s tay away (name feared s timulus) you could?

Obsess ivecompuls ive disorder

Have you ever been bothered certain embarrass ing, s cary, or ridiculous thoughts that came into your mind over and over even though you tried to ignore or s top them?

 

If yes : P lease describe them.

 

Have you ever felt you had to repeat a certain act over and even though it did not make much sense? Like checking or counting something over and over or washing your hands and over again, although you knew they were clean?

P os ttraumatic

Have you ever experienced 757

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 97 of 154

stress

flashbacks when you found yours elf reliving s ome terrible experience over and over

G eneralized anxiety disorder

Have there ever been days at a time when you felt extremely nervous, anxious , or tense for special reas on?

 

If yes : Have you s ometimes felt this way even when you were at home with nothing s pecial to

 

If yes : Have these nervous or anxious feelings ever bothered you off and on for as long as 6 months or more at a time?

S omatization disorder

Have you had a lot of phys ical problems in your life that forced you to see different doctors?

 

If yes : Have doctors had trouble finding what caused these phys ical problems ?

 

Did you start having any of problems before you were 30 years of age?

758 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 98 of 154

Dis sociative disorder

Do you experience at times a of memory for hours or longer without being under the of a drug?

 

If yes : Do you travel during s uch periods?

 

Have you felt not yours elf, or you been told that you use a name other than your own?

S exual disorders

Do you have problems with your sex life?

 

Do you get s exually aroused by expos ing yours elf, by female undergarments , by rubbing agains t noncons enting people, by children?

 

Do you intensely wish to be a member of the opposite s ex?

Anorexia nervos a

Have you ever deliberately lost much weight on a diet that people started to s erious ly about your health?

 

If yes : W ere you afraid of 759

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 99 of 154

fat even when other people s aid you were thin enough? B ulimia nervos a

Did you ever have a problem binge eating, when you would so much food so fas t that it you feel s ick?

 

If yes : W hen you were doing did you feel your eating binges were not really normal?

 

If yes : W as the urge to binge sometimes so strong that you could not stop, even though you wanted to?

 

If yes : After you had binged, did you often feel depres sed, as hamed, and dis gusted with yours elf?

 

If yes : Did you ever vomit after eating, us e laxatives, or excess ively exercise?

Adjustment disorder

In the las t 3 months, have you been very worried or upset something that happened to Like the death of a loved one, 760

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 100 of 154

of a job, s eparation, divorce, an accident, serious illness , or that sort of thing?  

If yes : Do you feel that you had more trouble handling this situation than most people have had?

S leep

Do you have insomnia or to fall as leep or wake up at a desired time?

 

Do you have s leep attacks the day, or do you feel always tired?

 

Do you snore or wake up for air?

 

Do you have nightmares, wake in terror, or do you s leepwalk?

P ers onality disorders

 

   C luster A

Are you a person who usually is suspicious of other people, who does not care much about the company of other people, or 761

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 101 of 154

realizes that things have a meaning beneath the s urface? C lus ter B

Are you a person who feels that you want to be paid attention to and be res pected you have to really put it on, express yourself loudly, and make your point?

 

Do you feel you are denied what you are entitled to?

C lus ter C

Are you a person who, to feel anxious, tries to be perfect, in to others , does what they to do, or tries to avoid public expos ure?

Adapted from Othmer E , P enick E C , P owell B J . P s ychiatric Diagnos tic Inte rvie w-R evis e d (P DI-R ). Manual and Adminis tration B ookle t. Los Angeles : Wes tern P sychological S ervices ; 1989. If the patient endorses any of the symptoms targeted the s creening questions, the interviewer loops back in diagnostic decision loop P.816 to search for clinical s ignificance (B ox B ) and 762 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 102 of 154

symptoms (B ox C in F ig. 7.1-1). T his active process yields psychiatric disorders in remiss ion, es pecially subs tance-related dis orders, and dis orders that start during childhood, such as learning dis abilities, deficit disorder with and without hyperactivity, conduct disorder, and personality dis orders. Active screening the disorders (B ox H in F ig. 7.1-1) as sures their the multiaxial diagnos es and their effect as factors for current psychiatric dis orders (T able 7.1-8). Ins truments s uch as the P sychiatric Diagnostic (P DI) or the S tructured C linical Interview for DS M-IV ensure diagnostic thoroughness . T he interviewer may keep track of all disorders excluded by negative the screen, thus lengthening the lis t of excluded ps ychiatric disorders.

Table 7.1-8 B iops yc hos oc ial C on Pres enting as Predis pos ing, Prec i Perpetuating, and Protec tive Fac Ps yc hiatric Axis I Dis orders Fac tor

B io

P redisposing P os itive ps ychiatric family history; delay in

Ps yc ho

S oc ia

Impaired premorbid personality, is olation,

Negle low ed poor p role m

763 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 103 of 154

reaching developmental miles tones ; ps ychiatric disorders firs t diagnosed in infancy, childhood, or adoles cence; medical history (head injury, central nervous system disorders Axis III)

suspicious nes s, poor impulse control, anxiousnes s, perfectionism, presence of personality disorders II), low adaptive defens e mechanisms

antis o behav subs ta pover

P recipitating

Onset of severe disorders

S tres s intolerance, poor impulse control, s elfpity, blaming (projection)

T raum job or increa (Axis

P erpetuating

C hronic medical

P oor ins ight, judgment, and impulse control; low noncompliance with R x.

S ocia unem pover

764 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 104 of 154

P rotective

G ood health maintenance, absence of chronic medical disorders

G ood ins ight, judgment, and impulse control; high IQ; with R x. (high ego s trength, high adaptive defens e mechanisms)

E xten suppo well-p satis fy

IQ, intelligence quotient; R x., prescription.

Taking the P s yc hiatric His tory After the interviewer has established the presence of or more ps ychiatric Axis I and II disorders , he or s he es tablis hes their history if not already done during the diagnostic looping. T he interviewer may follow a going either backward from the pres ent (e.g., when did happen last before this time) or forward, s tarting with childhood. Important points of the history are onset, cours e, and treatment respons es . T he onset can be ass es sed with a double question: did you first notice a symptom of your pres ent disorder? Up to which age do you feel you were at your best and had no ps ychiatric problems ? Often, patients give different ages for the end of their healthy, premorbid state and the beginning of their 765 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 105 of 154

ps ychiatric disorder. I: W hen did you first experience any problems with depres sion? P : During the s eventh grade, I had a time where I did want to get out of bed, felt tired and s ad all the time, did not even want to talk to my friends on the phone. I: F or how long did this las t? P : T wo or 3 months . P.817 I: If you look back on your life, when was the las t time you felt at your best and did not have any problems ? P : Maybe when I was 8 years old. I remember in the or third grade, I was often tearful for no reason. It did last very long. My mother told me that I was very T he answers to thes e two ques tions indicate that the patient had either a preexisting pers onality disorder or prolonged prodromal s tate to the onset of his or her depres sive dis order. T his dual questioning is a tool to identify premorbid states , personality dis orders, and prodromal s tates to Axis I psychiatric dis orders. T he onset of personality dis orders can be traced back focus ing on a s ymptom or behavior of which the patient aware, s uch as shyness or problems with authority F or example: W hen did you first notice that you were When did you firs t notice that you rebelled agains t authority figures? An alternate approach is to identify a pres ent conflict the interviewer judges to be due to a personality 766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 106 of 154

and s earch the patient's past for s imilar conflicts . T he interviewer should be able to trace pers onality back to at least teenage years becaus e they repres ent lifelong patterns of maladjus ted behaviors . T he course the ps ychiatric dis order can help to confirm the of the Axis I disorders . T o draw a profile of the cours e of a psychiatric disorder gives an idea about exacerbations and remis sions . Of importance are the intervals in which the dis order to be in remis sion. T hes e intervals can identify the capacity of functioning when relatively well and can to define the goal of treatment. P atients often have difficulties in relating their ps ychiatric history to years . T he interviewer s hould introduce anchors of memorable events, s uch as getting married, moving, or changes. His tory of treatment res pons es provides information what treatments have led to improvement, remis sion, failure, or adverse effects . T reatment respons e may be judged as being consis tent or not cons is tent with the diagnosis.

P s yc hiatric Dis orders in F ull or R emis s ion T he diagnostic decision loop als o helps to detect ps ychiatric disorders in full or partial remis sion. T hey be lis ted according to the developmental s tages before adulthood such as disorders diagnosed in infancy, childhood, and adolescence.

Phas e 3: His tory and Databas e Diagnos ing ps ychiatric dis orders may arouse the 767 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 107 of 154

sens itivities and activate defenses. S uch respons es mostly abs ent when family, medical, and even s ocial history and routine mental s tatus items are as sess ed. T herefore, the interviewer can take a dis order-centered approach.

Medic al His tory (A xis III) T he medical his tory is of importance to the ps ychiatric interviewer for three reasons: (1) Medical dis orders can caus e s ymptoms of panic, anxiety, depres sion, and delus ional thinking diagnosed as “ps ychiatric disorder to a medical condition;” (2) s ide effects of medications prescribed for medical disorders may mimic ps ychiatric symptoms and dis orders; and (3) any medical disorder its treatment can complicate course and treatment of ps ychiatric disorders and vice vers a. Drug–drug interactions can range from mild to s evere. B iopsychosocially, a chronic medical disorder may be a predis pos ing and perpetuating factor of a ps ychiatric disorder. T he onset of a s evere medical disorder may precipitate a psychiatric dis order (T able 7.1-7). A 51-year-old farmer without a family or personal of any ps ychiatric disorder developed a severe after he had a myocardial infarction. He feared that his phys ical incapacity to work might prevent him from paying off his expensive equipment. T he absence of a medical disorder in combination with good health maintenance is a protective factor in the agains t psychiatric disorders . A dual approach helps to detect medical dis orders, asking open endedly for the patient's medical health and reviewing all s ys tems as 768 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 108 of 154

us ually done in general medicine. T he open-ended questions may be followed by a request to lis t all disorders that the patient pres ently is treated for, by specialist, and with which medications. A his tory of surgeries and medication allergies rounds up this first approach. T he review of systems covers all medical specialties .

F amily His tory P sychiatric Axis I and II disorders are familial. twin and adoption studies s uggest that the familial occurrence is not merely learned but follows a genetic disposition. T he familial occurrence in firs t-degree and their treatment respons e can therefore confirm the patient's diagnosis and predict P.818 the treatment response. F urthermore, the parental history may provide a prognostic look into the patient's cours e. T herefore, family his tory is the most important predis pos ing factor of the biological part of the patient's biops ychos ocial condition. T he drawing of a pedigree men as s quares and women as circles is an effective as sess the family his tory with the patient's P sychiatrically affected members are repres ented by blackened s hapes, questionable members are striped. Names, ages, type of dis order, and treatment all fit into genogram.

Developmental His tory E ven if a psychiatric diagnosis during childhood or adoles cence is not made, the interviewer s hould 769 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 109 of 154

five important areas: Developmental miles tones: delayed ps ychomotor speech development and toilet training may point to early developmental problems . Ability to learn in school: s low learning or repetition the first grade may point to mental retardation; circums cribed deficits, s uch as dyslexia or may indicate a learning disorder. Attention problems with hyperactivity and poor impulse control may contribute to s ubs tance abus e and to the development of a personality disorder, as antis ocial pers onality disorder. Dis ciplinary problems may cover a broad range. Arguments with teachers , objections to rules, tantrums, resentfulnes s, and vindictivenes s point to oppos itional defiant dis order. F ighting, stealing, vandalis m, and school discipline problems characterize males ; lying, truancy, running away home, substance us e, and pros titution characterize females with conduct dis order. F urthermore, symptoms s uch as violent behavior toward peers, or animals and fire setting also sugges t disorder, which, in later adoles cence, may progress antis ocial pers onality disorder. T he earlier the conduct dis order, the worse the prognos is and the greater the risk for later mood, anxiety, and s ubs tance-related disorders . During childhood and adolescence, social with decline in hygiene, truancy, and anger may herald s chizophrenia; phobias , obsess ions , 770 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 110 of 154

compuls ions, and depress ive symptoms may adulthood ps ychiatric disorders .

S oc ial His tory A biographical, detailed s ocial history of key life events may be informative but may not serve the ass es sment social factors in the patient's ps ychiatric disorders . T he relations hip between s ocial factors and ps ychiatric disorders is reciprocal. T o teas e out this reciprocal relations hip is the interviewer's tas k in addition to sociodemographic fact finding. T he interviewer s hould target four topics: P remorbid vers us pos tmorbid psychosocial functioning. P remorbid functioning repres ents the highes t level of patient performance meas urable by the social component of the G AF . T he difference between the pres ent and the past G AF scores meas ures the morbidity caused by the ps ychiatric disorder. T he return to the premorbid level of functioning is a goal of ps ychos ocial rehabilitation. T herefore, the interviewer wants to clarify the premorbid vers us pos tmorbid level of functioning res pect to family life and work, including s chool and military, friends , and community functions such as church and s ocial organizations. S ocial factors as ris ks for psychiatric dis orders. factors can predispose to a ps ychiatric dis order, precipitate its onset, perpetuate its cours e, or the patient agains t morbid influences (T able 7.1-7). history of physical, s exual, and emotional abus e, rejection and neglect during upbringing, and 771 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 111 of 154

provis ion of poor role models can become a predis pos ing factor for the development of disorders . F or ins tance, patients with dis sociative disorders , including diss ociative identity disorder, often report a history of physical and s exual abus e, es pecially during childhood. B arring memory distortions, the pres ence of abuse can often be confirmed by outside evidence. S evere lifetrauma can predis pos e and precipitate the onset of posttraumatic stress disorder (P T S D). Acute or stress ors , s ingle or multiple, can predis pos e, precipitate, and perpetuate adjus tment disorders symptoms of depres sion, anxiety, or dis turbances conduct. T hes e factors are listed on Axis IV as ps ychos ocial and environmental problems. S ocial support. In contras t, the absence of abus e, rejection, and neglect and the pres ence of strong, positive role models and an extensive s upport in the pas t and present that s ecured adequate childrearing and education can be s trong protective factors against exacerbations of ps ychiatric S ocial support can improve prognos is. It can the patient to comply with treatment. Negative impact of ps ychiatric disorders on s ocial advancement. P s ychiatric dis orders can impede patient's s ocial development and can lead to demotion, job los s, and divorce.

Mental S tatus E xploration and T he interviewer monitors the patient's mental s tatus throughout the interview. T oward the end, the 772 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 112 of 154

us ually address es some mental status areas directly, es pecially by exploration (T ables 7.1-3, 7.1-4, and 7.1and tes ting (T able 7.1-6). If not previously ass ess ed, interviewer explores ris k factors s uch as s uicidality, homicidality, cognitive impairment, s ubs tance abus e, ps ychotic symptomatology, including command hallucinations .

Phas e 4: Diagnos ing and Feedbac k T hroughout the s es sion, the interviewer collects data he or s he organizes in a biopsychosocial formulation— as sets and s trengths , differential diagnos es, if and multiaxial diagnos is . He or she feeds this back to the patient when the interviewer dis cus ses the evaluation of the patient. T he interviewer also us es this information in phase 5 when he or s he proposes the treatment plan and dis cuss es the prognostic outcome.

B iops yc hos oc ial F ormulation T he interviewer may summarize the findings of the in the form of a biopsychosocial formulation. T he biops ychos ocial conditions that contribute to the development, ons et, and course of a ps ychiatric can be clas sified according to their impact as precipitating, perpetuating, or protective factors (T able 7.1-8).

A s s ets and S trengths T he interviewer als o as sess es the patient's ass ets and strengths . T his evaluation should be made in terms. It includes the patient's knowledge, interes t, aptitude, experience, education, and employment 773 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 113 of 154

all items that are clos ely related to the protective T able 7.1-8.

Differential Diagnos is Initial ps ychiatric diagnostic interviews may yield incomplete, vague, and contradictory information s o the interviewer believes he or she cannot make a with confidence. A differential diagnos is that weighs the pros and cons for a group of Axis I and II psychiatric disorders may then take the place of a s pecific T he advantage of the differential diagnosis is that it comprehensively captures the perimeter of ps ychopathology that the interviewer takes into P.819

Multiaxial Diagnos is DS M-IV -T R encourages multiple diagnoses on Axis I T he more pervasive disorder receives priority over the pervas ive one. F or instance, a patient who has the diagnosis of schizophrenia may not receive the diagnosis of dysthymic dis order because dys thymic disorder is believed to be an as sociated feature of schizophrenia. If a psychiatric disorder is judged to be to a medical condition, such as reserpine-induced depres sive dis order, the interviewer should not make additional diagnosis of major depress ive disorder. T R us es a host of s pecifiers to increas e the precis ion diagnosis. T heir dis cuss ion exceeds the frame of this chapter. However, some determinations are particularly us eful:

774 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 114 of 154

P rincipal diagnos is . T he interviewer as signs this determination to the psychiatric disorder that mos t reliably and comprehensively explains the pres ent symptomatology and is the focus of treatment. P rovis ional diagnos is . T he interviewer believes a patient fulfills sufficient criteria for a particular ps ychiatric diagnosis; however, the interviewer documentation for some of the criteria. P s ychiatric dis orde r NO S . T he patient does not sufficient s ymptoms to fulfill criteria for a specific diagnosis, even though the information appears accurate and complete. P as t ps ychiatric diagnos is . T his widespread term is replaced in DS M-IV -T R by s pecifiers such as “in full remis sion, partial remis sion, or residual state.”

A xis III Dis orders T hese are the medical disorders . If a medical dis order cons idered as the caus e of the psychiatric dis order, it listed on Axis I as a mental disorder due to a general medical condition and on Axis III as medical disorder.

A xis IV On Axis IV , the interviewer lis ts psychosocial and environmental problems that were pres ent during the preceding year of the diagnos is and that may affect diagnosis, treatment, cours e, and prognosis. However, stress ors that clearly relate to the pres ent psychiatric disorder, s uch as a life-threatening trauma in P T S D, also be included even if they fall outside the 1-year frame. DS M-IV -T R lists nine categories that us ually 775 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 115 of 154

as stress ors : problems with primary support group, environment, education, occupation, hous ing, health care access , legal system, and psychosocial environmental.

A xis V: G lobal A s s es s ment of F unc tioning T he G AF scale is a dual scale. It measures two ps ychiatric disorders: severity of s ymptoms and level of ps ychos ocial functioning. It ranges from 100 (s uperior functioning, no s ymptoms ) to 1 (persistent danger to others and self with inability to maintain minimal hygiene). T he interviewer as signs a s core that reflects lowest level of either of the two. T his score can be through key points of the patient's psychiatric history, it can trace the cours e of the illnes s. Usually, the interviewer measures the present level of functioning the highest level of functioning during the last year.

Phas e 5: Treatment Plan and In phas e 5, the roles of interviewer and patient stay revers ed: T he interviewer ans wers the patient's asked unasked ques tions . T he interviewer decides firs t which level of care the patient requires . He or she discuss es the patient the divers e treatment options and their poss ible advers e effects. T he interviewer may identify immediate targets of treatment and tell the patient what to expect if he or she cooperates . T he interviewer's interventions are most effective if he or s he has been to forge an alliance with the patient. If the patient is severely disabled, such as being s uicidal, homicidal, violent, or ps ychotic, or has los t impulse control, is 776 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 116 of 154

disoriented, or intoxicated, the patient may need hospitalization. Most patients can be treated as outpatients without interruption of their work s chedule. S ome need temporary disability or home supervision. T he interviewer des igns a biopsychosocial treatment T o improve the biological condition, the interviewer us e medication. Most ps ychotropic medications have a delayed ons et of action, as , for example, the s elective serotonin reuptake inhibitors (S S R Is) and mood T herefore, the interviewer may, for the immediate temporary effect, combine s ubs tances with delayed of action with thos e with an immediate ons et, such as anxiolytics, low dos ages of atypical neuroleptics, and, rarer cases , s timulants . A woman who has a major depress ion with retardation and no history of substance abuse who in 3 days wants to attend her daughter's wedding may be prescribed a s timulant for the day of the fes tivity. F urthermore, s he may des ign s trategies to manage key symptoms of the disorders behaviorally or cognitively. the ps ychological dimension, the interviewer may ps ychotherapeutic interventions used in cognitive that increase ins ight, correct perceptual distortions and maladjus ted behaviors , and support ps ychological functioning. S ocial conditions may be improved, for instance, by activating family s upport, with s hort-term relief of s tres s sick leave, by arranging vocational rehabilitation, or by facilitating the ventilation of traumatic events. us ed in interpers onal ps ychotherapy may help. R eferral a ps ychologist or s ocial worker as cas e manager may 777 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 117 of 154

cons idered. T he interviewer may contras t the natural history of the untreated disorder with the cours e that be achieved if the patient cooperates fully and the treatment is effective. T he patient's clear unders tanding the difference can be a s trong motivating factor for the patient's compliance.

P S YC HIA TR IC INTE R VIE W: A T he four components of interviewing are integrated and run s imultaneously. T heir course can be divided into phases, illustrated in the s ample interview below.

Phas e 1: Warm-up and C hief T he interviewer puts the patient and him- or hers elf at (rapport). T he interviewer s ets the scope of the openended screening ques tions (technique); observes the patient's appearance, movements , s peech, and affect (mental s tatus ); and notices clues and the chief (diagnosis).

Phas e 2: Diagnos tic Dec is ion L oop Interviewer and patient forge an alliance (rapport). T he interviewer progress es from questions with broader to narrower s cope. In case of an acute trauma, s uch as in cases of bereavement, divorce, rape, or recently cancer, the interviewer reduces anxiety by address ing emotions evoked by the trauma (technique). He or she explores the thought content, such as hallucinations , delus ions, obs ess ions, compulsions , avoidance panic attacks , and dangerousnes s to others and self (mental s tatus ). He or s he relates the chief complaint P.820 778 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 118 of 154

to concurring symptoms , s igns, precipitating events, stress ors . He or she verifies and excludes specific diagnoses (diagnosis).

Phas e 3: His tory and Databas e T he interviewer demons trates expertis e in handling the patient's problems and offers guidance (rapport). He or transitions from topic to topic to fill in gaps, follow and reconcile inconsistencies (technique). He or she probes judgment and ins ight and tes ts cognition and suggestibility (mental s tatus). T he interviewer as sess es patient's s ocial, family, and medical history (diagnosis).

Phas e 4: Diagnos ing and Feedbac k T he interviewer dis cus ses the diagnos is with the and s ecures the patient's acceptance (rapport). He or explains the nature of the disorder and the treatment options (technique). He or s he reflects on the patient's behavior during the interview (mental s tatus) and summarizes the diagnostic findings on five axes (diagnosis).

Phas e 5: Treatment Plan and T he interviewer outlines the future therapeutic relations hip, his or her availability, and the need for compliance (rapport) and obtains consent for the treatment plan (technique) using the patient's language and level of insight (mental status ). T he interviewer the prognos tic outlook with the patient (diagnosis).

S ample Interview 779 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 119 of 154

Ms. Lorraine R . is a 56-year-old, white, mildly obese with puffy, red eyes, and washed out mascara who is tearful and shaking.

P has e 1: Warm-Up and C hief (1) I: Hello, Ms. R . I'm Dr. O. P lease come in and take P : (W alking slowly into office, with a quivering voice) P lease call me Lorraine. (slumping into the chair) (2) I: What's going on? (P ause) Y ou are all tears. … P : (Looking up, sobbing, breathing rapidly, and her s houlders ) I cried all night. I heard my voice again and again: “S orry, Ms. R . It's s tage 1 cancer.” (3) I: Y our friend J oan called me yesterday. S he told really had to see you today. P : Y eah. It hit me yesterday afternoon. (C rying) I called because she went through the s ame thing. (4) I: S o that's why J oan called me. P : Y es, s he said you had helped her. (wipes her nos e, crying) (5) I: (Looking at her with concern) Hmm. I'm glad s he this way. P : (W iping her eyes but with a firmer voice) I had the biops y yesterday morning. (6) I: When did he first s us pect it? P : (E ven more collected) A week ago. I had a and he told me he felt a lump. (7) I: How did that s trike you? P : Like an out-of-body experience. I heard it without hearing it. 780 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 120 of 154

(8) I: And yes terday? P : It hit me right here. (grabbing her ches t) I couldn't crying. (her eyes fill with tears again)

R APPOR T T he patient reques ted to be called by her firs t name, expres sing her need to have a pers onal, close, dependent relationship to the interviewer (ans wer 1 T he interviewer address ed the patient's tearful affect, immediately s hifting toward a patient-centered interviewing mode. W hen the patient reported that s he cried all night (A2), the interviewer avoided with her (Q3) by saying s omething s uch as , “Y ou must really been torn up.” Ins tead of cathars is , the put her emotional pain into a social framework to her of her s upport s ys tem and steered her toward a cognitive management of her emotions . R eferring to he introduced her relations hip to the interviewer as a model of alliance.

TE C HNIQUE T he interviewer opens by addres sing the patient's status . T he patient res ponds by des cribing her chief complaint (Q2, A2). As a continuation technique, the interviewer points to the urgency of the patient's (Q3), which res ults in the des cription of the trauma and patient's emotional res ponse (A3 to A8) aided by (Q6 to Q8).

ME NTAL S TATUS T he patient displayed a sad affect, which intensified she reported the gynecologis t's telephone call. 781 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 121 of 154

this affect reacted to the interviewer's neutralizing (Q4, 5), excluding a melancholic depress ion. T he initial emotion to the gynecologist's telephone call indicated a diss ociative traumatic respons e (A7), which raised the pos sibility that the patient is s uggestible. T he patient's emotional res ponsivenes s confirmed her reactivity (A8) noted above (A4, 5), excluding the poss ibility that her affect was frozen into a depress ive but reacted according to thought content.

DIAG NOS IS In the dual opening approach, by asking for the chief complaint and by confronting the patient with her affect, the interviewer found an economic, individualized pathway to her chief complaint (Q2; B ox A in F ig. 7.1C larifying her emotions (Q7), the interviewer found a diss ociative traumatic response (A7), s ugges ting the of an acute s tres s disorder, which may turn into an P T S D if untreated. Alternatively, an adjus tment with mixed anxiety and depress ed mood could be cons idered.

P has e 2: Diagnos tic Dec is ion L oop (9) I: C ould you s leep? P : (W iping her eyes again, even though she is not Not at all. All night I heard the gynecologist's voice: “S orry, Ms. R ., it's s tage 1 breas t cancer.” (10) I: S o you relived the bad news … P : (Interrupting) Over and over again. His voice stirred up. (S itting up erect) Like from a bad dream. After the mammogram, I was , like, in a daze. Nothing sank in. 782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 122 of 154

her eyes) (11) I: S o it really s hook you up. P : (Looking pas t the interviewer) Y eah. I forgot to make new appointment. I didn't even fix my breakfast this morning. F elt, like, paralyzed. No appetite. (B ites her lip) Instead, I started smoking again. F ive cigarettes yesterday and one this morning. (12) I: Has anything like this ever happened to you P : Not really. … when my husband asked me for a felt numbed at firs t, but we had problems for a long (13) I: E ver felt down like you feel now? P : (T ilting her head left to right) During the las t 5 years, felt down most of the time. I never felt really normal, work kept me busy. (14) I: Did you get any treatment for depres sion lately? P : Not recently. Only for s moking. B ut 15 years ago, I treated for depress ion with P rozac and then again 10 ago before I got divorced. P.821 (15) I: W hen you were depress ed in the past, what in your life? P : I stayed away from people (with a s igh), even from own family. B ut I wanted them to tell me that that they love me. I did not want to do anything. I was so tired all time, couldn't fall as leep but overs lept in the mornings . ate a lot of junk food and gained weight. (16) I: How did you value your life then? P : I dropped to an all-time low. (17) I: Did you ever want to die? 783 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 123 of 154

P : I wished I wouldn't wake up in the morning. (18) I: E ver tried to do anything to hurt or kill yours elf? P : (W ith a frown) I thought about it, but I have my (19) I: Did you get down when you had your children? P : No. (20) I: T he baby blues? P : (W ith an open smile) No. I felt good. (21) I: Did those suicidal thoughts come back since yesterday? P : (F irmly) No. I want to live. (22) I: W hen you felt down and depress ed, did you feel that people were agains t you? P : I was hiding from them. (23) I: Did you ever get s o down that your thoughts became loud? P : I thought I was worthless . (24) I: Did you hear voices telling you that? P : No, jus t my thoughts . (25) I: E ver heard any voices when nobody was P : No. (F rowning) I don't think I was crazy. (S haking head) (26) I: S o your depres sion was never so severe that heard voices or that you were s erious about killing yours elf? P : I thought I was los ing it, but I didn't hear or see And then I would smoke more and that helped my (27) I: Did your mood ever become s o good that you full of energy or didn't seem to need much s leep? P : (W ith a laugh) I don't think so. 784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 124 of 154

(28) I: E ver become hypersexual. … have affairs. … frowns and s hakes her head), or go on buying s prees ? P : S ometimes when I was depress ed, I liked to buy but it didn't make me feel better. (T he corners of her mouth drop) (29) I: Have cleaning s prees? P : (W ith a sour s mile) No, jus t chain-smoking sprees . (30) I: W ere you a heavy smoker? P : T wo and a half packs a day. (Looking down) B ut I months ago. (Looking the interviewer in the eye) (31) I: W hat helped you quit? P : (F ast, with a firm voice and nodding) T he patches Zyban. I took them for 2 months. (32) I: How did that help you? P : (S miling) It lifted my mood, too. (33) I: Y ou felt depres sed? P : I think I have always been s omewhat unhappy—for last 4 or 5 years , or more. Did not want to do much, irritable and anxious , and cried easily. (S wallows) (34) I: Did you ever feel better in between? P : (S haking her head) Maybe for a few weeks , but it lasted. (35) I: How did Zyban help? P : I started to do more things and felt better. I could smoking. (36) I: Did you drink als o? P : (W ith dis gus t) I hate alcohol. It makes me woozy. (37) I: Do you drink coffee? P : No. I drink soda pop with caffeine. 785 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 125 of 154

R APPOR T R apport remained intact. T he patient actively in the interview, interrupting the interviewer (A10) and volunteering details in answering the interviewer's questions , thus engaging in a cooperative alliance (A9 11, 14, 15, 26, 28, 30, 33). Her ans wers portrayed insight into the pathological nature of her mood symptoms. T he interviewer worded the empathic statement (Q11) in a manner that elicited a des cription her traumatic symptoms. B ecause the patient showed emotions freely, the interviewer believed that the was comfortable with him (A9 to 11, 13, 15, 18, 20, 21, to 34, 36), making interventions to improve rapport unnecess ary.

TE C HNIQUE T he interviewer completed the coverage of the topic of recent traumatic res ponse (Q9 to 12). S he followed the interviewer's smooth transition when the interviewer screened for depres sion (Q13 to 15), s uicidal (Q16 to 18), postpartum depres sion (Q19, 20), symptoms (Q22 to 26), mania (Q27 to 29), nicotine addiction (Q30 to 32), dysthymia (Q33 to 35), and (Q36) and caffeine us e (Q37). T he interviewer the patient's evas ive answers (A22, 23, 26) by more questions for hallucinations (Q24, 25) and by the patient's res ponses (Q26). T he patient agreed with the interviewer's summaries , documenting good verbal unders tanding (Q10, 11, 26).

ME NTAL S TATUS T he patient res ponded with relevant details to closed786 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 126 of 154

ended ques tions or statements (Q9 to 14, 17 to 30, 33, 36, 37), showing that she remained verbally productive spite of her depres sed affect. S he handled open-ended questions in an appropriate, goal-directed manner 16, 31, 32, 35), s howing her ability to focus and to questions accurately. Her affect remained reactive and appropriate to the content of her ans wers (A9 to 11, 13, 18, 20, 21, 25, 27 to 32, 36) but showed a depress ive (A9, 11, 15, 18).

DIAG NOS IS T he interviewer ass es sed symptoms ass ociated with chief complaint (Q9 to 11; B ox C in F ig. 7.1-1), reliving traumatic experience, derealization (A10), and functioning (A10, 11; B ox B in F ig. 7.1-1), confirming initial impress ion of a firs t-time acute traumatic disorder (A12; B ox D in F ig. 7.1-1). W ith Q13, the interviewer searched for a second chief complaint (a “yes ” B ox G in F ig. 7.1-1) and found 5 years of anhedonia 33 to 35) with only s hort remis sions of a few weeks suggesting dys thymic disorder, which the interviewer not pursue any further. T he interviewer also clinical s ignificance for a third chief complaint, (A14; a “yes ” res ponse to B ox G in F ig. 7.1-1). T his complaint was as sociated with s everal s ymptoms (B ox F ig. 7.1-1): s ocial withdrawal, los s of initiative, and insomnia (A15), death wish (A17), suicidal feelings of worthles snes s (A23), and losing her mind A history of s uicide attempts (A18) or present suicidal thoughts (A21) were miss ing. T hese findings confirmed diagnosis of major depress ive disorder currently in remis sion (A14; B ox D in F ig. 7.1-1). T he patient persecutory delus ions (A23) or hallucinations (A23 to 787 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 127 of 154

excluding a major depress ion, s evere, with ps ychotic features (B ox D in F ig. 7.1-1). Actively, the interviewer s creened for ess ential of other ps ychiatric disorders (B ox H in F ig. 7.1-1). T he interviewer excluded mania (A27 to 29) and alcohol (A36; B ox H in F ig. 7.1-1) but found evidence for dependence in early partial remis sion (A29 to 33). T he reported depress ed, irritable, and anxious feelings may have been related to nicotine P.822 dependence and intermittent withdrawal because smoking relieved the depres sed feelings (A26). Alternatively, the depres sive symptoms could be part of dysthymic dis order with late onset (A33, 34) that, smoking, was improved by Zyban (bupropion) (A35).

P has e 3: His tory and Databas e ME DIC AL HIS TOR Y (38) I: W hat prescription medications or over-themedicines do you take? P : No pres criptions any more. My gynecologist stopped hormones when he felt the lump. B ut I have a chronic cough, and I take some cough drops . (39) I: Do you have any other medical problems? slowly) S uch as thyroid problems ? Diabetes? High press ure? A head injury? Allergies ? P : (S haking her head) No, not that I know of.

FAMILY HIS TOR Y 788 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 128 of 154

(40) I: W ho in your family had problems with mood like you? P : My three kids are okay, but I'm adopted (her voice cracking). I don't know my biological parents or (41) I: Y our voice changed when you said adopted. P : Y eah. My adoptive parents always told me I was (W ith s ad contempt) Y es , s pecial. I always fought

DE VE L OPME NTAL HIS TOR Y (42) I: How did you feel in school? P : I felt I had to prove mys elf, but I was a good student. (43) I: And in front of a clas s? … or in front of spells of anxiety? P : I got a lump in my throat and butterflies in my but it excited me. I could do it.

S OC IAL HIS TOR Y AND S UPPOR T (44) I: How do you feel about rejection now? P : T hat's the worst. I feel my daughter will s tay away me. S he will reject me because of my cancer. (45) I: S tay away from you? How's that? P : W ell… I s tayed away from my cous in for her las t when she had breas t cancer. I panicked when I saw did not know how to deal with it. Now I feel I'll lose my daughter over this . And I don't know what to do. (46) I: Do you have other children? P : Y es. I als o have two s ons , all are from my ex. (47) I: How is their support? 789 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 129 of 154

P : G ood. B ut my daughter is my friend, and I hate to her. I couldn't bear it. None of my children know what depres sion is. T hey are all so healthy. (48) I: W hat about your ex? P : W hat's left of him is a big s ettlement. He divorced marry his s ecretary. He rejected me, too, when I went through the changes. (49) I: S o you experienced rejection. W hat images mind? P : My cousin. (W ith express ion of fear and disgust) she s hriveled away when s he had cancer. How I could take it when she s hriveled away. (50) I: S o you can't s hrivel away yourself. P : Y ou're right. B ut how do I do that? (51) I: B y rejecting yourself. R eject your cancer! S tay F ear and depres sion may weaken your immune P : E verybody tells me I can do it. My friends s ay I can it. (W ith a thin smile and frown) I heard it over and over again since yesterday. (52) I: T hey don't want you to s hrivel away. P : T hat's right. T hey don't want me to shrivel away. sigh of relief) T hey say it for their own s ake. (53) I: T hat's right. T hey don't want to see you s hrivel like your cousin. (With emphasis) Y our friends and your daughter look at you as an example. T hey want you for their own s ake. Do you have any ties to religion? P : No. I'm not going to mas s, but I believe in a higher power. (54) I: Do you pray? P : No. 790 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 130 of 154

(55) I: Y ou told me you s ee your cous in s hrivel away. you work through your eyes ? P : Y es. I'm an interior des igner. (56) I: Oh? How did that start? P : I have a college degree in des ign. Decorating my profes sion. I still enjoy my work and my colleagues.

ME NTAL S TATUS E XPL OR ATION AND TE S TING (57) I: S o you can image things . W e will us e imagining fight your fears and your depres sions and teach you to imagine your cancer s hriveling. P : (S miles) (58) I: Let's s ee how s trong your imagining is. P leas e me your ring. (T he patient hands the interviewer her wedding band). I'm going to attach a string to your ring (interviewer does ). Let me s how you how one can the ring with imagining. (T he interviewer swivels his around away from his desk and sits now in front of the patient. T he interviewer holds the s tring in his right and unsupported arm with the ring hanging 1 in. above the floor.) Now I can swing the ring around like this the ring). I do this with my will power like we do many things . B ut I can also move the ring without s winging it voluntarily. (He brings the ring to a stands till.) I can just it hang down and s tart imagining. I imagine now that ring s tarts to swing… swing in a circle… swing in a (the ring moves s lightly back and forth, not in a circle). Now I imagine that the ring s wings in a circle, the circle gets rounder and rounder, the circle becomes bigger bigger (the ring actually swings in a circle of a 5-in. 791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 131 of 154

diameter). Y ou can train yourself in imagining. (T he interviewer offers the s tring to the patient.) Now you try. P : (T akes the s tring with the ring) (59) I: S wing the ring around in a circle. P : (C omplies ) (60) I: T hat's what we don't want to do. W e want to us e imagination. Hold the swinging. P : (C omplies ) (61) I: Now let the ring hang down still and s tart that the ring s tarts moving. (T he ring swings back and forth in a 1-in. swing). Now imagine that the ring starts go in a circle, rounder and rounder, in a circle, bigger P.823 and bigger. (T he ring starts to move in a 3-in. circle). can train yourself to do this . It's called the pendulum tes ts your imagination. In addition to the ring tes t, the interviewer als o us es the sway test, the S piegel E ye T est, and the finger s ticking (s ee X. Mental S tatus E xamination). T he four tests patient's moderate ability to follow images with motor action. 61. P : (S miling and shaking her head as in disbelief) I us e my imagination to help me. B ecaus e the interviewer is in a tes ting mode, he als o examines orientation, recent memory, and abs traction interpreting proverbs and identifying the common category of bicycle and airplane and finds the patient to fully oriented and have intact cognitive functioning. F urthermore, the patient has at least average 792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 132 of 154

because she could multiply 2 × 192 on the W ilson Approximate Intelligence T es t and by her res ponses to K ent T est. (62) I: W e need your fighting spirit. C an you believe? P : I don't trust eas ily. (63) I: C an you believe in s cience? P : I'm not sure. (64) I: Do you believe in medical science? P : I'm not sure, but I will do what they tell me. (65) I: I'm so glad that your cancer was detected at an stage and that you got your diagnos is 24 hours after biops y. T hat means treatment can s tart soon. Have met the oncologist? P : No. B ut I've heard of him. My friends recommend (66) I: S o you don't plan to go out of s tate to the X Ins titute? P : No. I'll s tay with the doctors here.

R APPOR T R eviewing the medical his tory s ignaled to the patient thoroughnes s and concern about her general health 39). T he interviewer address ed the cracking in her showing sens itivity to her affect about her adoption T he interviewer used her fear of rejection (A41 to 45) to explore her own rejecting of the cous in. T he interviewer channeled the patient's tendency to reject toward her cancer rather than toward hers elf (A51). T he built up her confidence in her ability to imagine her to shrivel (Q57) and to turn her imagination into action (Q58 to 61). T his approach initiated her positive 793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 133 of 154

and cognitive res tructuring, including imagining. W ith these interventions , the interviewer added to the diagnosis -centered interview a patient-centered therapeutic intervention. S uch ad hoc crisis intervention activated the therapeutic alliance and put guidance into action.

TE C HNIQUE Using a smooth transition (Q38), the interviewer attempted to complete the database, opening up family, developmental, and social history with openquestions (Q38, 40, 42, 44), followed by clos ed-ended questions and s ome open-ended ones (Q47 to 49). the interviewer noticed a s ign of fear and s adness in patient's voice (A40), the interviewer clarified this sign (Q41) and s earched for as sociated s ymptoms to be fit the sign into a pos sible diagnosis . B ecause the expres sed fear and disgust (A49), the interviewer to make an immediate therapeutic intervention agains t her harmful self-image of shriveling away. T he reverted the patient's tendency to project on hers elf to projecting on her cancer (Q51). T his revers al fed into supportive s tatements of the patient's friends (Q51 to and initiated training in image control (Q55 to 61).

ME NTAL S TATUS T he patient showed fear of abandonment (A40, 44), poss ibly based on her phobia of physically crippling disease, which s he projects on her daughter. T ests of suggestibility (A58 to 61), orientation, recent memory, abstraction are within the normal range. S uggestibility tes ted for two reasons: (1) to examine whether 794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 134 of 154

suggestibility can lead to pathological autos uggestions (i.e., diss ociative and conversion s ymptoms ), and (2) to increase the patient's control over imaging directing it agains t her cancer.

DIAG NOS IS T he medical his tory is pos itive for chronic cough (Q38, T he patient's fear of abandonment encountered during the as ses sment of the family history adds an additional chief complaint and reopens the diagnostic decision proces s (A40; B ox F in F ig. 7.1-1). T he interviewer the patient's developmental his tory for ass ociated symptoms of fear of rejection. S ocial phobia and disability (A42) are excluded, but the patient's respons e suggests the pos sibility of generalized anxiety in my stomach”), somatization, or conversion (“lump in my throat;” A43). Obsess ions and are not ass es sed. T he fear of rejection (Q44) s ignifies special phobia of phys ical decay (A49) also projected her daughter (A44, 45, 47), which intensifies her cancer. S he fears less premature death than because of her phys ical decay. T his specific phobia of terminal, crippling dis eas e (A45, Q49) is based on the defens es of s uppress ion and repress ion operating on a high adaptive and mental inhibition level, respectively. projection operated on the dis avowal level and not at level of defensive dys regulation, as is the cas e in projection. T he coding of defens es on a sixth axis, the defens ive functioning axis, is under cons ideration in the DS M-IV -T R . T he patient's average level of sugges tibility may lower ris k that her acute stress dis order progres ses to a 795 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 135 of 154

with pathological diss ociation (A61) as a result of autos uggestion. T he interviewer limited the predis pos ing, precipitating, perpetuating, and factors for the social history taking to the extent that it may be relevant for Axis IV . F or time reasons, the interviewer omitted exploration of relations hips to parents , coworkers, and friends other than J oan. her children, the patient did not seem to have support from her church or s elf-support from prayers (A53, 54) confidence in medical science (Axis IV ).

P has e 4: Diagnos is and F eedbac k (67) I: Let me tell you what I have learned from our meeting today. Y ou were overwhelmed when you that you have stage 1 breast cancer. Y ou felt numbed had flashbacks of the gynecologist's mess age. S uch res ponse may mark the ons et of an acute s tres s Y ou fear your friends , es pecially your daughter, will you as you avoided your cous in, so they don't have to with your was ting away. Y ou are sensitive to such abandonment becaus e lifelong you fought with the rejection that you imagined occurred from your parents . P : (E mphatically) Y es, yes , yes! W hat can I do about (68) I: B elieve in your daughter. S he does not have anxiety of s hriveling away. S he will not avoid you. W ith we want to fight the progres sion of your traumatic res ponse and prevent recurrence of depres sion. P : How? P.824 796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 136 of 154

R APPOR T T he interviewer s hows his or her expertis e in the patient's dependency needs from the patient's point insight, namely, as s ens itivity to abandonment (Q67). patient accepts the diagnos is (A67) and s hows interes t the interviewer's approach to her treatment (Q68).

TE C HNIQUE With an accentuated trans ition, the interviewer the patient for the diagnos tic feedback, a role reversal. Now the interviewer and not the patient provides the of information (Q67).

ME NTAL S TATUS T he patient's affect has dramatically changed s ince the beginning of the interview. S he had switched from sadness , anxiety, and des pair to an emphatic approval the interviewer's feedback, express ing openness and interes t in the interviewer's treatment plan s howing her affective reactivity (A67).

DIAG NOS IS T he interviewer initiates the diagnos tic feedback bas ed biops ychos ocial information, including the patient's and s trengths , and multiaxial diagnoses .

P has e 5: Treatment P lan and (69) I: W ell, you have conquered your addiction to with your determination and with the help of Zyban or Wellbutrin, which is an antidepres sant. Y ou had in the pas t and W ellbutrin has helped you. S o did 797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 137 of 154

S ince you started smoking again, I think Zyban can become our Old F aithful again. W e should s tart it now. you recall its major ris k? P : W hat do you mean? (70) I: T he potential for a seizure. P : Y es, I know. (71) I: Did you ever have a s eizure in your life? Like as child? P : No. (72) I: Did you have one when you took the Zyban? P : No. (73) I: Y ou told me you don't drink much. Alcohol withdrawal could poss ibly make you more sensitive to seizure risk by Zyban. P : I'm somewhat afraid of that. B ut Zyban made me well before. (74) I: If you wake up and have s oiled your clothes or your tongue, s top Zyban and call me immediately. your ability to tolerate the medication in the past gives an edge. P : I understand the risk, and I will take it again. (75) I: P s ychologically, you have strong feelings about rejection. T his feeling can hurt you, but it also can help you. P : How's that? (76) I: (W ith emphas is) It's you who rejects rather than being rejected. P : I can never do that. (77) I: Y ou've done it before. Y ou rejected the Y our determination agains t cigarettes helped you. 798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 138 of 154

Zyban would not have made you s top smoking. It's you who make the drug work. Y ou noticed how it lifted your spirits. Y ou have to use this s pirit to tell yourself you everything you can to fight the cancer. S ee the stay with the treatment, and have the image of Y ou said yours elf others want you to be strong for their sake. Y our cancer will shrivel away, (with emphasis) you. Y ou think in images . W e will work to implant the image in your mind how the cancer is s hriveling under therapy. P : B ut my cous in's… (78) I: (Interrupting her) P urge that image like you the cigarettes. P urge it like you'll purge your cancer. image of your wasting cous in is a cancer of the mind. P : B ut how do I fight it? (79) I: W henever your cousin's image pops up in your straighten your posture, take a deep breath, and how your own body rejects cancer cells after removal the small lump in your breast. P : (W ith a questioning express ion in her face and straightening her posture) (80) I: As homework to strengthen your imagination, the pendulum as often as you can but at leas t three day. I will see you weekly at the beginning and work you on other imagining exercis es , on positive thoughts, and I'll check the effects of the Zyban and the need for additional medication to control anxiety and B ut I need your help. W e have to put our heads make it work. And we may as k your daughter to come with you and maybe even J oan. P : I will take my medication and try to work on the 799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 139 of 154

I will also talk to my daughter and to J oan. (81) I: Our s ucces s depends on how well we can depres sion and anxiety. Y ou had success in smoking and depres sion in the pas t and that bodes for the future. P : (W ith a broad s mile) I feel s o much better now. I'll J oan and thank her for getting me here.

R APPOR T B ecaus e the patient has accepted the interviewer as expert, the interviewer continues this role as a guide for biops ychos ocial treatment plan: B iologically, the interviewer refers to the patient's pos itive experiences with Zyban and P rozac and emphas izes the concern the safety of treatment (Q69 to 74). P sychologically, interviewer uses the patient's thinking in images to combat her self-destructive vis ion. S ocially, the us es the patient's desire to be supported by her which rounds out the interviewer's role as a trustworthy guide.

TE C HNIQUE T he interviewer s ummarizes the patient's pos itive experiences and s trengths that she had s hown in the interview as a bas is for the treatment plan.

ME NTAL S TATUS T he prominent feature (Q,A69 to 81) is the patient's change from an anxious and doubtful to a confident

DIAG NOS IS T he patient's emotional reactivity to the interviewer's 800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 140 of 154

input added to a favorable prognos is of the patient's traumatic stress reaction.

C as e S ummary I. IDE NTIFYING DATA Ms. Lorraine R . is a 56-year-old, white, divorced, mildly obese, C atholic woman and the mother of three who had an acute s tres s res ponse to a recent breast cancer.

II. C HIE F C OMPL AINT “I cried all night. I heard my gynecologis t's voice again again: S orry, Ms . R . It's s tage 1 breas t cancer.”

III. INFOR MANTS T he patient and her friend, a former patient, who reques ted that the patient had to be s een immediately.

IV. R E AS ON FOR C ONS UL TATION Acute s tres s respons e to a recent diagnosis of breast cancer.

V. HIS TOR Y OF PR E S E NT IL L NE S S T he day before the interview, the patient was with stage 1 breast cancer. S he cried all night and in her mind the gynecologis t's telephone mess age of having breas t cancer. T wo days ago, s he had been forewarned of such a diagnosis. S he felt “numb” and avoided dis cus sing it with her family and friends. S he never had experienced a life-threatening trauma T he patient reported concurrent depress ive s ymptoms with anhedonia and ruminations of being abandoned 801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 141 of 154

because of her crippling dis ease, as she had avoided cous in dying of cancer. T hese chronic, continuous depres sive feelings were present over the last 5 years . patient had two periods of acute depres sive epis odes social withdrawal, los s of energy and initiative, P.825 overs leeping, overeating, weight gain, s ens itivity to rejection, and suicidal ideation but no attempts las ting several months. Her depres sion had responded to fluoxetine (P rozac). However, s he had no evidence of any mood elation, overactivity, excess ive s pending sprees , reduced need sleep, hypers exuality, or other symptoms of mania or hypomania. S he had no his tory of alcoholis m or abuse except for nicotine abus e for which s he was succes sfully with Zyban 5 months ago but had 1 day. S he reported avoidance behavior regarding a female cous in in her adopting family who became phys ically emaciated due to treatment-res is tant progres sive breas t cancer. T he patient gave no generalized anxiety disorder, panic dis order, or s ocial phobia. OC D was not ass ess ed. S he denied ever had any psychotic symptoms.

VI. PS YC HIATR IC DIS OR DE R S IN R E MIS S ION A major depress ive disorder, recurrent, was in for the last 10 years . Her nicotine abus e was in early remis sion, but s he had a relaps e for 1 day.

VII. ME DIC AL HIS TOR Y 802 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 142 of 154

P os itive for a recent diagnos is of breas t cancer s tage 1 chronic cough; menopause; no allergies.

VIII. S OC IAL HIS TOR Y AND PE R S ONALITY T he patient has been divorced for the las t 10 years. three children by the same man, works as an interior decorator, and is financially well off due to her divorce settlement and her present income. P remorbid personality: T he patient has a college education and functioned well before her firs t major depres sive and intermittently between two epis odes .

IX. FAMIL Y HIS TOR Y A ps ychiatric family history of parents and s iblings is unknown because of patient's adoption. However, her children show no evidence of ps ychiatric disorder.

X. ME NTAL S TATUS E XAMINATION A ppearanc e T he patient is a 56-year-old, mildly obese, white, woman who is alert, has good eye contact, and is cooperative during the interview. S he wore makeup, the tears had was hed out some of the mas cara.

Movements Appropriate reactive movements when address ed. G rooming movements were limited to wiping her eyes even when not crying. G oal-directed movements were appropriate but showed s ome s lowing when she the office and when s itting down. No illus trative movements but appropriate express ive movements 803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 143 of 154

she discus sed how s he avoided her cousin.

S peec h V oice was quivering at the beginning of the interview. talked with normal rate and appropriate modulation. Initially, s he breathed rapidly with pumping of C omprehended ques tions well and answered in a goaldirected, precise, mildly dramatic manner, volunteering appropriate details.

Mood and A ffec t Mood was depress ed and anxious . Affect was s ad, and anxious but became brighter and hopeful toward end of the interview, showing reactivity.

Thought C ontent Denied any ps ychotic s ymptoms in the past or present. S he had decreased interes t in living during her two depres sed episodes but expres sed a s trong will to live now. No evidence of panic attacks . Obs ess ions or compuls ions not as sess ed. F earful of being abandoned like s he felt about her being given up for adoption. B rief dis sociative experience during the las t hours. S uggestibility approximately average.

C ognition Oriented to place, time, and pers on. R ecent memory is intact. S pelling backward and serial sevens are normal. was able to interpret proverbs and to abstract the commonalties of categories. Her IQ is at leas t average according to the W ils on Approximate Intelligence T est the K ent T est. 804 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 144 of 154

Ins ight Aware that she has a depress ive disorder and nicotine addiction but less insight into the pathological nature of her res pons e to the cancer diagnosis. Limited insight her fear of abandonment is not bas ed on facts but on projection of her own behavior toward her cous in.

J udgment Affected by her recent trauma. E xpected a terminal of cancer and abandonment not bas ed on facts of her prognos is or her daughter's behavior.

XI. DIAG NOS TIC FOR MUL ATION B iologic al P redisposing factors: E xcept for three healthy family history of ps ychiatric disorders is unknown. history of head injury. His tory of major depres sion poss ibly dysthymic disorder. B oth may negatively impact on her traumatic stres s respons e. P recipitating: C oncurrent cancer, future pain, and side effects of cancer therapy may worsen the of her acute s tres s disorder, major depress ion, and nicotine addiction. P erpetuating: His tory of intermittent smoking may lead to dysphoric withdrawal reaction. C oncurrent stage 1 breas t cancer. P rotective: G ood respons e to antidepres sant medication to both depres sion and s moking.

805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 145 of 154

P s yc hologic al P redisposing: P hobic respons e to crippling with avoidance and projection. B oth mechanisms operate on a level below mature adjus tment. Her ability to emotionally support hers elf is limited. P recipitating: T he patient fears a terminal cancer cours e and abandonment. P erpetuating: C ancer therapy will be a steady of her cancer risk. P rotective: P as t succes s with therapy for her depres sion and s moking, cooperation with S he avoided a pos sible conflict between local phys icians and out-of-town experts . T he patient receptive to controlling her images of the cours e of cancer.

S oc ial P redisposing: Interpreted her adoption as a by her biological parents. Avoided a cous in who cancer. Interpreted her divorce as rejection by her husband. Ass umed the victim role. P recipitating: E xperiences the gynecologis t's voice cold, replays his mess age repeatedly in her mind. P erpetuating: T he memory of the crippling and fatal cours e of the cous in's cancer. P rotective: Has strong s upport from her friend who had a pos itive res ponse to therapy; support from friends who have express ed confidence in her 806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 146 of 154

to fight the cancer. T he patient is s till working as an interior decorator. S he enjoys her work and her colleagues, which distract her from her illness .

XII. DIFFE R E NTIAL DIAG NOS IS R is k for an acute s tres s dis order progress ing to a Adjustment disorder with anxious and depress ed mood Onset of a third major depres sive epis ode by acute s tres s S pecial phobia of crippling terminal illness T he patient developed a s pecial phobia but not an stress disorder to the terminal cours e of cancer in a S he res ponded with a major depress ion to her divorce. T herefore, a recurrence of major depress ion is likely. adjus tment disorder may be an initial res pons e P.826 but could progress to a major depres sive epis ode. intervention may reduce the risks for all three

XIII. MULTIAXIAL PS YC HIATR IC DIAG NOS IS Axis I: Acute s tres s dis order (308.3) Major depress ive disorder with atypical features , recurrent, in full remiss ion (296.36) 807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 147 of 154

S pecific phobia (300.29) R ule out dysthymic dis order (300.4) Axis II: features of dependent and his trionic pers onality Axis III: B reast cancer, stage 1 R ule out chronic bronchitis R ule out as thma R ule out pulmonary cancer Axis IV : T raumatic res pons e to recent diagnosis of breast cancer F ear of los s of support Axis V : current G AF equals 35, highes t last year was

XIV. AS S E TS AND S TR E NG THS T he protective factors discuss ed in the s ection XI. Diagnos tic F ormulation are identical with the patient's as sets and s trengths .

XV. TR E ATME NT PL AN AND B iologic al B upropion (W ellbutrin/ Zyban) has helped her in past with both s moking and depres sion: bupropion, 150 mg #1 AM, in 1 week #1 twice a day (B ID). 808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 148 of 154

In cas e of incomplete respons e, cons ider bupropion with fluoxetine (P rozac). P urs ue cancer therapy and make an appointment immediately.

P s yc hologic al P atient to take control and actively reject the V is ualize the cancer as s hriveling. Ins till hope by telling the patient that her cancer has been detected early and that early detection has excellent prognosis to res pond to therapy. Include her daughter in some of the upcoming sess ions.

S oc ial R eframe the fact that the patient has been s elected her adoptive parents as acceptance. Dis cus s her criticism of the husband, helping her to overcome the victim role and appreciate her own contribution to the divorce. E mphas ize the expediency of cancer diagnos is in hours, which allows timely treatment. P oint out s upport by her friend J oan.

P rognos is C ooperated with treatment in the past with good res ponse. P s ychiatric symptoms appear to be 809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 149 of 154

with therapy, thus preventing disability. P sychiatric prognos is appears good. T he main ris k factor for ps ychiatric well-being is a poor res ponse to cancer therapy.

S UG G E S TE D C R OS S S ection 7.4 deals with the typical s igns and s ymptoms ps ychiatric illnes s, S ection 7.5 deals with neurops ychological and intellectual as ses sment of and S ection 7.9 deals with ps ychiatric rating s cales . S imilarly, C hapter 8, on the clinical manifestations of ps ychiatric disorders , is an es sential correlate to interviewing and examining the patient. S ection 2.1 with the clinical as ses sment and approach to diagnosis neurops ychiatry. S ection 3.1 on perception and and S ection 3.4 on the biology of memory amplify made in this section. S ection 29.1 includes more information on suicide, and S ection 29.2 includes information on other ps ychiatric emergencies . C hapter deals with mood disorders and suicide in children and adoles cents . As pects of normal and abnormal development are found in S ection 6.2 on E rik H. C hapter 32 deals extensively with normal development children and adoles cents; adult development is great length in C hapter 50; and normal aging is the of S ection 51.2c.

R E F E R E NC E S Ayd F J . L e xicon of P s ychiatry, Ne urology and the Neuros cie nce s . 2nd ed. P hiladelphia: Lippincott & W ilkins ; 2000. 810 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 150 of 154

B eck AT . T he Inte grate d P owe r of C ognitive Y ork: G uilford; 1997. B ennett MJ . T he E mpathic He ale r: An E ndange re d S pe cie s ? S an Diego: Academic P res s; 2001. C arlat DJ . T he P s ychiatric Inte rvie w. P hiladelphia: Lippincott W illiams & W ilkins ; 1999. C heng AT : Mental illnes s and s uicide. Arch G e n P s ychiatry. 1995;52:594–603. C hochinov HM: Dignity—cons erving care. A new for palliative care. Helping the patient feel valued. J AMA. 2002;287:2253–2260. C ox A, R utter M, Holbrook D: P s ychiatric techniques. A second experimental study: E liciting feelings. B r J P s ychiatry. 1988;152:64–72. *F irs t MB , F rances A, P incus HA. DS M-IV -T R Diffe rential Diagnos is . W ashington DC : American P sychiatric P ublis hing, Inc.; 2002. F ish F . C linical P s ychopathology. B ristol, UK : J ohn and S ons; 1967. G oodwin DW, G uze S B . P s ychiatric Diagnos is . 5th New Y ork: Oxford University P ress ; 1996. Hill C J : F actors influencing phys ician choice. 811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 151 of 154

and H ealth S e rvice s Adminis tration. 1991;36:491– International G uidelines for Diagnos tic Ass es sment (IG DA): W orkgroup, W P A (World P s ychiatric Ass ociation). B r J P s ychiatry. 2003;182(S uppl S 59. Izard C . Human E motions . New Y ork: P lenum; Izard C . E motions in P e rs onality and New Y ork: P lenum; 1979. K eller MB , McC ullough J P , K lein DN, Arnow B , DL, G elenberg AJ , Markowitz J C , Nemeroff C B , J M, T has e ME , T rivedi MH, Zajecka J : A nefazodone, the cognitive behavioral-analysis ps ychotherapy, and their combination for the treatment of chronic depress ion. N E ngl J Me d. 2000;342:1462–1470. K endell R E : F ive criteria for an improved taxonomy mental disorders . In: Helzer J E , Hudziak J J , eds . P s ychopathology in the 21s t C entury. DS M-V and Was hington DC : American P s ychiatric P ublis hing, 2002:3–17. K es havan MS , R abinowitz G , De S medt G , S chooler N: C orrelates of insight in first episode ps ychos is . B iol P s ychiatry. 2002; 51:115S –116S . K lerman G L, W eis sman MM, eds . New Applications Inte rpe rs onal P s ychotherapy. W ashington DC : 812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 152 of 154

P sychiatric P ress ; 1993. K raemer HC , Measelle J R , Ablow J C , E ss ex MJ , K upfer DJ : A new approach to integrating data from multiple informants in ps ychiatric as sess ment and res earch: mixing and matching contexts and perspectives . Am J P s ychiatry. 2003;160:1566– Ludwig AM, Othmer E : T he medical basis of Am J P s ychiatry. 1977;134:1087–1092. Moran P , Leese M, Lee T , W alters P , T hornicroft G , A: S tandardis ed As sess ment of P ers onality— Abbreviated S cale (S AP AS ): preliminary validation brief s creen for personality dis order. B r J P s ychiatry. 2003;183:228–232. *Othmer E , Othmer S C . T he C linical Intervie w Us ing IV -T R . V ol 1: F undame ntals . W ashington DC : P sychiatric P ublishing, Inc.; 2002. *Othmer E , Othmer S C . T he C linical Intervie w Us ing IV -T R . V ol 2: T he Difficult P atie nt. W ashington DC : American P s ychiatric P ublishing, Inc.; 2002. Othmer E , Othmer S C , Othmer J P : B rain functions ps ychiatric disorders. A clinical view. In: Diagnos tic dilemmas, part I. P s ychiatr C lin North Am. 566. Othmer E , P enick E C , P owell B J , R ead MR , Othmer P s ychiatric Diagnos tic Inte rvie w-R evis e d (P DI-R ). 813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 153 of 154

and Adminis tration B ookle t. Los Angeles : Wes tern P sychological S ervices; 1989. P atterson W M, Dohn HH, B ird J , P atterson G : of suicidal patients : T he S AD P E R S ONS scale. P s ychos omatics . 1983;24:343–349. P ayne R W , Hewlett J HG . T hought Dis order in P atients. In: E ysenck HJ , ed. E xperiments in V ol. 2, P s ychodiagnos tics and P s ychodynamics . Humanities P res s; 1960. *S hea S C . P s ychiatric Inte rvie wing. T he Art of Unde rs tanding. 2nd ed. P hiladelphia: WB S aunders 1998. *S ommers -F lanahan R , S ommers -F lanahan J . Inte rviewing. New Y ork: J ohn W iley & S ons; 1999. T as man A, R iba MB , S ilk K R . T he Doctor-P atient R elations hip in P harmacotherapy. Improving E ffe ctive ne s s . New Y ork: G uilford P ublications; T atro DS , ed. Drug Inte raction F acts 2002. F acts C omparis ons . S t. Louis: A Wolters K luwer 2002. Warnock J K : T ips on taking the ps ychiatry and neurology oral exam. R es id S taff P hys ician. 123. Zimmerman M: What s hould the s tandard of care for 814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

Page 154 of 154

ps ychiatric diagnostic evaluations be? J Ne rv Ment Dis ord. 2003;191:281–286.

815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

01/01/2009

8

Page 1 of 185

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > 8 - C linic Manifestations of P s ychiatric Disorders

8 C linic al Manifes tations of Ps yc hiatric Dis orders J oel Yager M.D. Mic hael J . Gitlin M.D. Manifestations of ps ychiatric disorders expres s as a variety of alterations, from normal functioning, subtle to blatant, from intermittent to cons tant. S ome be recognized by laypeople from a dis tance. Detecting others may require discerning training and intimate familiarity with an individual over time. Deviations from normal, from mild to severe, may occur in intens ity, duration, timing and content of thoughts, emotions, and behaviors and may be highly context dependent. the subjective complaints, clinical s ymptoms , and signs ps ychiatric disorders requires his tory taking and formal examination proces ses that parallel thos e of general medicine. Many ps ychiatric complaints and dis orders to be understood in broad context, requiring a more thorough evaluation and comprehens ion of the interpersonal world, work role, family life, and culture is typical in general medical practice. T he nature and expres sion of ps ychiatric signs and s ymptoms are profoundly altered by the patient's strengths, coping capacities, ps ychological defens es , and s ituational 816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 2 of 185

so that the clinical picture ultimately repres ents a between psychopathology and ps ychological s trengths . T he disturbed and dis turbing behaviors that obs ervers view as pathological must als o be unders tood as part the individuals ' attempts to cope with the biological, ps ychological, and environmental challenges they face. When attempts to cope overwhelm individuals' to respond, less adequate, more disorganized, and ineffective thoughts and behaviors emerge, and these comprise the impairments that pres ent in clinical situations. T he most important distinction between typical presentations of medical diseases and those of disorders is the greater importance in ps ychiatric of the patients ' sometimes idiosyncratic des criptions of or her qualitative internal states , s ubjective that are often difficult to des cribe in words . P oets and novelis ts are often more capable than clinicians at characterizing and delineating the precis e quality and experience of many psychiatric s ymptoms . Many and clinicians often find it difficult to accurately communicate a fully comprehens ible and reliable description of even familiar, s omewhat univers al feeling states . A 34-year-old s ociology profess or was trying to explain difference in the s ubjective experience of fatigue from chronic fatigue s yndrome versus the fatigue of her depres sive dis order. Whereas she was typically articulate, s he s tumbled over both trans lating somatic ps ychological feelings into words that would make to her doctor. After a few attempts , s he gave up, 817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 3 of 185

her doctor s imply to trus t that there was a difference, she could distinguish the two s tates. T hese subjective descriptions of ps ychiatric symptoms inherently less reliable, or at leas t less objective, than directly meas urable and quantifiable data s uch as press ures , temperatures, and laboratory tes t res ults. A great deal of the res earch in psychiatric diagnosis over last 25 years has been concerned with increasing the reliability of observer-rated clinical s ymptom In many ways , this research has had the desired clinicians and res earchers us ing a variety of s tructured interviews can come to reasonable agreement on what symptoms patients are experiencing and whether thes e patients meet criteria for mos t of the specific disorders in the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV However, one of the costs of this increasing reliability in many instances, been the narrowing of the field of clinical vision. T hat is , clinicians who rely structured interviews and checklis ts may become somewhat clos ed minded and ris k ignoring clinical phenomena that are very important but that may not be part of the s tructured interview framework or mental F urthermore, the ques t for reliability can lead only so describing phenomena for which there are few precis e words . An additional related difficulty can be s een in us e of nonclinical res earch s taff who are trained to interview individuals us ing s tructured interviews (as in large epidemiological s tudies ). In thes e instances , the for interrater reliability is often achieved at the expens e a more nuance-based appreciation of the different meanings of subjective s ens ations , es pecially when the 818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 4 of 185

interviewer has no clinical experience with which to interpret the subject's descriptions . Des pite these difficulties, a thorough as sess ment of the clinical history and des cription of the psychopathology and detailed account of the patient's s ubjective experiences are important for the following reasons: 1. S ignificant diagnostic dis tinctions are made on the basis of the his torical information and phenomenology. T he more detailed, complete, and correct the diagnosis , the more rational and precis e the treatment planning and the more reliable the prognos is . C onsider, for example, the importance accurately distinguis hing between neurolepticinduced akathis ia vers us anxiety s ymptoms related ps ychotic thinking. B as ed on which of these the clinician s elects , the therapeutic s trategy might diametrically opposite. 2. T he clinician's capacity to fully hear and a comprehensive understanding of the patient's internal experiences helps diminis h the patient's of isolation so characteris tic of P.965 many of thes e disorders and fos ters the growth of a therapeutic alliance, increasing the likelihood of treatment adherence. T his chapter focuses on (1) predisposing vulnerabilities and s tres sors in whos e context psychiatric signs, symptoms, and other manifestations appear, (2) the of psychiatric manifes tations , and (3) des criptions of 819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 5 of 185

specific types of dis turbances seen in ps ychiatric 





P R E DIS P OS ING V ULNE R AB ILIT IE S C HAR AC T E R IS T IC S OF P S Y C HIAT R IC S IG NS S Y MP T OMS S OMAT IC MANIF E S T AT IONS OF P S Y C HIAT R IC DIS OR DE R S



DIS T UR B ANC E S IN T HINK ING



T HOUG HT DIS T UR B ANC E S



T HOUG HT C ONT E NT



DIS T UR B ANC E S IN P E R C E P T ION



DIS T UR B ANC E S OF MOOD



DIS T UR B ANC E S IN MOT OR AS P E C T S OF



LANG UAG E DIS OR DE R S



DIS T UR B ANC E S OF INT E R P E R S ONAL



F UT UR E P R OS P E C T S



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > V UL NE R AB ILIT IE S

PR E DIS POS ING VUL NE R AB IL ITIE S P art of "8 - C linical Manifes tations of P s ychiatric 820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 6 of 185

G enetic and Intrauterine F ac tors G enetic vulnerabilities play an important role in the expres sion of many, if not mos t, psychiatric disorders . P rominent among these are dementias of the type, schizophrenia, unipolar and bipolar mood anxiety dis orders, alcohol dependence, and s ome personality traits . F or virtually all of these dis orders and traits, what is largely unknown at this point is the nature the inherited vulnerabilities . Intrauterine proces ses contribute to many psychiatric disorders . F or example, maternal s tarvation and infections during the second trimes ter of pregnancy been implicated in the pathogenesis of s chizophrenia. Maternal s moking and low birth weight may be ris k in the pathogenesis of attention-deficit disorders in children. Maternal alcoholism may lead to fetal alcohol syndrome, a major caus e of developmental disability.

C ons titutional F ac tors C ons iderable research demons trates that, by birth and shortly afterward, infants differ widely in their s pontaneous activity levels and thres holds , and duration of their reactions to external s timuli; the regularity or irregularity of certain biological rhythms as s leep; tendencies to approach or withdraw from new stimuli; the speed and degree of adaptation; attention span and dis tractibility; the persistence of behavior; qualities of mood. B ased on such early behaviors , may be described as having easy or difficult temperaments , quick or slow to warm up. however, is not immutable. T here are discontinuities 821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 7 of 185

time, and the development of temperament and its impact on personality development is at least, in part, a function of the goodness of fit with a child's family. Nevertheles s, thes e temperamental qualities correlate somewhat with behavioral problems , at least through childhood. Aside from temperament, other persistent normal variations in personality development s eem to be cons titutionally related and may influence s ubs equent res ilience or vulnerability. T raits , such as introversion, extrovers ion, and neuroticis m, appear to be relatively enduring and s table personality dimens ions. Other temperamental qualities that endure include novelty seeking, being relatively open to new experiences , and stick-to-it-iveness . S ubtypes of intelligence, s uch as related to conceptual, mathematical, musical, and interpersonal abilities, have been postulated as separate genetic determinants and patterns of development. T he type A and B pers onality patterns , and res ilient personalities, high-strung, sensitive, fuss y, irritable, and pes simis tic characteristics have all been described as generally lifelong qualities that originate in early childhood. E ven dimensions of character, concepts about the s elf in relation to others that over time through s ocial learning and maturation of interpersonal behavior, have been s hown to have moderate heritability. T hese include s uch qualities as directedness , the ability to engage cooperatively with others , and the capacity to “transcend” the self by developing a sense of one's place or purpos e in the social context. Other characteris tics relevant to psychopathology but 822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 8 of 185

diagnostically specific may als o be inherited. T hes e ps ychos is proneness , cognitive s tyles (such as obses sionality or detail orientation), and emotional reactivity (which is part of the dimension of T he relations hip between the inheritance of these traits and the patterns of transmis sion of specific ps ychiatric disorders is unknown.

P hys iologic al S tres s ors P hysiological vulnerability may res ult from longproblems or from newly acquired ones. All of the metabolic, toxic, infectious , and other caus es of illness produce increased vulnerability to psychiatric disturbance. S tudies have s hown higher us e of services by those who are phys ically ill and higher than expected prevalence of physical dis ease among the ps ychiatrically impaired. S ome children with prepubertal onset, obses sivecompuls ive disorder (OC D), and tic disorders that have episodic symptom cours e have been found to have pediatric autoimmune neuropsychiatric disorders as sociated with s treptococcal (group A β-hemolytic streptococcus) infections (P ANDAS ). Accompanying symptoms during epis odes of exacerbation are lability, s eparation anxiety, nighttime fears and bedtime rituals , cognitive deficits , oppos itional behaviors , and motoric hyperactivity. In P ANDAS , patients ' flare-ups of behavioral problems are commonly as sociated with documented group A β-hemolytic s treptococcus or s ymptoms of pharyngitis and upper res piratory infections. Human immunodeficiency virus (HIV ) infection leading 823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 9 of 185

seropositivity and acquired immune deficiency (AIDS ) vividly illus trates the multiple and complex ways which s tres sors can lead to ps ychiatric disturbances . patients' ps ychiatric s ymptoms may represent organic changes that are the direct effects of the virus on the central nervous s ys tem (C NS ), producing changes in cognition, personality and mood, expectable ps ychological adjus tment responses of the patients in res ponse to an overwhelming life-threatening dis order, the emergence of latent or quiescent primary problems provoked by the ps ychological s tres s of the illness . Adding to the complexity, s ome individuals with clus ter B pers onality traits may engage in excess ive taking behaviors , increasing the likelihood of viral expos ure; they may then be at higher ris k for ps ychiatric s ymptoms/dis orders in res ponse to being positive because of their preexisting cluster B traits . A 42-year-old phys ician noticed the ons et of decreased stamina, fatigue, disinterest in work, and weight gain without a feeling of increas ed appetite. B ecause his initially believed he was getting depress ed, he ps ychiatris t. After the initial interview, the psychiatrist ordered a standard chemistry s creening panel that revealed a thyroid-stimulating hormone of 48 mIU/L. was referred to an endocrinologist and treated for his hypothyroidism, and all of his depres sive s ymptoms disappeared.

E nvironmental S tres s ors C omplex relations hips exis t between the occurrence of various life events, particularly threatening, 824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 10 of 185

and uncontrollable negative events, and the of psychiatric symptoms . In general, such undes irable events predis pos e individuals to develop psychiatric symptoms, es pecially if they already have a preexisting ps ychiatric disorder. After exposure to the s ame stress ors , s uch as a s erious accident or act of violence, P.966 individuals who previously had anxiety disorders are prone than thos e without such his tories to develop s ymptoms of pos ttraumatic s tres s dis order Other factors , such as gender, may als o predict ris k of developing P T S D, with women more likely to develop disorder given the same expos ure to stress . Although individual res ponses vary widely, truly catas trophic such as incarceration in a concentration camp, caus e enduring psychiatric disturbances in a high percentage survivors regardless of whether they had prior problems . S imilarly, the s tres s -related consequences combat also vary widely, s o that s ome heavily combatexpos ed veterans develop long-lasting P T S D, whereas others develop very few pers istent symptoms . T he of a parent or s pous e, divorce, and major physical affect some people profoundly and others hardly at all the long run. S ignificant s tres sors are likely to be more traumatic during early development rather than later or certain critical developmental periods, compared with other times. F or example, the los s of a parent at a very young age is likely to be more traumatic and have profound and lasting effects than the los s of a parent adult. T he combined impact of negative life events and poor 825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 11 of 185

emotional and practical s ocial s upports is important in predicting the emergence of at least s ome ps ychiatric disturbances . One B ritis h s tudy found that women who were depres sed were much more likely to have lost a parent at an early age, to be relatively hous ebound three or more young children, and to lack a good relations hip with a spous e or other confidant. In that study, at leas t, biological vulnerability to depres sion seemed less important than the accumulation of life circums tances in the development of the disorder. P eople who are ordinarily very competent in all role functions may fall apart completely when a s upportive spous e who has bols tered them and taken care of their needs s uddenly dies. P atients presenting with a major depress ive epis ode have experienced more uncontrollable actual and threatened los ses s uch as death of a spouse in the year before onset. not all ps ychiatric disturbance is attributable to easily identified, provoking negative life events; indeed, some major negative life events that at first glance appear to have preceded the ons et of a serious ps ychiatric disturbance may, in fact, have occurred only after the ps ychiatric disturbance actually began. F or example, someone who attributes the ons et of depres sion to been fired from a job several months previous ly may already have been functioning s uboptimally at that time and may have been fired as a cons equence of a depres sion-induced decline in role function. C ertain environmental features can counter the effects environmental s tres sors and protect agains t S table families and friends, good financial and s upportive churches and communities offer s ome 826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 12 of 185

protection. R es earch has s hown that individuals with ps ychiatric disturbances have fewer s ocial supports normal controls. T his may be due to friends' and withdrawal from deviant behaviors or to the disturbed individual's withdrawal from deleterious family and relations hips . In contrast, physically ill people have social s upports than others , perhaps reflecting their to recruit help in times of need. Of course, the quality, well as the quantity, of s ocial s upports is important. As been demonstrated in schizophrenia and mood for example, negative relations hips even in close may have deleterious effects, both in initiating and in sustaining psychiatric disturbance. T he negative impact of a physiological or stress or is clos ely related to its pers onal meaning. F or example, the los s of a spouse who has been demented, dis abled, and burdens ome ordinarily has a different impact than the los s of a vital, s upportive, spous e. F inally, an elegant s tudy has demons trated the of genetic vulnerabilities with advers e life events . In a study involving s everal hundred young adults followed prospectively, genetic vulnerability to depress ion was conferred by certain polymorphis ms of the serotonin receptor. Over a period of several years , individuals one or two copies of the short allele of the 5hydroxytryptamine T promoter polymorphism exhibited more depres sive symptoms, diagnosable depress ion, suicidality in relation to stress ful life events involving finances , housing, employment, and relations hips than individuals homozygous for the long allele. T his provides strong evidence for gene–environment 827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 13 of 185

interactions, in which a pers on's respons es to environmental insults are moderated by his or her makeup. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > OF P S Y C HIAT R IC S IG NS AND S Y MP T O M

C HAR AC TE R IS TIC S OF PS YC HIATR IC S IGNS AND S YMPTOMS P art of "8 - C linical Manifes tations of P s ychiatric S igns and symptoms form the two major categories of clinical phenomena. C lass ically, for most medical the distinction between the two is clear. S ymptoms subjectively experienced dis turbances that are not neces sarily observable by others . P atients complain of symptoms—ches t pain, headache, tingling sensations. S igns are abnormalities that are obs ervable by an examiner, including thos e that are eas ily evident in the cours e of a routine encounter with the patient as well those elicited only through specific physical, mental or laboratory examinations. In psychiatry, the line between s ymptoms and signs is often blurrier than in general medicine. F or ins tance, phenomena often cons idered to be symptoms of ps ychiatric disorders may not be experienced as ps ychiatric problems by patients. Hearing an angel's may repres ent a manifes tation of a psychotic disorder, 828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 14 of 185

the patient may vigorous ly dis pute that the experience ps ychopathological s ymptom. Additionally, auditory hallucinations are often cons idered to be signs of a ps ychotic dis order, even though, by their very nature, are subjective internal experiences (s ymptoms ). complicating the distinction, s ome ps ychiatric phenomena, s uch as the class ic ps ychological defens e mechanisms, may only be inferred from s peech and behaviors but are not directly observable. S igns and symptoms are said to be pres ent when the of normal variability are s urpass ed. Abnormalities may manifest as alterations in amplitude (e.g., excess es or deficits ), duration, intensity, timing, and modifiability of phys iological events , perceptions, emotions, thoughts , motor activities . T hese limits are often arbitrary. include the number of hours of sleep, the intens ity of anger, or the extent of mood lability. However, for other experiences , the dis tinction between normal and abnormal is qualitative, not quantitative. F or s ome phenomena, “any” is “too much.” In mainstream culture, for ins tance, any experience of thoughts being broadcast out loud is cons idered pathological. T hes e and s ymptoms mus t all be considered in context: what constitutes normal varies from culture to culture from s ituation to situation. A behavior or subjective experience that may be defined as s ymptomatic in one context may be perfectly acceptable and within normal bounds in another. A phenomenon s hould be abnormal only if it s eems deviant within the patient's specific culture after its full phys iological and environmental context is taken into account and if it caus es personal or interpersonal impairment. T oo 829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 15 of 185

phenomena prematurely mis labeled as turn out to be perfectly unders tandable and nonpathological once the whole s ituation is appraised. C onvers ely, s ome examiners are loath to label certain phenomena as ps ychopathological even when they are, for fear of s tigmatizing the patient. P.967 On the other hand, some relatively normal-appearing behaviors , or behavioral omis sions , may signal impairments . F or example, individuals may overtly or covertly us e s o-called s afety behaviors to avoid feared outcomes , but these behaviors may in fact perpetuate very pathological s tates they are intended to alleviate because they may prevent the individual from facing directly dealing with their problems or from the cognitive distortions that may be underpinning the problems in the first place. E xamples of safety include drinking alcohol to deal with insomnia, cons istently talking about traumatic events in an intentionally affectles s manner to put off dealing with as sociated emotions, and avoiding mas turbation to delus ionally imagined persecutors who go around castrating masturbators. Although, on the s urface, behaviors may not in thems elves appear to be pathological, they cons titute les s -than-satis factory mechanisms and may coincide with those commonly described in the psychoanalytical and psychological literatures , s uch as reaction formation, dis sociation, others . Within cultures, mos t interpersonal interactions are carefully regulated by tight sets of rules and controls 830 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 16 of 185

cons trained by reasonably well-defined s ets of expectations and acceptable limits . E ven s light from these acceptable limits are quickly perceived by laypeople, as well as profes sionals, becaus e deviances are often experienced as threats . Deviations amplitude, duration, and intensity can occur in facial expres sions , gestures, pos tures, vocalizations, and other express ions of emotion and thought. A s mall increase in the rate of speech, an intrus ion into one person's conversation by another who does not allow proper paus es , a gesture that comes jus t a bit too a face, an exces sively rigid or distant s tance, or a gaze is too staring or too avoidant each s ignals s ocial insensitivity and alerts the observer to deviant

R eliability P roblems Among the core difficulties in psychiatric evaluation has been that multiple obs ervers may note different symptoms or interpret signs differently when the same patient. T hese dis crepancies may be due to differences in the patient's s tatus or in information imparted by the patient from examination to in the obs ervers' definitions of the s ymptoms or signs in question, and differences in perceiving and interpreting the patient's respons es to general presentation or questions within the interview. T hese three types of reliability problems are called information variance , crite rion variance , and obs e rvation bias . A s ubstantial amount of information variance in clinical practice the impos sibility of as king all ques tions within the time available for clinical evaluation. As an example, in one study, the rate of sexual side effects increas ed from 14 percent when depending on spontaneous patient report 831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 17 of 185

to 58 percent when the interviewer directly as ked about these side effects. A 37-year-old woman, treated with a selective reuptake inhibitor (S S R I) for the las t 2 years , s aw a ps ychiatris t on relocating to a new city. As part of the history, her new ps ychiatrist as ked about s exual side effects from the antidepress ant. S he acknowledged she had new-onset anorgas mia for 2 years since she started the antidepres sant. When as ked why she had discuss ed this with her previous psychiatrist, she said he had never asked, and she was too embarras sed to spontaneously mention it. Although good interrater reliability can be achieved for most s ymptoms of Axis I disorders , this may not hold for pers onality disorders or for s ome s pecific F urthermore, good interrater reliability may occur cons istently only under optimal circumstances and may not be as common in clinical practice. E ven when s imply res ponding to direct ques tions about symptoms, patients may res pond differently depending the interviewer's manner, how the ques tions are as ked, their personal sense of trust or s afety, whether they answered these questions before, the amount of cuing that may signal the “desired” res ponse, their fatigue, or host of other variables. Most clinicians still rely heavily on their own clinical intuition and s ubjective res ponses to patients as part of diagnostic ass es sment. However, thes e clinical whether accurate or not, are often bas ed on as sumptions , comparisons with other patients not well 832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 18 of 185

remembered, or dis tortions based on the clinician's personal experiences. W hen the bas es for these can be identified and described clearly, they may prove be reliable and valid. However, intuitions are often wrong—simple trust in intuition alone is not s ufficient. T hus, a clinician's sense that a patient is angry and potentially violent may result from the patient's s ubtle verifiable) body language and tone of voice, or it may represent a countertransference distortion that is not prompted by any obs ervable patient behavior. In this regard, clinicians are becoming more aware of the presence of the s o-called inters ubjective field in clinical encounters . T his term recognizes the fact that clinical phenomena that emerge from the patient are often dependent on the nuances of behavior and perception that the clinician brings to the encounter. T he clinician's contributions may powerfully shape how the patient behaves and what the patient reveals, in turn seriously distorting what the clinician perceives. C linicians often too quickly label behaviors as inappropriate when they do not appreciate and unders tand contextual or cultural cons iderations. Appropriateness depends heavily on context, and definitions of what is proper in a given context may also highly s ubjective. Appropriate behavior (or dres s) in parts of C alifornia may be inappropriate in B os ton. A intens ity of emotional express ion leading to a clinical description of “cons tricted affect” may reflect cultural norms or a ps ychopathological state.

Nons pec ific Nature of S igns and S ymptoms 833 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 19 of 185

Until ps ychiatry dis covers reliable diagnos tic laboratory tes ts to define clinical s yndromes, the field will continue cons truct diagnostic categories based on the clustering signs and s ymptoms within specific time frames . pathognomically s pecific s igns or symptoms rarely ps ychiatry; virtually all ps ychiatric symptoms are nonspecific and are us ually s een in many different disorders . Depress ed mood, for example, occurs in a variety of diagnostic groups , including major disorder, s chizophrenia, some pers onality disorders, organic mood syndromes , and s o on. E ven the s ofirst-rank s ymptoms of s chizophrenia des cribed by K urt S chneider are diagnostically nonspecific. T hey are with some frequency in otherwis e clas sic depress ive bipolar disorders . Apathy offers another good example an important nons pecific phenomenon. Although is often part of depres sion, research has s hown this symptom to be a clinically dis tinct s yndrome. Apathy is marked by lack of s pontaneity, initiation, and as well as lack of activity and interest in friends, family, hobbies. Apathy and the as sociated symptom of amotivation may exis t in their own right without the presence of s ignificant depres sion, as in initial phas es abstinence from cocaine and in other syndromes characterized by reduction in dopaminergic tone, s uch frontotemporal dementias , P arkins on's dis eas e, or progres sive s upranuclear palsy. P.968 In general medicine, symptoms not recognized as part clearly defined s yndrome are often described as being unknown origin. T hus, a fever that cannot be as cribed 834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 20 of 185

known disorder, such as pneumonia, is des cribed as a of unknown origin. G iven the nons pecific nature of ps ychiatric symptoms, it seems wis e to us e s imilar conventions , referring to hallucinations of unknown or depress ed mood of unknown origin when a cannot be clearly linked to a well-described syndrome. However, the dominance of the categorical s ys tem of DS M-IV -T R and the demands of a health care and insurance system that requires a specific diagnosis for reimbursement make this type of diagnos tic thinking unlikely in the near future. E ven though individual s igns and symptoms may be organized into s yndromes and dis orders, they often cours es of their own. T hus, in the appearance or the res olution of a disorder, certain ass ociated s igns and symptoms may appear very early or may pers is t after the others have waned. F or example, in the restricting form of anorexia nervosa, exces sive exercise is often first s ymptom to appear and the las t to abate even after dieting has s topped. In s ome cases, certain s igns and symptoms that are commonly ass ociated with a given disorder may not appear. E ach sign and s ymptom may have its own pattern and variable respons e to In the treatment of s chizophrenia, for example, some patients experience rapid res olution of hallucinations have pers istent delusions without ever having any thinking dis orders, whereas others may have no hallucinations or delus ions but s till have prominent thinking dis orders.

S ign and S ymptom C ategories S igns and symptoms have been categorized in a 835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 21 of 185

ways: s tate versus trait, primary vers us secondary, and form versus content. T he s tate ve rs us trait distinction to whether the sign or s ymptom is an enduring characteristic of the pers on (“traits ”) or time-limited phenomena as sociated with s pecific Axis I disorders , are us ually s tate phenomena. However, some enduring traits may also be s ymptoms . A person who always a great deal, chronically exhibits catas trophic thinking, feels subjectively nervous in many different since early childhood may have trait anxie ty. However, such symptoms of anxiety are pres ent only during a specific time frame, for example, over a 9-month period conjunction with a full depres sive syndrome, they are described as state-related symptoms. At times , trait state symptoms may be one and the s ame. F or one s tudy, patients who had remis sion of their with treatment s till showed relatively high rates of and s leep disturbances . In thes e circums tances , longsymptoms of fatigue and s leep disturbances may be trait markers of the depres sive dis order as well as symptoms of the acute depress ive epis ode. During the acute stages of ps ychiatric disorders marked by state characteris tics, it is unwis e to infer that any of the prominent signs or s ymptoms are enduring traits, even those usually ass ociated with pers onality. T hus , a of dependent personality traits based on an acutely depres sed patient's behavior is often incorrect. manipulative behavior in the mids t of a hypomanic or manic epis ode should not be cons idered evidence for enduring manipulative traits unles s thes e behaviors are also pres ent when the mania has clearly res olved. Dis tinctions between primary and s econdary symptoms 836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 22 of 185

have been confused by varying definitions of thes e T he distinction may refer to caus al relationships what is primary and secondary, temporal sequence between the two symptom sets, or inability to more unders tand the origin of the various s ymptoms. B asing distinction between primary and s econdary on caus ality implies that it is actually understood what is caus e and what is effect. In attention-deficit/hyperactivity dis order (ADHD), for ins tance, the attention deficit is believed to primary, whereas the hyperactivity is believed to be secondary, caus ed by the inability to attend. P atients develop s evere dependent personality traits and demoralization only after numbers of incapacitating ps ychotic mood episodes might be des cribed as having primary mood dis orders and s econdary pers onality disorders . C onceptual models of ps ychopathology in which s ome s igns and s ymptoms are s een as albeit ineffective, attempts to cope with more fundamental ps ychopathological deficits us e a secondary model. T o illus trate, E ugen B leuler viewed thought disorder as a primary symptom in whereas he viewed hallucinations and delusions as secondary s ymptoms, formed to help the patient cope with the chaos of the primary s ymptoms . T hese models must be viewed as hypothetical cons tructs only and with great caution because, in the vast majority of phenomena, little evidence indicates that one s ymptom more primary than another. T emporal s equence in the appearance of certain symptoms is regularly used as the basis for deciding primacy of certain s ymptoms , behaviors , or dis orders, trying to determine what is primary and what is 837 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 23 of 185

when substance abuse occurs in conjunction with depres sion or anxiety s ymptoms. T hese differences trivial but may have treatment implications because, for example, treating a primary mood disorder in a abusing patient (with a long course of medication) may quite different from simply expecting that, with sobriety, a s econdary mood dis order will res olve on its own. However, the primary–secondary distinction with mood and substance abus e problems , although logical, may not always be cons istent with treatment s tudies . an example, in one s tudy, patients with primary alcohol abuse and s econdary depres sion (whose depres sions should theoretically have responded to s imple sobriety) res ponded better to antidepress ants than to placebo. F urthermore, it is becoming increas ingly clear that the presence of certain preexisting psychiatric conditions , as personality dis orders , increas es one's vulnerability the subsequent development of other ps ychiatric disorders such as major depres sive dis orders. However, establishing temporal sequence with any certainty is typically difficult. T o illus trate, although a high comorbidity between bulimia nervos a and major depres sive dis order, in exces s of 50 percent in some studies, attempts to es tablis h which dis order is primary have been inconclusive. E ven with careful historical analysis, major depres sion precedes bulimia nervosa, bulimia nervosa precedes major depres sive episodes, the two conditions start concurrently in approximately equal percentages . Ultimately, making s imple categorical dis tinctions between primary and s econdary s igns, symptoms , and disorders is les s important than unders tanding the 838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 24 of 185

contribution of each element as a thread in the and development of a given clinical pres entation. F rom this pers pective, each element can be viewed as dynamically affecting the appearance, manifestations, cours e of the others, exerting its own influence on the pathogenes is and treatment of the s pecific s yndromes as sociated dis orders. T his view is particularly important because, des pite the excellent conceptual contributions made by categorical diagnostic s ys tems, such as the American P s ychiatric As sociation's DS M-IV -T R , in practice dis tinctions are often fuzzy, and comorbidity among so-called categorically dis tinct disorders is often the rule rather than the exception. F or example, data the National C omorbidity S tudy s how that 14 P.969 percent of the population experience three or more comorbid psychiatric dis orders. In s uch individuals , the dynamic interactions and mutual influences of various signs and s ymptoms, and their biological become imposs ible to dis entangle. F urthermore, the categories that currently compris e IV -T R are not going to be the last word in the evolving history of ps ychiatric diagnosis . R ecent studies s how ps ychiatric signs and symptoms may be usefully into psychotic syndromes that differ in s ome res pects current DS M-IV -T R categories. In a large family s tudy probands with broadly defined s chizophrenia and illness and their first-degree relatives, using a statis tical technique called latent clas s analys is , K endler and colleagues found six clas ses of ps ychos is , including clas sic s chizophrenia, major depress ion, 839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 25 of 185

schizophreniform disorder, bipolar s chizomania, schizodepress ion, and hebephrenia. Although these clas ses bore s ubs tantial res emblance to current or historical nosological cons tructs, s everal of them from DS M-IV -T R nosological cons tructs. In another the three factors ordinarily as sociated with s ymptoms schizophrenia, repres enting positive, negative, and disorganized symptom domains, were found not to be specific to schizophrenia but were found in other schizophrenia-spectrum ps ychos es and in nonschizophrenia-like psychotic conditions as well. Additionally, a dimensional view of ps ychopathology much recent data better than the categorical view that inherent in DS M-IV -T R . P ers onality disorders fit poorly a categorical scheme, and the frequent “comorbidity” of these dis orders likely reflects the descriptive overlap than the patient having two dis tinct dis orders . S imilarly, DS M-IV -T R , dysthymia and major depress ion are s een two mood disorders when recent s tudies indicate that they are more likely manifestations of one disorder that differs in course and intens ity.

C ontext S igns and symptoms are us ually not s tatic entities ; depending on the context, they often vary in intensity or even in their existence. T he depres sed mood of a melancholic depres sion may pers is t regardless of the external s ituation, whereas the depres sed mood in reactive depress ion may vanis h completely during situations —including a psychiatric interview—only to reappear at other times . S igns and s ymptoms that only in s pecific s ettings or with certain internal s tates 840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 26 of 185

referred to as s tate depe nde nt. F or example, certain hallucinations or memories may be present only during states of drug or alcohol intoxication; in s ome patients, hives may erupt as a ps ychophysiological response during s tates of anger. Interpersonal context is also important. S ome people become violent only when involved in sadomasochistic relationships or in certain group s ettings such as adoles cent gangs . In gangs, press ures for conformity and expectations for behavior may provoke or release pathological that might otherwis e never be express ed by gang members individually.

P roblems and Impairments B eyond the class ic signs and symptoms of ps ychiatric disorders , recent attention has focused on the and impairments that ps ychiatric s igns, s ymptoms , and disorders generate in affecting s pecific role functions caus ing social and economic burdens for the patient others . T hese problems and impairments often cut traditional sets of s igns and s ymptoms of which categorical diagnos es are compris ed, affecting, for example, bas ic abilities to care for oneself and one's marital functioning, child rearing, wage earning, s chool performance, and s ocial behavior. T hey constitute the is sues with which patients and families contend, and need to appear on the problem lists that treatment and s pecific interventions target. S tudies reveal, for example, that the impairments imposed by major depres sion are cons iderable with regard to phys ical functioning, role limitations, and social functioning. P roblems s uch as violent temper outbursts , s exual aggres sion, or lack of job s kills , which may impair role 841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 27 of 185

functioning in s everal spheres , must be directly regardless of the ass ociated DS M-IV -T R diagnoses. impairments enter determinations of ratings for Axis V the DS M-IV -T R , which address es the global functioning, and are of cons iderable importance in evaluating treatment outcomes. T able 8-1 lists s ome illus trative critical impairments that have been as often requiring urgent or intensive levels of care.

Table 8-1 Illus trative C ritic al Impairments That May R equire S ervic e-Intens ive Treatment, Intens ive Treatment S ettings , or Ac ute C are Anxiety

Medical ris k factor

Ass aultiveness

Medical treatment noncompliance

C ompulsions

 

C oncomitant medical condition

Mood lability

Delusions (nonparanoid)

Obsess ions

842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 28 of 185

Delusions (paranoid)

P hobia

Dis sociative s tates

P hysical abuse perpetrator

Dys phoric mood

P sychomotor

E ating dis order

P sychotic thought/behavior

F ire setting

R unning away

Hallucinations

S elf-mutilation

Homicidal thought/behavior

S exual trauma perpetrator

Inadequate health care skills

S ubstance abuse

Manic

S uicidal thought/behavior

Adapted from G oodman M, B rown J , Deitz P M. Managing Manage d C are II. A Handbook for Health P rofe s s ionals . 2nd ed. W ashington DC : American P s ychiatric P res s, Inc.; 1996. F urthermore, the relationship between symptoms and 843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 29 of 185

disorders on one hand and functional impairments on other is not always s traightforward. F or example, in bipolar and unipolar mood disorders, many patients recover s ymptomatically from episodes but achieve premorbid psychosocial function either months later or not at all. In one review of previously published s tudies major depress ion, there was a consis tent lag time symptomatic and functional recovery. W hether this disparity between s ymptomatic and functional recovery reflects s ubtle residual symptoms, unrecognized disturbances , personality difficulties, or a combination factors is unknown. A 45-year-old teacher with a relatively severe major depres sion s topped work because of depress ive symptoms. He was treated with a combination of medication and psychotherapy and became as ymptomatic, with virtually complete normalization of mood, sleep, appetite, concentration, and energy. Nonetheles s, he felt unable to return to work s oon after the depres sion remitted, being unable to explain this than as s imply feeling “not ready” for the stress es of job he had done cons is tently for 15 years. P.970

Need for a C omprehens ive P ers pec tive A ps ychiatric disorder may be characterized by disturbances involving a wide variety of areas in the patient's life, including the biological, ps ychological, behavioral, interpersonal, and s ocial s pheres . In 844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 30 of 185

common psychiatric s yndromes often manifes t in each these dimensions (T able 8-2). V iewing the patient from multiple perspectives, using the s o-called model (similar to the multiaxial approach of DS M-IV enables clinicians to cons ider ps ychopathology and its effects on a patient's life in the broades t pos sible T o illustrate, F igure 8-1 lists s ome clinical hypothes es commonly used by clinicians as they link collections of signs and s ymptoms into syndromes and cons ider the treatment options that logically follow.

Table 8-2 C ommon C urrent Hypothes es Us ed to As s es s and S ymptoms : Ways of Unders tanding the Patient's Problems B iologically derived hypothes es     R elated to a brain impairment or organic disorder     R elated to mood disorder     R elated to nonaffective functional psychosis     R elated to the abuse of drugs or alcohol

845 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 31 of 185

    R elated to biologically mediated developmental is sues     As a dis order other than those listed above in biologically derived hypotheses category P sychodynamically derived hypotheses     R elated to personality and temperament s tyle     R elated to environmentally mediated developmental iss ues , s uch as abuse, neglect, traumatic events, and more subtle life process es regarding nurture by primary caregivers, with family, peers , and others in both s hared and nonshared environments     R elated to precipitating life events and their dynamic meaning     R elated to manifestations of unres olved grief     R elated to a current developmental cris is     R elated to ego functioning and as sociated ps ychodynamic iss ues S ocioculturally derived hypotheses     R elated to the nature and the s ocial effects of 846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 32 of 185

stress ful life events     R elated to the extent, nature, and acces sibility practical (particularly financial) or emotional support, or both     R elated to definitions of and res ponses to breakdown in the sociocultural grouping     R elated to the patient's motivation, treatment goals , and the dynamics of the entry process to seeking     R elated to practical matters in negotiating and sustaining ongoing relationships with profes sional caregivers and care-giving s ys tems     As s ocial communication B ehaviorally derived hypotheses     As disordered thinking, feeling, or acting from s pecific antecedent events     As disordered thinking, feeling, or acting from reinforcing cons equences of the behaviors     As disordered thinking, feeling, or acting in res ponse to s ociocultural and biological events

847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 33 of 185

    As a deficit of behaviors (rather than behaviors ) in the areas of thinking, feeling, and acting     As compens atory behaviors us ed to for behavioral deficits     B y an analysis of areas of effective functioning

Adapted from Lazare A. Hypothesis testing in the clinical interview. In Lazare A, ed. O utpatie nt P s ychiatry: Diagnos is and T re atme nt. B altimore: Williams & W ilkins ; 1979.

848 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 34 of 185

FIGUR E 8-1 B iological, ps ychological, and s ocial forces interact and affect the ps ychiatric health of a person. (Adapted from R ichmond J B , Lustman S L: T otal health: conceptual vis ual aid. J Me d E duc. 1954;29:23.) B ecaus e the amount of information gathered in a thorough as sess ment of a psychiatric disorder is potentially overwhelming, clinicians often tend to limit their fields of vision and appreciate only part of the 849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 35 of 185

available information; the clinician's theoretical and other personal and cultural factors als o limit what perceived. R es earch has demons trated that clinicians to perceive primarily those signs and symptoms that most in accord with their theoretical points of view and with the tools they have available to treat ps ychiatric disorders , a phenomenon known as conce pt-drive n pe rce ption. T he theoretical bias es of clinicians s eem to related both to the microcultures of their training programs and to their own pers onality traits . S uch differences may lead one clinician to s ee a major mood disorder to be treated with medication, whereas sees a pervasive personality problem with depres sed mood to be treated with ps ychotherapy and to us e different technical terms to label roughly the s ame phenomena. A psychodynamic psychiatrist might s ee ps ychomotor retardation, whereas a neuropsychiatrist sees bradykinesia; a psychodynamicist might s ee depres sed affect and muted s peech, whereas a neurops ychiatris t s ees mask-like facies and apros odic speech; the psychodynamicist might s ee ruminative thought, whereas a neuropsychiatrist sees forced a psychodynamicist might s ee a grimace, whereas a neurops ychiatris t s ees a tic. G iven the extent to which words thems elves s hape our concepts of reality, the cons equences of us ing these different labels for very similar phenomena may be significant. F igure 8-1 illus trates concept-driven perception in which each clinician who adheres to a prominent contemporary of view perceives only s ome of the potentially available phenomena related to a ps ychiatric dis order. Although there is overlap, each observer als o perceives not appreciated by the others . At the s ame time, some 850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 36 of 185

information that may be highly relevant to diagnosing treating the disorder may be mis sed by all the so clinicians 100 years from now will, no doubt, be able detect and unders tand the significance of signs and symptoms not appreciated by anyone today. T he intermittent nature of many ps ychiatric signs and symptoms; the potential unreliability, selective recall, false remembering of patients and others in reporting symptoms and events ; differing interpretations of information or obs ervations; and subjective driven biases that influence the clinician's perception of signs and s ymptoms all contribute to potential errors in data collection. T o help guard against mis information simplis tic unders tandings and formulations , whenever poss ible, complete as sess ment of a psychiatric patient requires cons ultation with family, friends, coworkers, other profes sional observers to enrich the history and provide s upplemental observations of the patient over time. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > S OMAT MANIF E S T AT IONS OF P S Y C HIAT R IC DIS O R DE

S OMATIC OF PS YC HIATR IC P art of "8 - C linical Manifes tations of P s ychiatric Most psychiatric dis orders and virtually all Axis I based disorders are characterized by dis turbances in least some bas ic physiological functions . Although 851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 37 of 185

frequently nonspecific in nature, the s everity of thes e somatic signs and symptoms provides markers as to amount of biological disruption s een in the disorders caus e them. F urthermore, s omatic s ymptoms can als o caus e exacerbations of some dis orders. If untreated, proces ses can create destructive feedback loops in the disorder caus es symptoms , which then the disorder, which causes increases in the s ymptoms, so on. As examples , the ins omnia of manic or states , if untreated, caus es a marked wors ening of the mania; s imilarly, the weight los s of anorexia nervosa starvation P.971 effects, s uch as a preoccupation with food, thus exacerbating one of the hallmark features of the underlying disorder.

S leep Dis turbanc es Abnormalities of s leep may manifest in the amount, quality, and timing of sleep as well as by the pres ence abnormal events during s leep. Ins omnia is us ually defined by its s ubjective the sensation of sleeping poorly. Mos t, but not all, complaining of ins omnia demons trate some sleep abnormality if examined in a s leep laboratory. Insomnia a common, often chronic symptom or s ign of many different ps ychiatric disorders , including s ubs tance depres sion, generalized anxiety disorder, panic, mania which the diminis hed sleep does not always provoke a complaint), and acute s chizophrenia. It may als o occur cons equence of aging or as a s ymptom or dis order not 852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 38 of 185

as sociated with other ps ychopathology. Ins omnia may also result from the ingestion of subs tances that alter normal sleep–wake cycle, including alcohol or and by the discontinuation of sedative-hypnotics. Although much attention is often paid to distinguishing patterns of ins omnia, such as difficulty falling as leep middle or terminal insomnia (early morning linking specific patterns to a s pecific dis order (for melancholic depres sion with terminal ins omnia), the clinical us efulness of thes e distinctions is unclear. A 62-year-old woman complained of chronic insomnia, characterized by both initial ins omnia and fitful s leep during the night. S he had a his tory of recurrent major depres sions in ass ociation with marked life stress ors had not had a depress ive episode for 10 years. A workup, including an extensive medical and psychiatric history, revealed no obvious caus e for the insomnia. mood was euthymic, and no evidence of sleep apnea other primary s leep disorder was apparent. S he was treated with low-dose trazodone, which was s omewhat effective and which s he used intermittently for the next few years. Hype rs omnia, characterized by either excess ive sleep or excess ive s leepiness during the day, is less common than insomnia. It, too, however, may reflect a number of different pathological s tates. S ome patients, especially thos e with a his tory of mania or hypomania, may exhibit hypersomnia. Hypers omnia also be s een during s timulant withdrawal, with us e of sedatives or tranquilizers, or in conjunction with variety of medical dis orders. In narcoleps y, the patient 853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 39 of 185

sudden attacks of irresistible s leepiness , a symptom may be part of a broader syndrome that includes (s udden attacks of generalized muscle weakness to physical collapse in the pres ence of alert s lee p paralys is (waking from s leep with a s ens ation of being totally paralyzed that may persis t for minutes), hypnagogic hallucinations (vivid vis ual hallucinations occur at the point of falling asleep). Narcoleptic attacks often precipitated by unus ual states of arousal (e.g., cataplexy may immediately follow unres trained or orgas m). Daytime sleepines s may reflect s lee p this dis order, typically middle-aged patients severe s noring—often first reported by their bed partners —and periods when breathing s tops. T he condition P.972 res ults from s oft palate abnormalities that caus e intermittent airway obs truction throughout the night; patients awake repeatedly to find thems elves gas ping air. Ass ociated daytime fatigue is common in sleep P eriodic hypersomnia also occurs in the K le ine -L e vin s yndrome , a condition typically affecting young men in which periods of s leepiness alternate with confusional states , ravenous hunger, and protracted s exual activity. Intervals of days , weeks , or months may pass between these episodes. S omnambulis m, or sleepwalking, and s lee p te rror (night terror) are two sleep dis orders characterized, res pectively, by aimles s wandering with incomplete arousal and by acute anxiety and phys iological arous al without awakening. Although both disorders typically 854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 40 of 185

begin in childhood, sleepwalking may be als o initially precipitated by s ome ps ychotropic medications. A 51-year-old woman with complex P T S D was treated olanzapine. W ithin 1 year after starting this medication, she had gained 35 lbs. During this period, her hus band noted that she often went to the refrigerator in the of the night, s ound as leep, and ate indiscriminately. he woke her during these episodes , she appeared and had no awarenes s of her purposive behaviors . T o best of her recollection, confirmed by her husband, treatment with olanzapine (Zyprexa), she had no somnambulistic phenomena. Nightmares are a common complaint, often as sociated with traumatic events , anxiety dis orders , and mood disorders , but not uncommon as an occasional event in otherwis e healthy individuals. V ivid dreams and nightmares may als o be a medication side effect. A 32-year-old woman was treated for a mild depress ion with an S S R I. Her s leep pattern before treatment had characterized by hypers omnia, s leeping between 10 12 hours nightly. S oon after the initiation of her S S R I antidepres sant, s he noticed that her sleep was not only shorter and more fractured but that s he had remarkably intens e dreams that s he remembered vividly. S he clear that thes e were not nightmares , just dreams with intens e colors and clarity, which s he rather enjoyed. S ensory s ymptoms during s leep, typically des cribed by patients as peculiar feelings in their legs caus ing an irresistible need to move around, are characteristic of re s tle s s le gs s yndrome . T he motor abnormality of 855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 41 of 185

myoclonic jerking of the legs , awakening both patients and their partners, is known as nocturnal myoclonus .

A ppetite and Weight Dis turbanc es Aside from the anorexia of medical illnes ses , es pecially their later s tages, los s of appetite is mos t commonly in depress ive disorders , grief, some anxiety disorders, primary anorexia nervos a and as a s ide effect of some medications . Anorexia is often accompanied by tas te (e.g., foods begin to taste different, bitter, or flat have an unpleas ant aroma). In eating disorders , may resist hunger to res trict food intake to achieve a phys iologically unrealis tic low weight. Hyperphagia (increased appetite) occurs in s ome depres sed both with and without a history of mania or hypomania. B inge eating, of up to s everal thousand calories per episode, may occur as an attempt to s elf-soothe and emotionally self-regulate during times of increased and anxiety and as a key feature of bulimia nervosa or binge-eating dis order. Increased appetite may be s een, albeit rarely, in s ome hypothalamic dis orders or in temporal lobe dysfunction s uch as the K lüver-B ucy syndrome, in which it occurs in as sociation with placidity, hypersexuality, hyperorality, and other symptoms.

E nergy Dis turbanc es Normal energy levels vary cons iderably among people. S ome people fatigue easily and are perceived by thems elves and others as having “weak cons titutions,” whereas others appear to have almost boundles s and much less need for sleep. 856 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 42 of 185

F atigue is an common nons pecific s ymptom that both medical and ps ychiatric dis orders. It is also seen as an unexplained complaint in primary care practices ; in one s tudy, 24 percent of patients of fatigue received no medical or psychiatric diagnosis. His torically, fatigue not due to another disorder, in as sociation with “nervousness ,” has been des cribed terms such as as the nia, ne urocirculatory as the nia, ne uras the nia, and ps ychas the nia. C onsistent with this tradition, many fatigued patients, having been labeled depres sed or neurotic by their phys icians , are referred ps ychiatris ts after routine workup has ruled out anemia, hypothyroidism, sleep apnea, and other frequent caus es. R ecently, thos e patients with primary complaints of tiredness have been mos t commonly diagnos ed as chronic fatigue s yndrome (previous ly and incorrectly labeled E pstein-B arr viral s yndrome), a dis order characterized by fatigue las ting months to years , beginning soon after a viral syndrome. In addition to fatigue, chronic fatigue syndrome is characterized by myalgias and cognitive changes s uch as forgetfulness poor concentration. Although controversy still exists the extent to which cases of chronic fatigue s yndrome represent discrete postviral diagnostic s yndromes , mislabeled cas es of depress ion, or modern versions of ps ychas thenia, evidence continues to mount to that these s yndromes are discrete pos tinfectious and are not simply variants of or disguis ed mood or anxiety dis orders. A highly accomplis hed, energetic 40-year-old woman 857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 43 of 185

referred for ps ychiatric cons ultation after her physicians were unable to offer a definitive phys iological diagnosis despite extensive medical workup after the acute ons et profound fatigue occurring in the wake of a mild viral illness . T his fatigue caus ed her to be totally and bedridden for many months and left her feeling helpless and distraught. It was exacerbated by even amounts of alcohol. T wo independent psychiatric evaluations concluded that the patient had no disorder. T he patient developed this syndrome after jogging near Lake T ahoe. E pidemiological s tudies were found that reported a s eries of other cases of profound fatigue originating in this particular area after vigorous exercise. V arious antidepres sants seemed to provide partial relief, but tolerance to their positive effects developed. T he fatigue s lowly improved over many 7 years after the original symptoms , the patient to experience waxing and waning fatigue but at a level than originally.

Dis turbanc es in S exual Drive As with energy, the normal range of s exual drives is S ome individuals are naturally lus ty, whereas others limited s exual des ire. Diminished s exual drive with impotence or decreas ed libido is seen in a wide variety neurological, metabolic, and other s omatic s yndromes. Among neurological disorders, complex partial seizures are commonly as sociated P.973 with hypos exuality, occurring in 50 percent of patients. P sychiatric dis orders known for diminis hed sexual drive 858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 44 of 185

include depres sive dis orders, s chizophrenia, s ubs tance abuse dis orders, and marital conflict. Diminished libido, erectile dys function, and anorgasmia are als o common sequelae of many ps ychotropic agents, especially serotonergic antidepres sants . A depres sed 36-year-old man had an excellent antidepres sant res ponse to an S S R I but developed decreased sexual interest and anorgasmia with relative preservation of erectile function. W hen the s exual side effects did not diminis h after 4 weeks, his ps ychiatris t a number of potential antidotes. Although s ildenafil (V iagra) improved his erections s omewhat, his libido orgasmic function continued to be markedly impaired. R eluctantly, he and his ps ychiatris t agreed to s witch to different antidepres sant clas s that was not as sociated sexual s ide effects. Increased sexual activity may be s een in some neurological, drug-induced, and psychiatric dis orders. Manic patients frequently exhibit hypersexual interes ts and behaviors to an unus ual degree, compared with euthymic interes ts and behaviors . Hypersexuality is occasionally seen in conjunction with epileptic or in patients who have had diencephalic injuries . Altered sexuality, including fetis hes , s adomas ochis m, pedophilia, and other paraphilias , may be s een as ps ychiatric syndromes. In individuals whose previous sexual behaviors were within the bounds of social propriety for their groups , inappropriate sexual may s ignal early brain dis eas e or psychos is. C ross may occur in transves tites, transgenderis ts, 859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 45 of 185

or, occas ionally, in other psychiatric conditions. A 54-year-old married engineer became preoccupied viewing pornographic sites on the Internet. He had been excited by the visual s timulation of early girls. He had never acted on these feelings, had never an affair s ince being married, and, even when younger, had always had cons ens ual sex with girls his own age. the advent of the computer, he had become preoccupied by finding and spending s ignificant of time on W eb s ites devoted to photos of young girls. E ventually, he was spending 3 hours daily at thes e sites . At that point, he sought treatment for a pattern of behavior that he believed he could not control at all.

A ppearanc e S tudies s how that clinicians often formulate an initial ps ychiatric diagnosis within 30 seconds of s eeing a Although approximately one-half of such initial impres sions prove to be incorrect, the remainder are validated by ps ychiatric history and mental s tatus examination, revealing jus t how much information is communicated by appearance and body language. Among the physical dis orders whose appearances coexistent ps ychiatric conditions are acromegaly, C us hing's s yndrome, Down syndrome, s ys temic lupus erythematosus, fetal alcohol s yndrome, K linefelter's syndrome, and W ils on's dis eas e, to name a few. T he general appearance of the s kin may s uggest the of occult ps ychiatric problems. T he general condition flush of the s kin may reveal hypervascularity and ruddiness , s uggestive of alcoholism, absces ses 860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 46 of 185

of hypodermic needle abuse, tattoos indicative of group affiliations , or weathering and was ting indicative self-neglect and malnutrition. Healed s cars on the and arms sugges t a pattern of s elf-mutilation from depres sion, pers onality disturbance, or both. P atchy baldness , es pecially in conjunction with torn or infected cuticles , indicates trichotillomania, a syndrome of compuls ive hair pulling. P s ychophys iological symptoms reflecting ps ychiatric dis turbance include urticarial reactions and neurodermatitis , the latter resulting, in from s elf-excoriation, des tructive s cratching s econdary compuls ions, and unrelenting s ens ations of dis comfort. A 23-year-old woman who had recovered from a episode of anorexia nervos a as an adoles cent had recurrent depres sions and pers is tent personality disturbances characterized by odd and eccentric ideas , shyness , and avoidance. S he became enchanted with gothic themes, s pent hours on the Internet in chat featuring dark and morbid poetry, and s tarted to have herself tattooed. W ithin 1 year, s he had tattooed every inch of her upper extremities , s calp, and torso with complex, intricate, gothic des igns. S he acknowledged tattooing her s kin in such an extreme manner s erved to mark her as deviant and to warn people away from her. E xamination of the head and neck may reveal exophthalmos or puffy eyelids , s uggesting thyroid marked pupillary dilation with anxiety or s timulant mios is with narcotic abuse, abnormal pupillary Wilson's diseas e, s alivary gland enlargement in bulimia nervos a, or necros is of the nasal septum in cocaine among other s igns . F requent s ighing is a common 861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 47 of 185

res piratory sign in depres sion. S imple sighing must be distinguished from res piratory dyskinesia in ps ychotic patients who have been treated with neuroleptics . T he latter may occur as an acute dyskinesia due to antips ychotic medication, or it may be a late and component of tardive dyskinesia. Deviant appearance is quickly perceived by laypeople profes sionals and may contribute to the frightened and stigmatizing s ocial withdrawal by strangers, as well as acquaintances, so often experienced by ps ychiatric patients. Akathis ia and dys tonic movements and parkinsonian s huffling gait in patients taking (es pecially the older, conventional antipsychotics), as as the dilapidated and unkempt appearance of some ps ychiatric patients, can immediately signal ps ychiatric patient status to obs ervers. T he term Diogene s has been used to des cribe old people who have filthy personal appearance and demons trate s evere s elfabout which they have no shame. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > T HINK ING

DIS TUR B ANC E S IN P art of "8 - C linical Manifes tations of P s ychiatric

Normal Thinking T hinking refers to the ideational components of mental activity, process es used to imagine, appraise, evaluate, forecast, plan, create, and will. Most thought involves 862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 48 of 185

complex rules that are probably bes t currently approximated (albeit inexactly) by fuzzy-logic decisionmaking algorithms that use neural net technology, increasingly applied by s cientists and engineers in situations in which all-or-none, black-or-white thinking does not apply but in which multifaceted, contradictory, and competing poss ibilities and biases are the rule. of what is known about thinking derives from the s tudy language as the product (and reflection) of thought, yet great deal of thinking takes place preverbally and nonverbally. T hinking occurs in images, mus ic, and kines thetic sensations and in s ymbols other than ones. Attempts to trans mit preverbal and nonverbal thought us ing only words are frustrating P.974 and unsatisfactory. C reative artis ts have cons iderable difficulty describing the inner states of tens ion and inchoate awarenes s from which ideas are dis tilled. Ordinary thought is far from logical. S treams of thought are intruded on by competing thoughts and as sociations and by outs ide stimuli, and attention is distracted. Ordinary conversation is marked by as ides, interruptions , delays, and the los s of ideas . Decisions are often made on the bas is of very few cues inadequate evidence: P eople jump to conclus ions. are zealously held that are not s upported by evidence. T hinking in s tereotypes is more common than thinking logical categories ; from an evolutionary pers pective, thinking in s tereotypes and by approximation has probably been more adaptive than thinking in s trictly defined categories. T his tendency helps account for 863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 49 of 185

clinicians ' tendencies to make diagnos es by and intuition bas ed on prototypes and to feel less comfortable us ing formal lis ts of criteria found in manuals such as DS M-IV -T R . C onsis tent with this recent study found that more than 60 percent of being treated for personality dis orders by clinicians had diagnosable personality dis orders when s trict DS M-IV criteria were applied. C ons iderable variation exis ts among individuals predominant cognitive s tyles , and an individual's s tyle thinking als o s hifts cons iderably from time to time. C ognitive s tyle refers to one's predominant manner of information process ing and decis ion making; the biases and dis tortions thinking process es make by of augmenting, elaborating, or minimizing incoming information; and the extent to which people use careful and deliberate logic versus intuition vers us thoughtless , anxiety-induced impuls ivity to guide decis ion making. some individuals , a particular cognitive style may come dominate that pers on's repertoire s o completely as to interfere with the flexible, adaptive responses required deal with the us ual variety of daily needs. An style of thinking is marked by attention to detail and hypervigilance concerning the pos sible implications of particular thought or event. T his may take the form of preoccupation with strict adherence to es tablished values, or beliefs. An obses sional s tyle may be highly adaptive in certain s ituations , as in profess ions meticulous detail s uch as librarians , computer programmers, and s urgeons . However, exces sively obses sionality may be maladaptive, as when s omeone scrupulously s ticks to the rules even when s uch 864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 50 of 185

is self-destructive and short sighted. A hys te rical s tyle thinking is characterized by global, diffuse, emotionally laden evaluations of situations in which attention is given to details and nuances . T his style is poorly adaptive to detail-oriented work but may be in the arts , certain as pects of marketing and sales , and some social s ituations. A 36-year-old attorney reported difficulty at work he s ometimes got bogged down in trivial details about cases that he could not seem to drop. His mind him to follow s mall, usually irrelevant leads that his legalis tic sensibilities even though his clients and partners had no interes t in these aspects of the cases faulted him for was ting their time and money.

Types of Thinking B ecaus e of the different ways in which both normal and abnormal thinking expres ses itself, differences that are apparent to even a cas ual observer, attempts have made to s ubtype thinking by the extent to which logical versus nonlogical thought is used. Although less commonly used than before, S igmund F reud's division thought into primary and s econdary process thinking provides a us eful description class ification.

P R IMA R Y P R OC E S S P rimary proces s thinking, the more primitive type, is typically s een in dreams but is als o prominent in young children and in psychotic states . T his type of thinking disregards logic, permits contradictions to exist simultaneously, disregards the linear notion of time, 865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 51 of 185

dominated by wis h and fantas y. It us es symbol, imagery, condensation, dis placement, and concretism its organization, creating the jumbled and incoherent of thinking characteristic of dreams . P rimary proces s thinking represents what has been loos ely and metaphorically called right brain thinking, ass ociated visual images and creative thought.

S E C ONDA R Y P R OC E S S S econdary process thinking is characterized by logic. contrast to primary proces s thinking, the s econdary proces s uses linear notions of time, clearly delineated abstract categories, and deductive rules of logic. T he abilities to think abstractly and to think in detail about future plans are characteristic of s econdary process thinking. Normal s econdary process thinking is also characterized by predictability, coherence, and redundancy. W ords , vocal inflections , and gestures important contextual cues and create a sense of overall coherence to the communication. Ideas follow one another in a s equence that is unders tandable to the listener. A non-F reudian typology of thought divides thinking three types : fantas y thinking, imaginative thinking, and rational or conceptual thinking. F antas y thinking allows the person to escape from, or deny, reality and can be in normal as well as pathological thinking. E veryone occasionally uses fantasy thinking when daydreaming. S ome diss ociative and ps ychotic phenomena illustrate most pathological manifes tations of fantasy thinking. Imaginative thinking merges fantasy and memory to generate plans for the future. R ational or conceptual 866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 52 of 185

thinking uses logic to solve problems . R egardless of how one categorizes thought, people fluidly s hift from linear/s econdary, process /rational thought to fantasy/primary, process /nonlogical thought, as in the free ass ociative method us ed in During this proces s, individuals willfully surrender the controls that maintain s econdary process thinking and switch to the less controlled modes of primary proces s thinking in which thoughts are loosely as sociated by emotional as sociations or bas ed on peripheral, coincidental, loos ely similar, or trivial aspects of a Additionally, the fact that increas es in primary process thinking can be induced in normal people under experimental conditions or with fatigue s ugges ts that more primitive thought proces ses, such as those seen ps ychos is , are us ually inhibited by higher-order and that their appearance may be release that is , nonlinear or psychotic thinking may indicate the functional absence of thos e overriding control systems that ordinarily sift, evaluate, and regulate the form and flow of thought before it reaches consciousness . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > T HO UG DIS T U R B ANC E S

THOUGHT DIS TUR B ANC E S P art of "8 - C linical Manifes tations of P s ychiatric

Flow and F orm Dis turbanc es B ecaus e the underlying process es that govern thought 867 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 53 of 185

not unders tood, current systems for class ifying thought abnormalities are primarily descriptive. C onventional clas sification separates form and flow from the content thought, yet many types of abnormal thinking include both form and content abnormalities. T hus , although delus ions are us ually class ified as thought content disturbances , they are also marked by formal abnormalities , s uch as rigidity and impervious ness of thought to external influence or to information that contradicts the delusional idea. P.975 Although formal thought dis orde r typically refers to abnormalities in the form and flow or connectivity of thought, s ome clinicians us e the term broadly to any psychotic cognitive s ign or s ymptom. As with energy and s exuality, normal variations in the and form of thought are considerable. F or s ome thinking appears to be effortless —rapid and productive, exhibiting linear, goal-directed thoughts and creativity, with digres sions and occas ional leaps but always controlled and comprehensible. F or others, thinking is difficult exercise—a s low, painstaking process with low output, compared with other people, or “scattered,” with difficulty s taying with a topic or finis hing a single Most people experience admixtures of thes e extremes . Dis turbances in the flow and form of thought occur with regard to rate, continuity, control, and complexity. T hinking can be unusually slow or accelerated. S lowed retarded) thought, s uch as noted in depres sion, is goal directed but characterized by little initiative or 868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 54 of 185

planning. P atients experiencing retarded thought often describe feeling that even s imple thought requires monumental effort, as if molass es were cluttering their thinking. T hese difficulties are express ed as s lowness decis ion making and as long latency of res ponse, increased pause times when speech is initiated and speech. T hought blocking, s een in schizophrenia, is experienced as the s napping off or as a s udden break train of thought, as if a wall s uddenly comes down, interrupting thinking (and speaking) in mid-sentence. an outside obs erver, without further explanation from patient, thought blocking may appear identical to withdrawal, a disturbance in the control of thought in which the patient feels as if some alien force has intentionally withdrawn the thoughts from T he patient's further des cription and explanation of the inner experience is necess ary to distinguish these two symptoms. A 35-year-old woman with s chizophrenia had a core delus ion that a group of beings/s pirits/forces watched over her, directing her behavior with variable intens ity. times , s he began to des cribe a part of her thinking to her psychiatrist, only to stop midway through, to go on with the discuss ion. At another time, she acknowledged that she was being told by the forces the ans wers to the psychiatrist's ques tions were too personal to divulge and that she had been instructed to stop talking. Accelerated rates of thinking, typically accompanied by fas t talking, can be seen as a normal variant. R apid speech, influenced heavily by cultural and s ituational 869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 55 of 185

factors , only sometimes reflect truly rapid thought. (F or example, it is not at all clear that New Y orkers , who characteristically speak more quickly than people from some other cities, actually think at a fas ter rate. auctioneers and s ome radio and televis ion announcers speak with as tonishing rapidity, likely reflecting both innate capacities as well as learned psychomotor P res s ure of s pe ech—speech that is rapid, excess ive, typically loud—is characteristic of mania (or stimulant intoxication, and, occas ionally, anxiety. F light ide as occurs when the flow of thought increas es to the point at which the train of thought switches direction frequently and rapidly. T he as sociative links between conceptual topics during flight of ideas are comprehensible to the listener, although not without cons iderable effort at times . Listening to a flight of that is not overwhelmingly fast can be both a dizzying enjoyable experience for the listener, as exemplified by succes sful performance s tyle of certain contemporary comedians, notably R obin W illiams.

C ontinuity Dis turbances in the continuity of thought may take forms. In circums tantiality, the flow of thought includes many digress ive turns and as sociations, often including great deal of unneces sary detail. T ranscripts of circums tantial thought or s peech are marked by commas , subclaus es , and parenthetic as ides. in circums tantial thought or s peech, the speaker eventually returns to the point that was initially intended without having to be prompted by the listener. In contras t, in tange ntiality, the person's thought 870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 56 of 185

further and further away from the intended point, ever returning, so that the pers on may not even what the original point was suppos ed to be. is a mild form of de railme nt in which there is a in as sociations. Loos e as sociations exemplify more derailment, in which the flows of ideas are no longer comprehensible to the listener becaus e the individual thoughts s eem to have no logical relation to one L oos e as s ociations are clas sically a hallmark feature of schizophrenia. In extreme cas es, the ass ociations of phrases and even individual words are and s yntax—the rules of grammar by which phras es organized into s entences and words into phrases — disrupted. W ord s alad describes the s tringing together words that s eem to have no logical ass ociation, and ve rbigeration describes the disappearance of unders tandable s peech, replaced by strings of utterances . C lang as s ociation refers to a sequence of thoughts stimulated by the s ound of a preceding word. F or a manic patient s aid, “I'll kill with a drill or a pill—G od, ill—what swill.” In echolalia, the patient repeats a just uttered by the examiner. R epetition of only the las t uttered word or phrase is called palilalia, a symptom most often in chronic s chizophrenia. P ers everation and s tereotypy are two other as sociative abnormalities in which the flow of thought or s peech appears to get stuck. In pe rs e veration, a sentence or is repeated, s ometimes several times over, after it is no longer relevant. P ers everation is commonly seen in delirium and other organic mental disorders . refers to the cons tant repetition of a phras e or a 871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 57 of 185

in many different settings, irres pective of context. Dis turbances in the control of thought include pass ivity experiences and obses sional thinking. In de lus ional thought pas s ivity, patients experience their thoughts as being under the control of other forces . T hought pass ivity may take s everal forms: In thought ins e rtion, thoughts are experienced as having been within the patient's mind from the outside; in thought withdrawal, thoughts are whisked out of the mind; in thought broadcas ting, patients experience their as es caping their minds to be heard by others . T hese experiences are often combined with specific delus ions control, s eemingly to explain the pas sivity experiences . S everal of thes e phenomena were included by among the s o-called first-rank s ymptoms of T oday, these symptoms are viewed more broadly as nonspecific ps ychotic s ymptoms , more likely to be schizophrenia but not pathognomonic of the disorder. A 42-year-old man with s chizophrenia rarely went out his hous e and typically believed that others were toying with him during the few convers ations he had. W hen as ked about thes e feelings and behaviors , he the complete conviction that everyone could hear what was thinking. He found this very embarrass ing when in public and therefore liked P.976 to stay in his hous e. Additionally, when he did convers e with others, he attributed their as king him questions as form of mocking him becaus e he was s ure they knew he was thinking anyway. 872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 58 of 185

O bs e s s ional thinking is s tereotyped, repetitive, thinking that is recognized as one's own thoughts . In contrast to patients with delus ional thought pas sivity, obses sional patients do not experience their thoughts being controlled by outs ide forces . Nonetheles s, they experience only partial control over the obses sional thoughts. T hey can, with great effort, s top thinking the obses sional thoughts but cannot prevent them from recurring. T hus , characteristic of obses sions are the subjective experience of compulsion and the resis tance it. In class ic obsess ional thinking, insight is retained, as bizarre as some obs ess ions are, patients know that these thoughts are irrational and their own. However, more recent s tudies have revealed that ins ight into obses sional thinking is more variable than had been previous ly believed, at times becoming delus ional. At times , obsess ions may be pervasive enough to the patient's cons cious nes s. Obses sions may be sequence of words, or elaborate, such as enumerating poss ible cons equences of a pas t behavior and a cascading sequence of typically catastrophic events. T ypical obs ess ional themes in OC D involve with dirt and contamination, fear of harming others , symmetry, and thos e related to health and appearance. Whenever s he drove her car over a bump in the road, year-old woman with OC D worried that s he had hit a pedes trian. B ecaus e s he could not s ee the body, she around the block to look for it. After s eeing no body in road, s he was trans iently reas sured but, within became concerned that the body may have rolled parked car. S he drove around the block for at leas t 30 minutes searching for the body when this obs es sional 873 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 59 of 185

thought poss ess ed her. Obsess ional thoughts are usually s een in conjunction compuls ive behaviors , which are rituals linked to the obses sions typically cons tructed to undo the effects of thought. T hus, contamination obs es sions are linked to cleaning rituals , fears of harming others lead to rituals , and s o forth. T he most prominent disturbance of thinking complexity an impaired capacity to think abstractly. Abs tract is the ability to as sume a mental set, to keep simultaneously in mind all of the aspects of a complex situation, to move from feature to feature as indicated the situation, and to abs tract common properties . C omplex thinking als o concerns the ability to simultaneously cons ider many different, vague, and as pects of s ituations; to appreciate differing and contradictory points of view; and to integrate thes e multiple dimens ions to form opinions that are marked differentiatedness and nuance. Normal individuals vary greatly in their abilities to engage in abs tract thinking— genius es in mathematics and theoretical phys ics leave most mortals far behind. C oncrete thinking is a in the ability to form abstract concepts, generally illus trated by literal mindedness and the inability to abstract the commonality of members of a group, for example, the fact that a flea and a tree are similar in they are both living things. C oncrete thinkers seem to free themselves from the literal or superficial of words . C oncrete thinkers may be more prone to prejudice and stereotypical thinking and more likely to manifest unidimens ional or “all-or-none” reactions to complex situations. C oncrete thinking can be seen in 874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 60 of 185

individuals with lower intelligence, organic mental disorders , and schizophrenia. S chizophrenic patients also exhibit highly s elective dis turbances of E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > T HO UG H T

THOUGHT C ONTE NT P art of "8 - C linical Manifes tations of P s ychiatric T he normal content of thought, the buzzing, booming stream of cons cious nes s that constitutes the s tuff of everyday life, compris es awarenes s, concerns , beliefs, preoccupations, wishes, and fantasies occurring with various degrees of clarity, vividness , differentiation, imagination, and strength. Normal thought is often illogical, containing many beliefs and prejudices that be clearly contradictory but are nevertheles s held with pass ion and conviction. B elief s ys te ms are the scaffolding of thought, chains of impres sions , and expectations around which plans and behaviors are organized. B elief s ys tems may be setting general expectations and bias es about the that inform how incoming information is process ed; examples are optimism, pess imis m, and paranoia. beliefs are effervescent and fleeting, whereas others pervas ive, tenacious, enduring, and influential. T he enduring belief s ys tems are as sociated with behaviors cons istent with the belief, at times dominating interpersonal relationships and lifes tyles . S ome beliefs unique and private, whereas many are s hared by 875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 61 of 185

A 48-year-old man had been deeply pes simistic s ince childhood. Although he had no vegetative features of depres sion, he believed and behaved as if the world an awful place dominated by dis honest and selfis h individuals . Having any goals seemed foolish to him, the nature of the world. He express ed thes e beliefs regularly to his children, to the dis may of his wife, who not share his belief system. Imaginative fantasy is an important component of thought. T he vivid, eidetic imaginations of young can produce vivid fantasies in which children become immersed, almost as if in hypnotic states. During many children develop imaginary companions as playmates. In later years , imaginative thinking in which previous ly separate streams of thought playfully with one another to produce new ideas may be the es sence of the creative reverie. Artis ts, writers , and scientis ts may retain access to thes e forms of thinking more readily than others. Meditative states of mind facilitate the emergence of imaginative insights . S uch thinking may also occur in dreams. Intrus ive reveries normal and common components of the us ual adult stream of consciousness . During periods of specific deprivation, s uch as starvation or s exual deprivation, elaborate wish-fulfilling daydreams frequently occur. Ide as are the contents of the stream of thought. T hos e are consistent with one's s ens e of self, compatible with individual's self-image, are called ego-s yntonic. Other thoughts that conflict with one's central values are ego-alien or ego-dys tonic. An ego-dystonic impulse to someone, incons is tent with one's predominant value systems , may generate a counteractive ego-syntonic 876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 62 of 185

thought such as “you really don't mean it.” P.977

Dis turbanc es in Thought Abnormal beliefs and convictions form the core of content disturbances . C onsiderations of abnormality regarding beliefs and convictions must take the culture into account. B eliefs that may seem abnormal one culture or subculture may be commonly accepted another. F or example, religious hallucinations , to psychological or biological factors by contemporary Wes tern societies, are routinely attributed to religious spiritual causes by many other cultures . With regard to intens ity of conviction, distorted beliefs range on a continuum from overvalued ideas to the determined, unshakable belief that is characteris tic of fixed Abnormal beliefs and delus ions are, in most diagnostically nonspecific. Delusions are commonly in mania, depres sion, s chizoaffective dis order, dementia, and substance abuse–related syndromes, well as in schizophrenia and delus ional dis orders. O ve rvalued ide as are unreas onable and s ustained abnormal beliefs that are held beyond the bounds of reason. P atients with overvalued ideas have little or no insight into the fact that their ideas are very unlikely to valid; however, the ideas themselves are not as unbelievable as most delusions . T he distorted body images of body dys morphic disorder exemplify ideas . Morbid jealousy and preoccupation with a poss ible infidelity may constitute an overvalued idea if real evidence has ever existed to warrant suspicion. 877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 63 of 185

A 42-year-old man who had a brief relationship with a woman was unable to accept the fact that s he no wanted to see him. He ruminated about every they had and interpreted s mall gestures in the past as indicating her undying love for him. His infatuation led to follow her repeatedly to work and school, and he pursued her relentless ly, to the point that s he brought charges against him for stalking. Ide as of re fere nce are false pers onalized actual events in which individuals believe that or remarks refer specifically to them when in fact they not. Ideas of reference may be les s firmly held than delus ional beliefs . A 24-year-old ps ychotic woman from a religious background was completely dis tracted when anyone in the room cleared his or her throat. S he explained that interpreted throat clearing as a distinct mes sage to her, reminding her that she was a s inner who needed to be cleaner and purer in her behaviors and thoughts.

Delus ions Delus ions are fixed, false beliefs , s trongly held and immutable in the face of refuting evidence, that are not cons onant with the pers on's educational, s ocial, and cultural background. T hus, delus ional thoughts can be understood or evaluated with at leas t s ome of patients ' interpers onal worlds , such as their involvements with religious or political groups. One of mind's primary functions is to generate beliefs, myths and meaning systems . T hese beliefs provide the 878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 64 of 185

individual with a sense of personal and group identity with ways of unders tanding reality. T hey are mos t noticeable when s hared untestable beliefs form the for group cohes ion, as in religions and cults. S ome adhere to their cheris hed beliefs despite the plaus ible contrary evidence—for example, the fundamentalist s ects that take the biblical creation s tory literally. In the face of contrary evidence or grave threat, individuals often cling to their primary beliefs as matters of faith (i.e., alternative, nonrefutable bas es for unders tanding). T he strong faith with which religious , political, and nationalistic convictions are held, even at cost of death, s hows the power that untestable beliefs have on behavior. P otential mental health advantages religious beliefs have been demonstrated in epidemiological s tudies showing that those with a personal devotion report fewer depres sive symptoms . S ubjectively, delus ions are indis tinguishable from everyday beliefs. T herefore, the subjective experience delus ion is no different from the s ubjective experience believing that the earth is round or that one's s pouse is same pers on one married on his or her wedding day. B ecaus e of the identical experience of delus ions and strongly held beliefs, it is generally impos sible to argue patient out of a delus ional belief. T he content of is highly influenced by culture. As an example, in a comparing delus ions among Aus trian and P akis tani schizophrenic patients , persecutory delusions were predominant in both cultures , but differences were the sources of the persecutory beliefs. S imilarly, centuries ago, delusions of persecution often persecution by the devil and had religious 879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 65 of 185

persecutory delusions today often take on technological, political, and social perspectives. A 38-year-old s chizophrenic woman was certain that profus ion of televis ion satellite dis hes in her were all meant to beam radio s ignals from alien civilizations far off into the s tars into her head, and that, turn, these satellite dis hes could pick up her thoughts beam them all over the univers e. S he was particularly embarrass ed by the fact that the sexual fantas ies s he frequently imagined would be publicly broadcast and her s infulness would become known. Although delus ions are diagnostically nonspecific, types of delus ions are more prevalent in one disorder another. F or example, although delus ions of control delus ional percepts are often s een in s chizophrenia, also occur, albeit less frequently, in ps ychotic mood disorders . S imilarly, clas sic mood-congruent delusions , with grandiose themes seen in mania or delus ions of poverty characteristic of depres sion, may also be s een schizophrenia. T able 8-3 lists s ome characteristics by which delus ions have been class ified. S imple de lus ions contain elements , whereas complex de lus ions may contain extensive elaborations of people, spirits , motives , and situations.

Table 8-3 C harac teris tic s of Delus ions 880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 66 of 185

S imple vs . complex C omplete vs. partial S ys tematized vs . nons ys tematized P rimary (autochthonous ) vs . P ers ecutory vs. nonpersecutory How they affect behavior

S ys te matize d de lus ions are us ually res tricted or circums cribed to well-delineated areas and are as sociated with a clear s ensorium and abs ence of hallucinations . T hey are often is olated P.978 from other aspects of behavior. In contrast, nons ys te matize d de lus ions us ually extend into many of life, and new data—new people and situations —are cons tantly incorporated to further s upport the presence the delus ion. T he patient us ually has concurrent mental confusion, hallucinations , and s ome affective lability. Whereas the patient with a clos ed systematized system may go about life relatively unperturbed, the patient with a nons ys tematized delus ion frequently has 881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 67 of 185

poor s ocial functioning and often behaves in respons e the delus ional beliefs . C omple te de lus ions are those held utterly without contrast, partial de lus ions are those in which the entertains doubts about the delus ional beliefs . S uch doubts may be s een during the s low development of a delus ion, as the delusion is gradually given up, or intermittently throughout its course. During an acute schizophrenic epis ode, a 23-year-old was completely convinced that the s ubtle pattern of superficial veins on his legs was evidence of “as tral domination” by extraterres trial beings . After 1 week of antips ychotic medication, he believed the veins were caus ed by others with s pecial powers but was less T wo weeks later, he denied believing that the patterns his legs were other than superficial veins and previous belief with a shrug. An autochthonous de lus ion is one that takes form in an instant, without identifiable preceding events, as if full awarenes s s uddenly burs ts forth in an unexpected insight like a bolt from the blue. T hese delusions may quite elaborate. After a 2-year period of gradual academic and interpersonal decline, a 21-year-old man had the conviction that certain songs played on the radio us ed voice in the role of lead singer. He could not explain this would be s o nor why this belief emerged s uddenly when it did. Aside from the autochthonous types, three other types 882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 68 of 185

delus ions have been described as primary. Delus ional pe rce pt refers to the experience of interpreting a perception with a delus ional meaning, one that has enormous pers onal s ignificance to the patient. atmos phe re or de lus ional mood is a state of perplexity, sens e that s omething uncanny or odd is going on that involves the patient but in uns pecified ways . Ordinary events may take on heightened s ignificance, but the delus ional interpretations are fleeting, although the uncanny feeling stays . T ypically, after a period, fulldelus ions develop, replacing the delusional mood. Delus ional me mory is the memory of an event that is delus ional. As an example, a patient “remembered” his fourth-grade teacher s lipped lys ergic acid (LS D) into his apple juice; this memory s erved to his psychotic dis order. T he elaboration of false and their s ubsequent fixed belief may as sume proportions . A young schizophrenic woman attended a “trauma with her roommate and gradually came to believe that had been repeatedly s exually as saulted by her father the time s he was in the crib. W hat started out as vague dream-like images gradually coalesced into a series of “sens ed” memories that then took on specific vis ual images of her father's fingers penetrating her and of his looking down at her in the crib leering. Her parents horrified by these accus ations , and there was not a of evidence to corroborate her increasingly venomous accusations . P atients vary considerably in the extent to which they action in res ponse to delus ional thoughts . J ust as 883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 69 of 185

can experience delusions of their thoughts being controlled (thought pas sivity), they may similarly experience their feelings, behaviors, and will as by outside forces. T hese de lus ions of control (or experiences ) occasionally, albeit uncommonly, res ult in dramatic self-destructive or aggres sive behaviors, as illus trated by the murderer who called himself S on of T his psychotic killer murdered a series of people in Y ork and claimed that he was the powerles s agent of a force that required him to commit the acts. T o defend thems elves and others agains t delus ional anticipated events, s ome patients may take bold and occas ionally destructive actions . A 38-year-old man with untreated s chizophrenia was transferred from jail to hospital for evaluation and treatment after s hooting (but not killing) his neighbor. explained that the neighbor had been “hass ling” him for months by making nois e in the middle of the night, laughing at him, and listening to his conversations through the wall. T he patient explained that he s hot the neighbor as a warning to back off. T able 8-4 lists s ome clas sic types of delus ions. less common than thos e involving paranoia, and influence, delus ions of mis identification are prominently reported because of their inherently intriguing nature. In C apgras ' s yndrome , the patient believes that s omeone close to him or her has been replaced by an exact double. In F ré goli's phe nome non, strangers are identified as familiar people in the life. In the de lus ion of doubles , patients believe that person has been physically transformed into 884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 70 of 185

Table 8-4 S ome C las s ic Types o Delus ions Delusions of pers ecution Delusions of grandeur Delusions of influence Delusion of having s inned Nihilis tic delus ions S omatic delus ions Delusion of doubles (doppelganger) Delusional jealousy (Othello s yndrome) Delusional mood Delusional perception Delusional memory Delusions of erotic attachment (C lérambault's syndrome)

885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 71 of 185

Delusions of replacement of s ignificant others (C apgras ' s yndrome) Delusions of dis guis e (F régoli's phenomenon) S hared delusions (folie à de ux, folie à trois , folie famille)

Olfactory delus ions that one emanates a foul odor are common in s ocial anxiety s yndromes, in which are particularly concerned about potentially thems elves and others. P.979 Delusions are not only s een in isolated individuals . delus ions may occur in couples (folie à de ux) and in (folie à famille ). Many ps ychiatris ts cons ider group delus ions to be pres ent in s ome cults as well, but where the cutoff points occur between delus ions and other zealous beliefs held by larger, more traditional well-organized religious, political, and other groups is arguable. A husband and wife appearing at a ps ychiatric department both wore skullcaps made of sheets of aluminum foil. T he reas on for the caps, they concurred, was to ward off radio s ignals being beamed to their from outer s pace. T he hus band was a dominant personality who had originated this fixed delus ion. His 886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 72 of 185

wife, a mild-mannered, pas sive pers on, s eemed to accepted her hus band's interpretation of events without challenging them at all.

Dis turbanc es of J udgment J udgment involves a complex and diverse group of functions that includes analytical thinking, social and ethical action tendencies , and depth of unders tanding insight. Analytical thinking includes the capacity to discriminate and to weigh the pros and cons of alternative actions. S ocial and ethical action tendencies clos ely related to culture and upbringing. T he evidence genetic factors in antis ocial pers onality disorder primarily by judgments that lead to criminal behaviors ) points to the additional role of cons titutional factors. Ins ight may reflect intelligence, learning, cognitive and the capacity to integrate intellectual knowledge emotional awarenes s. Impairments of judgment occur in many ps ychiatric disturbances . Anxiety s tates, intoxications , fatigue, and even group pres sures may caus e temporary of judgment in otherwis e normal individuals . In mood disorders , judgment may be impaired by either an exaggerated evaluation of ris k or failure in depres sion conversely, of inadequate appreciation of risk or mania. Organic brain damage and ps ychotic dis orders chronically impair any aspect of judgment in any regardless of premorbid character. P oor role models deviant s ocial backgrounds may lead to social and action tendencies quite different from thos e of the examiner. T hus, s omeone raised in a criminal may have s uperb analytical judgment and s elf887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 73 of 185

which are, however, put to illegal us e. A 48-year-old man with bipolar disorder became depres sed. As part of his guilt s ymptoms, he believed he could no longer be a good enough husband and divorced his wife, des pite her protes ts. W hen his depres sion remitted, he realized the depth of his poor judgment and remarried his wife. J udgment may be impaired in one dimens ion and in others. Individuals may retain sound ethical when their analytical capacities fail or may retain analytical abilities for nonpersonal matters, although lacking ins ight into personal situations or behaviors. some people who can provide s ocially appropriate res ponses to traditional mental s tatus examination questions , s uch as what one would do in a movie fire broke out or what one would do with a stamped sealed addres sed envelope found in the s treet, might the same time be incapable of accurately as ses sing clinical or more pers onal matters s pecifically related to one's capacity to provide informed cons ent, such as pros and cons of receiving a medication or electroconvuls ive therapy (E C T ); regarding judgments neces sary to provide ones elf with food, clothing, and shelter; or ins ight into one's state of health or illnes s. apocryphal s tory about the delus ional patient able to accurately evaluate and fix a broken-down car that had stymied the mechanics, ending with the patient's declaring, “I may be crazy, but Iapos;m not stupid,” indicates the s elective nature of poor judgment within ps ychiatric disorders. T he term ins ight, usually in the context of self888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 74 of 185

has been used in a variety of ways. B as ic ins ight refers superficial awareness of one's situation. In evaluating insight into one's ps ychiatric condition, bas ic insight allows an individual to acknowledge the pres ence of an illness . A deeper level of insight is operating when the patient has an intellectual appreciation of what is going (e.g., “I have hallucinations and delusions , and my have told me that I have s chizophrenia and mus t take medication”). S till deeper levels of insight reflect more complete cognitive and emotional appreciation of a situation (e.g., “I realize that I have s chizophrenia, that impairs my judgment and s ocial function at times, and I will have to take medications if I am to minimize my symptoms and try to make the mos t of my life. I feel profoundly disappointed about this affliction because it prevents me from achieving some of the goals Iapos ;ve always wis hed for. Nevertheless , I have do my bes t to over my disappointment and hurt feelings s o that I can whatever I can out of life.”). Of cours e, different depths of insight as s elf-awarenes s be evaluated in many other situations , s uch as phys ical illness , quality and nature of relationships , an of strengths and weakness es in profess ional s ituations, and s o forth. In formal studies of ins ight us ing standardized instruments , lack of insight correlates with poor outcome in s chizophrenia and bipolar disorder, medication noncompliance, and s uicidality. of ps ychosis does not necess arily correlate with insight. Impaired insight may be ass ociated with frontal lobe abnormalities. Ins ight may be as s eriously mania as in schizophrenia and, contrary to earlier may be lacking in OC D. 889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 75 of 185

J udgment may be impaired by s everal factors , cognitive clouding (as in dis turbances of e.g., intoxication, s o that one's us ual analytical abilities impaired), self-deception, and impulsivity. S elf-de ce ption refers to the almost universal tendency hide certain iss ues about the external world or about oneself from various levels of awarenes s. S elffunctions as a coping s trategy, fos tering or maintaining comfortable perspectives about the world and avoiding confrontation with iss ues and realities that inevitably up painful conflicts or the need for difficult actions , thereby preserving emotional calm. In addition, s tudies suggest that self-deception enables us to act and to be perceived as more convincing in the service of goals , as in romantic relations hips or bus iness T herefore, although “kidding ours elves ” may reflect impaired judgment, it may at times also yield certain important strategic advantages . Impulsive judgment describes a tendency to avoid the time and thought to fully understand and integrate of the facts and levels of awarenes s required for decis ion making. Impuls ive judgment may occur only certain is sues or s ituations (s uch as how one picks inves tments ), s ignal an impaired state (s uch as intoxication), or reflect a pervas ive character trait. R apidly made judgments , and even s o-called s nap judgments , may not be maladaptively impuls ive, even when they involve very important areas of life. R apid decis ions can be very accurate, highly adaptive, and life-saving, es pecially if made against a background P.980 890 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 76 of 185

of great experience, wis dom, and forethought the area requiring the decision. B ecaus e, in clinical practice, the terms ins ight and judgment are often applied to individuals ' awareness decis ion making about their ps ychiatric s tatus, complex motivational states that incorporate insight and related to how one is dealing with one's problems , the called s tages of readiness for change, bear mention at point. Initially des cribed in relation to subs tance abus e, including alcoholism and smoking, these stages have received considerable attention and form an important as pect of clinical as sess ment acros s other diagnos tic categories s uch as eating dis orders. S everal s tages been described: (1) precontemplation: the pers on expres ses no intention to change (may be in denial); contemplation: the person acknowledges a problem states an intention to change within several months but not right away; (3) preparation: the pers on intends to something about changing in the near future and may have already made s ome false starts; (4) action: the individual has engaged in making s ustained behavior changes; (5) maintenance: the individual has been engaged in changed behavior for more than 6 months; and (6) termination: the individual has s ucceeded in the change and is unlikely to ever return to the original behavior.

Dis turbanc es of C ons c ious nes s C ons cious ne s s can be defined as s ubjective the self and environment. B iologists increasingly that a continuum of cons cious nes s exists , extending 891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 77 of 185

lower animals through Homo s apie ns . However, cons ciousnes s is s ubject to conflicting definitions and conceptualizations , and exactly where cons cious nes s begins in evolution remains unclear. P hilosophers that it is the s ubjectivity of experience, the s o-called of consciousness , that clearly dis tinguis hes living cons ciousnes s from at least this generation's best of self-regulating automata, elegant computers, or All current attempts to even approach an of consciousness are very unsatis fying, and remains unexplained and as yet unexplainable from a scientific point of view. C ons cious nes s has been an emergent property of complex biological nervous systems , as a poorly understood general property of an even more mysterious and complex univers e, or as a phenomenon to be unders tood only in religious and spiritual terms. One of the bes t analyses to date of relations hips between the construction of a brain and poss ibility of consciousness has been s et forth by E delman, who believes that reflective cons cious nes s cannot occur until complex higher-order brain s ys tems evolve whose major functions are to monitor the experiences , activities, and results of activities of those lower-order brain s ys tems that deal directly with appraising and res ponding to the external and internal environments . S uch higher-order metas ys tems require presence of memory so that current and immediate impres sions can be checked and compared agains t experiences . T hese metas ys tems may us e a variety of sens or mechanisms to detect and signal their perceptions of various events. S ome of thes e s ens ors corres pond to feeling states , and some may initially to preverbal thought-like mechanis ms that 892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 78 of 185

the capacity to develop and recognize abstract and, ultimately, conceptual language-based thought. C linically, conscious nes s can be considered from both qualitative as well as quantitative viewpoints. cons ciousnes s does not seem to be an all-or-none phenomenon. R ather, conscious experiences may gradually and phas ically shift in focus, intensity, and altered states of cons cious nes s may occur in which as pects of cons cious nes s, such as s ens ation, memory, orientation, and judgment, are enhanced or impaired relative to other as pects. Quantitatively, crude divis ions can be made between states depending on relative presence, or impairment, or total absence of cons ciousnes s. E ven within the single individual, cons ciousnes s is not a unitary phenomenon. Multiple streams of thought, operating at multiple levels of preconsciousness es appear to exist in all people of the time, with various elements in thes e coexis ting streams constantly shifting into higher or lower levels of cons cious awareness . In pathological states , even remarkable properties of cons cious nes s are s een, for example, the existence of cocons ciousnes s in humans have had commiss urotomies and of s eemingly multiple discrete consciousness es in patients with dis sociative identity disorders . E xperiments involving patients with commis surotomies the corpus callosum have shown the exis tence of two virtually separate s ys tems of cons cious nes s that s eem operate side by s ide. F or example, when in the cours e an experiment, the picture of a nude woman was only to the right brain (the left vis ual field) of a commis surotomized patient, the s ubject verbally 893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 79 of 185

being aware of anything unusual (i.e., the left brain— verbal brain—was unaware). B ut, at the same time, he started to s quirm and blush, blurting out, “Oh, you have some machine!” S imilarly, when a cup was presented the right brain (left visual field) only, the patient denied seeing anything (left brain was unaware, and language output of the left brain indicated no awarenes s), but he was able to pick out the cup from an ass ortment of with his left hand (right brain control). T hat literal of verbal awarenes s from visual–spatial awareness in brain produces behavior that is at least superficially to that of patients who deny being consciously upset by an event but who react with s trong visceral res pons es . Although this formulation is s implistic, the s eparate cons ciousnes s for logical–verbal and for s patial–visual awarenes s demons trated in split brain experiments be crude analogs for more highly differentiated and discrete types of awarenes ses and modes of proces sing. F urthermore, the very fact that there are separate and, to s ome extent, competing modes of cons ciousnes s may increas e the likelihood of ps ychological distress becaus e the various modes are capable of yielding internally conflicting views of reality.

Ps yc hologic al and Phys iologic al Fac tors In ordinary states of alert consciousness , individuals able to deploy adequate amounts of attention to their surroundings and to reflective thought. Normal people vary enormous ly in their ability to pay careful attention different s ettings without being distracted; individual variations may reflect temperamental and cognitive differences as well as phys iological s hifts within the 894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 80 of 185

individual. Many functions of attentive consciousness , including attention, planning, and the capacity to appropriately switch between mental tasks, s o-called distractor res istant memory, have been linked to the activity of specific neurons in area 46 of the prefrontal cortex. A s ens e of increased consciousness with heightened alertness , awarenes s, and sharper thinking may be experienced in s tates of highly arous ed emotional such as threat, s exual attraction, falling in love, or other high-stakes events such as hunting among primitives , sporting competitions, or performing in front of an important audience. High levels of arous al do not neces sarily guarantee effective attention becaus e cons ciousnes s depends on optimal arous al. T oo little arousal due to illnes s or fatigue may result in stimulation and mental lethargy, diminis hing the s ens e alertness and attentivenes s, whereas too much arousal may result in hyperintense alertnes s but distractibility scattered attention. P.981 C ons cious nes s involves , among other things , the experience of a continuous sense of s elf and of the environment, existing coherently in time and s pace. experience of time and its pas sage may be altered by in the level of awareness and by emotional s tates s uch boredom, concentration, pain, and discomfort. T he experience of time and s pace may be altered by marijuana, ps ychoactive and psychedelic drugs, and events directly affecting brain phys iology. 895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 81 of 185

Dis turbanc es in the L evel of C ons c ious nes s Levels of cons ciousnes s (i.e., alertnes s, awareness , attentivenes s) may be pathologically increased or decreased. S uch changes are diagnostically and can occur in many different dis orders. W hen levels arousal and alertness are mildly elevated, as in or with the inges tion of small amounts of ps ychos timulants , s ubjective experiences are typically positive. In thes e s ituations, the pers on experiences intens e alertness , prolonged concentrating ability, and hyperesthesias in which perceptual vividness is heightened: C olors are brighter, s ounds are s harper, touch is more intens e than usual. W ith further arousal and cons cious nes s as s een in mania, more intoxications with amphetamines and cocaine, and catatonic excitement, attention fragments . Heightened alertness transforms into hypervigilance and paranoia, hyperesthesias become unpleasant. Diminished levels of cons cious nes s can be des cribed continuum. C louding of cons cious ne s s is marked by diminis hed awarenes s of s ens ory cues and diminished attentivenes s to the environment and to the s elf. S econdary process thinking is most notably and more primary process thinking emerges into cons ciousnes s. In this s tate, one's ability to appreciate subtleties and to think in a nuanced manner is and is replaced by more dichotomous all-or-none, stereotypical thinking. T he level of consciousness may fluctuate rapidly in relation to the internal phys iological state or to the degree of external s timulation. In of cons cious nes s, confus ion may occur with 896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 82 of 185

to time, place, or person. T he patient is us ually highly distractible and unable to pay sus tained attention to a single s timulus. T orpor is a condition in which the patient is drowsy, as leep easily, and shows a narrowed range of and s lowed thinking. S tupor is a state of diminished cons ciousnes s in which the patient remains mute and although the eyes are open and may follow external objects. In the mos t extreme impairment of coma, there is no evidence of mental activity at all. T he patient es sentially appears to be functioning on a decorticate or decerebrate level. In akine tic mutis m, or coma vigil, patients with profound brainstem lesions appear to be awake with their eyes open, but there is in fact no evidence of consciousness . T he commonly G las gow C oma S cale incorporates these dimensions. Delirium, the acute confus ional state, is us ually characterized by a relatively abrupt onset and short duration of clouded, reduced, and fragmented impaired memory and learning; perceptual and abnormalities , s uch as hallucinations and delusions ; disrupted sleep; and other autonomic dysfunction. T he level of consciousness may be consistently diminis hed may fluctuate. T he electroencephalogram (E E G ) shows diffuse slowing. T ypical motor abnormalities include an increase in general res tless nes s, fine and tremors , and myoclonic jerks . Autonomic disturbances commonly include tachycardia, fever, elevated blood press ure, diaphores is , and pupillary dilatation. T he of delirium are legion, including s ys temic medical disorders , such as metabolic imbalances or infections, intracranial disorders due to traumatic, structural, and 897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 83 of 185

electrical caus es , and drug intoxications and states . Atte ntional difficultie s are manifest by impairments in person's ability to deploy, focus, and s us tain attention. S ome attentional difficulties first appear in early as developmental problems of uncertain caus e and are described as attention-deficit disorders (inattentive or hyperactive types). S econdary attention-deficit may appear de novo in adulthood due to a variety of exogenous agents , psychiatric disorders , and late-life developmental and degenerative factors . In narcoleps y, characterized by s udden laps es into one's us ual ability to s tay alert and maintain is impaired. At times , the onset of profound s leepines s gradual, accompanied by hypnogogic phenomena, in which dream-like images invade cons cious nes s, and at other times the s hift in conscious ness appears to be instantaneous . T his s yndrome, occurring in 1 in 10,000 persons, is thought to be the s econd mos t frequent caus e of automobile collisions after alcohol intoxication.

Altered S tates of C ons c ious nes s C ons cious nes s may also be qualitatively changed, with production of altered s tates. Drugs such as (T ransderm) with s trong central anticholinergic some seizures, and, on occas ion, other conditions as sociated with delirium can induce twilight s tate s , like states of wakeful cons cious nes s in which attention poor, an admixture of primary and secondary proces s thinking appears , and patients fade in and out of Dream-like experiences intrude into the s tream of 898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 84 of 185

conversation. E motional outburs ts or violent acts may occur during twilight s tates . Mys tical s tate s of cons cious nes s may occur in normal pathological conditions. Intense meditation and peak or epiphanic experiences , reported by more than 10 of normal individuals in community surveys, may a s ense that the s elf diss olves or expands , that the s elf fus es mystically with the cosmos, that time s tops , and universal meaning becomes clear. T hese perceptions be accompanied by a s ens e of rejuvenation and personal identity, ineffability, intens e emotionality, and concurrent perceptual changes. S uch experiences do ordinarily last more than a few minutes . Many people achieved these states through the use of ps ychedelic agents such as mes caline and LS D. R eports of a white at the end of a tunnel, described by individuals us ing ps ychedelics and in near-death experiences , have linked to specific neurophys iological pathways believed be stimulated under thes e conditions. A 43-year-old female accountant with no prior history of spiritual or religious practice s ustained a severe head in an automobile accident that left her comatos e for approximately 6 months . W hen s he awoke, s he that at some point during her coma, s he estimated in third month, s he experienced a profound mys tical experience, which included a glorious union with G od knowing that s he would not only awaken to return to but that all was “as it should be” with the univers e. After recovery, with ongoing motor impairment, she became profoundly spiritual, started attending church and teaching the B ible, and cons tantly evidenced a beatific 899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 85 of 185

glow, which s he attributed to her mys tical experience. Although hypnosis lacks a cons ens ually accepted definition, its hallmarks are s elective attention, suggestibility, and diss ociation. Mos t, but not all, can be hypnotized to some degree. Up to 90 percent of people are capable of achieving a light trance, whereas to 20 percent are capable of entering a deep trance exhibiting remarkable hypnotic phenomena. Hypnos is occurs when the s ubject is P.982 in a s tate of heightened, not diminished, attention. E E G studies have s hown hypnotized subjects to be fully and alert. T he heightened concentration probably accounts for the unus ual levels of s ens ory and motor performance often s een under hypnos is and selfHypnotic phenomena include hypnotically induced hallucinations (including negative hallucinations in the subject s electively does not perceive sights , other s timuli), anesthes ia, sus tained motor behaviors acts of s trength ordinarily beyond the individual's and distortions of memory (both hypermnes ias and amnes ia). S everal phenomena that reveal the multiple nature of cons cious nes s, for example, also demons trable. E xperiments have s hown that even when a s ubject in deep trance has achieved profound hypnotic anesthesia and can, for example, keep a hand submerged in ice water for longer periods of time than us ual, part of the hypnotized subject's cons cious nes s continues to register exactly how painful the actually is and can s ignal the researcher about the 900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 86 of 185

finger movements , without the s ubject having any cons cious awareness or dis turbance. T his called the hidde n obs e rver, has als o been s een in posts urgical patients who, under hypnotic trance after surgery, have been able to accurately recall in the operating room that occurred while they were under general anes thes ia. Dis sociative and phenomena have als o been induced with hypnos is . posthypnotic s uggestion, for example, s ubjects may out complex actions without any hint that they are doing so becaus e they were previous ly ins tructed to that way under hypnosis. W hen as ked why they are carrying out thes e activities, s uch subjects us ually various reasons , although s eemingly unaware of the reasons for their actions . It has been suggested, not entirely facetiously, that many normal daily activities conducted in a trance-like pos thypnotic s tate, and although thes e activities are attributed to conscious intention, they may in fact be carried out due to suggestion. Advertis ers know this well. Urticaria (hives) be hypnotically induced and hypnotically made to disappear. P lantar warts have been s ucces sfully with hypnos is , and, in these conditions, diminished supplies to their bas es have been demonstrated. It has recently been appreciated that yoga mas ters can exert remarkable control over basic bodily functions through self-hypnosis . As yet, little is known of the full extent to which heightened concentration may influence phys iological regulation.

S ugges tibility P athological sugges tibility may be seen in several conditions. Automatic obedience has been des cribed in 901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 87 of 185

echolalia (the automatic repetition of a sentence or just uttered by another pers on), echopraxia (the mimicking of a movement performed by another and waxy flexibility (maintaining for a prolonged period time a pos ture in which one is placed), s ymptoms in catatonic states . In s ituations of group delusions , sometimes in cults, pas sive individuals adopt the delus ional beliefs of s tronger ones . In epidemic described among young women at the S alem witch in Arthur Miller's T he C rucible , distorted and even delus ional perceptions and beliefs may s weep over a group that has been highly arous ed by a charis matic leader. Autos ugge s tibility can be s een in the cons tructions of memories in which an individual progress ively comes believe that something that never happened in fact occurred. S uch false memories may be held with such great conviction that they are indis tinguishable from the memories of real events . B ecaus e of this, memories recovered during therapy (in which there is often great press ure to “remember” certain events) cannot be face value without corroboration from other s ources . V arious types and degrees of self-deception may be common in individuals who are more s uggestible.

DIS S OC IA TIVE P HE NOME NA Dis s ociation refers to the s plitting off from one another what are ordinarily closely connected behaviors, or feelings . Dis sociative s tates are those in which there disturbance or alteration in the normally integrated functions of identity, memory, or cons cious nes s and include trances , fugues , blackouts, multiple 902 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 88 of 185

(diss ociative identity disorder), and dis sociative Although diss ociative states are ordinarily believed to functional in nature, aris ing as an adaptive defense in individuals subjected to a great deal of trauma, at early ages , they occur regularly with a variety of neurological disorders , particularly thos e with partial complex seizures . In one series , one-third of patients complex partial seizures had dis sociative phenomena, including multiple pers onality. In these patients, the diss ociative phenomena were not related to the s eizure activity but to interictal alterations. As in pos thypnotic amnesia, elaborate activities can in diss ociative states for which the subject has no cons cious memory. T his amnesia is functional in and may be revers ed by hypnos is or drug-facilitated disinhibition, for example, with amobarbital (sodium Amytal) infus ion. In many of the functional dis sociative states , amnestic epis odes may occur for years or before the patient s eeks medical or ps ychiatric B lackouts are periods of amnes ia in alcoholism, other intoxications, or after head trauma. An alcoholic period may last for hours to days , after which the has no recollection of what transpired, although other observers attest to the fact that, during this period, the individual carried out multiple complicated behaviors . Although memory of the blackout is lost to the predominant cons cious nes s, during s ubs equent reintoxication, memories of events occurring during the previous blackout may be reawakened. T his known as s tate -de pendent me mory, occurs in many conditions as well, signifying that one's ability to specific memories may be highly influenced by specific 903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 89 of 185

phys iological alterations due to external intoxicants or other unus ual phys iological states . A 43-year-old man with a 20-year history of s ustained alcohol abus e was unable during a period of s obriety to recall for hos pital s taff the names, phone numbers , and addres ses of his clos e friends and as sociates . S everal later, when he returned to the emergency department an intoxicated s tate, he was able to recall all of thos e details in a reas onably straightforward manner. P s ychoge nic fugue is characterized by prolonged which individuals carry out very complex activities having any recollection for their previous lives , or even names . T hey often travel away from customary locales and as sume entirely new identities. B y ps ychogenic fugue cannot be due to a neurological disorder. In comparis on, the dis continuity of experience ps ychoge nic amne s ia is typically more circums cribed does not involve as suming an entirely new identity. T he diss ociated memories and affects often reveal in dis guised form s uch as nightmares , intrus ive visual images, and convers ion s ymptoms. T ypically, in ps ychogenic amnesia, an individual may not be able to recollect what trans pired during a s pecific period, for example, before the age of 9 or 10 years in the context traumatic childhood; during catastrophic events, such traumatic, gruesome combat; P.983 or during less momentous events that a person prefers forget to preserve s elf-es teem by denying shameful, immoral, or illegal activities. 904 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 90 of 185

A 28-year-old infantryman could not recollect the of the combat s ituation in which he had been wounded and s everal of his comrades killed. S everal months afterward, he participated in a s eries of Amytalinterviews , during which the events of combat came to him. He recalled becoming panicky during the turning, and running away while s everal other s oldiers his s quad, s everal of whom were killed, yelled to try to him to stay in place and fight. After the interviews, he inconsolably and blamed himself, s omewhat for their deaths , wondering if his remaining in place and fighting might have saved their lives .

Dis s oc iative Identity Dis order Dis s ociative ide ntity dis orde r, previous ly known as pe rs onality dis orde r, is a chronic, diss ociative state in two or more s eparate ongoing identities or alternate in cons cious nes s. It us ually occurs in people as young children, were s everely and repeatedly brutalized. T he number of identities is variable, with cases reporting 25 or more identities . T he development diss ociated alter personalities is believed to be a lastprimitive ps ychological defens e against ines capable unbearable traumatic s ituations. T he pers onalities may of different ages and even different s exes. T ypically, presenting identity is dys phoric, anxious, and may have headaches and periods of blackout or and is not aware of the other personalities. A second identity is typically vivacious and uninhibited. Another identity may know all about the other pers onalities and has a wise pers pective on the life events leading to the problems and regarding poss ible s olutions . A clas sic 905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 91 of 185

is described in a popular book and film T he T hre e E ve . In so-called channeling, dis sociated, complex part personalities are produced in trance states in which fictitious past lives or s pirit lives are created.

Gans er's S yndrome In G anser's s yndrome, the patient res ponds to by giving approximate or patently ridiculous answers , example, in respons e to the question “what sound does dog make? ” the patient answers “moo.” Additional features of the syndrome include alterations in cons ciousnes s, hallucinations (or conversion phenomena, and amnesia for the epis ode during which these symptoms are manifest. T his has mos t commonly been reported in prisoners and is generally believed to be a diss ociative s tate, although organic features may contribute.

Depers onalization and Derealization Depe rs onalization refers to an alteration in one's experience and awareness of the s elf, leading to being unreal or detached from one's own body, of like an automaton; it is often accompanied by the complaint that the individual lacks all feelings or experiences . T hose experiencing depersonalization frequently fear that they are going crazy. B ecaus e of fear, patients often endure depers onalization for long periods before des cribing them to a mental profes sional. Depersonalization is als o characterized frequent internal nonaudible dialogues between the participating self and the observing s elf but with full 906 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 92 of 185

awarenes s that both parties are the s ame person (a that distinguishes it from hallucinations ). Mild sens ory distortions —but not hallucinations —are commonly as sociated with the experience. Depers onalization is in a variety of neurological and ps ychiatric dis orders common in complex partial seizures . It may occur in context of depres sion, anxiety disorders , or certain personality dis orders, or it may occur as an entity by In derealization, individuals feel thems elves to be real feel that the world around them has s uddenly become unreal. Derealization often, but not always , depers onalization. T rans ient episodes of and derealization occur frequently in normal people, particularly during s tates of fatigue, sleep deprivation, stress ful situations s uch as bereavement, learning of a terminal diagnos is , or s udden awareness that one is to be in an inescapable vehicle collis ion. A 45-year-old mother of two underwent a breas t biops y a s uspicious lesion. Afterward, sitting in the surgeon's office, hearing him tell her that the lesion was she recalled feeling numb and dis tant, saying to if from a distance, that this was all a dream. S he felt as she were living in an “alternate reality” that would disappear and return her to the real world when s he left the office.

Dis turbanc es of the S elf At the mos t bas ic level, the key components of selfawarenes s are the reality and integrity of the s elf (that I one person), the continuity of s elf (that I am the same person now that I was in the past and that I will be in 907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 93 of 185

future), the boundaries of s elf (that I can distinguis h between myself and the res t of the world as not-self), activity of self (that it is I who is thinking, doing, Additional components of a sense of s elf include body image and various s elf-evaluations , including s elfand ego-ideal (ideal s elf). B ody image is an individual's mental representation of his or her own body. S elfis believed to reflect how one meas ures up to the self-image. T o the extent that what one s ees in oneself approximates what one would like to be, s elf-es teem is positive. E go-ide als are fantas ies of the optimum one could ever wish to be. Any of thes e qualities may disturbed in psychiatric disorders . Within each individual is a group of s ocial selves comprised of the roles and identities that a pers on as sumes and that are evoked in various contexts . T he presenting “self” varies depending on the people with whom one interacts , s uch as parents , romantic partner, child, friend, or employer, and depending on what role as sumes , s uch as child, parent, colleague, or lover. Accompanying each of thes e “selves” are various objective and s ubjective self-awarenes s and s elfunders tanding.

Dis turbanc es in S ens e of S elf Dis turbances of the basic elements of self-awarenes s be seen in a variety of dis orders. Discontinuity are characteris tic of diss ociative states such as ps ychogenic amnesias and psychogenic fugue. Depersonalization reflects a mild disturbance in the awarenes s of s elf as the agent of activity. More severe disturbance is characteris tic of the psychotic pass ivity 908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 94 of 185

phenomena seen in s chizophrenia. B oundary may be cons idered characteris tic of all psychotic s tates regardless of diagnos is . Dis orders of self-integrity are characteris tic of both diss ociative identity dis orders and s evere borderline personality dis orders in which a person's s elf-concept expres sion of this concept to others is erratic, leading sens e of uns table identity. F als e s e lf describes a pers ona or a faulty and limited superficial aspect of the personality that an individual builds up as a mechanism for adapting to a hostile to please, control, or negotiate with others and with hims elf or herself. However, the fals e s elf does not P.984 incorporate, integrate, or validate important needs , wants, values , and beliefs. T hrough s elfand denial, the individual may cons cious ly believe that “self” cons titutes his or her entire being. However, the self is a relatively fragile cons truction that has usually warded off and denied fundamental s trivings, which include needs for autonomy; acting with integrity; expres sing certain desires, beliefs , or talents ; or other unacknowledged aspects of the s elf. W hen these off needs finally break through and demand express ion various points in development, the defective false s elf collaps e, leading to a period of dis tres s and identity confusion, which individuals sometimes describe as a “nervous breakdown.” P atients with ps eudologia fantastica and the impos tor syndrome demonstrate extreme examples of 909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 95 of 185

inconsistency in the sense of s elf. In ps eudologia patients compulsively s pin out webs of lies, ordinarily aggrandizing ones, and als o appear to be trying very to deceive themselves into believing that they are true. the impos tor s yndrome , s uch fantas ies are acted out and impostors who seem to fervently wis h that these fantas ies were their reality, as if they cannot accept thems elves and would be overwhelmingly as hamed to known for who they actually are. T he impostor compuls ively adopts the identities of others and may, example, show up properly attired at diplomatic and s ociety galas and interact with the other guests the as sumed identity. S ome famous impos tors have repeatedly insinuated thems elves into inner circles of society and government. T rans s exualis m is a syndrome characterized by the that one was born into a body of the wrong sex and marked by the desire, starting at an early age, to be a person of the opposite s ex. Male to female is reported most often. B oth ps ychodynamic and biological theories have been advanced to explain unusual phenomena. Of note, studies following who undergo s uccess ful male to female transgender surgery have not revealed higher rates of ass ociated ps ychopathology than in comparis on groups. S elf-es teem is a measure of one's self-appraisal in to one's values and ego-ideals. Negative self-es teem is characteristic of depres sive dis orders, many disorders , and situational failures . S uperficially inflated es teem may be s een in mania (or hypomania) or, in a fluctuating manner, with narciss istic and other disorders . 910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 96 of 185

Although s ome individuals regard their ego-ideals as unattainable and are content to live as imperfect beings , others s trive to approximate their ideals. who feel driven to achieve unattainable ideal goals or become unrealis tically perfect ideal selves are likely to chronically dysphoric and have poor self-es teem their attempts to become their ego-ideals are doomed failure.

Dis orders of the Will C entral to the sense of self is the concept of will or P sychologically, will is linked to the concepts of intentionality and of transforming awareness and knowledge into initiating action, as the bridge between desire and action. F or individuals to manifes t normal they mus t be aware and feel desires —and these must aris e from within thems elves. C oncepts related to that may become the focus of clinical attention when disturbed include motivation and decision making (i.e., capacity to make choices ). P athologically heightened will, seen primarily in manic states , is characterized by excess ively intens e desires an overly facile capacity to make decis ions, with questions being decided on in an ins tant. With ps ychological energy, these individuals can start new cours es of action with as tonishing rapidity. C loser examination of thes e actions in more extreme cas es, however, reveals that they share much in common with decreased will in that the intens e desires and quick decis ions often reflect impulsivenes s, which can be cons idered an es cape from true willing and decision making, rather than enduring desires or thoughtful 911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 97 of 185

decis ion making. T he term abulia has been us ed to des cribe the loss , impairment of the power to will or to execute what is in mind. Abulic individuals show a diminis hed sense of motive or des ire and impairment in making the from motive and des ire to execution of action. in will may be s een in a variety of psychiatric dis orders at the end of life, when patients have s urrendered their to live and are simply waiting to die. In schizophrenia, a diminis hed sense of will can be s een in pas sivity phenomena, already described above, as well as in negative (or deficit) s ymptoms that may affect feelings, and behaviors . T hes e include lack of drive, impers is tence at tasks, and a general inner flatnes s. Depress ed patients also des cribe volitional general apathy and anhedonia. P atients who inhale solvents (e.g., glue, gas oline, toluene), smoke marijuana very heavily, and chronically us e have a characteristic amotivational s yndrome . T he which this lack of motivation results from or contributes the chronic s ubs tance abus e is a matter of debate. In OC D, both the obsess ional thoughts and the rituals are experienced as ego dys tonic and not with the patient's conscious desires and will. S imilarly, although patients with anorexia nervosa initially have cons cious experience of willing and controlling their of food, during the course of the disorder, the sense of willfulnes s is replaced by one of pas sivity, of being subjugated by obses sional thoughts and compulsive behaviors that as sume control of the eating behavior. A 28-year-old woman with anorexia nervos a and OC D 912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 98 of 185

described having as mental background nois e a loud audible thought that cons tantly tallied the caloric value not only of everything s he ate but also of all the foods others in her vicinity ate or that s he saw on s tore T his other stream of thinking occurred nons top, and, calculator, the thoughts constantly did s ums and the tally for the day. T hes e thoughts were experienced parallel to but s eparate from any other thinking in which s he happened to be engaged. Dis turbances of volition are among the more common complaints of patients with pers onality disturbances reques t ps ychotherapy. Individuals with dependent personalities are characterized by difficulties in making decis ions by themselves and often engage in cours es action contrary to their own des ires . S imilarly, with pas sive-aggres sive pers onalities obscure their desires by being excess ively involved in the demands made on them by others. T heir courses of action do not reflect their own decis ions s o much as the thwarting of others ' desires . P eople with compulsive personalities inflexible rules , thereby precluding cours es of action on independent evaluation, individual des ires, and decis ions. In other s ituations , they are indecis ive, sometimes making impulsive decisions at the las t when forced to decide. F inally, many individuals s eek treatment becaus e of self-designated disturbances of willing: T hey do not know what they want, or they make choices among several options, or they excess ively. Often, thes e problems may mas k other of wanting, commitment, taking initiative, hard work, succes s, making a mis take, P.985 913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 99 of 185

being criticized, angering others, and of all the cons equences related to such actions.

Dis turbanc es of Orientation O rie ntation refers to one's awareness of time, place, person. Accurate orientation requires the integrity of attention, perception, memory, and ideation. occur primarily in organic mental dis orders (i.e., and toxic metabolic brain abnormalities) and in dis sociative and psychotic states . Normal individuals vary tremendous ly in their attention the details of time and in the extent to which their automatically keep time. S ome people have reliable in clocks by which they can awaken themselves at times or accurately gauge the pass age of time with uncanny accuracy, even in the absence of external in a psychotherapy ses sion, for example. Others have difficulty making judgments about time and may pathological lateness or habitually schedule more activities than could ever be accomplished in the time. P oor time judgments may be s een in a variety of ps ychiatric disorders, such as ADHD, or as an problem. B enign disorientation to time is common. few days in a hos pital bed, mos t people do not know exactly what the day or date is because they are not attending to or receiving their us ual cues. P athological time disorientation can be mild or s evere, with inaccuracies of es timation ranging from days to T he dates reported by disoriented individuals may have personal s ignificance such as thos e of important births, 914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 100 of 185

marriages , or deaths. B ecaus e s patial cues are generally more available and obvious than temporal cues, dis orientation to place signifies a greater degree of cognitive impairment than disorientation to time and, therefore, rarely occurs in absence of time dis orientation. Dis oriented people may know, more or less , the type of place they are in knowing the specific place—patients may recognize they are in a hospital without being able to name the hospital. A 79-year-old former bus iness man with severe was able to s mile responsively in appropriate circums tances and seemed to follow convers ations, his deficits by his well-honed social s kills . When as ked concretely about either time or place, he became momentarily confus ed and then diss embled, s aying or four half sentences that were incomprehensible and then looking plaintively toward his wife for help. Dis orientation to person, a lack of awarenes s of one's identity, is typically s een only in advanced dementias as primary degenerative dementia of the Alzheimer's or in diss ociative states . In organically induced postconcus sion amnesia, transient global amnesia, presumably, psychogenic fugue s tates, knowledge of own identity may disappear, and a pers on may remain unidentified for an indefinite period until the memory for self returns.

Dis turbanc es of Memory Memory is not a unitary phenomenon. C apacities to remember vary for the different s ens es and 915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 101 of 185

One pers on may have prodigious mus ical memory, the capacity to remember and reproduce whole pieces after one hearing, but be incapable of people's names or telephone numbers. E xceptionally detailed verbal memories have been as sociated with obses sional cognitive s tyles . When individuals with extraordinary memories complain of memory loss , ordinary memory tests may be inadequate to detect deficits , as their relative memory los s may have their capacities to a point within the range of most people. Memory functions have been divided into three s tages: registration, retention, and recall. R egis tration (or acquisition) refers to the capacity to add new material memory. T he material may be s ens ory, perceptual, or conceptual and may come from the environment or within the person. F or new material to be acquired, the person must attend to the information presented, and it must then be registered through the appropriate channels and then be proces sed or cortically R ete ntion is the ability to hold memories in s torage. numbers of neurons are believed to be involved in the storage of a s pecific memory, and it is believed that reverberating circuits are formed in which memory are held by means of changes in proteins or synaptic connectivity, or both. R ecall is the capacity to return previous ly stored memories to consciousness . Newly registered material is transferred incrementally immediate to short-term memory to long-term memory. Immediate memory lasts for 15 to 20 s econds ; s hortmemory (or recent memory) for several minutes up to 2 days (the time involved in new learning and its early 916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 102 of 185

cons olidation); and long-term (or remote) memory for longer periods . Different physiological process es each of these stages of memory. B ecaus e of this, that affect immediate or s hort-term memory often spare long-term memory. T he process es by which memories transferred from short-term to long-term s tores are unknown. C ognitive s cientists now refer to s hort-term memory as working me mory, the s ys tem that briefly s tores and proces ses information needed for planning and R ecent studies s uggest that the working memory cons ists of at leas t two short-term memory buffers, one verbal and another for vis ual memories , plus a central executive that manipulates and coordinates information stored in the two buffers for problem s olving, planning, and organizing activities . P arallel proces sing s ys tems involving s pecific areas of the prefrontal cortex and brain areas appear to operate separately with respect various process es concerned with working memory. example, separate prefrontal areas appear to be in working memory functions concerned with object identity and spatial locations . Other studies s uggest that different types of memories stored and retrieved by different brain s ys tems, s o that there is at least a dual memory s ys tem. T he first sometimes called a conditioned-emotional s ys te m, or system for implicit me mory, or pe rce ptual me mory, or nonde clarative memory, is present from birth, through life, and is addres sable by situational, s ens ory, affective cues. P as t experiences are express ed images, behaviors , or emotions. T hese memories need involve any cons cious memories of a past experience. 917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 103 of 185

C onditioned fear res pons es represent examples of memories elicited in this s ys tem. T he second s ys tem, sometimes called narrative -biographical me mory, or me mory, or re flective me mory, or de clarative memory, emerges during the preschool years and includes information s ignificant to the s elf. Memories are addres sable through intentional retrieval efforts , apart from the original learning conditions . T hey are as representing personally experienced events and compose the individual's life his tory, approximately equivalent to memory with cons cious nes s or memory awarenes s. C linical s tudies sugges t that, in at least amnes ias, implicit and explicit memory functions may diss ociated. Dis turbances in memory occur through the interruption registration, retention, or recall.

Dis turbanc es in R egis tration R egistration and short-term memory retention are impaired in disorders that affect vigilance P.986 and attention, such as head trauma, delirium, intoxications, psychosis, spontaneous or induced anxiety, depres sion, and fatigue. A variety of other metabolic and s tructural brain disturbances can affect short-term memory as well, particularly lesions the mammillary bodies , hippocampus , fornix, and as sociated areas . P atients with impaired attention and concentration who are able to demonstrate immediate recall may not be able to retain or recollect these items from s hort-term memory. B enzodiazepine us e has 918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 104 of 185

as sociated with working memory difficulties, especially the elderly. S ome short-acting, high-potency benzodiazepines used as sleeping pills may be troublesome in this regard.

Dis turbanc es in R etention T he retention of memories is impaired in posttraumatic amnes ia as well as in a number of cognitive disorders as dementia of the Alzheimer's type and W ernickeK ors akoff s yndrome. T he latter, which ordinarily results from chronic thiamine deficiency seen with alcoholism, as sociated with pathological alterations in the bodies and thalamus .

Dis turbanc es in R ec all Dis turbances in recall can occur even when memories have been regis tered and are in s torage. At times , to recall may s ignify that the memory traces have dis appeared and are no longer retrievable. difficulties in recall can occur separately, as in the event of forgetting the name of a pers on or object, only spontaneously remember it hours or days later. In forgetting, more remote events are les s well than recent ones, and important events are most vividly retained in memory. S ome demented patients may los e memories for all events occurring after a specific date event, as if the s late has been wiped clean, but retain earlier memories . S ome individuals may progress ively erase memories s o that they recall only earlier and events. S pecific types of memory functions may be to selectively different control mechanisms in the brain. F or example, recent animal res earch s uggests that 919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 105 of 185

endocannabinoids may facilitate the extinction of memories , but not their acquisition or consolidation, through their s elective inhibitory effects on local networks in the amygdala. A 27-year-old woman with P T S D s ymptoms related to history of childhood phys ical, emotional, and sexual developed a s ignificant and persistent habit of abuse. S he had tried a variety of s treet drugs but cannabis as her drug of choice. S he was certain that marijuana was far better than other drugs at enabling to “forget” and not dwell on the past while permitting to get about her us ual day-to-day tasks and Under us ual conditions, forgotten events can be with prompting, as sociative memories , or other forms stimulation such as hypnos is. As des cribed earlier, dependent memories are recall failures , reversed by reinstituting the context in which the memory was originally formed. Amnes ias are syndromes in which s hort-term and longterm memory is impaired within a state of normal cons ciousnes s. T hus , memory disturbances in delirium should, s trictly s peaking, not be considered amnes tic syndromes. Ante rograde amne s ia is the inability to or learn new information (and therefore to form new memories ) from a specific event onward; it typically follows head trauma, s tates of cerebral phys iological imbalance, or drug effects. P atients who receive E C T frequently have anterograde amnes ias during the of the treatments; the amnesia gradually fades over numbers of weeks. R etrograde amne s ia is an recalling memories that were es tablished before a 920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 106 of 185

traumatic event, extending backward in time for periods. As memory is regained, the more remote memories us ually return first. A patient originally for the 3-month period before an accident may be left with amnes ia for events only a day or an hour before the accident. In organically caused retrograde amnes ias, remote memories are usually intact, amnes ia may exis t for more recent events. T his with ps ychoge nic (functional) amne s ia, in which the periods of forgotten events may be more s potty or selective. Hype rmnes ia, unus ually detailed and vivid memory, occur in gifted people, in as sociation with obs es sivecompuls ive and paranoid pers onality traits, and in hypnotic trances . Intrus ive me morie s may occur in signaling failure of the mechanisms that usually keep unwanted memories and information out of working memory. A 36-year-old man with mild developmental disability living on a remote and is olated ranch witnes sed his brother murder a violent, drug-dealing neighbor with a shovel. T he patient was implicated as an accomplice spent s everal years in jail. S tarting on the day of the murder and pers is ting on a daily basis for 5 years thereafter, the patient experienced vivid visual, and tactile images of the murderous act—reacting with strong emotions to all of thes e relived s ensations . T he images were particularly strong when the patient external s timulation and just before falling as leep. Although many forgotten memories can be recalled in hypnotic trance, retrospective falsification and 921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 107 of 185

may als o occur under hypnosis. (Memories recalled hypnosis us ually are not accepted as evidence in R etrospective fals ification of memory, the development false memories , is called paramne s ia, also known as re connais s ance . C onfabulation is another common paramnesia in which the patient fills in memory gaps inaccurate information. T he respons es given to by patients who confabulate may reflect pas t or bizarre, fantas tic s tories. C onfabulation correlates with memory deficit and is believed to reflect frontal dysfunction and a failure of s elf-monitoring. is prominent in certain alcohol amnes tic s yndromes, as Wernicke-K ors akoff s yndrome, as well as other of the mammillary bodies , thalamus , or frontal lobes. Déjà vu is the s ens e that one has previous ly seen or experienced what is trans piring for the firs t time; it is a false impres sion that the current stream of has previous ly been recorded in memory. R elated phenomena are dé jà e ntendu, a sense that one has previous ly heard what is actually being heard for the time, and dé jà pe ns é , a feeling that one has at an time known or unders tood what is being thought for the first time. E xperiences of jamais vu, jamais e nte ndu, jamais pens é involve feelings that one has never s een, heard, or thought (res pectively) things that, in fact, one has. T hes e phenomena are all common in everyday may increas e in states of fatigue or intoxication and in as sociation with complex partial seizures or other ps ychopathological s tates. Deme ntia is a syndrome in which the es sential feature acquired impairment of s hort- and long-term memory as sociated impairments of abstract thinking, judgment, 922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 108 of 185

personality changes , and other cortical disturbances . symptoms always involve more than one sphere of function. In later stages , demented P.987 patients may become helples s, too confused to us e a stove, and incapable of remembering the names of relatives . T hey may wander into dangerous situations , oblivious of their s urroundings . Dementias are caus ed variety of pathogenic proces ses, some of which are revers ible, s uch as hypothyroidis m and subdural hematoma, whereas others are irreversible, s uch as dementia of the Alzheimer's type and multiinfarct dementia. Although the characteristic cognitive disturbances seen in s evere major depres sive us ually called ps eudode me ntias , many believe that profound cognitive dysfunction meeting criteria for dementia ass ociated with depres sion s hould properly be labeled as a revers ible dementia T he presence of ps eudodementia, however, is the development of Alzheimer's disease (but not in all cases), indicating that the depress ion was a prodrome the primary cognitive disorder or that the pres ence of ps eudodementia marks thos e with an underlying progres sive cognitive dis order. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > P E R C E P T ION

DIS TUR B ANC E S IN PE R C E PTION 923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 109 of 185

P art of "8 - C linical Manifes tations of P s ychiatric Normal perception first requires that the individual be capable of receiving information as s ens ations . T he must then be organized to make them meaningful and comprehensible such as dis tinguis hing figure from or focus ing attention s electively on s ome part of the sens ory field. T he organized entities are called states of sensory deficit, such as blindnes s, deafnes s, anesthes ia, perception is impaired, but perception is poss ible because individuals generally perceive information about an object through s everal sensory modalities concurrently. T he intensity of sensation and perception is affected by vigilance and attention. Highly focus ed attention, as in intens e concentration or may result in unus ually acute s ens ation and hyperesthesia, hyperacusis, or extraordinary vis ual F ocus ed attention may als o res ult in the inability to or perceive: Deep anes thes ia and negative induced by hypnosis are s imply induced failures to perceive what exists in the world. Humans us ually operate in an “average expectable environment” in which certain types and levels of input are expected and for which the nervous system is primed. E xces sive or inadequate s timulation in any modality, levels of input that are extraordinarily intense, the presentation of novel stimuli that are entirely from anything previously experienced by the individual can provoke dis torted perceptions in mos t normal F or example, total sensory deprivation produced in carefully controlled artificial environments may elicit 924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 110 of 185

and auditory illusions and hallucinations . Individuals generally exhibit selective perception of the world, depending on what is s alient at the moment, and on his or her individual memories , emotions , fantas ies, values. P regnant women are more likely to perceive around them than are people who are not as with childbearing. T he intens ity of perceptions depends on individual sens itivities as well as on mood, anxiety, and us e. Unmedicated patients with s chizophrenia have deficits in olfactory acuity. Depres sed patients often describe that colors look faded, that the world looks was hed out or gray, even though their capacity to recognize specific colors is unchanged. S imilarly, often characterized by heightened perceptions, hype re s the s ia. W hen extreme, these intens e are uncomfortable. Hyperes thesia can also be seen benzodiazepine withdrawal, hallucinogen us e, and, occasionally, as part of an epileptic aura. T he intens ity of perception may vary with cognitive and other ps ychological and neurological factors . individuals tend to be augme nte rs and others bodily experiences . C hronic pain and s ome hypochondriacal syndromes may occur more among somatic augmenters . S elective deficits in the perception of emotions may E motional apros odies have been described in which patients with specific neurological deficits or are selectively unable to recognize the expres sion of emotion. T hes e have been linked by positron emis sion tomography (P E T ) s can to blunted activity in the right 925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 111 of 185

prefrontal cortex and insula.

Illus ions P erceptual dis tortions in es timating s ize, s hape, and relations are common even in the absence of disorders , es pecially when one is fatigued or aroused. Illus ions are misinterpretations of real sensory stimuli, as when a child in a dark bedroom at night mons ters emanating from shadows on the walls . are playful and whims ical voluntary illus ions that can seen when one looks at ambiguously defined or evanescent images such as clouds or flames in a B oth the ons et and termination of thes e perceptions entirely voluntary. T railing, another visual illusion, is the perception that an object moving s teadily in space is followed by temporally distinct, after-images of itself. effect is that of a s eries of strobos copic photos . T his phenomenon may occur with fatigue and is typically with marijuana and mes caline intoxication, during withdrawal from S S R Is , or, les s commonly, in with nefazodone (S erzone).

Halluc inations Hallucinations are perceptions that occur in the corres ponding sensory s timuli. P henomenologically, hallucinations are ordinarily s ubjectively from normal perceptions. Hallucinations are often experienced as being private s o that others are not see or hear the same perceptions . T he patient's explanation for this is typically delus ional. can affect any s ens ory system and s ometimes occur in several concurrently. W hen perception is altered, 926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 112 of 185

combinations of illus ions and hallucinations , and often delus ions as well, are frequently experienced together. some studies, 90 percent of patients with hallucinations also have delus ions, and approximately 35 percent of patients with delus ions als o have hallucinations. and early adolescents , however, are more likely to hallucinations in the absence of delus ions. 20 percent of patients have mixed s ensory (mostly auditory and visual) that may accompany functional, as well as organic, conditions . A given stimulus may evoke very different perceptual different people. T hree s cientists floated in sensory deprivation tanks for long periods. One experienced a few illusions and no hallucinations ; the second had many illus ions and a faint auditory and visual hallucinations ; and the third vivid, dramatic, and complex visual and auditory hallucinations . Hallucinations are experienced by many normal people under unus ual conditions. It has been es timated that between 10 and 27 percent of the general population experienced memorable hallucinations, mos t visual hallucinations . T he large majority of self-reported hallucinations in community s tudies , particularly hallucinations , have been ass ociated with depres sive subs tance use dis orders rather than frank ps ychotic disorders . Hypnogogic and hypnopompic hallucinations are predominantly visual hallucinations that occur during moments immediately preceding falling as leep and the transition 927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 113 of 185

P.988 from s leep to wakefulness , respectively. Hypnagogic hypnopompic hallucinations both occur in normal and are also characteris tic s ymptoms of narcoleps y. In acute bereavement, up to 50 percent of grieving have reported hallucinating the voice or presence of the deceased, and after amputations , phantom limb hallucinations are common. P atients who become impaired often develop pseudohallucinations (i.e., visual hallucinations with pres erved insight) with preserved cognitive s tatus, the s o-called C harles B onnet parallel phenomenon is the emergence of hallucination, including musical hallucinations in individuals with acquired deafness . T hese obs ervations sugges t a “supers ens itivity deprivation” hypothes is that, when deprived of important and anticipated perceptual stimuli, the mental apparatus may overinterpret any sensory stimulation as evidence of the presence of the needed objects. A perceptual releas e theory suggests that hallucinations emerge from the combined presence of intense states internal arous al and diminis hed s ens ory input (including poor attention and poor capacity to s ort out relevant irrelevant input). T hus , diminis hed input from the environment (as in s ens ory deprivation) or reduced capacity to attend to and take in the input (as in states ) heightens the likelihood that internal sensations, images, and thoughts are interpreted as originating in outside environment. Hallucinations vary according to s ens ory modality, of complexity of the hallucinated experience, the levels 928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 114 of 185

conviction about their reality, the clarity of their the location of their s ources of origin, the degree of volitional control over them, and the degree to which hallucination influences the pers on's behavior. Auditory hallucinations range in complexity from unstructured s ounds, such as whirring noises or whis pers, to ongoing multipers on dis cuss ions about the patient. T he s imple auditory hallucinations are more commonly ass ociated with organic ps ychos es such as delirium, complex partial s eizures , and toxic and encephalopathies. Auditory hallucinations are as sociated with s chizophrenia (seen in 60 to 90 patients) but are also frequently seen in ps ychotic disorders . T wenty percent of manic patients and les s 10 percent of depress ed patients experience auditory hallucinations . T hree types of auditory hallucinations commonly as sociated with s chizophrenia (which, however, are seen les s commonly in patients with ps ychotic and mania) are (1) audible thoughts des cribed as hallucinated voices that s peak aloud what the patient is thinking, (2) voices that give a running commentary on patient's actions , and (3) hearing two or more voices arguing with each other, often about the patient, who is referred to in the third person. A 42-year-old man with chronic schizophrenia that he had chronic and pers is tent daily auditory hallucinations . Although he was not quite clear about etiology of thes e voices, he s urmis ed that they were celes tial beings. W hen his ps ychos is was relatively could hear their discus sions about his behavior and 929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 115 of 185

occasional commands , which he was able to ignore. his psychosis wors ened, the voices became more res ulting in s ocial withdrawal and a marked increas e in depres sion and s uicidal ideation. While auditory hallucinations in s chizophrenia are frequently mood neutral, hallucinations in patients with mood dis orders are characteristically cons is tent with mood. In psychotic depres sion, the voices may be unrelievedly critical and sadis tic, whereas in mania, the voices often refer to the patient's s pecialnes s. A 31-year-old bipolar man described a recurrent shift in the quality of auditory hallucinations as sociated with his changing mood s tates. W hen he was depres sed, hallucinations were unrelentingly critical of him, telling him that he did not deserve to live and that he should commit s uicide for the good of the world. T ypically, his severe depres sions alternated with irritable manic During those periods , auditory hallucinations not only him that he was great but also belittled and berated in his life and s ometimes instructed him to lash out and harm them when they thwarted his grandios e plans . C ommand hallucinations order patients to do things . the commands are benign reminders about everyday tas ks : “P ick up your s hoes ” or “C lean off the table.” However, the voices may also be frightening or commanding acts of violence toward the self or others such as “J ump off the roof, youapos ;re not worth or “P ick up the knife and kill your mother.” T hese vary in insistence and persis tence, and patients differ their capacities to ignore these commands. P atients marked pass ivity may be helpless in the face of 930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 116 of 185

hallucinations and may feel impelled to carry out the orders. E ven though one study did not find command hallucinations to be as sociated with a higher risk of to the patient or others, the presence of command hallucinations and the patient's ability to resis t must be as sess ed carefully. A 46-year-old woman with s chizophrenia heard hallucinations on a daily basis for the last 20 years . her symptoms were relatively quies cent, the voices benign, and the commands referred to daily behaviors (s uch as “say thank you”). Under stress , her ps ychos is exacerbated and the voices became louder, more and commanded more complex and dangerous once precipitating a self-stabbing when the voices demanded it. V is ual hallucinations occur in a wide variety of and ps ychiatric disorders , including toxic disturbances , drug withdrawal syndromes, focal C NS les ions, headaches, blindnes s, schizophrenia, and psychotic disorders . Although visual hallucinations are generally as sumed to characteristically reflect organic disorders , they are s een in one-fourth to one-half of schizophrenic patients, often—but not always —in conjunction with auditory hallucinations . V is ual hallucinations range from s imple and elemental, which hallucinations consist of flashes of light or geometrical figures, to elaborate visions s uch as a flock angels . S timulation of one sensory modality s ometimes evokes perceptual distortions in another. Marijuana and 931 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 117 of 185

intoxication, for example, have been ass ociated with s yne s the s ia, an experience in which sensory seem fus ed. T his is also a normal experience for many people. Music may be experienced vis ually, the s ound fus ing with visual illus ions; a tactile s ens ation may be experienced as a color (e.g., a hot s urface may “feel In certain religious subcultures , vis ual hallucinations be experienced as normal. In one fundamentalist P entecostal church, worshipers danced themselves frenzy, and, without us ing any drugs, several shared visions of the V irgin Mary at the altar. A 45-year-old His panic farmer who lived in a rural farm area all of his life attended church regularly. He that he and others in his P.989 family were always aware of the presence of angels guarding over their lives . As they worked in the fields , they were often comforted by thes e angels, they took to repres ent the souls and s pirits of departed ances tors who had lived and worked in the same for hundreds of years . Autos copic hallucinations are hallucinations of one's phys ical s elf. S uch hallucinations may s timulate the delus ion that one has a double (doppe lganger). near-death, out-of-body experiences in which see themselves rising to the ceiling and looking down thems elves in a hospital bed may be autos copic hallucinations . In L illiputian hallucinations , the sees figures in very reduced s ize, s uch as midgets or dwarfs. T hey may be related to the perceptual 932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 118 of 185

of macrops ia and microps ia, res pectively, the of objects as much bigger or s maller than they actually Haptic hallucinations involve touch. S imple haptic hallucinations , such as the feeling that bugs are over one's s kin (formication), are common in alcohol withdrawal syndromes and in cocaine intoxication. unkempt and physically neglectful patients complain of these sensations, they may be due to the pres ence of phys ical s timuli, s uch as lice. S ome tactile having intercours e with G od, for example—are highly suggestive of s chizophrenia but may also occur in syphilis and other conditions and may, in fact, be stimulated by local genital irritation. Olfactory and gustatory hallucinations, involving smell and tas te, res pectively, have most often been as sociated with organic brain dis eas e, particularly with the uncinate fits complex partial seizures . Olfactory hallucinations may be seen in ps ychotic depress ion, typically as odors of decay, rotting, or death. A 32-year-old woman with s chizophrenia des cribed over the 15 years of her illness , s he had experienced a array of hallucinations. S he initially noticed celestial auditory hallucinations that included angelic mus ic and comforting words . However, over the years, in with a pes simis tic turn of mind, the voices became demonic and threatening. At the s ame time, s he began experience s omatic hallucinations , consisting of s harp, intermittent electric currents being run through her s kin and genitals , which, she was convinced, were the work evil neighbors intent on driving her out of her With medication, she was partly able to perceive these 933 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 119 of 185

experiences as hallucinatory; however, most times, particularly when s he neglected to take medications , never doubted their authenticity. T he term ps eudohallucination has been us ed in two F irst, pseudohallucination refers to perceptions experienced as coming from within the mind (i.e., not at the boundary or outside the mind). Using this definition, loud voices that are alien, ascribed to other beings, but which the patient knows are actually within the mind rather than out in s pace, are ps eudohallucinations. T he term has als o been used to des cribe hallucinatory experiences whos e validity the patient doubts . A better term for this s econd phenomenon is partial analogous to partial delus ion. F unctional hallucinations rare hallucinations that occur only in connection with a specific external perception, for example, in the of a s ound, s uch as running water, or a color, or a place. However, unlike illusions , the hallucinated are not elaborations of the perception but are s imply triggered only in that s pecific context. Ictal hallucinations , occurring as part of seizure activity, typically brief, las ting only seconds to minutes , and stereotyped. T hey may be s imple images , s uch as of light, or elaborate ones , such as vis ual recollections past experiences . W hile the hallucinations are being experienced, the patient ordinarily experiences altered cons ciousnes s or a twilight s leep. Migrainous hallucinations are reported by 50 percent of patients with migraine. Mos t are simple visual hallucinations of geometrical patterns , but fully formed visual hallucinations , s ometimes with microps ia 934 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 120 of 185

and macropsia, may als o occur. T his complex has called the Alice in W onde rland s yndrome after Lewis C arroll's des criptions of the world in T hrough the G las s , which mirrored some of his own migrainous experiences . In turn, these phenomena closely visual hallucinations induced by psychedelic drugs mescaline. A flas hback is an intens e vis ual reexperience of highly charged past events , which are often replays of hallucinations . T hey are typically ass ociated with heavy of hallucinogens , s uch as LS D and mescaline, and occur months after the last drug ingestion. T he images may be s imple or complex geometrical patterns , or may consis t of previous ly experienced elaborate druginduced hallucinations . F las hback phenomena may be state dependent. F or example, visual hallucinations initially experienced with hallucinogens are more likely be subsequently experienced as flashbacks when the subject is smoking marijuana. In P T S D, s ome complex, intrus ive flashback-like images may attain a vividness . Images often include horrifying memories of traumatic events that may force thems elves repeatedly into cons cious nes s until they are acknowledged and worked through. Hallucinos is is a state of active hallucination occurring someone who is alert and well oriented. T his condition seen mos t often in alcoholic withdrawal, but it may als o occur during acute intoxications and other drugstates . A 21-year-old man used LS D daily for 3 days , after the visual hallucinations that firs t occurred while under 935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 121 of 185

influence of the drug waxed and waned. He des cribed pareidolias with distracting images of animals when he looked at traffic lights, the sky, or billboards . T railers common after he turned his head. F inally, he saw colors when he stared at any object for more than a transient time period. He as sumed that these represented a lingering effect of the LS D and was not frightened by them. T he hallucinations disappeared 1 week.

B ody Image Dis tortion B ody image includes both perceptual and ideational components and may reflect primarily perceptual distortions or combinations of dis turbed perception and self-appraisal, or both. B ody image disturbances can occur as normal abrupt changes in the body (e.g., after amputation), in brain dis eas e, and in ps ychiatric disorders . P hantom phenomena are class ic body image problems in which amputated limb is s till felt to be pres ent. T he sensation may diminish gradually over time; the phantom feels as is receding into the stump. A 53-year-old maintenance worker underwent the traumatic amputation of both legs above the knees in a motor vehicle collision. F or more than a decade, after obtained and mas tered the us e of bilateral prosthes es, P.990 his mos t disturbing impairments were painful phantom limb experiences. He constantly felt as if both legs present but raw and s hattered. In s pite of optimal 936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 122 of 185

pain medication management, thes e experiences persis ted, and the patient continued to s earch for a neuros urgeon who might alleviate the pain. Agnos ias , lack of awarenes s of some parts of the body, accompany brain damage, mos t often of the parietal lobe. P atients with obvious motor or s ens ory deficits may deny that any deficit exis ts at all (anosognosia), or the denial may be limited to one-half the body (hemiagnos ia), us ually the left side. In he midepe rs onalization s yndrome s , a les s common (hemis omatognos ia), patients feel that one of their miss ing, again us ually on the left side. B ody image distortions in which a limb feels too heavy (hypers chemazia) or weightles s (hyposchemazia) can occur as a cons equence of neurological conditions infarction of the parietal lobe. In duplication patients feel as if part or all of them has doubled (e.g., have two heads or two bodies ). T hese rare phenomena may occur in s chizophrenia, complex partial s eizures, migraine. Dys morphophobia refers to conditions in which patients distortedly perceive and intens ely dislike the shape of a particular body part. As such, these symptoms are misnamed because there is no true phobic component such as fear or avoidant behavior. F ine lines exist perceptual distortions and realistic but unhappy of one's body, given the high social values placed on phys ical appearance. Dys morphophobia may occur in context of some pers onality disorders or as an is olated disorder called body dys morphic dis order. In s ome dysmorphophobia res embles an overvalued idea. may develop dysmorphophobias in relation to any body 937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 123 of 185

part; common concerns are hair, breas ts, penis s ize, shape of the nose, or the s hape of the entire body. F or some, changing the body part, as in rhinoplas ty for who do not like their nose, seems to effect a lasting positive change in body image, with patients becoming happier with thems elves and feeling more attractive for years or lifetimes. In s evere dysmorphophobia, patients may undergo multiple plas tic s urgeries and feel diss atis fied with every res ult. At times , the condition part of a larger and more pervas ive syndrome, such as anorexia nervosa. An attractive 19-year-old woman was preoccupied and perplexed by the fact that s he perceived her eyelids as being unequal in size and s hape and by the fact that cleft in her chin was too deep. S he spent hours each front of the mirror, trying to pos e in ways that, from her perspective, did not expose thes e facial blemis hes . sought cons ultation from a plas tic s urgeon, who her for psychiatric cons ultation. After 2 months of treatment with an S S R I, her preoccupations with appearance diminis hed considerably, and she was turn her attention to other is sues in her life. Hypochondriacal complaints also combine perceptual ideational distortions. S elective hypervigilance to bodily sens ations may res ult in a higher likelihood of of unpleas ant and potentially pathological body experiences among the “worried well,” hypochondriacal populations, patients with s omatization disorder syndrome), and s ome patients with panic disorder. B ody image distortions may, at times , be severe or S ome ps ychotic patients, either with schizophrenia or 938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 124 of 185

depres sion, develop somatic delus ions. In depres sion, often express es its elf as a delus ion that part of, or the entire, body is rotting or filled with cancer. S ome bound s yndromes in non-Wes tern culture expres s thems elves with body image distortions s uch as koro, which the man fears that his penis is s hrinking into his abdomen. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > MO OD

DIS TUR B ANC E S OF MOOD P art of "8 - C linical Manifes tations of P s ychiatric Defining, describing, understanding, and categorizing moods have long been among the mos t important, and difficult, tas ks in ps ychiatry. T he language of feelings is filled with terms that s eem to have mos tly idios yncratic meanings , as patients, phenomenologists , and ps ychiatris ts all struggle both to describe inner and to correlate them with external behavior. E ven terms, such as mood, affe ct, emotion, and fe e lings , universal definition. T he most common convention, is us ed here, defines mood as a sus tained or prevailing subjective feeling tone or range of tones. Affe ct is the moment-to-moment feeling s tate, s ometimes rapidly shifting in response to a variety of thoughts and that the clinician can obs erve. E motions have been as moods and affects that are connected to specific or to the phys ical concomitants of moods and affects. F e e lings are the most poorly defined of all, leading K arl 939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 125 of 185

J aspers to ultimately des cribe them as everything for which there is no other name. In common parlance, often profes sionally as well, these words are us ed interchangeably. T he term mood dis orders , for DS M-III-R and now DS M-IV -T R , replaced DS M-III“affective dis orders” to des cribe the s ame group of ps ychiatric syndromes. Moods , affects, and emotions can be des cribed by a number of important qualities : intens ity (shallow to range (broad to narrow [or flat]), stability (rigid to reactivity to external events (none to much), periodicity (periodic to aperiodic), congruence with thought (congruent [or appropriate] to incongruent), s peed of res olution (rapid to s low), and vis cosity (evanescent to persis tent). T he individual's lifelong predominant mood one component of temperament. T hus, for example, may be described as having a calm, buoyant, irritable, depres sive, anxious, or s ens itive temperament. Moods , affects, and emotions s erve as internal and external s ignal s ys tems. T hey signal the state of the individual to others and often elicit necess ary help and support from the environment. A baby's face communicates its s tate of need, tension, or thereby recruiting appropriate maternal interventions . adults , much of our mos t important interpers onal communications is trans mitted nonverbally through that s ignal the observer about our moods. P ositive communicated by a scowling or sullen face lead to perceive an angry mes sage regardles s of our words . Moods also have an infectious quality and serve important ways of influencing others . T hus, when we cheerfully toward others , they, in turn, are more likely 940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 126 of 185

feel cheerful and to reciprocate that cheerfulnes s. Internally, moods , affects, and emotions let individuals know how well or how poorly they are doing, allowing them, for instance, to gauge the distance between self-appraisal and des ired s elf-expectations . F or individuals who des ire to master important goals and that they have a reasonably good chance of doing s o ordinarily experience pleas ant emotional s tates in to thes e goals. If something intervenes to prevent them from reaching thes e goals s o that there is an insurmountable gap between their des ires and the likelihood of s ucces s, they may feel hopeles s. In serving as s ignal systems , emotional states of tension, arous al, or anger us ually imply that some neces sary to secure their discharge or release. P.991 E motional states and their expres sion are regulated by biological, ps ychological, and cultural influences . F or example, emotional or affective lability, characterized rapidly s hifting emotions that seem unattached to the situation, typically occurs premens trually in some with varying periodicity in cyclothymic individuals and in those with cluster B pers onality disorders , and in to need states such as hunger, s leep deprivation, and sexual frustration. Mood shifts have als o been related environment-related phys iological influences s uch as seas onal changes in light. P s ychological regulation of emotions may be related to specific coping and the ability to s elf-soothe, which are determined. C onscious and preconscious mechanisms, including varieties of self-talk, may help 941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 127 of 185

or inflame emotions . C ulture factors s ignificantly emotional express ion. Although the facial expres sions basic emotions are similar in all cultures studied, the and s tyle of emotional express ion permitted in relation specific contexts varies greatly from culture to culture from family to family. S ome cultures and families are lipped and inhibit the open express ion of emotion, whereas others encourage emotional display. Marked differences exis t among cultures in the emotional expres sion of acute grief, fear, pain, and affection.

Depres s ion T he term de pres s ion has been us ed variously to emotional state, a s yndrome, and a group of specific disorders . When s een as part of a syndrome or depres sion has autonomic, vis ceral, emotional, cognitive, and behavioral manifes tations , as illus trated T able 8-1. As a nonpathological, ubiquitous mood state lasting hours to days, but s ometimes longer, feelings of depres sion are s ynonymous with feeling s ad, blue, in the dumps , unhappy, and miserable. Depress ed common and appropriate after a dis appointment or F or mos t people, innate psychological res ilience, alternative coping options, and supportive social help alleviate these brief depres sive states and prevent them from becoming chronic. S ome individuals have chronically depres sed mood, tend to view the world as difficult place filled with obstacles and burdens , see thems elves as victimized, and lack hope for the future. extent to which constitutional, developmental, and ongoing avers ive life events contribute to this pervasive world view is unknown. P eople who, in early life, were deprived and traumatized may be less res ilient and 942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 128 of 185

prone to chronic depress ive features than are others. R epeated failures and the impact of unrelenting, uncontrollable, and unpredictable negative life events set the s tage for learned helples sness in humans jus t they do in animals. A subs et of chronically depress ed individuals may als o have temperamental, biologically driven depres sion, often seen in conjunction with genetic loading for s evere mood dis orders. S ome depres sive states are normal and common to major unwelcome and undes irable life events . be re ave me nt best exemplifies this . In bereavement major los ses, s uch as the death of a parent, s pouse, or child, people experience s adness , pining, and yearning do not ordinarily have the feelings of guilt, and s elf-reproach that characterize depres sive F eelings of helpless nes s and hopeles sness may be temporarily present in bereavement, but they ordinarily pass with time. In uncomplicated cas es, the proces s of bereavement takes 3 to 6 months in the acute phas e up to 1 year for complete res olution. B ereaved people more likely to feel physically ill and seek general health care than at other times, and older widowers are more likely to die than age-matched nonbereaved controls. P athological grie f re actions , bereavements that last than 1 year, may be s een when the s urviving s pouse excess ively dependent on the deceased and is unable obtain emotional and practical (e.g., financial) support elsewhere or when the s urvivor is unable to grieve fully because of markedly ambivalent feelings toward the deceased. Dis tinguis hing between pathological grief grief triggering a depres sive epis ode may not always poss ible. T he inadequate express ion of grief due to 943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 129 of 185

incomplete bereavement is believed to be pathogenic many subsequent ps ychiatric disorders . F or example, impulsive acting out among adoles cents who lost a parent is often as sumed to be due to unres olved grief. A variety of medical dis orders may cause depres sive syndromes. Mos t common among thes e are endocrine abnormalities , s uch as hypothyroidism and hyperparathyroidism, and C NS dis orders s uch as cerebrovas cular dis eas es and P arkinson's disease. Depress ions are more common in strokes affecting left anterior les ions than other locations . S ome es pecially antihypertens ive agents affecting adrenergic tone, s uch as res erpine (S erpas il) and poss ibly βmay als o trigger depress ions. T he importance of a diathesis in these iatrogenic depress ions is not yet Depress ive s yndromes and dis orders in general, are unques tionably familial and are likely to have contributions , es pecially in depress ions ass ociated with bipolar disorder. C ognitive features of depres sion are prominent. C haracterizing the exact nature of the memory us ing standardized tes ts has been difficult. T he tas ks requiring s us tained effort and elaborate cognitive proces sing may be more disrupted in depress ion than those tas ks that can be accomplis hed more T he so-called cognitive triad of depres sion cons is ts of pervas ive cognitive s chema related to feelings of worthles sness , helpless ness , and hopeless nes s — expectations that no one and nothing can, or is likely help now or in the future: “Iapos ;m not OK , the world is OK , and it's never going to get any better.” 944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 130 of 185

S uicidal phenomena are of particular concern. S uicide common in s evere depres sive dis orders, with recent es timates of up to 9 percent of s uicidal hospitalized patients ending their lives in suicide. Depres sed compose the largest diagnostic group of all completed suicides. However, suicide occurs at high rates in other conditions as well, notably s ubs tance abus e disorders , schizophrenia, and s evere pers onality S uicide may occur in these conditions with or without a diagnosable comorbid depress ive dis order. Depress ed patients with comorbid alcohol abus e may be at particularly high ris k for suicide. Although cons istent, us eful, validated predictors of do not exis t, certain demographic features are with higher risk. T hese include being white, male, and older and living alone. In the ps ychiatric history, the most important factor is that of pas t suicide attempts . A history of violent behavior may also predict suicide. Murderers have a very high s uicide rate, es pecially who murder family members during episodes of violence. Among clinical signs , hopeless nes s, and s evere anxiety may predict increased s uicide ris k. S erious physical illness in as sociation with other ris k factors , s uch as depres sion, may place a patient at ris k. A genetic predis pos ition toward suicidal behavior acros s diagnostic lines and plays a role in suicide ris k. may reflect a tendency toward impulsive behavior, correlating with low C NS levels of 5acid (5-HIAA), the major metabolite of serotonin. S uicidal ges tures and various acts of self-mutilation are also common among impuls ive, dependent, and s elfhating depress ed people, for whom they serve as 945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 131 of 185

releas ing behaviors and as cries for help that may desired s ocial support. B ecaus e s uicidal P.992 gestures have been ass ociated with an increased ris k subs equently completed s uicide, they should not be lightly. S uch self-harm behaviors have been s hown to persis t in patients with borderline pers onality disorder into the s ixth decade of life. C ontrary to earlier thinking, they do not appear to “burn out” with age. suicide may res ult when suicidal ges tures go awry or reckless behavior, s uch as taking unnecess ary ris ks in combat or driving while drunk, prove fatal.

E lated Moods E lated moods include euphoria, elation, exaltation, and ecstasy. T hey are marked by feelings of well-being and expansiveness , optimis m, capability, pleas ure, and S uch moods are normally experienced when life is very well, when long-sought-after goals are achieved, in states of love, religious fervor, and s piritual transcendence. P eak experiences and experiences of mys tic fus ion are often accompanied by feelings of exaltation and ecstasy. S exual pleas ure and some chemically mediated states of altered cons cious nes s also induce thes e feelings . Abnormal elated moods are primarily seen as part of states and from the effects of certain medications and street drugs . W hen subtle, as in hypomania, the mood be ebullient and brimming with s elf-confidence but with occasional irritability. Other characteristic s ymptoms of hypomania are increased energy, decreased need for 946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 132 of 185

sleep, rapidly flowing thoughts, exces sive talking, self-es teem with a demanding nature toward others , diminis hed judgment. Mania is a more extreme s tate in which judgment and s leep are impaired to the point of marked functional disruption. As the mania irritability and anger increase, alternating rapidly with a brittle expans iveness . C ognitions become increasingly disorganized. P s ychotic s ymptoms , us ually involving themes of grandiosity or s pecialnes s, occur in 50 or more of manic patients . W ith increasing escalation the manic s tate, thinking becomes very fragmented, ps ychotic symptoms are more prominent, and the syndrome may appear indis tinguishable from acute schizophrenia. T hes e three manic states—hypomania, mania, and the ps ychotic, fragmented manic state— been referred to as s tage I, II, and III mania, Manic s tates occur in bipolar disorder, bipolar dis order otherwis e s pecified, and cyclothymia and as a mania caused by a variety of physical and toxic S uch s econdary manias may follow specific cerebral insults, accompany s ys temic disorders , or occur after inges tion of some drugs , including amphetamines, antidepres sants, bromocriptine (P arlodel), and corticos teroids , among others . Mania is the second most common neuropsychiatric disturbance induced by steroids, occurring in 30 to 35 percent of patients who develop s teroid-induced behavioral dis orders. Up to 12 percent of patients treated with levodopa (Larodopa) bromocriptine for parkins onism develop mania. R ight hemis pheric brain lesions are specifically ass ociated secondary mania. Although not a DS M-IV -T R diagnosis, hype rthymic 947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 133 of 185

pe rs onality refers to personality characteris tics similar hypomania. T hese include unus ual energy, ebullience, confidence, intensity, and so forth but without either the episodic cours e or the functional impairment of hypomania. W hether hyperthymic personality s hould cons idered a bipolar s pectrum disorder or refers s imply high energy individuals is s till unclear.

A nxiety Like depress ion, the term anxie ty refers to a number of different entities : a normal transient feeling, often with adaptive functions; a s ymptom s een in a wide variety of disorders ; and a group of dis orders in which the of anxiety forms a dominant element. As a transient, disagreeable emotional state, anxiety may be adaptive, signaling anticipated or impending threat and neces sary action. In contrast to fe ar, the emotional that exis ts when a source of threat is precise and well known, anxiety occurs when the threat is not well P atients often find it difficult to des cribe feelings of precis ely; at its core, however, anxiety is characterized intens e negative affect, as sociated with an undefined threat to one's phys ical or ps ychological s elf. P atients terms such as te ns e , panicky, te rrifie d, jittery, ne rvous , wound up, apprehe ns ive , and worrie d, to describe their sens ations. Anxiety is additionally characterized by somatic, cognitive, behavioral, and perceptual T he somatic symptoms of anxiety are legion and often dominate; a partial list includes twitching, tremors , hot cold flas hes , s weating, palpitations , ches t tightness , difficulty s wallowing, nausea, diarrhea, dry mouth, and decreased libido. C ognitively, anxiety is characterized 948 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 134 of 185

hypervigilance, poor concentration, subjective fears of losing control or of going crazy, and thinking. B ehavioral symptoms include fearful withdrawal, irritability, immobility, and hyperventilation. P erceptual dis turbances, including depersonalization, derealization, and hyperesthesia (especially are als o common. T rait anxie ty refers to a lifelong pattern of anxiety as a feature of temperament. Individuals with trait anxiety skittish, are hypers ens itive to s timuli, are ps ychophys iologically more reactive than others, and exhibit catastrophic thinking. In contras t, s tate anxiety refers to episodes of anxiety that are tightly bound to specific s ituations and do not persist after the situation has abated. F re e -floating anxiety is by a pers is tently anxious mood in which the cause is unknown and in which large numbers of diverse and events all s eem to trigger and compound the In contras t, s ituational anxiety occurs only in relation to specific occasions or external stimuli, as in phobias. Anxiety s ymptoms can res ult from numerous physical conditions as well as from other psychiatric disorders . Many endocrine, autoimmune, metabolic, and toxic disorders , as well as medication s ide effects , are generate anxiety. T he ps ychiatris t must differentiate res ponse of the patient to an underlying condition (e.g., secondary anxiety) from symptoms generated by the primary disorder itself. In ps ychiatric populations, symptoms are prevalent among patients with organic mental disorders , depres sion, and s ubs tance abuse dis orders as well as in the s pecific anxiety In patients with s chizophrenia, anxiety mus t be 949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 135 of 185

differentiated from akathisia, a common and often overlooked s yndrome of subjective restless ness , and agitation res ulting from antipsychotic medication. coexistence of anxiety s ymptoms and depress ion in depres sive dis order is substantial; anxiety s ymptoms, as anxious mood and irritability, are s een in the depres sed patients. Additionally, one-half to two-thirds patients with panic disorder experience a major episode during their lifetime. Medication and drug effects —from acute us e, s ide effects , or as part of withdrawal phenomena—are als o common causes of anxiety. Many patients with severe anxiety become dependent on anxiolytic drugs, including benzodiazepines, other s edatives, and alcohol, for symptom relief. During attempts to discontinue these subs tances , or s ometimes during their ongoing us e, confusing admixtures of anxiety symptoms , medication effects, and withdrawal s ymptoms may occur. Although all of the anxiety s ymptoms caused by drug are als o s een in primary anxiety disorders , perceptual disturbances , s uch as depers onalization and hyperesthesia, may be more common in s edativewithdrawal syndromes than in primary anxiety F rom a psychological point of view, anxiety may signal conflict between opposing des ires , wis hes , or beliefs the one hand and major disequilibria generated by negative life events on the other hand. R ole s trains , conflicts among the major social roles that form a identity P.993 —spous e, parent, child, wage earner, profes sional, 950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 136 of 185

community member—are common s ources of anxiety. more important the conflict and the les s obvious the res olution, the greater is the ass ociated anxiety. F or example, anxiety s ymptoms may first emerge when an individual is confronted with an unavoidable, unhappy choice, such as between sustaining a marriage or accepting a career advancement requiring a major that is unacceptable to the spous e. At times, thes e conflicts may es cape cons cious awarenes s: S omeone feel anxious but not know why. Anxiety syndromes frequently res ult from a combination of several factors . person in a work conflict facing an important deadline try to alleviate initial anxiety s ymptoms by overwork, inges t caffeine or amphetamines to keep alert, then become exhausted and fatigued, and ultimately use alcohol exces sively to calm down, with each of these elements contributing s eparately to an anxiety s tate. C ertain developmental life s ituations are as sociated anxiety. S trange r anxiety develops when infants 6 to 8 months of age begin to recognize the difference mother and others. W hen children firs t go to s chool, anxiety symptoms are common; if the anxiety is s e paration anxie ty or school phobia may res ult. During adult life, anxiety often centers around is sues of and accomplis hment, both in pers onal and work life. P erformance anxie ty, or s tage fright, is a specific type pathological anxiety in which anxiety es calates to panic when public performance is required. In later life, the deterioration of one's body may engender anxiety to feelings of helpless nes s and de ath anxiety. P anic attack is a circumscribed epis ode of severe state anxiety las ting minutes to hours, with symptoms 951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 137 of 185

es calating in a crescendo pattern. T he s ubjective experience is one of utter terror, fears that one will die, crazy, or los e control, accompanied by many of the somatic s ymptoms of anxiety mentioned above, severe ches t pains , marked s hortnes s of breath, and exhausting fatigue. Individual is olated panic attacks are common, with up to 30 percent of the general experiencing at leas t one attack each year. P anic occur more regularly, and typically more s everely, as of panic dis order or in as sociation with other anxiety disorders . In class ic panic dis order, the attacks are spontaneous; that is , they are not triggered by a predictable environment. In contras t, panic attacks as sociated with other anxiety disorders are triggered by specific s ituations s uch as in social anxiety disorder by social s ituations or in s pecific phobia by confronting the feared object or s ituation. P atients with other disorders may experience limited-symptom panic with epis odes characterized by less intens e anxiety fewer and milder physical s ymptoms such as isolated paresthes ias or difficulty breathing. T hese limitedsymptom attacks may represent aborted full-blown episodes that are not further exacerbated by secondary ps ychological reactions to the initial s ymptoms. A 43-year-old man with crippling shyness and s ocial phobia since youth started to experience increas ing episodes of shortnes s of breath and chest pain in his 30s. On numerous occasions , he called 911 for to take him to the local emergency room, fearing that was having a heart attack. T hese episodes increased frequency at the point in his life when his parents, who had previous ly supported and hous ed him, were 952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 138 of 185

becoming ill and s howing s igns of not being able to continue to s us tain him. He gradually came to these episodes to be panic attacks and decreas ed the frequency with which he called for emergency s ervices. Although American psychiatry has s egregated panic attacks from other forms of anxiety, ass uming phenomenological, and biological differences, thes e distinctions are far from univers ally accepted. Much of E uropean ps ychiatry views panic as simply an extreme form of anxiety to be unders tood as part of a continuum intens ity. P hobias are irrational fears . In an effort to reduce the intens e anxiety attached to phobic objects and patients do their bes t to avoid the feared stimuli. T hus , phobias consis t both of the fears and the avoidance components. T he fear its elf may include all the of extreme anxiety, up to and including panic. In phobias , persistent, irrational fears are provoked by stimuli. T able 8-5 lists s ome illus trative phobias. specific phobias include fear of dirt, excreta, s nakes, spiders, heights, and blood (also termed blood-injury phobias ).

Table 8-5 S pec ific Phobias Phobia

Definition

953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 139 of 185

Acrophobia

F ear of heights

Agoraphobia

F ear of open spaces

Alektorophobia

F ear of chickens

Amathophobia

F ear of dus t

Amaxophobia

F ear of riding in a car

Apiphobia

F ear of bees

Arachibutyrophobia

F ear of getting peanut stuck on the roof of the mouth

Astrapophobia

F ear of lightning

Aviophobia

F ear of flying

B lennophobia

F ear of slime

C laustrophobia

F ear of enclos ed spaces

C ynophobia

F ear of dogs

Decidophobia

F ear of making decis ions

Didaskaleinophobia

F ear of going to school

954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 140 of 185

E lectrophobia

F ear of electricity

E phebiphobia

F ear of teenagers

E remophobia

F ear of being alone

G amophobia

F ear of marriage

G atophobia

F ear of cats

G ephyrophobia

F ear of cros sing bridges

G ynophobia

F ear of women

Hydrophobia

F ear of water

K akorrhaphiophobia F ear of failure K atagelophobia

F ear or ridicule

K eraunophobia

F ear of thunder

Musophobia

F ear of mice

Nyctophobia

F ear of night

Ochlophobia

F ear of crowds

Odynophobia

F ear of pain

955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 141 of 185

Ophidiophobia

F ear of snakes

P nigerophobia

F ear of smothering

P yrophobia

F ear of fire

S cholionophobia

F ear of school

S ciophobia

F ear of shadows

S pheks ophobia

F ear of wasps

T echnophobia

F ear of technology

T halas sophobia

F ear of the ocean

T riskaidekaphobia

F ear of the number 13

T ropophobia

F ear of moving or making changes

B ehavioral, ps ychodynamic, and biological theories all been advanced as caus es of phobias. S ome wellphobias, such as fear of animals, may result either early traumatic events (developing P.994 along the paradigm of class ic P avlovian conditioning) from displacements of early ps ychodynamic conflicts. 956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 142 of 185

G enetic influences may also play a role in the of phobias . F or example, some individuals with bloodinjury phobias, which strongly cluster among biological relatives , may be genetically predis pos ed by vagal res ponses to certain stimuli. Animal models als o poss ible biological vulnerability. S ome monkeys that never previously been exposed to snakes become when placed in the presence of a snake. B ecaus e s uch res ponses obvious ly have adaptive value, it has been suggested that s ome human phobic res ponses also represent exaggerations of adaptive behaviors s haped evolutionary biology. C omple x phobias , more elaborate than s pecific phobias , involve fears related to a broader range of situations. Agoraphobia, the best known, fear of the marketplace, s ymbolizing a fear of open C urrent thinking sugges ts that agoraphobia is a reaction to panic attacks. In this view, individuals who become terrified of having panic attacks in public to the safety of their own homes, hoping to reduce the likelihood of panic attacks by avoiding places where were once triggered and where they may feel exposed embarrass ed. In s ocial anxiety dis orde r (s ocial phobia), patients overwhelmingly anxious and fear situations in which may be observed. In the limited type, only a few situations evoke the fear, s uch as speaking in public or us ing a public lavatory. In the general type, broadfears of s ocial s ituations globally hamper the person's interpersonal life.

A ggres s ion, Hos tility, and Violenc e 957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 143 of 185

T he spectrum of aggres sive emotions and behaviors is characterized by heightened vigilance in response to a sens e of threat and enhanced readiness to attack. P hysiological tone may be geared for a fight. Ass ertivenes s, the adaptive as pect of thes e emotions , includes sens ing that something needs to be done and feeling willing and competent to take cons tructive T he manner and extent to which aggres sive emotions be expres sed varies from s ociety to s ociety and from situation to s ituation. T hes e emotions are among the carefully regulated because of their potential destructiveness . Acts of aggres sion are on a beginning with irritability, progres sing to verbal threats and intimidation, and extending to physical bullying and as sault to homicide, sometimes including acts of calculated violence and s adism. Irritability is an unpleasant feeling s tate characterized inner unease. In contrast to anger, irritability does not less en after an outburst. Often, others are more aware an individual's irritability than is the pers on him- or It is diagnos tically nons pecific, s een in a variety of phys iological states —ps ychotic, anxiety, and mood disorders —and as a lifelong temperamental quality. Hunger, s leepiness , s exual frus tration, and pain are the physiological triggers commonly as sociated with irritability. Individual differences in the tendency toward experiencing and express ing anger and violence are biological, developmental, and cultural in origin. S ome infants are irritable from birth. S ubtle early birth injuries and brain anoxia may increase the susceptibility of people to be violent. F urthermore, studies of E E G 958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 144 of 185

in violent people s how increased abnormalities, in those with repeated violence and violence with little no obvious motive. S oft neurological s igns are also violent criminals. B iochemically, low cerebrospinal fluid (C S F ) 5-HIAA has been as sociated with a variety of impulsive behaviors, such as violent crimes , recurrent setting, and violent suicide attempts . C ons is tent with the hypothesis that an invers e exis ts between central serotonergic s ys tem function impulsive, aggress ive behavior, a few double-blind, placebo-controlled studies in patients with cluster B personality dis orders have demons trated that central s erotonergic function by using S S R Is reduces irritability and impuls ive aggres sive behavior. A 42-year-old woman was described by those who her as controlling, obs ess ional in s tyle, and rigid in expectations . W hen events in her hous e did not turn she wis hed or when others (husband and children) did behave according to her demands , s he became very irritable, yelling, criticizing, and berating. E ventually, agreed to treatment with an S S R I, which markedly diminis hed her reactivity to events. T he pos itive effect far more apparent to her family members than to the patient herself. T he pathological childhood triad of bed-wetting pas t the age of 6 years , s etting fires , and torturing animals has as sociated with s ubs equent violent behavior in adults . Interpersonally, s tudies show that violence-prone individuals require more personal s pace around their phys ical person than do others . V iolent individuals feel threatened when approached too clos ely, particularly 959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 145 of 185

the rear. P sychological and social contributions are als o s trong. V iolence in families breeds violence, and battered often grow up to be battering adults. C ultural norms for the expres sion of violence differ cons iderably. In s ome socioeconomic and ethnic groups , violent gangs the energies of many adoles cent youth. F or some, behavior is an adolescent socialization pattern to prove one's manhood or womanhood. Like other organizations , violent gangs have detailed rules that inhibit and govern the express ion of violence. S ome unpredictable and uns ocialized violent people, loners , too violent to be contained even in gangs. Aggress ive and violent behavior is diagnostically nonspecific. V iolence in s chizophrenia may occur as a cons equence of paranoid delus ions , in res ponse to command auditory hallucinations , or secondary to pass ivity experiences . Manic patients and thos e in states may be violent, often in res ponse to minimal provocation. V iolent behavior commonly occurs in patients with antis ocial and borderline personalities (in latter often self-directed as well as other directed). behavior may occur in epileps y, although rarely during true ictal periods ; in frontal lobe syndromes as a phenomenon”; and in as sociation with abus ed particularly disinhibiting s edatives , such as alcohol, or stimulants such as amphetamines and cocaine, which increase irritability, aggres sivenes s, and paranoia. Impulsive violence may be provoked by a number of stimuli and s ituations. Alcohol is perhaps the most common dis inhibitor of violence. Intrafamilial violence, most common s etting for homicide, is frequently related 960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 146 of 185

to alcohol intoxication. In epis odic dys control and intermitte nt e xplos ive dis orde r, violent behaviors erupt after a pers on has inges ted alcohol, a known as pathological intoxication. In these often outburs ts , the individual may confront or provoke any potential target for violence, including total s trangers police, but girlfriends, wives , and parents are frequent victims . P atients with epis odic dyscontrol commonly histories of violent sexual behavior, including rape, often while intoxicated, s peeding and reckles s driving, sometimes chasing down, s topping, and attacking motorists who they believe “get in their way.” An attractive 40-year-old woman had been highly after by rich and powerful men, several of whom she married and several of whom divorced her becaus e of uncontrollable rages . S he des cribed hers elf as “insanely jealous” in a flas h whenever she s aw her P.995 glancing at other attractive women, and her behavior flared out of control, particularly when she had been drinking alcohol. On one occasion, she bit off one husband's ear. S he attacked another with pots and nearly killing him. S he recognized how serious her problems were and s ought ps ychotherapy, medication (S S R Is were helpful), and anger management training help her control her emotions and behaviors .

Temper Tantrums Immature individuals with persistent personality may not develop mechanis ms to inhibit temper 961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 147 of 185

they dis played as children. P articularly if childhood tantrums produced the des ired res ult, learned tantrum behaviors may pers ist into adult life. Although s uch individuals may be pleas ant and s ociable when life is going well, they lack the capacity to tolerate frustration and are eas ily provoked by threats to s elf-es teem and image and by not having their own way. When or threatened, they may act like bullies , glare, s narl, shout, intimidate, pout and s ulk, and s ometimes be phys ically violent.

Dis plac ed R age When circums tances prevent the expres sion of rage directly agains t those people or institutions provoking frus tration, other outlets for aggres sion are often found. Acts of violence that are either calculated or wanton res ult. C ruelty to animals and fire setting may pers ist adult forms of destructive behavior. R ape, an act of intimidation, terror, and humiliation, may als o displace frus trations that are not expres sed more adaptively. S adism may occur with or without explicit s exual gratification. C alculated cruelty conducted s eemingly without anger or emotional arous al may reflect inadequate development of s ocial morality or individual cons cience, as in the conduct of torturers and some blooded murderers. In s ome s ocieties and under circums tances at certain times in history, such activity been s ocially sanctioned, s uggesting at leas t that some people lack inborn inhibitions agains t cruelty or A 50-year-old man with antis ocial pers onality disorder seen in a psychiatric emergency room for violent 962 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 148 of 185

During the cours e of the as sess ment, he described had been emotionally and phys ically abus ed by a father who whipped him repeatedly until he bled and chained him to a tree in the backyard. T his man grew feeling callous . He enjoyed intimidating and phys ically hurting others, as he often did in pris on. W ith a laugh smirk, he reflected on how he turned out to be “just like my old man.”

S elf-Mutilation F or a variety of reasons, in many different cultures and many different disorders , people commit acts of agains t themselves , ranging from body piercing to and burning to autoamputation. P sychotic patients may perform extremely self-destructive acts s hort of actual suicide that often have symbolic import, s uch as enucleating their eyes or castrating thems elves . with borderline pers onality dis orders or borderline traits may cut thems elves repeatedly with broken glas s or blades or burn themselves with cigarettes on arms, breasts, or other body parts . P atients typically deny these acts are meant to be s uicidal but describe the to feel external pain to mirror internal suffering, or to releas e tension, or to counteract diss ociative-like numbness . R ecently, self-cutting has become more common in teenagers , es pecially girls, as a tensionrelieving mechanis m. A 20-year-old college student was taken to the room by her friends , who were alarmed by the recent transvers e cuts on her arms. None of the cuts were enough to require s utures but, even when they had 963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 149 of 185

healed, they left obvious s mall red s cars on her skin. In explaining her behavior, the s tudent described that she was upset, such as after a fight with her boyfriend negative telephone call with her parents, she became agitated, and cutting herself consis tently relieved the agitation and anxious feelings . T richotillomania is a syndrome of compuls ive hair res ulting in bald patches. It is often ass ociated with self-mutilatory behavior, such as picking the face, nails, cuticles to the point of infection and bleeding. T richotillomania may s ometimes be related to OC D. C hildren with L e s ch-Nyhan s yndrome , a developmental disability syndrome caus ed by a congenital metabolic abnormality, bite and pick at thems elves so as to do themselves great harm and routinely require res traint. Occas ionally, patients with T ourette's demonstrate compuls ive s elf-harming behavior.

Other Dis turbanc es of F eelings Diminished levels of emotional intensity may be s een in anxiety disorders , mood dis orders, and s chizophrenia. emotional flattening with blunted ability to feel joy is common in dys thymia. S ome patients with narciss istic borderline pers onality disorders complain of inner emptines s and pervasive boredom and ennui without demonstrating diminis hed affect in interviews . S imilarly, patients with prominent depers onalization describe numbed emotions . P athological levels of blunt or affe ct, indicating markedly diminished affective in relation to specific thought content, may be s een in chronic s chizophrenia (as part of the deficit s yndrome), some organic mental syndromes, and s evere 964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 150 of 185

and as a s ide effect to many medications , including antidepres sants, antips ychotic medications, or tranquilizer use. Although the term blunte d affect is not clas sically us ed to describe the affective flatnes s of depres sion, it is not always easy to dis tinguis h between schizophrenic and depress ive flatness on phenomenological grounds. Anhe donia, the lack of pleas urable feelings from activities that ordinarily pleas ure, is als o s een as part of s evere depres sions or schizophrenia. C hronically ps ychotic patients often emotional deterioration in which affective experience expres sion are entirely unrelated to thought content. Inappropriate affect is incongruency of affective and thought content. T he patient may dis play loud and raucous laughter or giggling in relation to bland or s ad thoughts or may s how grief without apparent reason. Inappropriate affect sometimes indicates that the thoughts have private meanings for the patients ; the emotional expres sion might make better s ens e if the private meanings were understood. Inappropriate affect must be dis tinguis hed from affective express ions that actually be appropriate in a given s ubculture or ethnic group that is unfamiliar to the observer and from defens ive affect, s uch as the nervous laughter us ed to alleviate tension or ward off crying. Affe ctive (or mood) lability is characterized by rapid emotional s hifts, often within s econds to minutes. It is commonly s een during hypomanic s tates, late luteal phase dysphoric disorder (premenstrual s yndrome), pos tpartum blues, other of physiological instability, and in clus ter B pers onality disorders . P.996 965 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 151 of 185

A 51-year-old man with lifelong dys thymic dis order was treated with an S S R I. Although he had an excellent antidepres sant res ponse, 2 months after beginning treatment, he noted an affective flatness . He des cribed becoming as easily ups et as before treatment (which he and his wife interpreted positively), but also he his s ens e of joy, in being with his children or in nature, markedly blunted. He enjoyed pos itive events but with marked diminution of affective intens ity. Ale xithymia is difficulty identifying, describing, and differentiating feelings or distinguishing between and phys ical s ens ations . Alexithymic individuals often have constricted imaginations and fantas ies, are preoccupied with objects and events in the outside and have little private, pers onal internal life. When distress ed, the patients are s imply aware of not feeling well and us ually complain of s omatic s ymptoms, to frus trating interactions with their phys icians who cannot find phys ical caus es for the pres enting phys ical complaints . S ome view alexithymia as a condition in affect is communicated through somatic language. With regard to other feeling states that may contribute pathological conditions, recent writers have focus ed on the role of “shame” as a potentially important emotional mediator of specific types of narcis sis tic injury that may provoke s tates of depres sion, rage, P T S D, and suicide, among others . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > MO T OR AS P E C T S O F B E HAV IO R

966 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 152 of 185

DIS TUR B ANC E S IN MOTOR AS PE C TS OF B E HAVIOR P art of "8 - C linical Manifes tations of P s ychiatric Motor behavior is normally finely coordinated, and adaptive, and neces sary activities are usually out efficiently. In ps ychiatric disturbances , motor abnormalities can involve generalized overactivity or underactivity or manifes t in a wide range of s pecific disorders of movement.

Overac tivity R es tle s s ne s s and agitation are diffus e increases in movement, us ually noted as fidgeting, rapid and leg or hand tapping, and jerky s tart-and-stop of the entire body, accompanied by inner tension. R es tles sness accompanies psychiatric conditions of emotional arousal or confusion, s uch as toxic s tates , mania, agitated depres sive dis orders, and anxiety disorders , as well as many medical disorders such as hyperthyroidism. In some depress ive states , agitation often accompanied by pacing and hand wringing. G eneralized overactivity, in which patients seem to increased phys ical energy, is distinguis hed from by its lack of inner tension and by more purposeful movements. It is commonly seen in mania, hypomania, and anorexia nervos a and as part of ADHD and in to stimulating drugs and medicines . 967 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 153 of 185

A 25-year-old extraordinarily restless man in a emergency room, whos e glances darted incess antly around the room, paced agitatedly, picked at his skin, shifted cons tantly on his feet, and jiggled his arms and legs. His speech was rapid, and his mood was irritable. had been us ing intravenous (IV ) methamphetamine on “run” for more than 1 week and was brought to the emergency room by relatives who were concerned that was s tarting to get paranoid. In catatonic exciteme nt, much less common now than the preneuroleptic era, patients exhibit dis organized overactive behaviors , including frantic jumping, of limbs , and seemingly s ens eless menacing or behaviors . S uch excitement is seen in mania, periodic catatonia, catatonic forms of s chizophrenia, and some culture-bound s yndromes such as amok. C onfus ional exciteme nt is a state of res tles sness and generalized purpos eless activity s een in ictal s tates, s ome acute intoxications, and deliria.

Dec reas ed Motor A c tivity G lobal reductions in motor activity—motor are seen in a variety of phys ical disorders , s uch as hypothyroidism, Addison's disease, s ome infectious postinfectious conditions , including C F S and pos tpolio syndrome, and other fatiguing conditions, as well as in some organic mental disorders , intoxications, schizophrenias , and depres sive dis orders. P overty of movement (akinesia, or more properly, hypokines ia) occur in schizophrenia and as a neuroleptic s ide effect. C hanges in the voice frequently accompany the motor activity in s chizophrenia and depress ion, with 968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 154 of 185

normal inflection replaced by monotonous tone and prolonged speech latency. In s tuporous states , patients remain immobile, although their eyes are open, and are apparently awake. C onvers ion reactions are functional, nonphys iological, ps ychogenic impairments in sensory or motor C ommon motor forms include various paralyses and pareses, including limb paralyses, ataxias , and globus hys te ricus , the patient is unable to swallow. with as tas ia-abas ia have marked uns teadiness of gait. S ensory convers ion reactions include blindnes s, anesthes ia, and analges ia. S ome hyperes thes ias and syndromes may als o originate as conversion An 18-year-old s oldier from a very rural area was to the emergency room at an army pos t during his of bas ic training because his gait had become very unsteady. He was s tumbling into walls and seemed to maintain an erect posture. He found it necess ary to crutches to ambulate. T here was no history of us e. On examination, the s oldier was found to be tremulous , anxious , and homes ick. He had never been away from his family before and miss ed them deeply. When he was reas sured that he would be is sued a see his family, his demeanor changed, and his gait instantly improved. T o the amazement of his and drill sergeant, he was able to leave his crutches at door. T he diagnosis was as tas ia-abasia.

Mutis m Mutis m may res ult from a variety of peripheral muscle C NS conditions and from functional disorders. Mutis m 969 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 155 of 185

occur in profound depres sion, catatonic states, and conversion reactions. E le ctive mutis m is occasionally in acute adjustment disorders and some pers onality disturbances .

Motor Dis turbanc es Many motor disturbances are seen in psychiatric S ome form part of the core s ymptoms of the disorders ; some occur in disorders that, by their nature, bridge neurology and ps ychiatry (s uch as T ourette's others are acute or chronic medication side effects.

S imple Motor Phenomena TR E MOR T remors , involuntary oscillating movements of the head, may occur at res t or with movement. tre mors , which are minimal at res t and increase with activity, are P.997 characterized by small amplitude and high frequency. T hey are characteristic of anxiety, fatigue, and toxic or metabolic disorders , s uch as caffeinis m or hyperthyroidism, and are commonly s een in patients taking a number of different ps ychiatric medications , including lithium (E s kalith), valproate (Depakene), and stimulating antidepress ants. C oars e tre mors , with amplitude and lower frequency, are seen in P arkinson's disease and cerebellar dis eas e. As te rixis is a largeamplitude flapping tremor of the hands s een in hepatic disease. P arkins onian s ymptoms and s igns may be ps ychiatric disorders, particularly in patients taking 970 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 156 of 185

antips ychotic medications. S ymptoms include with marked decrease in normally spontaneous stiff gait with diminished arm s wing, pill-rolling nonintention tremors (which seem to be less common drug-induced parkinsonis m, compared with the type), express ionless soft and monotonous speech, micrographical handwriting, and cogwheel rigidity.

DY S TONIC MOVE ME NTS Although dystonic movements are s een in many neurological disorders , in ps ychiatric patients, they are almos t always s econdary to the us e of antips ychotic medications . Dys tonic reactions consis t of intermittent sustained muscle spasms, typically of the head or C ommon varieties include tongue spas ms causing dysarthria, torticollis (neck s pas m), and oculogyric which there is a forced upward gaze. Opisthotonus (s pas ms of paras pinal mus cles leading to an arched posture) is s een les s often. T hese reactions are most common in young males and typically occur s oon after beginning or increas ing the dos e of a conventional antips ychotic medication.

A K A THIS IA Akathis ia is a syndrome of motor res tless nes s seen predominantly in the context of antips ychotic and s ome antidepres sant medication use. It has subjective, as motor, components. S ubjectively, patients experience muscle tens ion, difficulty finding a comfortable body position, and inability to s top moving; they feel as they are “jumping out of their s kin.” Objectively, clas sically manifes ts by rocking from foot to foot while 971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 157 of 185

standing, frequently cros sing and uncross ing the legs when seated, and pacing. S leep may be disturbed of phys ical discomfort. S ubjective components of may be difficult to distinguish from anxiety caused by primary disorder (typically s chizophrenia). R arely, the res tless nes s and inner agitation become sufficiently uncomfortable to provoke acts of violence. In ps eudoakathisia, objective s igns of akathisia are but the patient denies feeling res tless . A 45-year-old man with OC D and T ourette's syndrome being treated with fluvoxamine (Luvox), 200 mg per inadvertently took 400 mg per day for 3 days. On the day, he s tarted to feel increasingly agitated, his legs res tless and jittery, and he started to fidget. He also noted frequent s ighs in his breathing, his usual res piratory pattern. He recalled feeling these sens ations a decade earlier when a previous treated his T ourette's syndrome with haloperidol and that his psychiatrist had diagnos ed akathis ia. After discontinuing the fluvoxamine for 4 days , these all abated.

TA R DIVE DY S K INE S IA T ardive dys kine s ia is a movement dis order that occurs in the context of antips ychotic medication us e, occasionally after many months but more commonly years . T he abnormal movements may persist with or without continued medication us e or may diminis h or disappear over time. T he dyskinetic movements occur res t and can usually be temporarily s uppress ed or by purposeful action, dis traction, or sleep. T he 972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 158 of 185

movements are varied. In the most common type, affects the face, es pecially the mouth and lips, tongue thrusting, chewing movements, lip s macking, and eye blinking are seen. Another common type is by choreoathetoid movements, such as writhing finger motions. In the less common but more s evere truncal dyskinesias, the tors o moves in thrusting motions , and res piratory dyskinesia is characterized by grunting and irregular breathing patterns. Other tardive (late) syndromes include tardive akathisia and tardive in which the abnormal movements emerge late in treatment or on medication dis continuation.

NE UR OL E P TIC MA L IG NA NT Neuroleptic malignant syndrome (NMS ), a potentially complication of antips ychotic medication, is by muscle rigidity, fever, diaphoresis, delirium, mutism, and blood pres sure abnormalities. S ome view NMS as most severe end of a spectrum that starts with antips ychotic-induced parkins onism, progres ses to extrapyramidal s yndrome with fever, and then to fulminant NMS .

R A B B IT S Y NDR OME T his uncommon drug-induced extrapyramidal often mis diagnos ed as tardive dys kines ia. It mos t res embles a limited express ion of a parkins onian P atients make rapid chewing movements s imilar to made by rabbits, ordinarily fas ter and more regular the orofacial tic of tardive dys kines ia. T he tongue is

B L E P HA R OS P A S M 973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 159 of 185

B le pharos pas m is a rapid and violent repetitive, movement of the eyelids. T hes e movements are often side effect of antipsychotic or other medications but are also common in a variety of neurological disorders, including Meige's s yndrome and T ourette's s yndrome.

TIC S T ics are rapid, repetitive, often s pas modic jerking involuntary movements that s erve no apparent T he person may try to disguise or hide the tic in a seemingly purposive movement, and the movement ultimately be s haped into a mannerism. T ics are the feature of tic dis orders , are as sociated with other and may occur as a consequence of s timulant use. T ourette 's dis order is characterized by a chronic array of motor and vocal tics . T he tics may include coughs, clicks, or sniffs , whereas motor s ymptoms may include eye blinking, tongue protrus ions, facial hopping, and twitches. C omplex tics may merge into complex compuls ive behaviors such as squatting, deep knee bends, and retracing steps . C oprolalia, by sudden verbal outburs ts of obscenities, occurs in than one-third of T ourette's patients. Me ntal coprolalia an as sociated feature in which obscene words or suddenly intrude into cons cious nes s in an ego-dystonic manner. Obsess ive-compuls ive s ymptoms, as well as attention-deficit s ymptoms , are als o common in syndrome.

S E R OTONIN S Y NDR OME S erotonin s yndrome is a dis order caused by excess ive serotonergic input in the C NS , probably within the 974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 160 of 185

hypothalamus. T he most common caus e of serotonin syndrome is the combination of two or more with serotonin-enhancing properties , us ually by mechanisms. It is characterized by res tles sness , hyperreflexia, diaphores is , shivering, tremor, changes, including fever, and mental s tatus changes , as confus ion.

Motor Dis turbanc es of Many of the abnormal movements ascribed to tardive dyskinesia and other antipsychotic-induced extrapyramidal s yndromes have been des cribed in P.998 chronically ps ychotic patients before the introduction of antips ychotic medications. In one s eries of 100 the large majority of whom were diagnos ed as schizophrenic, a review of medical records before 1955 revealed that abnormal purpos ive movements were in 83 percent, manneris ms and tics in 71 percent, abnormal eye movements in 27 percent, abnormal postures or facial movements in 42 percent, and gait abnormalities in 10 percent. T hese findings s uggest many patients with s chizophrenia have neurological symptoms not due to medications and that s evere ps ychiatric disorders may have a neurological as well.

C A TA TONIC B E HA VIOR S C atatonia refers to a broad group of movement abnormalities us ually as sociated with s chizophrenia also found in other dis orders s uch as mania, 975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 161 of 185

many neurological dis orders (es pecially those involving the bas al ganglia, limbic system, diencephalon and lobes ), s ys temic metabolic dis orders, toxic drug states, periodic catatonia. C atatonic s tupor and excitement already been noted. S te re otypie s are repetitious , seemingly non–goal-directed, complex organized or pos tures that are believed to have private meanings the patient. E xamples include continuous ly and cross ing oneself or bless ing others in a religious waving in a stylized manner, and making profane T he stereotypic behaviors commonly seen in autistic children (constant s pinning or rocking) may provide soothing, steady sens ory input that helps the patients reduce the degree to which they are dis turbed by the ordinarily unpredictable and uncontrollable s timulation coming from the environment. B izarre pos turing may be seen in catatonia. One chronic schizophrenic routinely stood for hours on one leg with his arms in the like a crane. In echopraxia, the patient imitates the examiner's movements and in echolalia imitates if in mimicry. S ome catatonic patients exhibit waxy fle xibility, maintaining unusual postures in which they been posed for prolonged periods of time. Negativis m take the form of refusing to behave in a prescribed or resisting pass ive movement.

Other Movement Dis turbanc es G ait dis turbance s in patients with ps ychiatric disorders include a variety of neurogenic gaits consistent with disease, intoxications, and medication side effects . include the festinating gait of parkins onis m, spastic and ataxic gaits of neurological disease and ps ychiatric medications , waddling and reeling gaits as sociated 976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 162 of 185

intoxications, and the nonphys iological gait seen in as tas ia-abasia, a form of convers ion disorder. manneris ms include clowning, prancing, military, and effeminate gaits . B ruxis m, chronic jaw clenching, may occur involuntarily during tens ion states , as an is olated occurrence during delta s leep, in which it has s ometimes been as sociated with benzodiazepine or alcohol us e, or in as sociation S S R I us e. In s evere cases, serious damage to dental and temporomandibular joint pain may occur. Myoclonus , characterized by focal muscle jerking, can caus ed in ps ychiatric patients by certain medications, as S S R Is or monoamine oxidas e inhibitors (MAOIs). Myoclonic jerks may be difficult to dis tinguish from tics, but the latter often repres ent larger mus cle groups and more highly organized motor patterns . Myoclonus may seen at res t but is more obvious during motor activity.

S eizure-L ike B ehaviors In addition to the generalized, petit mal and complex partial s eizures s een in s ome ps ychiatric patients, a number of nonepileptic s eizure-like behaviors mus t be distinguished. B reath-holding s pells , generally impulsive, and tantrum-like phenomena, us ually occur small children who hold their breaths during moments oppos itional rage and who may faint as a res ult. twitching motor movements may occur. T e mpe r in young children may look like seizures , es pecially to uninformed observer. T he children may lie on the floor, screaming and kicking, and do not res pond to the environment. C onvers ion s e izures (hysterical seizures, ps eudoseizures ) must be differentiated from genuine 977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 163 of 185

epileptic seizures . P atients retain consciousness , lack abnormal reflexes , and are not incontinent. However, because so many convers ion seizures occur in patients who have genuine epileps y and who know a good deal about the condition, the differential diagnos is is sometimes difficult. C ompuls ive be haviors may occur relation to everyday activities, s uch as gambling, conquest, shopping, and watching T V , or in relation to subs tances such as alcohol, cocaine, narcotics, and Other compulsions involve reckless ris k-taking that provide s timulation and dispel dysphoric moods. S exual compuls ive perversions, such as exhibitionism sadomas ochis m, may serve similar purpos es . are seen in a variety of psychotic and nonps ychotic ps ychiatric disorders. T he cravings that underlie compuls ive behaviors are s trong motivating forces , and the compuls ive behaviors may regulate emotions. Unknown s imilarities may underlie all compulsive and addictive mechanisms. C urrent controversies s urround relations hips of compulsive, impulsive, and addictive behaviors . S ome authorities have propos ed that all should be s ubs umed under the rubric of a s o-called deficiency syndrome, resulting from various of gene polymorphis ms governing dopamine and mechanisms and including s erotonin, cannabinoid, and other transmitter s ys tems as well. F rom this the compuls ive, impulsive, and addictive behaviors all increase the amount of dopamine and potentially other transmitters in specific brain areas . S tudies in the pas t decade have shown that, in various s ubject groups, the T aq 1 a1 allele of the DR D2 gene is as sociated with alcoholism, drug abuse, s moking, obesity, compuls ive gambling, and several personality traits. S everal other 978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 164 of 185

candidate genes are als o under investigation. S tudies also shown that certain impulse-like behaviors may be as sociated with very specific genetic polymorphis ms . In studies of patients with s evere obes ity, binge eating behavior was s een only in those individuals who had specific mutations in genes controlling the expres sion melanocortin 4 receptors . In OC D, the compuls ions are ritualized, repetitive behaviors that are performed with the goal of neutralizing, and undoing obses sional thoughts. intended to decrease anxiety, rituals are never more transiently s ucces sful. T he mos t common compulsions involve checking to make certain that gas jets and have been turned off and that windows and doors are locked, hand washing, repeating certain phras es , objects, and placing objects in a pres cribed order. A 47-year-old woman had always been fus sy about and cleanlines s but, s ince the birth of her child 14 before, had become increasingly obsess ed by S he spent 3 hours daily ritualis tically cleaning the apartment, using 3 to 4 rolls of paper towels daily. If a family member left even a fingerprint on a table, she became agitated and spent much time recleaning the surface and admonis hing the family member. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > LANG U AG DIS OR DE R S

LANGUAGE DIS OR DE R S 979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 165 of 185

P art of "8 - C linical Manifes tations of P s ychiatric C ommunication difficulties may be due to dis orders of thinking as previous ly des cribed, abnormal s peech patterns in mood dis turbances and s chizophrenia, or primary s peech fluency disorders , such as stuttering stammering, dis orders of the articulation and P.999 speech apparatus , and C NS disturbances involved in hearing and speech generation (aphas ias ). Manic patients typically exhibit pre s s ured s pee ch, in the speed of word stream is accelerated. If severe, the speech may be garbled, imprecise, and difficult to unders tand. P atients with ps ychomotor retardation depres sion s peak s lowly and monotonously and have a long s peech latency in res pons e to questions . S chizophrenic patients may exhibit a variety of s peech abnormalities , including poverty of s peech and poverty content of speech (in which the amount of speaking is normal, but unders tanding the central mess age is or imposs ible). S chizophrenic patients may als o be to understand becaus e of the dys arthric effect of antips ychotic medication. Allus ory s pe e ch is vague, imprecis e, and hard to comprehend because too few cues and details are provided for the listener. S uch speech may be heard some patients with s chizophrenia or certain personality disorders or even normal individuals who wis h to sens e of mystery by just being s ugges tive, whose suspicious nes s causes them to be reluctant to s pell out clearly, or who believe that the listener is more 980 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 166 of 185

of their private codes , meanings , and allusions than is case. S tuttering and s tammering (ordinarily s ynonymous) disturbances in the rhythm and fluency of s peech due blocking, convuls ive repetition, or prolongation of T his dis order affects males two to three times as often females, and there is a high rate of familial Aphas ias , impairments of language produced by brain dysfunction, are ordinarily des cribed as being fluent nonfluent. In fluent aphas ias , which generally reflect dysfunction in the left temporal and parietal area, have a normal or even elevated verbal output, with logorrhea, but they ignore the s ocial conventions conversation. T hey produce many well-articulated with normal pros ody, but there is little informational content. T he fluent aphas ias are further divided to the extent of comprehension by the patient and the ability of the patient to repeat what the examiner s ays. principal fluent aphasias are W ernicke's aphas ia, conduction aphasia, anemic aphas ia, and transcortical sens ory aphasia. Nonflue nt aphas ias are characterized by s low and poor verbal output, difficulty with spontaneous s peech, omis sion of grammatical connecting words, and poor prosody. P atients may produce one-word replies or short phras es . B rain lesions that cause nonfluent typically tend to occur in the anterior left hemis phere. principal nonfluent aphas ias are B roca's aphas ia, transcortical motor aphas ia, global aphas ia, and the transcortical aphas ias . In apros odias , the nonverbal as pects of s peech, the 981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 167 of 185

melody, paus es , timing, s tres s, accent, and intonation impaired. Damage to the right prefrontal region has as sociated with express ive apros odias, and damage to right temporal region and insula has been as sociated receptive aprosodias . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > INT E R P E R S ONAL R E LAT IONS HIP

DIS TUR B ANC E S OF INTE R PE R S ONAL R E L ATIONS HIPS P art of "8 - C linical Manifes tations of P s ychiatric Normal interpers onal relations hips include relationships with parents, children, s pous es , lovers , s iblings, family members , friends , colleagues , coworkers, and members of the larger community. T hes e relations hips ordinarily help provide for the satis faction of bas ic for affiliative needs , and for finding purpos e and in life. T hrough s table and s atis fying relationships , needs are met for intimacy, including love, s ex, and affection; to be cared for and nurtured, provide care, play, relax, dominate, and be productive through effort. Interpersonal relationships are carefully by means of interpers onal s igns and s ignals . T he which deviance from thes e patterns is tolerated in a relations hip varies from behavior to behavior, to relationship, family to family, and culture to culture. 982 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 168 of 185

Dis turbances in interpersonal relationships may be as characteristics attributable to a s ingle person or as characteristics of an interpersonal system. Individual disturbances are considered to be undes irable or maladaptive pers onality traits . W hen thes e traits are present to a s ignificant extent and interfere with social functioning or cause distres s, they may compose a personality dis order. Dis turbances of interpersonal relations hips have als o been des cribed at a systems (e.g., as dyadic and family patterns of system

P ers onality Traits and Dis orders P ers onality, variably defined, is the characteristic an individual's attitudes , behaviors , beliefs , feelings , thoughts, and values —the sum of a pers on's cognitive, and interpersonal attributes. P ersonality are the prominent and characteristic features of an individual's pers onality and do not imply ps ychopathology. As pects of pers onality are pres ent early life, and personality traits are relatively s table adoles cence onward, cons is tent acros s different environments , and recognizable by friends and acquaintances. T he term pe rs onality dis orde r s hould res erved for those consistent patterns of thought, and behavior that are inflexible and maladaptive. P ers onality disturbances manifest primarily in interpersonal contexts and in this way can be viewed interpersonal behavior disorders . T he determinants of personality are multiple and innate and early biological, developmental, and environmental factors inside and outs ide the home. T hrough learning and the environment, temperamental 983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 169 of 185

factors (genetic or constitutional) are shaped into character. T he dimensional approach to pers onality and pathology characterizes individuals along a continuum traits. F ive dimens ions of temperament have been described that appear to be s omewhat independent to have strong genetic contributions: neuroticis m emotional, reactive, and thin s kinned, contrasting with emotional stability), extrovers ion (contras ting with introversion), opennes s (contras ting with dis comfort novel experiences ), agreeablenes s (contrasting with contrarines s), and cons cientious nes s (contras ting with fickleness ). T hese temperamental attributes may have implications for the course of psychotherapies that cut acros s diagnostic categories . Another dimens ion of personality not adequately dealt with in the DS M-IV -T R concerns moral behaviors such hones ty and integrity. T he extent to which individuals behave hones tly and with integrity differs cons iderably acros s individuals and in different s ituations. Deception and lying are common behaviors that occur in benign forms (e.g., in “white lies ”) and in pathological forms , ps ychiatrically important in antisocial and s ociopathic disorders , pathological liars , and malingerers. and lying may be difficult to as sess clinically in the of additional informants . S tudies of nonhuman primates indicate that, at leas t among chimpanzees, deception (equivalent to lying and dishones ty) is relatively and, in some situations , adaptive. Another pers onality typology characterizes personality along three dimensions related to temperamental characteristics pres umed to be strongly influenced 984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 170 of 185

genetically: harm avoidance , nove lty s e e king, and de pendence . High s cores on the three dimens ions characterize inhibition and pess imism, impuls ive and exploratory behavior, and dependency and res pectively. Different personality types can be according to patterns of s cores on the three F or example, antisocial personalities are characterized high novelty seeking, low harm avoidance, and low dependence, whereas dependent characters have low novelty seeking, high harm avoidance, and high reward dependence. P.1000 DS M-IV -T R , by contrast, us es a categorical approach, both the large overlap among the DS M-IV -T R disorders and the clustering of these pers onality into three broad groups imply a lack of clear the currently defined categories . T he three DS M-IV -T R clus ters describe odd or eccentric types (clus ter A); dramatic, emotional, and erratic types (clus ter B ); and anxious and fearful types (clus ter C ). T he odd or eccentric group includes paranoid, s chizoid, and s chizotypal personality dis orders. P atients with personality dis orders have the core traits of being interpersonally dis tant and emotionally cons tricted. P aranoid personalities are quick to feel slighted and jealous, carry grudges , and expect to be exploited and harmed by others. S chizoid personalities lack or close relationships with others and are indifferent to praise or criticism by others. S chizotypal personalities display odd beliefs, engage in odd and eccentric 985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 171 of 185

and practices , and exhibit odd s peech. T he dramatic, emotional, and erratic group includes borderline, histrionic, narciss is tic, and antis ocial personality dis orders. P atients with these pers onality disorders characteris tically have chaotic lives , and relations hips. B orderline pers onalities are unpredictable, angry, temperamental, unstable in relations hips , compuls ively interpersonal, and s elfdamaging with regard to sex, money, and s ubs tance His trionic personalities are attention s eeking, exhibitionis tic, s eductive, self-indulgent, exhibit exaggerated express ions of emotions, and are overconcerned with physical appearance. Narcis sistic personalities tend to be hypers ens itive to criticis m, exploitative of others, egocentric with an inflated s ens e self-importance, feel entitled to s pecial treatment, and demand cons tant attention. Antis ocial personalities are described almos t exclus ively by behavioral rather than affective or relational terms . T hey are truant, lie, steal, fights , break rules , are unable to s us tain work or and s hirk everyday res ponsibilities. T he anxious and fearful group includes avoidant, dependent, and obsess ive-compuls ive personality disorders . P atients with these dis orders are by cons tricting behaviors that serve to limit ris ks . As examples, avoidant people avoid relationships , personalities avoid being res ponsible for decisions , and obses sive-compuls ive people us e rigid rules that new behaviors. Avoidant personalities are to rejection and are reluctant to enter clos e spite of s trong desires for affection. Dependent personalities s how excess ive reliance on others to 986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 172 of 185

major life decis ions, stay trapped in abusive for fear of being alone, have difficulty initiating projects their own, and cons tantly seek reass urance and praise. Obsess ive-compuls ive personalities exhibit restricted expres sions of warmth, tenderness , and generosity also exhibit stubbornness with a need to be right and to control decis ions; indecisive at times , they often use rigid application of rules and morals to the point of inflexible. A characteristic pers onality disturbance s een with lobe damage is referred to as organic pe rs onality the tenth revis ion of the Inte rnational C las s ification of Dis e as es and R e late d He alth P roble ms (IC D-10) and pe rs onality change due to a gene ral me dical condition DS M-IV -T R . Its features include irritability, jocularity with euphoria, inappropriate socially behavior, and impuls iveness . Other patients with to different areas of the frontal lobe, in contras t, exhibit apathy and indifference.

Interpers onal S ys tems C ouples and families have been studied as s ys tems in own right, and many qualities of these systems have identified as being clinically important. A scheme for categorizing relational dis orders has been propos ed for future editions of the DS M-IV -T R , but, as yet, no s ingle generally accepted typology of family psychopathology interactional types has been es tablis hed. However, elements of marital dis cord and harmony have been operationalized in s everal standard marital inventories. C haracteris tics of couples and families that have the most attention include the rules of communication, 987 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 173 of 185

such as thos e governing the directnes s or indirectness with which disagreement and conflict are address ed; manner (organized or chaotic) in which are conducted; taboo topics and secrets about which one can openly communicate; the nature and degree of emotional expres sion, including affection and anger; cohes iveness , loyalty, and compatibility of members; nature of the members' s hared identities on the one and their autonomous development and s eparateness the other; the extent to which members treat one res pectfully or take one another for granted and us e another; the dis tribution of power and decis ion making among members; the maintenance of generational boundaries (e.g., age-appropriate performance of life roles); and the members' orientation toward and concurrence and disagreement about important values involving moral, religious , intellectual, cultural, financial, occupational, and childrearing is sues, as well as as pirations, health practices, leisure activities, and belief systems . A characteristic family environment, called high emotion, has been identified that defines a relapsefamily environment in which one individual has schizophrenia, bipolar dis order, anorexia nervos a, or depres sive dis order. T his interactional pattern includes demeaning, intense pers onal criticis m (“Y ou are rotten lazy”) and emotional overinvolvement with the patient. As pects of overinvolvement can be meas ured quantifying the numbers of hours of face-to-face and by the extent to which relatives categorically as sert how the patients feel without ever bothering to as k the patients. Despite thes e descriptive generalizations, the 988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 174 of 185

specific elements of high expres sed emotion families make patients vulnerable to relaps e are still obs cure. C ouple and family system difficulties are most likely to erupt during predictable s tres sful events in the normal family life cycle, s uch as during the newlywed period; pregnancy and childbearing; difficult or contentious childrearing; difficulties with parents, in-laws , and other extended family; insurmountable and unanticipated financial or career problems ; serious illness or death of child or relative; the children's adoles cence; departure children from the home; infidelity; and separation. Interpersonal attachme nt s tyle s , based on cognitive schemas that have been linked to earlier repeated experiences with caregivers, influence how individuals perceive and act within interpersonal relations hips. S pecific types that have been described include attachments (several s ubtypes include preoccupied, fearful, and anxious -ambivalent attachment), avoidant attachment (including angry-dismiss ive and withdrawn attachment), enmeshed attachment, unres olved attachment (in which s ignificant los ses have not been dealt with), and secure attachment styles . S pecific and s ubtypes have now been linked to certain types of health behaviors and clinical outcomes. F or example, diabetic patients with dismiss ive attachment s tyles , a found in approximately 25 percent of the general population and characterized by low trus t of others and excess ive self-reliance, s how a decreas ed ability to collaborate with providers and have poorer glycemic control than patients with secure attachment styles . In study at a primary care clinic, patients with insecure attachment s tyles reported more unaccounted for 989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 175 of 185

symptoms than others. Among these, patients with preoccupied attachment had the highest primary care costs and us efulness , whereas patients with fearful attachment had the lowest, reflecting their res pective tendencies to overus e or underus e medical services . P.1001

Interpers onal Dis turbanc es in B ehavior Abnormal illne s s be havior (dysnos ognosia) is a pathological mode of experiencing, evaluating, and res ponding to one's own health s tatus des pite lucid and accurate apprais al and management options provided a health profes sional. T hese behaviors can be as interpersonal dis orders between patients and health care profes sionals. C entral to all of thes e behaviors is adoption of the sick role by the patient, who then in characteris tic interactions with health care which typically leave both the provider and the patient diss atis fied. P atients with abnormal illnes s behavior typically s eek repeated medical evaluations from a multitude of physicians, often undergoing a s eries of expensive laboratory tests . At times, the level of complaints provokes unneces sary invasive laboratory examinations or surgeries, which, in turn, thereby place the patient at genuine medical ris k. Abnormal illness behaviors may be unconscious or cons cious. Uncons cious abnormal illne s s be haviors those in which the patient believes the symptoms some genuine illness . T hese behaviors may occur in somatization disorder (in which multiple s ymptoms and 990 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 176 of 185

organ s ys tems are affected), convers ion disorders, somatoform pain dis order (in which no cause for the subjective level of pain can be found), and hypochondriasis (in which the primary fear is of having serious dis order). Abnormal illness behaviors in which patients act sick when they are fully aware that they not include malingering (in which external incentives — us ually financial—are the motivating factors) and factitious disorder with phys ical or ps ychological symptoms (Munchausen's s yndrome). In s yndrome , patients repeatedly and compulsively thems elves for medical care with feigned or selfillness . T hese self-induced conditions may be s o to ultimately caus e death: S ome patients inject with feces to caus e s ys temic infections that then hospitalization and intens ive care. W hen the s elfnatures of the illnes ses are dis covered, medical s taffs become outraged at these patients. T he patients rarely accept or cooperate with ps ychiatric care, s o few have been adequately s tudied. Most do not appear to be ps ychotic, but there seems to be a disturbance in personality s tructure. In Munchaus en's s yndrome by caregiver, us ually a parent, induces illnes s in a child. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > F UT UR E

FUTUR E PR OS PE C TS P art of "8 - C linical Manifes tations of P s ychiatric Like psychiatric diagnos tic clas sifications, fas hions ps ychiatric signs and symptoms change so that thos e 991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 177 of 185

described above must be taken in his torical C haracteris tics once given prominence, s uch as the protuberances of the s kull s tudied by phrenologis ts a century ago, are no longer accorded much importance, whereas only in the past few decades have newly described clinical phenomena, s uch as family, emotion, and alexithymia, been appreciated. B ecaus e the shifts in what is considered relevant and becaus e the current dominance of biological res earch, it is easy as sume that the nuances of clinical, descriptive ps ychopathology are mostly of his torical interes t. As as the ultimate goals of clinical ps ychiatry are to help patients feel better and function better, attending to patients' s ubjective complaints with a firm knowledge of clinical descriptors will continue to be vital as pects of ps ychiatris ts' s kills . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > R E F E R E NC E S

S UGGE S TE D C R OS S R E FE R E NC E S P art of "8 - C linical Manifes tations of P s ychiatric T he ps ychiatric interview, history, and mental status examination are discuss ed in S ection 7.1. Additional definitions of typical signs and symptoms of ps ychiatric illness are included in S ection 7.4. P erception and cognition are dis cuss ed in S ection 3.1, memory in 3.4, and clas sification of mental dis orders in S ection 992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 178 of 185

R E FE R E NC E S Amador X, David A, eds . Ins ight and P s ychos is . UK : Oxford University P res s; 1998. B errios G E , G ili M: Abulia and impulsiveness conceptual his tory. Acta P s ychiatr S cand. B ranson R , P otoczna N, K ral J G , Lentes K U, Hoehe Horber F F : B inge eating as a major phenotype of melanocortin 4 receptor gene mutations. N E ngl J 2003;348:1096. C as pi A, S ugden K , Moffitt T E , T aylor A, C raig IW , Harrington H, McC lay J , Mill J , Martin J , B raithwaite P oulton R : Influence of life s tres s on depress ion: Moderation by a polymorphism in the 5-HT T gene. S cience. 2003;301:291. C iechanowski P S , W alker E A, K aton WJ , R us so J E : Attachment theory: A model for health care and s omatization. P s ychos om Me d. 2002;64:660. C loninger R C , S vrakic DM, P rzybeck T R : A ps ychobiological model of temperament and Arch G e n P s ychiatry. 1993;50:975. C omings DE , B lum K : R eward deficiency s yndrome: G enetic aspects of behavioral disorders . P rog B rain 2000;126:325. C ommittee on the F amily, G roup for the 993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 179 of 185

of P s ychiatry: A model for the clas sification and diagnosis of relational disorders . P s ychiatr S erv. 1995;46:926. C ons tantino J N, C loninger C R , C larke AR , Has hemi P ryzbeck T : Application of the s even-factor model of personality to early childhood. P s ychiatry R e s . 2002;109:229. C os ta P T J r, McC rae R R : S tability and change in personality ass es sment: T he R evised NE O Inventory in the Y ear 2000. J P e rs As s e s s . C richton P : F irst-rank s ymptoms or rank-and-file symptoms? B r J P s ychiatry. 1996;169:537. *C ummings J L. C linical Ne urops ychiatry. New Y ork: G rune and S tratton; 1985. Dapos;E s pos ito M, G ross man M: T he physiological of executive function and working memory. Neuros cie ntis t. 1996;2:345. Dhos sche D, F erdinand R , V an Der E nde J , Hofstra V erhuls t F : Diagnostic outcome of self-reported hallucinations in a community s ample of P s ychol Me d. 2002;32:619. F laum M, Arndt S , Andreasen NC : T he reliability of “bizarre” delus ions. C ompr P s ychiatr. 1991;32:59. F reeman D, G arety P A, K uipers E : P ers ecutory 994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 180 of 185

Developing the understanding of belief maintenance and emotional distress . P s ychol Me d. 2001;31:1292. G eorge MS , P arekh P I, R osindky N, K etter T A, T A, Heilman K M, Herscovitch P , P os t R M: emotional prosody activates right hemis phere Arch Neurol. 1996;53:665. G oodman M, B rown J A, Deitz P M. Managing C are II: A Handbook for Mental He alth Was hington, DC : American P sychiatric P res s, Inc.; G oodwin F K , J amis on K R . Manic-Depre s s ive Y ork: Oxford Univers ity P res s; 1990. G riffiths T D: Musical hallucinos is in acquired P henomelonogy and brain substrate. B rain. 2000;123:2065. Harvey AG : Identifying safety behaviors in ins omnia. Nerv Me nt Dis . 2002;190:16. Hays R D, W ells K B , S herbourne C D, R ogers W, F unctioning and well-being outcomes of patients depres sion compared with chronic general medical illness es. Arch G e n P s ychiatry. 1995;52:11. Hilgard E R . Divide d C ons cious ne s s : Multiple Human T hought and Action. New Y ork: J ohn W iley; *J aspers K . G e ne ral P s ychopathology. C hicago: Univers ity of C hicago P ress ; 1963. 995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 181 of 185

J udd LL, Akis kal HS , Maser J D, Zeller P J , E ndicott C oryell W , P aulus MO, K unovac J L, Leon AD, R ice J A, K eller MB : A prospective 12-year s tudy of subs yndromal and s yndromal depress ive symptoms unipolar major depres sive dis orders . Arch G e n P s ychiatry. 1998;55:694. K alechstein AD, Newton T F , Leavengood AH: syndrome in cocaine dependence. P s ychiatr R e s . 2002;109:97. K es sler R C , McG onagle K A, Zhao S , Nelson C B , M, E s hleman S , W ittchen H-U, K endler K S : Lifetime 12-month prevalence of DS M-III-R ps ychiatric in the United S tates: R esults from the National C omorbidity S urvey. Arch G e n P s ychiatry. K oenigs berg HW, Handley R : E xpress ed emotion: predictive index to clinical construct. Am J 1986;143:1361. Lazare A, ed. O utpatie nt P s ychiatry: Diagnos is and T re atme nt. 2nd ed. B altimore: Williams & Wilkins; Miller W R , R ollnick S . Motivational Inte rviewing: P reparing P eople F or C hange . 2nd ed. New Y ork: G uilford; 2002. Mintz J , Mintz LI, Arruda MJ , Hwang S S : T reatments depres sion and the functional capacity to work. Arch G e n P s ychiatry. 1992;49:761. 996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 182 of 185

Montejo-G onzalez AL, Liorca G , Izquierdo AJ , A, B ousono M, C alcedo A, C arrasco J L, C iudad J , E , de la G andara J , Derecho J , F ranco M, G omez Macias J A, Martin T , P erez V , S anchez J M, V icens E : S S R I-induced s exual dysfunction: paroxetine, s ertraline, and fluvoxamine in a multicenter, and des criptive clinical s tudy of 344 patients. J S e x Marital T he r. 1997;23:176. Nayani T H, Davis AS : T he auditory hallucination: A phenomenological s urvey. P s ychol Me d. Nemiah J : Alexithymia: P resent, past—and future? P s ychos om Me d. 1996;58: 217. Nierenberg AA, K eefe B R , Les lie V C , Alpert J E , Worthington J J , R os enbaum J F , F ava M: R es idual symptoms in depres sed patients who respond to fluoxetine. J C lin P s ychiatry. 1999;60:221. P.1002 Oulis P G , Mavreas V G , Mamounas J M, S tefanis C linical characteris tics of auditory hallucinations . P s ychiatr S cand. 1995;92:97. P ilowsky I: T he concept of abnormal illnes s P s ychos omatics . 1990;31:207. P rochas ka J O, DiC lemente C C : T rans theoretical toward a more integrative model of change. 997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 183 of 185

T he ory R es P ract. 1982;19:276. P urdon S E , F lor-Henry P : As ymmetrical olfactory and neuroleptic treatment in s chizophrenia. R es . 2000;44:221. *R apaport D, ed. O rganization and P athology of New Y ork: C olumbia University P ress ; 1951. R aymond NC , C oleman E , Miner MH: P sychiatric comorbidity and compulsive/impulsive traits in compuls ive s exual behavior. C ompr P s ychiatry. 2003;44:370. S achdev P , Loneragan C : T he present s tatus of J Ne rv Ment Dis . 1991;179:381. S ansone R A, G aither G A, S onger DA: S elf-harm behaviors acros s the life cycle: A pilot study of inpatients with borderline pers onality disorder. P s ychiatry. 2002;43:215. S chneider K . C linical P s ychopathology. New Y ork: and S tratton; 1959. S chwartz C E , Wright C I, S hin LM, K agan J , R auch Inhibited and uninhibited infants “grown up”: Adult amygdalar syndrome res ponse to novelty. S cience . 2003;300:1952. S hapiro D. Neurotic S tyles . New Y ork: B asic B ooks ;

998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 184 of 185

S ierra M, B errios G E : T he phenomenological depers onalization: C omparing the old with the new. Nerv Me nt Dis . 2001;189:629. *S ims A. S ymptoms in the Mind: An Introduction to Des criptive P s ychopathology. London: B ailliere 1988. S naith P : Anhedonia: A neglected s ymptom of ps ychopathology. P s ychol Me d. 1993;23:957. S obin C , S ackeim HA: P s ychomotor symptoms of depres sion. Am J P s ychiatry. 1997;154:4. *S tone MH. Abnormalities of P e rs onality: W ithin and be yond the R ealm of T re atme nt. New Y ork: W .W. 1993. S tope T , F riedman A, Ortwein G , S trobl R , C haudry Najam N, C haudhry MR : C omparison of delusions among schizophrenics in Austria and in P akis tan. P s ychopathology. 1999;32:225. T ada K , K ojima T : T he relationship of olfactory delus ional dis order to s ocial phobia. J Ne rv Ment 2002;190:45. T aylor C B , Arnow B . T he Nature and T re atme nt of Dis orde rs . New Y ork: F ree P ress ; 1988. T rumbell D: S hame: An acute s tres s respons e to 999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

8

Page 185 of 185

interpersonal traumatization. P s ychiatry. Ulloa R E , B irmaher B , Axelson D, W illiams on DE , DA, R yan ND, B ridge J , B augher M: P sychosis in a pediatric mood and anxiety disorders clinic: P henomenology and correlates . J Am Acad C hild P s ychiatry. 2002;39:337. Wes ten D, Arkowitz-Wes ten L: Limitations of Axis II diagnosing personality pathology in clinical practice. Am J P s ychiatry. 1998;155:1767. Y alom I. E xis te ntial P s ychotherapy. New Y ork: B asic B ooks ; 1980. Y udofs ky S C , Hale R E , eds . T e xtbook of 3rd ed. W as hington, DC : American P s ychiatric 1997.

1000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

01/01/2009

Page 1 of 173

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 9 - C las s ification in P s ychia try > 9.1: P s ychiatric C las s ificati

9.1: Ps yc hiatric Mark Zimmerman M.D. R obert L . S pitzer M.D. P art of "9 - C las sification in P s ychiatry" In the chapter on nosology in the firs t edition of the C omprehe ns ive T e xtbook of P s ychiatry (C T P ), 1967, Henry B rill dis cuss ed the purpos es and clas sification, reviewed criticis ms of the class ification of mental disorders , and identified problems with applying the diagnostic manual to clinical practice. T hese same is sues remain relevant today and are discus sed in this chapter on class ification as well. At the time of the first edition of the C T P , the firs t edition of the Diagnos tic S tatis tical Manual of Me ntal Dis orde rs (DS M-I) was the official diagnos tic manual, although the second edition the Diagnos tic and S tatis tical Manual of Me ntal (DS M-II) was published 1 year later in 1968. B rill, of the American P s ychiatric Ass ociation's (AP A's ) C ommittee on Nomenclature and S tatistics from 1960 through 1965, delineated s ix advantages of the then current nomenclature: (1) wides pread use, thereby facilitating communication among profes sionals; (2) definition and delineation of the dis orders; (3) compatibility with the Inte rnational C las s ification of Dis e as es (IC D) diagnostic system; (4) clear guidelines compilation and reporting of patient diagnostic data; (5) comprehensive collection of diagnos tic terms in one 1001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 2 of 173

source; and (6) eas e of us e. During the 35 years after chapter was publis hed, the AP A's diagnos tic manual been revis ed four times and plans are under way to the manual again within the next decade. Although of the iss ues regarding psychiatric clas sification have remained the s ame s ince the first edition of the C T P , because the AP A's DS M has grown in s tature, political forces have increas ingly voiced opinions regarding clas sification is sues, and discus sions about conceptual is sues in clas sification have raised new ques tions. T he present chapter is divided into nine s ections . It with a general description of the purpos es of Next, the chapter turns to the fundamental is sue underlying a class ification of mental disorders —the definition of mental dis order. T his s ection includes a discuss ion of the impact of the operationalization of mental disorder on the epidemiology of ps ychiatric disorders and an examination of the core component of DS M definition of mental disorder—“a behavioral, ps ychological, or biological dysfunction in the T his s ection ends with a review of J erome C . critique of DS M's definition of mental disorder and a review of his concept of dis order as harmful T he subs equent three s ections pres ent an overview of history of ps ychiatric class ification, the his tory of official clas sifications during the pas t two centuries, and the recent his tory of class ifications s ince the 1970s . T he revis ion of the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) clas sification is then described, highlighting and summarizing the features of disorders included in the current nomenclature. F ollowing this is a review of 1002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 3 of 173

related to the use of DS M-IV -T R , and a summary of recent commentaries and research on the use of DS M clinical practice. F inally, s ome controversies in the clas sification of mental dis orders are described.

P UR P OS E S OF C L A S S IF IC A TION C las sification is the process by which the complexity of phenomena is reduced by arranging them into according to some established criteria for one or more purpos es. At present, the clas sification of mental cons ists of specific mental disorders that are grouped various clas ses on the bas is of s ome s hared phenomenological characteris tics. T he ultimate clas sification is to improve treatment and prevention efforts . Ideally, a clas sification of dis orders is based on knowledge of etiology or pathophysiology, becaus e this increases the likelihood of improving treatment and prevention efforts . T he purposes of a class ification of mental disorders involve communication, control, and comprehension.

C ommunic ation A clas sification enables users to communicate with other about the disorders with which they deal. T his involves us ing names of categories as s tandard ways of summarizing a great deal of information. When indicating that an individual has a particular disorder, confers information about the cluster of clinical features that the individual is experiencing without lis ting all of specific features that together cons titute the disorder. communication to be effective, there mus t be a high of agreement among us ers of the clas sification. 1003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 4 of 173

C ontrol C ontrol of mental dis orders primarily refers to the prevention of their occurrence or the modification of cours e with treatment. C ontrol also refers to knowledge the cours e of a condition, as this too is often important clinical management.

C omprehens ion C las sification s hould provide comprehens ion or unders tanding of the caus es of mental disorders and proces ses involved in their development and maintenance. Dis orders can, of cours e, be treated knowledge of their etiology or pathophysiology. C omprehens ion is not an end in itself but is desired in clas sification because it usually leads to more effective treatment and prevention (i.e., better control).

WHA T IS A ME NTA L DIS OR DE R ? T here are many reas ons why mental health should care about the way in which me ntal dis order is defined. T he definition of P.1004 mental disorder guides dis tinguis hing pathology from what is normal. C ons equently, the definition of mental disorder can influence estimates of the prevalence of ps ychiatric disorders in the community, which, in turn, influences the allocation of public health expenditures . T he definition of mental dis order can impact which behavioral, cognitive, and emotional perturbations are included in the class ification, and the inclusion and exclusion of s pecific disorders from the DS M have 1004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 5 of 173

source of criticism and controvers y. W hether a problem cons idered a dis order influences medical insurance reimbursement, and definitions of mental disorder have varied in mental health parity s tatutes in different Determination of the pres ence of mental disorder has potential legal implications in criminal cases and regarding disability determinations . Lack of conceptual clarity regarding the definition of mental disorder can contribute to abus es of ps ychiatric diagnoses as a of controlling or s tigmatizing socially undes irable behavior. F inally, lack of clarity in the conceptualization a fundamental, core is sue s uch as the definition of disorder reduces confidence in the profes sion as an authority regarding diagnostic iss ues and It s hould be noted that a definition of medical (nonps ychiatric) disorder is as elus ive as a definition of mental disorder, although this has not been the topic of much dis cuss ion. In fact, the definition of what a medical condition may attain greater vis ibility during coming years as technological advances improve the detection of pathology. F or example, there has been a recent growth of facilities offering full-body imaging procedures , s uch as computed tomography (C T ) detect occult illness es in their early stages . T he clinical significance of the early detection of abnormalities is unknown, because the natural course of the lesions detected at an early s tage is unknown. C onsequently, boundary between normal variation and pathology will challenged as the tools to detect gros s abnormalities improve in the absence of understanding pathophys iological mechanisms producing clinically significant pathology. 1005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 6 of 173

Although it may be reass uring that difficulty in defining disorder is not limited to the mental health field, the question of what is a mental disorder s hould be to guide the development of the class ification. In to mos t medical disorders , mental disorders are manifested by a quantitative deviation in behavior, ideation, and emotion from a normative concept. T he debates over whether certain behaviors , ways of or emotional s tates s hould or should not be included in the DS M class ification (i.e., s hould or s hould not be cons idered disorders ) are grounded in ambiguities in definition of mental dis order. T he firs t DS M to offer a definition of mental dis order the third edition of the Diagnos tic and S tatis tical Me ntal Dis orde rs (DS M-III), and this definition has only slightly been modified in the revised third edition of the Diagnos tic and S tatis tical Manual of Mental (DS M-III-R ) and the DS M-IV -T R . T he history of the introduction of a definition of mental disorder into DS Mbegins in 1973, when R obert S pitzer s ided with thos e ps ychiatris ts and activists who wanted to remove homos exuality from DS M-II. T o justify the removal of homos exuality from the DS M-II, S pitzer proposed this definition of mental disorder: “In order for a mental or ps ychiatric condition to be cons idered a ps ychiatric disorder, it must either regularly cause subjective or regularly be ass ociated with generalized impairment social effectiveness or functioning.” With this definition, S pitzer argued that homosexuality per se does not the two requirements of his definition, becaus e “many homos exuals are quite satisfied with their sexual orientation and demonstrate no generalized impairment 1006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 7 of 173

in social effectivenes s or functioning.” During the early years in the development of the DS MS pitzer recognized that his 1973 definition of mental disorder had ignored the concept of dysfunction. W ith help of many other colleagues, a new definition of disorder was developed, was included in DS M-III, and subs equently was modified in DS M-III-R and DS M-IV DS M-IV -T R , mental dis order is defined as a clinically significant behavioral or psychological s yndrome or pattern that occurs in an individual and that is with pres ent dis tres s (e.g., a painful s ymptom) or (i.e., impairment in one or more important areas of functioning) or with a s ignificantly increas ed risk of suffering, death, pain, dis ability, or an important loss of freedom. In addition, this syndrome or pattern must not merely an expectable and culturally sanctioned to a particular event, for example, the death of a loved Whatever its original caus e, it must currently be cons idered a manifestation of a behavioral, or biological dysfunction in the individual. Neither behavior (e.g., political, religious , or s exual) nor that are primarily between the individual and society mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as above.

Definition of Mental Dis order, Ps yc hiatric E pidemiology, and the Impairment or Dis tres s C riterion T he definition of mental dis order can potentially impact the prevalence estimates of psychiatric and s ubs tance disorders in epidemiological s tudies . C ritics of the DS M 1007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 8 of 173

have sugges ted that the application of the definition of mental disorder has been too broad. One pos sible manifestation of the expans ion of the domain of mental disorder is the number of conditions identified in the S ince the publication of DS M-I, the number of identified diagnoses has increas ed by more than 300 percent 106 in DS M-I to 365 in DS M-IV -T R ). In fact, every the DS M has been accompanied by an increase in the number of diagnos es . It has been argued that the increased number of diagnos es represents a the concept of mental disorder, and behavioral, or emotional patterns that previously would not have been identified as pathological are reconceptualized as representing a dis order. However, a careful analysis of increase in diagnos tic labels s uggests that it almos t entirely repres ents greater specification of the forms of pathology, thereby allowing more homogeneous to be identified. Moreover, s ome of the highest epidemiological rates of mental disorders preceded the publication of DS M-III. S ince the publication of DS M-III, two large psychiatric epidemiological s tudies have been conducted in the United S tates —the E pidemiological C atchment Area study and the National C omorbidity S tudy (NC S ). T he res ults of these studies were reanalyzed by applying a higher threshold to define a mental dis order—the symptoms were required to cause “a lot” of interference the person's life or to result in treatment. On application the clinical significance criterion, the 1-year prevalence rate of any ps ychiatric or s ubs tance use disorder from 30.2 to 20.5 percent in the NC S and from 28.0 to percent in the E C A study. 1008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 9 of 173

Impairment or Dis tres s C riterion C ons idered T he high prevalence rates of DS M-III and DS M-III-R ps ychiatric disorders in the NC S and the E C A s tudy concern that the diagnos tic criteria were overly or incorrectly applied in an overly broad manner, and they identified nondisordered individuals as disordered. P.1005 S pitzer and W akefield indicated that there were two in which the DS M diagnos tic criteria, even when correctly, might nonetheles s identify nondisordered individuals as having a mental disorder. One instance occurs when individuals experience normal reactions to stress ful environments , and the other occurs when individuals experience mild s ymptoms of a dis order are ins ufficiently s evere to be considered a disorder. S pitzer and W akefield labeled this the fals e -pos itive proble m with the DS M criteria. T o reduce the problem of potential overdiagnosis, in IV -T R , the threshold to diagnos e ps ychiatric disorders raised by explicitly adding a clinical s ignificance to approximately one-half of the criteria sets. P recedent this was found in the DS M-III-R criteria for social simple phobia, and obsess ive-compuls ive disorder T he wording of the DS M-IV -T R clinical s ignificance varies s omewhat from dis order to dis order, although most common wording is “the symptoms caus e significant distress or impairment in s ocial, or other important areas of functioning.” T he to the DS M-IV -T R manual indicates that the purpos e of 1009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 10 of 173

criterion is to “help establish the thres hold for the diagnosis of a disorder in those situations in which the symptomatic presentation by itself (particularly in its milder forms) is not inherently pathological.” T his however, only address es one of the two potential of fals e positives—the labeling of mild, subthreshold conditions as dis orders . T he criterion does not addres s is sue of labeling normal reactions to stress ful events as disorders . One problem with DS M-IV -T R 's clinical s ignificance criterion is the uncertainty in how to interpret and apply Does dis tre s s refer to dis tres s about having the distress when experiencing the s ymptom? In a on S pitzer and W akefield's critique of the clinical significance criterion, K enneth S . K endler des cribed case of a 38-year-old woman who feared snakes s ince childhood. B ecause she lives in a metropolitan area, only way in which this fear impacts on her life is her to take her children into the s nake hous e at the zoo. B ecaus e it is easy for her to success fully avoid s nakes , fear does not res ult in clinically significant impairment. B ecaus e it is unclear how the distress component of clinical s ignificance criterion should be interpreted, it is unclear whether this presentation warrants a diagnos is specific phobia. T he woman is highly anxious when expos ed to the fear-inducing s timuli, much more than mos t people. Does this meet the dis tres s of the criterion? On the other hand, becaus e expos ure snakes is success fully avoided, she denies being (distress ed) by having this fear. Does this mean that does not meet the criterion? Does it mean that if s he bothered by having the fear, despite the fact that the 1010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 11 of 173

degree of impairment is limited, then she does have a mental disorder? S pitzer and W akefield s uggest that distress that is intrins ic to the condition s hould be cons idered when determining dis order pres ence or absence. If distress about having a condition is a defining feature of mental disorder, then falsediagnoses might res ult (e.g., Does s omeone who is distress ed about having curly hair or being overweight have a mental disorder? ). A s econd problem with DS M-IV -T R 's clinical criterion is that it is often redundant with the s ymptom criteria. F unctional impairment is intrinsic to many disorders . F or example, the s ymptom criterion for the disorder s elective mutism is “cons istent failure to speak specific s ocial s ituations (in which there is an for speaking, e.g., at school) despite s peaking in other situations.” It is unclear how an individual can meet this criterion and not meet the additional clinical criterion that “the disturbance interferes with or occupational achievement or with s ocial communication.” T hus, the clinical significance criterion unnecess ary. A third problem with the addition of the clinical significance criterion to the s ymptom criteria s ets is that some individuals who have a mental disorder cannot diagnosed as having the disorder, becaus e the clinical significance criterion is not met. T his can be the fals e -ne gative problem with the clinical significance criterion. F or example, a child with frequent motor and vocal tics is not diagnosed with T ourette's s yndrome unles s the distress or impairment criterion is also met. alludes to the cardinal problem of diagnos ing a 1011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 12 of 173

the abs ence of knowledge about underlying (T he is sue of dys function and its importance in defining disorder is described in greater detail in the following section.) T o s ay that one child with tics has a disorder, because clas smates, parents, or teachers are the symptoms and are thus res ponsible for the child's distress or impairment, whereas another child with the same symptom expres sion does not have a dis order because of a different res ponse from others , indicates the concept of mental disorder cannot s imply be bas ed the presence of impairment or dis tres s. Disorders in areas of medicine are diagnosed without explicit to concepts of distress and impairment, although one the other is us ually pres ent. However, for most medical disorders , a biological abnormality or underlying dysfunction can be identified. B y virtue of laboratory conditions s uch as cancer, liver dis ease, and cardiac disease can be diagnos ed in the absence of dis tres s or impairment (or even the manifes tation of clinical symptoms). Until underlying ps ychological and dysfunctions are identified, then the definition of mental disorder involves drawing an arbitrary line to minimize false-positive and false-negative diagnos es . Although the nature of the underlying dysfunction may currently unknown, the concept of disorder, as well as differentiation from normal variation, implies the of an underlying dis ruption of normal function. Dis tres s impairment is not s ynonymous with underlying dysfunction. T he same s ymptom presentation in two individuals may be s imilarly ass ociated with degrees of dis tres s or impairment but different degrees underlying dysfunction. C onsider, for example, the 1012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 13 of 173

evaluation of depres sion. T he diagnosis of depress ive disorder poses conceptual challenges, becaus e pathways have been well es tablis hed as to their the ons et and maintenance of s ymptoms of S ome of the factors implicated in the caus e of include genetic vulnerability, s tres sful life events, and advers e child-rearing experiences. T he DS Ms explicitly recognize that individuals with s ymptoms of depres sion may or may not have a disorder. B ereavement, characterized by a full depress ive P.1006 syndrome, is not cons idered a mental disorder if the symptoms las t less than 2 months after a death and complicated by suicidal tendencies or ps ychos is . depres sive s ymptoms after a different stress ful event cons idered a dis order (unles s the s ymptoms last les s 2 weeks ). T hus, two individuals can have similar patterns, s imilar degrees of impairment, and a s imilar cours e of symptoms , yet be diagnosed differently depending on whether the stress ful event precipitating the depres sion was or was not a los s due to death different type of loss . T he clinical s ignificance criterion does not clarify how to distinguish between dis order no dis order in this instance. R ather, there is a of unknown validity, that there is a dys function in mood regulation as sociated with a depres sive s yndrome after stress ful life events other than a death. C ons ider example in which a diagnos is of depres sion does not follow from application of the clinical significance Immediately after a stress ful event, an individual who experiences a full depress ive s yndrome of brief, less 1013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 14 of 173

weeks, duration is not diagnosed with major depres sive disorder. F or example, after being told unexpectedly her hus band wanted a divorce, a 35-year-old woman daily, developed insomnia, lost her appetite, had concentrating, felt res tless and agitated, and mis sed days at work. After a week, her symptoms began to improve, she returned to work, and s he thought that was coping better. A definition of disorder based on the presence of impairment and dis tres s would class ify her having a disorder. According to DS M-IV -T R , s he would be diagnosed with major depres sive dis order unles s full s yndrome lasted for at leas t 2 weeks. A mental could be diagnos ed according to DS M-IV -T R — disorder—if it was concluded that the symptoms were excess of what cons titutes a normal reaction to the stress or. T his indicates that the determination of then, is not s imply bas ed on s ymptom picture nor impairment or dis tres s, but on the presumption of the exis tence of a dys function of an underlying regulatory mechanism that is inferred from the nature, cours e, context of the s ymptoms.

C ritique of the DS M Definition of Mental Dis order from Wakefield's Harmful Dys func tion Pers pec tive E xplicit in the DS M-IV -T R definition of mental dis order the requirement of underlying dysfunction, although is sometimes not explicitly discus sed, even by F or example, in discus sing the iss ue of adding new diagnostic categories to DS M-IV -T R , the principal of DS M-IV -T R , when discuss ing the pos sible inclusion minor depress ion and mixed-anxiety/depress ive noted that “there is no inherent problem in high 1014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 15 of 173

prevalences of disorders … so long as it is clear that threshold es tablis hed is as sociated with clinically significant dis tres s and/or disability and that the is us eful in predicting prognos is and guiding treatment.” Likewise, in a recent article comparing definitions of mental disorder used in different federal and s tate mandating parity coverage for mental health treatment, Marcia C . P eck and R ichard M. S cheffler indicated that DS M defines mental dis order as “a clinically s ignificant behavioral or psychological s yndrome or pattern that occurs in an individual… is as sociated with present distress … or dis ability… or with a significant increas ed of suffering.” In a paper entitled “R hinotillexomania: P sychiatric Disorder or Habit? ” J ames W. J efferson T rent D. T hompson indicated that nose picking, a universal practice in adults, should be considered a disorder when it becomes exces sive and caus es impairment or dis tres s. No reference was made to dysfunction of underlying mechanisms. It is therefore uncommon for dis cuss ions of the definition of mental disorder, or dis cuss ions of whether a behavioral or ps ychological syndrome should be characterized as a mental disorder, to focus on impairment and dis tres s to ignore the iss ue of dysfunction in underlying mechanisms. P erhaps the reason for paying les s to this component of the definition of mental dis order is the lack of knowledge of thes e dysfunctions. In a s eries of articles over the pas t 15 years, W akefield critically examined DS M's definition of mental dis order elaborated his own conceptualization of medical and mental disorder as harmful dys function. Dys function is defined as an inability of an internal mental mechanis m 1015 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 16 of 173

perform its intended, natural function, from an evolutionary pers pective. As noted previously, the definition of me ntal dis order already includes the of dys function. However, Wakefield critiques the way the DS M criteria operationalize the concept of merely as s tatistical deviation from normative reaction. It is for that reas on that DS M excludes a normative (expected) grief reaction, becaus e it is an “expectable and culturally s anctioned res pons e to a particular event, for example, the death of a loved one.” problem with DS M's attempt to operationalize dis order harmful s tatistical deviation is the failure to cons is tently apply this defining principle to determine what is and what is not a disorder. E xamples of conceptual inconsistency include pers istent mental or behavioral states , s uch as gullibility, lazines s, and s loppines s, that frequently unwanted, cause distress or impairment, are statis tically deviant. Although apparently meeting DS M's conceptualization of mental disorder as harmful statis tical deviation, thes e states are not considered disorders . Moreover, conceptual inconsistency is even within the DS M clas sification. DS M's V codes are heterogeneous collection of problems, such as phas e life problems , medication-induced movement dis orders, relational problems, problems related to abus e or and malingering, that may be the focus of clinical attention, are distress ing and unexpected (thereby meeting the DS M definition of mental disorder), and yet are not considered mental disorders . F ollowing this line of reas oning, W akefield critiques the criteria us ed to diagnos e adjus tment disorder, which based, in large part, on s tatistical deviation (“marked 1016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 17 of 173

distress that is in exces s of what would be expected expos ure to the s tres sor”). A poss ible, literal, of the adjus tment disorder criteria is that individuals in the upper one-half of the dis tribution of dis tres s after stress ful event qualify for the diagnosis. Much of Wakefield's dis cus sion focuses on how the definition of mental disorder mus t be broad enough to include conditions that are triggered by s tres s but not broad that all environmentally induced perturbations in homeostasis are considered pathological. A definition identifies the normal reactions to stress es in everyday as disorders trivializes the concept of disorder. As Wakefield puts it, [T ]he critical distinction that to be drawn is between those situations in which an environmental s tres s caus es a breakdown of an internal mechanism such that the breakdown becomes of the original stress versus a natural res ponse that is initiated and maintained directly by the ongoing s tres s and that would subs ide if the s tres s T he former kind of reaction is a disorder but the latter is not, according to the dys function conception…. Life naturally contains a certain amount of distress , and distress that is 1017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 18 of 173

cons istent with the natural functioning of the organis m is a disorder. C ons ideration of dysfunction is als o important for distinguishing between functional impairment that is indicative of disorder and impairment in functioning that instead reflects inability. C ons ider illiteracy and a reading disorder. B oth are characterized by impairment reading ability. However, illiteracy due to inadequate education is not considered a dis order, because there presumed underlying dysfunction. A reading dis order is diagnosed only when reading achievement is below expected by the individual's education and intelligence (i.e., there is a presumed dys function in the mental res ponsible for reading). Wakefield suggests that the framers of DS M-III did not incorporate the concept of dysfunction into the criteria individual dis orders , because reliability was valued highly than validity. Although the actual nature of the dysfunction may be unknown, W akefield argues that it poss ible for clinicians to judge whether symptoms are to internal dysfunction. F or example, W akefield and colleagues found that clinicians could reliably agree children growing up in violent, threatening who exhibit features of conduct dis order that are appropriate to the s ocial context s hould not be to have a mental dis order. Unfortunately, W akefield yet to s how that clinicians, for a variety of disorders , distinguish normal reactions (e.g., depres sion after a from P.1007 1018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 19 of 173

harmful conditions that are the result of a dysfunction (e.g., the dysfunction of mood regulation in severe depres sion). S ome researchers have suggested that future clas sification should focus on identifying the of cognition, emotion, and motivation that underlie the signs and s ymptoms of mental disorder. S uch a would evolve simultaneous ly with the development of tes ts to evaluate these functions and to identify abnormalities in them. T his would move ps ychiatric clas sification clos er to the rest of medicine, for which laboratory testing has increas ingly as sumed identifying and class ifying pathological conditions.

Harmful Dys func tion and the Definition of Mental (and Phys ic al) Dis orders T he development of tests to identify underlying abnormalities would move ps ychiatric clas sification system primarily based on des cription clos er to one on etiology. It is s obering to realize that only 40 years during the 1960s, the failure to identify underlying abnormalities was taken as evidence that the concept mental illness was a myth. T o better appreciate a dysfunction definition of mental dis order, W akefield reviewed the arguments of the critics of psychiatric clas sification and, in doing so, illus trated that harmful dysfunction is as relevant to defining physical dis order mental disorder. T homas S . S zas z argued that a dis order requires the presence of a phys ical lesion, with a le s ion being 1019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 20 of 173

an identifiable deviation in anatomical structure. T he failure to identify brain lesions in individuals with conditions was prima facie evidence that these are not dis orders. R ather, the term me ntal dis order is adopted to label behavior that deviates from societal norms and to empower the medical es tablis hment. Wakefield identified two problems with S zasz's thesis : that a lesion (i.e., a pathological anatomical s tructure) be defined solely in terms of s tatistical deviation and that phys ical dis order is defined by the presence of a T he statis tical deviation argument fails on two F irst, normal variations of anatomical s tructures , s uch webbed toes , are not synonymous with a pathological proces s (i.e., dys function or malfunction). S econd, pathological anatomical process es, such as are not statis tical deviations . T hus, the s tatistical argument fails , because infrequent variants are not neces sarily pathological, and pathological anatomical variation is not necess arily infrequent. T he second component of S zas z' argument, that physical disorder defined by the presence of a les ion, cannot account for disorders s uch as migraine headaches and trigeminal neuralgia, for which there are no known anatomical lesions . Wakefield suggests that variations in structure, whether they be anatomical structures or mental mechanisms, lesions when “the variation impairs the ability of the particular structure to accomplish the functions that it designed to perform,” and the lesion is a dis order “only the deviation in functioning of the part affects the wellbeing of the overall organism in a harmful way…. T hus, the harmful dysfunction approach to the concept of 1020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 21 of 173

disorder would s eem to explain… which anatomical deviations are lesions and which lesions are disorders.”

Harmful Dys func tion and Diagnos tic C ontrovers ies In concluding his 1992 paper on the concept of mental disorder, W akefield illus trated how a lack of knowledge naturally selected mechanis ms and changes in cultural mores can influence judgments about dys function and harm, and, consequently, determination of whether a condition is a dis order. He reviewed opinions about orgasm during intercourse that were formed a century apart: According to the eminent V ictorian phys ician and William Acton (1871), the female sexual organs do not naturally function to produce orgas m during intercourse, and the occurrence of orgasm in a is a form of pathology due to an excess of s timulation beyond her body was designed to According to Mas ters and (1966, 1970, 1974), orgas m intercours e is a natural function the female sexual organs , and of orgas m in a woman is a due to inadequate stimulation of the sort to which her body was designed to respond. Acton and 1021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 22 of 173

Masters and J ohnson knew that there are many women who do have orgas ms during and many women who do not. Acton interpreted these facts to mean that there are a lot of women who are disordered because they s uffer from overs timulation, whereas and J ohnson interpreted thes e facts to mean that there are a lot of women who are disordered because they s uffer from unders timulation. T he nonstatis tical nature of function and disorder, combined with ignorance of the evolutionary history of female s exual enabled these oppos ite beliefs be consistent with the s ame set data and with the same concept disorder. Wakefield indicates that facts alone do not determine disorder s tatus. T he harm component of the disorder definition is , in part, a value judgment bas ed on sociocultural s tandards . T hus , Acton and Mas ters and J ohns on could have come to an agreement on what cons titutes female orgasmic dys function based on evolutionary knowledge but might nevertheless have disagreed as to whether orgas m during intercours e is a desirable goal, thus dis agreeing regarding the 1022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 23 of 173

female orgasmic disorder. T he harmful dys function definition of mental dis order does not, therefore, diagnostic controversies that are disputes based on

Problems with the Harmful Dys func tion Definition of Mental Dis order T here have been conceptual critiques of the harmful dysfunction definition of mental dis order, although have been well refuted by W akefield. T he authors with W akefield's conceptual analysis of the definition of disorder, although a weakness in W akefield's is the lack of specific details in implementation. T hat is, not clear how to operationalize and incorporate the concept of dysfunction of naturally s elected into the diagnostic criteria. Wakefield simply indicates this task needs work. Wakefield indicates that the reason that it is important define, in part, the DS M dis orders in terms of to decreas e the number of false-positive diagnoses . If concept of dysfunction is incorporated into the criteria, then s ome, perhaps many, pers ons who are currently diagnosed with a dis order will not be given a diagnos is . C ons ider the following cas e described by Wakefield: T he patient, a male profes sor in the s ocial sciences , to the cons ultation s eeking antidepress ant medication medicine for ins omnia. He had to pres ent a paper in another city as part of a job interview and was afraid he could not function adequately to do so. He reported for the pas t month, he had experienced depress ed 1023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 24 of 173

and extreme feelings of sadnes s and emptiness , as lack of interest in his usual activities (in fact, when not friends , he mostly s tayed in bed or watched T V ). His appetite had diminis hed, and he laid awake long into night, unable to fall asleep becaus e of the pain of his sadness . He was fatigued and lacking in energy during day and did not have the ability to concentrate on his work. T here was no suicidal ideation or feelings of guilt worthles sness . However, there was functional T he patient was barely managing to meet minimal occupational obligations (e.g., he showed up at clas s relatively unprepared and had not attended the monthly faculty meeting or worked on his research). He als o avoided s ocial obligations , except to be with clos e to les sen his pain. When asked what event might have precipitated thes e distress ing feelings , he reported, holding back tears as spoke, that approximately a month earlier, an intens e and pass ionate 5-year love affair with a woman (the patient was s ingle) to whom he had been completely devoted had been ended by the woman she made a final decis ion that she could not leave her husband. B oth lovers had perceived this relationship as unique, once-in-a-lifetime romance in which they had their s oul mate and had experienced an extraordinary combination of emotional and intellectual intimacy. P.1008 T his individual meets the DS M-IV -T R s ymptom and impairment criteria for major depress ive disorder. However, W akefield argues that the loss res ponse is “reasonably proportional” to the nature of the los s, and 1024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 25 of 173

only on cons ideration of the subjective meaning of the loss can the clinician determine whether there is a dysfunction of the loss res ponse mechanis m. He notes that s uch loss es can trigger a “genuine” disorder, and “an interesting challenge… is to try and formulate criteria that would distinguish truly cases from normal reactions to extreme loss es.” It is absence of an attempt to generate and to validate such criteria that limits the practical application of thesis.

HIS TOR Y OF C L A S S IF IC A TION K arl Menninger and colleagues presented a of clas sification from ancient times to the modern era. According to Menninger and colleagues , the firs t description of a mental illnes s appeared in 3000 bc in a depiction of s enile deterioration ascribed P rince P tah-hotep. T he syndromes of melancholia and hysteria appeared in the S umerian and E gyptian as far back as 2600 bc. In the E bers papyrus 1500 bc), s enile deterioration and alcoholism were described. In India, in approximately 1400 bc, a clas sification of psychiatric dis orders was included in medical class ification system of Ayur-V eda. Hippocrates (approximately 460 to 370 B C ) is us ually regarded as the one who introduced the concept of ps ychiatric illnes s into medicine. His writings described acute mental dis turbances with fever (perhaps acute mental dis turbances without fever (probably analogous to functional ps ychoses but called mania), chronic dis turbance without fever (called me lancholia), hysteria (broader than its later us e), and S cythian 1025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 26 of 173

(s imilar to transves tis m). C aelius Aurelianus , a fifth century phys ician living in R oman E mpire, described homos exuality as an a dis eas ed mind that was found in men and women. Mental deficiency and dementia were noted by S wiss R enais sance physician F elix P latter (1536 to 1614). B efore the time of the E nglis h phys ician T homas S ydenham (1624 to 1689), all illnes s, des pite the in appearance between the different s yndromes, was attributed to a single pathogenic proces s, a disturbance the humoral balance or a dis turbance in the tensions of the solid tis sues. S ydenham, on the other hand, that each illnes s had a specific cause. He called for the study of morbid process es and likened the the s pecificity of dis eases to the botanis t's s earch for species of plants. P hilippe P inel (1745 to 1826), a F rench phys ician, the complex diagnostic s ys tems that preceded him by recognizing four fundamental clinical types : mania (conditions with acute excitement or fury), melancholia (depres sive dis orders and delus ions with limited dementia (lack of cohesion in ideas ), and idiotism and organic dementia). P inel thus reacted against the specific disease entity tradition of S ydenham and went back to a noncomplex hippocratic s ys tem of All mental illnes ses were in a category of physical called ne uros e s , which were defined as functional of the nervous system—that is , illness es that were not accompanied by fever, inflammation, hemorrhage, or anatomical les ion. B y the 19th century, mental disorder began to be 1026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 27 of 173

cons istently as the manifes tation of physical pathology, and s cientis ts searched for specific lesions, parallel to inves tigation of bodily diseases. B enedict-Augustin (1809 to 1873) was the first to us e the cours e of an as a basis for clas sification. His de me nce pre core was disease entity but a particular form of the cours e of disease. K arl Ludwig K ahlbaum (1828 to 1899), a G erman descriptive ps ychiatris t who foreshadowed E mil introduced the concepts of (1) the temporary symptom complex, as oppos ed to the underlying disease, (2) the distinction between organic and nonorganic mental disorder, and (3) the cons ideration of the patient's age the time of onset and the characteris tic development of the disorder as bases for class ification. T he finding made by Antoine B ayle in 1822 that progres sive pares is was a s pecific organic dis eas e of brain and the discovery of P aul B roca (1824 to 1880) in 1861 that s ome forms of aphasia were related to lesions of the cortex increased attempts to base all clas sifications of mental disorders on demons trated lesions or disturbances in vascular and nutritional phys iology. T hose findings led W ilhelm G ries inger 1868) to coin the slogan “mental diseases are brain diseases .” B ecaus e the knowledge of brain pathology limited, he recognized the need for a provis ional functional category for mental illness es with as-yetunknown somatic pathology. In the las t two decades of the 19th century, K raepelin (1856 to 1926) synthesized three approaches : the descriptive, the somatic, and the cons ideration of the cours e of the dis order. He viewed mental illness es as 1027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 28 of 173

organic disease entities that could be clas sified on the basis of knowledge about their causes, courses , and outcomes . He brought the manic and depres sive disturbances together into one illness , manicps ychos is , and distinguished it, on the basis of its of remiss ion, from the chronic deteriorating illness de me ntia prae cox, which E ugen B leuler later renamed s chizophre nia. K raepelin also recognized paranoia as distinct from dementia praecox, distinguished delirium from dementia, and, for the firs t time in a class ification system of mental disorders , included the concepts of ps ychogenic neuros es and ps ychopathic personalities “born criminal,” the “unstable,” “pathological liars and swindlers,” and “litigious paranoiacs ”). T he basic approach of K raepelin toward clas sification to search for that combination of clinical features that would best predict outcome. In contrast, B leuler (1857 1939) based his class ification s ys tem on an inferred ps ychopathological process , such as a disturbance in as sociative process in s chizophrenia. T he personality dis orders were firs t noted in the ps ychiatric literature by J . C . P richard in 1835 with his introduction of the concepts of moral ins anity and moral imbecility. In 1891, August K och coined P.1009 the phrases ps ychopathic pe rs onality and ps ychopathic cons titutional inferiority. S igmund F reud (1856 to 1939), after studying hysteria, prototypical neurosis, went on to divide the neuroses the actual ne uros e s , the result of dammed-up sexual 1028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 29 of 173

excitation, and the ps ychone uros e s , the result of unconscious conflict and compromise symptom formation. As interest in the actual neuros es the term ne uros is came to be s ynonymous with ps ychone uros is . F reud recognized only the following subtypes of neurosis: anxiety neuros is, anxiety hys teria (phobia), obsess ive-compuls ive neuros is , and hysteria. was not until much later, in the American Medical Ass ociation's (AMA's) S tandard C las s ifie d Dis e as e (1935), that reactive depres sion was added as additional s ubtype of the neuros is , later to find its way, with other neurotic s ubtypes , into DS M-I and DS M-II. F reud's dynamic concepts and interest in the ps ychopathology of everyday life led to an expans ion the boundaries of what was cons idered mental illness include mild forms of pers onality deviation. As Hagop S . Akiskal and W illiam McK inney noted, the advances in the unders tanding of mental dis orders the pas t 50 years , the major categories of mental in the standard clas sification systems are based on the concepts of K raepelin and B leuler—organic disorders , affective dis orders, and schizophrenia—and F reud—neuros es and personality dis orders.

HIS TOR Y OF OF FIC IA L C L A S S IF IC A TIONS T he firs t official system for tabulating mental disorder in the United S tates was initially us ed for the decennial cens us of 1840. It contained only one category and lumped together the idiotic and the ins ane. F orty years later, in the cens us of 1880, the mentally ill were subdivided into separate categories for the firs t time 1029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 30 of 173

(mania, melancholia, monomania, paresis , dementia, dipsomania, and epilepsy). It is s obering to realize that conceptual iss ues that modern clas sifiers wres tle with today were well recognized by the authors of that In the introductory remarks to the census office report, authors lamented about the difficulties of creating a clas sification system for the mentally ill: Much effort has been put forth to secure uniformity in the clas sification of the ins ane in country of the world; but it impos sible for thos e best to form an opinion to agree upon any s cheme which can be S ome clas sifications are bas ed upon s ymptoms and some upon phys ical caus es ; others are a mixture of the two; and s till take into account the complications of ins anity. F or purpos es of the cens us , it to us advisable to dis regard all minute s ubdivisions and to a s imple analysis on the poss ible outlines. In 1889, the International C ongres s of Mental S cience P aris adopted a class ification proposed by a headed by Morel that included 11 categories , including those “upon which the majority (of the commiss ion's members) was unanimous ” and omitting thos e “upon 1030 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 31 of 173

which opinion was divided.” T hose early clas sifications presented in T able 9.1-1.

Table 9.1-1 19th C entury C las s ific ations of Mental 1840 U.S . C ens us

1880 U.S . C ens us

1889 International C ongres s of Mental S cience

Idiocy (insanity)

Mania

Mania

 

Melancholia

Melancholia

 

Monomania

P eriodical ins anity

 

P aresis

P rogress ive systematic insanity

 

Dementia

Dementia

 

Dips omania

Organic and senile dementia

 

E pilepsy

G eneral paralys is

1031 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 32 of 173

 

 

Ins ane neuros es

 

 

T oxic insanity

 

 

Moral and impuls ive insanity

 

 

Idiocy, etc.

In 1923, to conduct a special cens us of patients in for mental disease, the B ureau of the C ens us used a clas sification system developed in collaboration with AP A (then the American Medico-P sychological Ass ociation) and the National C ommittee for Mental Health. T hat system, cons is ting of 22 disorders , had adopted by the AP A in 1917 and was us ed until 1935, when it was revis ed for incorporation into the first of the AMA's S tandard C las s ifie d Nome nclature of T he purpos e was to gather uniform s tatistical in mental institutions . T hat 1935 class ification was designed primarily for inpatients and, therefore, proved inadequate for us e World W ar II ps ychiatric casualties , who required clas sifications for acute dis turbances , ps ychosomatic disorders , and pers onality disorders , which were not represented in the 1935 clas sification. In addition, the system was considered anachronis tic by the increasing number of psychodynamically oriented psychiatrists were emerging from training programs and whose 1032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 33 of 173

interes ts lay more in the treatment of private F or thos e reasons , shortly after W orld W ar II, the Administration and the military services developed their own systems . In 1948, the World Health Organization (W HO) the res ponsibility for revising what had previously been called the International List of C auses of Death and had been revis ed every 10 or 20 years s ince its 1900. T he s ixth revision was renamed the Manual of Inte rnational C las s ification of Dis eas e s , Injurie s , and of Death (IC D-6) and contained, for the first time, a clas sification of mental disorders , entitled “mental, ps ychoneurotic, and pers onality disorders .” It contained ten categories of psychos is, nine categories of ps ychoneurosis , and s even categories of disorders of character, behavior, and intelligence. Des pite the fact that American psychiatrists had participated in the development of the mental disorders section of IC D-6, the abs ence of such important as the dementias , many personality dis orders , and adjus tment disorders rendered it uns atis factory for use the United S tates . Other countries apparently als o the mental disorders section unsatis factory, becaus e F inland, New Zealand, P eru, T hailand, and the United K ingdom made official use of it. T he lack of wides pread international acceptance of that section of IC D-6 led the W HO to as k E rwin S tengel, a ps ychiatris t, to inves tigate the s ituation. S tengel concluded that the lack of general acceptance of the international class ification of mental disorders was due the fact that the diagnostic terms frequently had etiological implications that were at odds with various 1033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 34 of 173

theoretical s chools of psychiatry. His s uggestion was to develop a clas sification in which all diagnos es should described operationally and without etiological implications in a companion gloss ary. (As the furor the elimination of neuroses in DS M-III has indicated, not so eas ily done!) In 1951, the U.S . P ublic Health S ervice commiss ioned workgroup party, with repres entation from the AP A, to develop an alternative to the mental disorders section IC D-6 for us e in this country. T hat document, prepared largely by G eorge R aines and bas ed heavily on the V eterans Administration clas sification s ys tem P.1010 developed by William Menninger, was published in by the AP A as the DS M. DS M-I included 106 T he significance of DS M-I was that it replaced the mental disorders section of the AMA's S tandard Nome nclature of Dis e as e and the s ys tems devised by military and the V eterans Administration, and, for the time, it provided a glos sary of definitions of categories. addition, for the first time, a specialty medical the AP A, developed what became the official American clas sification of mental dis orders. T he AP A is the only medical specialty that is in charge of its official clas sification of medical disorders . In the definitions of the diagnos tic categories , the us e of the term re action, as in s chizophre nic re action ps ychone urotic re action, express ed the s trong environmental orientation of Adolf Meyer, and the frequent reference to defens e mechanisms, particularly 1034 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 35 of 173

an explanation of the neuroses and personality reflected the wide acceptance of ps ychoanalytical concepts . Des pite its widespread influence and impact American psychiatric literature, DS M-I was not accepted as the official nomenclature throughout the country. T he New Y ork S tate Department of Mental Hygiene, for example, retained the old S tandard Nome nclature of Dis e as e until 1968. B ecaus e mos t of the other countries that used the IC D found the mental disorders section of the sixth revision unsatisfactory, the W HO s ponsored an international to develop a class ification s ys tem for mental disorders would improve on IC D-6 and would be acceptable to all member nations. T hat tas k was coordinated in this by the U.S . P ublic Health S ervice, which sent American representatives to the international committees revis ions of the mental dis orders s ection. T he eighth revis ion of the IC D (IC D-8) was approved by the W HO 1966 and became effective in 1968. (T he mental section of the s eventh revision of the IC D [IC D-7], appeared in 1955, was identical to the mental dis orders section of the s ixth revis ion of the IC D [IC D-6].) In 1965, the AP A, which had maintained clos e ties with international committees preparing IC D-8, ass igned its C ommittee on Nomenclature and S tatis tics, under the chairmanship of E rnes t M. G ruenberg, the tas k of preparing for the AP A a new diagnostic manual of disorders bas ed on the IC D-8 class ification but defining each dis order for use in the United S tates. S uch were necess ary because, when IC D-8 was first did not have an accompanying gloss ary. It was only later, in 1972, 4 years after DS M-II was adopted, that a 1035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 36 of 173

gloss ary was publis hed. A draft of the second edition of the AP A's DS M was circulated in 1967 to 120 ps ychiatris ts known to have a special interes t in the area of diagnosis, and it was on the bas is of their criticisms and sugges tions. After further s tudy, the draft was adopted by the AP A in and was publis hed and officially accepted throughout country in 1968. At approximately the s ame time, the G eneral R egis ter Office in G reat B ritain publis hed its gloss ary, largely written by S ir Aubrey Lewis , which interpreted the IC D-8 clas sification. T he DS M-II clas sification cons isted of 182 disorders in ten major categories : 1. Mental retardation. T his category had been called me ntal de ficiency in DS M-I and had been limited to idiopathic or familial varieties of the disorder. In II, it was s ubdivided according to severity and 2. Organic brain syndromes. T he DS M-I distinction of acute (revers ible) vers us chronic (irrevers ible) was dropped and was replaced by the s ubdivision into ps ychos es as sociated with organic brain and nonps ychotic organic brain s yndromes. 3. P sychos es not attributed to physical conditions previous ly. T his s ection included the functional ps ychos es : schizophrenia, major affective paranoid s tates, and other ps ychos es (psychotic depres sive reaction). T he DS M-II category of schizophrenia included the latent type, not included DS M-I. T he DS M-I category of involutional reaction was s ubdivided into involutional 1036 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 37 of 173

and involutional paranoid s tate in DS M-II. 4. Neuroses. T his category included disorders in the chief characteristic was anxiety, whether “felt expres sed directly” or “controlled unconsciously automatically by convers ion, displacement and other psychological mechanisms.” T he DS M-I were retained with the addition in DS M-II of neuras thenic neurosis, depersonalization neurosis, hypochondriacal neuros is. 5. P ers onality disorders and certain other mental disorders . T his category included disorders , sexual deviation, alcoholism, and drug dependence. In DS M-I, all of those categories were subs umed under the rubric of pe rs onality dis orde rs . the personality disorders s ection its elf, DS M-II hysterical personality and eliminated the somewhat related DS M-I category of emotionally unstable personality. 6. P sychophys iological dis orders. T his group of was characterized by phys ical s ymptoms caused emotional factors and involving a s ingle organ us ually under autonomic nervous system T he disorders were s ubdivided by the organ involved. 7. S pecial s ymptoms. T his category was for a small symptoms occurring in the abs ence of any other mental disorder and mos t likely s een in children. II added s everal s ymptoms to the DS M-I list. 8. T ransient situational disturbances . T his category res erved for more or les s trans ient dis orders of any severity, including those of ps ychotic proportions 1037 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 38 of 173

occurred as acute reactions to overwhelming environmental s tres s in persons without any underlying mental disorders . T ransient situational personality dis orders in DS M-I did not s pecifically include acute reactions to stress that reached ps ychotic proportions , as did the category of situational dis turbances in DS M-II. 9. B ehavior disorders of childhood and adoles cence. category included six s pecific diagnos es . DS M-I not provided a separate category for dis orders of childhood and adolescence. 10. C onditions without manifes t ps ychiatric disorder nonspecific conditions. T his category, not pres ent DS M-I, performed the function of encompass ing “conditions of individuals who are psychiatrically normal but who nevertheles s have s evere enough problems to warrant examination by a ps ychiatris t.” T hese conditions are, therefore, not mental T his category was s ubdivided into three groups: maladjus tment without manifes t ps ychiatric nonspecific conditions, and no mental disorder. Unlike DS M-I, which discouraged multiple diagnoses, II explicitly encouraged clinicians to diagnos e every disorder that was present, even if one was caus ally to another—for example, alcoholis m s econdary to a depres sion. T he reaction to the publication of DS M-II in 1968 was mixed. T hos e who were mos t critical of DS M-II as one commentator s tated as a “giant leap into the century and a return to a kraepelinian view of mental disorders as fixed dis eas e entities”—despite the fact 1038 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 39 of 173

the word dis e as e was limited to certain categories in mental retardation and organic brain s yndromes and even though the word illne s s appeared only in the manic-depres sive conditions , where it was adopted to avoid the IC D term manic-de pres s ive ps ychos is . K arl Menninger summarized the view when he s aid: T his year the AP A took a great backward when it abandoned principle us ed in the s imple nosology (DS M-I) which Dr. Will (W illiam Menninger) worked s o hard to get P.1011 installed…. In the interest of uniformity, in the interes t of having s ome kind of code of designations for different kinds of human troubles , in the interes t of statis tics and computers , the American scientis ts were asked to some of the advances they had made in conceptualization and designation of mental illness . Although child ps ychiatris ts were pleas ed that DS M-II, unlike DS M-I, had a special category for children and adoles cents , many were disappointed that the G roup the Advancement of P s ychiatry's P s ychopathological Dis orde rs in C hildhood: T he ore tical C ons ide rations and 1039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 40 of 173

P ropos e d C las s ification, which had been available for several years , was not us ed by the committee that developed DS M-II. Many applauded the elimination of the term re action, which had been appended to most of the DS M-I terms , an honest retreat from the position that, by adding the term re action to diagnostic labels, one thereby communicates some important knowledge about the etiology of the mental disorders . As G ruenberg T he routinizing of the word “reaction” in our standard nomenclature (DS M-I) has accomplis hed little that is positive—it has given many ps ychiatris ts the false notion that mental disorders are reactions the organis m to circums tances that tuberculosis and diabetes nephritis and measles and are “things ” independent of the patient's nature. F or all medical diseases are also reactions of organism to certain life circums tances and do not exis t independently of the people who are sick. T hose who were most enthusiastic pointed to the potential benefits that might accrue to international res earch and to communication between ps ychiatris ts different nations becaus e this country had adopted a 1040 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 41 of 173

system based on the IC D. Although DS M-II was the basis for the official manuals us ed in C anada, India, and several Latin countries , other national glos saries were prepared, and they defined the IC D lis t of terms in their own way. T he most influential gloss ary, other than DS M-II, was G re at B ritain's G los s ary of Me ntal Dis orders , prepared in under the direction of Aubrey Lewis. In the abs ence of an internationally accepted gloss ary, was inevitable that different countries would define categories s omewhat differently. An important example inconsistent definition occurred with s chizophrenia. II defined s chizophre nia broadly, cons is tent with the of schizophrenia held by American psychiatrists in the 1960s , and included mild cas es that most E uropean ps ychiatris ts would not have cons idered to be schizophrenia. T he B ritis h glos sary defined the more narrowly, and the differences in the reported prevalence of schizophrenia in the two countries was found to be mainly due to differences in diagnostic definition, rather than due to differences in actual rates disorder. In 1975, the ninth revision of the IC D (IC D-9) of mental disorders was publis hed, together with a gloss ary, to go into effect in 1978. Although many changes in the IC D-8 class ification and glos sary were made, thes e were not radical changes . As with IC D-8, ps ychiatris ts from the United S tates provided some input into the final document. An examination of the IC D-9 class ification reveals a difficulty in developing a class ification that is 1041 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 42 of 173

internationally. It is far eas ier to allow each country to introduce terms that are us ed only by that country than is to ins is t that different countries us e a single agreedterminology. T hus , as R obert E . K endell noted, the clas sification actually includes several “alternative and quite incompatible” ways of clas sifying depres sion. F or example, definitions of the categories of manicps ychos is , depres sed type, and depress ive type of nonorganic ps ychosis are not mutually exclus ive.

MODE R N HIS TOR Y OF C L A S S IF IC A TION In 1972, a group of researchers publis hed an article in Archive s of G ene ral P s ychiatry entitled “Diagnos tic for Us e in P s ychiatric R esearch.” R eferred to as the crite ria (after the lead author of the article), or the W as hington U nive rs ity crite ria (after the academic of the authors), for the first time, s pecific inclus ion and exclusion criteria for different dis orders were T he criteria were limited to the 15 dis orders that the authors cons idered to have been validated by empirical res earch. T he methods of establishing diagnos tic had been described in another paper from this group 2 years earlier and were recapitulated in the 1972 article. Was hington Univers ity five-phase approach toward es tablis hing diagnostic validity of individual categories dominated empirical psychiatry during the past 30 (T able 9.1-2).

Table 9.1-2 Was hington Approac h toward E s tablis hing 1042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 43 of 173

Validity of a Ps yc hiatric C linical description

Includes symptoms of the dis order, as well as demographic features , age of onset, precipitating life events, other variables that more clearly define the clinical picture.

Delimitation from other disorders

R efers to exclusion criteria, so individuals with other disorders who share s imilar clinical are not included in the diagnos tic group.

Laboratory studies

Includes biological and ps ychological tes ts .

F ollow-up study

T he same dis order may have variable prognosis, but, until is known about the fundamental nature of the disorder, marked differences in outcome rais e questions about the validity of original diagnos is.

F amily s tudy

Includes family, adoption, and studies.

1043 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 44 of 173

Adapted from F eighner J P , R obins E , G uze S B , Diagnos tic criteria for us e in ps ychiatric research. Arch G e n P s ychiatry. 1972;26:57–67.

Als o in 1972, S pitzer and J os eph F leiss publis hed a article of studies examining the reliability of psychiatric diagnosis. T hey reexamined the reliability s tudies conducted during the 1950s and 1960s, and computed kappa coefficients of diagnostic agreement, which was then a relatively novel s tatistical procedure for determining the level of agreement after accounting for agreement due to chance. T hey concluded that the reliability of ps ychiatric diagnosis was poor. T his es tablis hed the groundwork for revising how ps ychiatric disorders were defined, as poor reliability limits the of a diagnostic s ys tem. As part of a longitudinal s tudy of the course of mood disorders , the R es earch Diagnostic C riteria (R DC ) developed along with a s emi-structured diagnos tic interview that evaluated these criteria. T he criteria for almos t every disorder originally defined by the Was hington Univers ity group were modified in the and s tudies were s ubs equently conducted to compare res pective reliabilities of these criteria sets (along with DS M-III criteria). As with the Was hington Univers ity only a limited number of disorders were defined in the 1044 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 45 of 173

R DC . DS M-III was published in 1980. S even years later, was published. Less than 1 year after the publication of DS M-III-R , P.1012 plans were announced for the publication of DS M-IV . Delayed by 2 years , DS M-IV was ultimately publis hed 1994. R obert S pitzer was the chair of the T as k F orce DS M-III and DS M-III-R , and Allen F rances the chair of T as k F orce for DS M-IV . T he publication of DS M-III was received with significant comment, as it represented a marked departure from ps ychiatric disorders had been previous ly specified and described. Although controversy surrounded s ome decis ions, such as the removal of the term ne uros is the clas sification, the achievements of DS M-III resulted widespread and continued adoption of its approach toward ps ychiatric clas sification.

A C HIE VE ME NTS OF DS M-III DS M-III was the first official diagnos tic system to inclusion and exclus ion diagnostic criteria. DS M-III thus followed the precedents s et in the W ashington criteria and R DC for defining disorders and brought the reliable diagnos tic approach used by a few research groups to the clinical community. B ecause an official clas sification system mus t be comprehensive and mus t include thos e disorders for which individuals seek treatment, DS M-III expanded the number of dis orders defined with specified criteria from the handful in the to more than 200. T his required that the criteria be 1045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 46 of 173

on expert clinical consensus rather than systemic T he s pecified diagnos tic criteria of DS M-III have advantages over the prototypic descriptions of DS M-II. Diagnos tic reliability is better, and this is of benefit to res earchers attempting to replicate another findings and to clinicians who can communicate more effectively with one another. T he specification of diagnostic criteria als o enables of the boundaries between dis orders and between disorder and no disorder. T hus , the validity of the diagnostic criteria can be evaluated s cientifically. In was as sumed when DS M-III was published that would be made, and it was anticipated that thes e would follow scientific s tudy rather than ideological debate. DS M-III was the first official psychiatric clas sification to introduce a multiaxial evaluation system in which domains of information are described on five different axes . T he purpos e of multiaxial evaluation is to comprehensive, biopsychos ocial approach toward as sess ment. Axis I cons ists of all clinical disorders , for personality dis orders and mental retardation, both which are reported on Axis II. P rominent maladaptive personality traits that do not meet criteria for a s pecific disorder and defense mechanis ms are als o noted on Axis III is for general medical conditions that might be relevant to unders tanding or managing the patient's ps ychiatric disorder. Axis IV is for noting psychosocial environmental problems that are relevant to the treatment, and prognosis of Axis I and Axis II dis orders. Axis V is the global ass es sment of functioning (G AF ) a 100-point rating based on symptom severity, social 1046 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 47 of 173

functioning, and occupational functioning. Another major achievement of DS M-III was the of the definition of schizophrenia and the requirement that, during some point in the illness , overt psychotic features must be pres ent. T he redefinition of brought the American s ys tem closer to the E uropean approach toward diagnosing this disorder. T he descriptions of dis orders included in DS M-III were much more detailed than the des criptions provided in DS M-II. T able 9.1-3 provides the DS M-II des cription of mania as an example of the brief descriptive found in DS M-II. In contrast, the DS M-III text a manic epis ode covered s ix pages and included information on demographic characteris tics, age of familial patterns , cours e of illnes s, and differential diagnosis. (In DS M-IV -T R , this has expanded to five of text on a manic episode, another s ix pages of text to describe mixed and hypomanic episodes, and 14 more pages to des cribe the diagnosis of bipolar disorder.)

Table 9.1-3 DS M-II Des c ription of Manic -Depres s ive Dis order T hese dis orders are marked by s evere mood and a tendency to remis sion and recurrence. P atients may be given this diagnosis in the of a previous his tory of affective ps ychosis if no obvious precipitating event. T his dis order is 1047 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 48 of 173

divided into three major subtypes: manic type, depres sed type, and circular type.    296.1 Manic-depres sive illnes s, manic type depres sive psychosis, manic type): T his dis order cons ists exclus ively of manic epis odes. T hes e episodes are characterized by excess ive elation, irritability, talkativeness , flight of ideas, and accelerated s peech and motor activity. B rief of depress ion sometimes occur, but they are true depres sive episodes.    296.2 Manic-depres sive illnes s, depres sed type (manic-depres sive psychosis, depress ed type): disorder cons is ts exclus ively of depress ive T hese episodes are characterized by severely depres sed mood and by mental and motor retardation progress ing occas ionally to s tupor. Uneasines s, apprehens ion, perplexity, and may als o be pres ent. When illus ions, and delus ions (usually of guilt or of or paranoid ideas) occur, they are attributable to dominant mood disorder. B ecause it is a primary mood dis order, this psychosis differs from the ps ychotic depress ive reaction, which is more attributable to precipitating s tres s. C ases incompletely labeled as ps ychotic depre s s ion be clas sified here rather than under ps ychotic de pres s ive re action.

1048 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 49 of 173

   296.3 Manic-depres sive illnes s, circular type (manic-depres sive psychosis, circular type): T his disorder is distinguis hed by at leas t one attack of depres sive epis ode and a manic epis ode. T his phenomenon makes clear why manic and types are combined into a s ingle category.

DS M-III ass umed a descriptive approach to because it was recognized that the etiology of disorders was largely unknown. T o facilitate the us e of diagnostic class ification by clinicians with different theoretical orientations, etiological perspectives were included in DS M-III. T he bas is of the disorder was shared clinical features. DS M-III, for the first time in an official clas sification of mental disorders , included a definition of mental As noted previous ly, the definition has been debated criticized, but it at least provided a bas is for discus sing relevant iss ues .

DS M-IV-TR C L A S S IF IC A TION DS M-IV was published in the midst of the criticism that represented the third version of the DS M publis hed 14 years. T his contrasted with the 16-year interval DS M-I and DS M-II and the 12-year interval between and DS M-III. Mark Zimmerman argued that the of three DS M editions within s uch a short interval could res ult in six problems : (1) an ins ufficient amount of time between DS M editions to allow the accumulation of 1049 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 50 of 173

replicated res earch necess ary to justify a change in diagnostic criteria, thereby impeding progres s in the development of a valid clas sification; (2) the of resources to compare the new diagnostic criteria the old and thus divert effort toward dis covering pathophys iological mechanisms; (3) difficulties in interpreting and res olving discrepant research findings based on different criteria sets; (4) an increased diagnostic errors becaus e of the lack of time to learn nuances of frequently changing diagnos tic criteria; P.1013 (5) impeded communication among clinicians, because three diagnostic manuals will be in widespread use; frus tration from patients who have their diagnoses changed when the diagnostic manual changes . T he leaders of the T as k F orce charged with the DS M-IV acknowledged concerns about the brief between DS M editions and indicated that DS M-IV was be the mos t empirically grounded psychiatric system. T he three components of the empirical underpinning DS M-IV were comprehensive literature reviews , reanalys es of exis ting data bases, and a field trials comparing existing and propos ed criteria Along with the proliferation of DS M vers ions, the 1980s and 1990s witnes sed a proliferation of comment on the overall revis ion proces s, as well as s pecific decisions regarding behavior and cognitive patterns that were or were not included as dis orders in the DS Ms. press ures thus ass umed greater visibility (and pos sibly influence) in revising the class ification. T he ultimate political s tatement on class ification came in the form of 1050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 51 of 173

referendum that was placed on the 1994 general ballot the AP A. T he referendum asked the AP A members hip vote on whether the tenth revision of the IC D (IC D-10) should be adopted as the official diagnos tic system and the DS M-IV 's publication s hould be pos tponed for 3 T he referendum was defeated; however, the fact that a petition drive was success ful in getting the iss ue on the ballot indicated that the level of dis satis faction with the frequent DS M revisions was not insignificant. DS M-IV -T R lists 365 disorders in 17 s ections (T able plus some diagnos tic criteria propos ed for further s tudy included in the appendix. T his is an increase from the disorders in 17 s ections in DS M-III and the 292 18 sections in DS M-III-R . T he DS M-IV -T R clas sification mental disorders is provided in T able 9.1-5. In the following s ection, the salient features of the disorders each section are briefly des cribed.

Table 9.1-4 G roups of C onditions DS M-IV-TR Dis orders usually firs t diagnos ed in infancy, childhood, or adoles cence Delirium, dementia, amnes tic, and other cognitive disorders Mental disorders due to a general medical 1051 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 52 of 173

S ubstance-related dis orders S chizophrenia and other ps ychotic dis orders Mood dis orders Anxiety disorders S omatoform dis orders F actitious disorders Dis sociative disorders S exual and gender identity disorders E ating dis orders S leep disorders Impulse-control disorders not els ewhere Adjustment disorders P ers onality disorders Other conditions that may be a focus of clinical attention

1052 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 53 of 173

Table 9.1-5 DS M-IV-TR C las s ific ation of Mental (With International S tatis tic al C las s ific ation of Dis eas es , Tenth R evis ion, C odes ) Dis orders us ually firs t diagnos ed in infancy, childhood, or adoles c enc e (39)    Mental retardation (41)      Note : T hese are coded on Axis II.      F 70.9 Mild mental retardation (43)      F 71.9 Moderate mental retardation (43)      F 72.9 S evere mental retardation (43)      F 73.9 P rofound mental retardation (44)      F 79.9 Mental retardation, severity uns pecified    Learning dis orders (49)      F 81.0 R eading disorder (51)      F 81.2 Mathematics disorder (53) 1053 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 54 of 173

     F 81.8 Dis order of written express ion (54)      F 81.9 Learning dis order NOS (56)    Motor skills dis order (56)      F 82 Developmental coordination dis order (56)    C ommunication dis orders (58)      F 80.1 E xpres sive language dis order (58)      F 80.2 Mixed receptive-expres sive language disorder (62)      F 80.0 P honological disorder (65)      F 98.5 S tuttering (67)      F 80.9 C ommunication disorder NOS (69)    P ervasive developmental dis orders (69)      F 84.0 Autistic dis order (70)      F 84.2 R ett's syndrome (76)      F 84.3 C hildhood disintegrative dis order (77)      F 84.5 As perger's s yndrome (80) 1054 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 55 of 173

     F 84.9 P ervas ive developmental dis order NOS    Attention-deficit and disruptive behavior (85)    -.- Attention-deficit/hyperactivity disorder (85)      F 90.0 C ombined type      F 98.8 P redominantly inattentive type      F 90.0 P redominantly hyperactive-impulsive      F 90.9 Attention-deficit/hyperactivity dis order (93)      F 91.8 C onduct Dis order (93)        S pe cify type: childhood-onset type or onset type      F 91.3 Oppositional defiant disorder (100)      F 91.9 Dis ruptive behavior dis order NOS (103)    F eeding and eating dis orders of infancy or early childhood (103)      F 98.3 P ica (103)

1055 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 56 of 173

     F 98.2 R umination disorder (105)      F 98.2 F eeding disorder of infancy or early childhood (107)    T ic dis orders (108)      F 95.2 T ourette's s yndrome (111)      F 95.1 C hronic motor or vocal tic dis order      F 95.0 T ransient tic disorder (115)        S pe cify if: single epis ode or recurrent      F 95.9 T ic dis order NOS (116)    E limination dis orders (116)      __._ E ncopresis (116)       R 15 W ith cons tipation and overflow (als o code K 59.0 cons tipation on Axis III)       F 98.1 W ithout cons tipation and overflow incontinence      F 98.0 E nures is (not due to a general medical condition) (118)

1056 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 57 of 173

       S pe cify type: nocturnal only, diurnal only, or nocturnal and diurnal    Other disorders of infancy, childhood, or adoles cence (121)      F 93.0 S eparation anxiety dis order (121)        S pe cify if: early ons et      F 94.0 S elective mutis m (125)      F 94.x R eactive attachment disorder of infancy early childhood (127)       .1 Inhibited type       .2 Disinhibited type      F 98.4 S tereotypic movement disorder (131)        S pe cify if: with self-injurious behavior      F 98.9 Dis order of infancy, childhood, or adoles cence NOS (134) Delirium, dementia, and amnes tic and other cognitive dis orders (135)    Delirium (136) 1057 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 58 of 173

     F 05.0 Delirium due to… [indicate the gene ral me dical condition] (code F 05.1 if s upe rimpos e d de me ntia) (141)       __._ S ubstance intoxication delirium (re fe r to s ubs tance-re late d dis orde rs for s ubs tance code s ) (143)       __._ S ubstance withdrawal delirium (re fe r to s ubs tance-re late d dis orde rs for s ubs tance code s ) (143)       __._ Delirium due to multiple etiologies (code each of the s pecific e tiologie s ) (146)      F 05.9 Delirium NOS (147)    Dementia (147)      F 00.xx Dementia of the Alzheimer's type, with early ons et (als o code G 30.0 Alzhe ime r's early ons e t, on Axis III) (154)       .00 Uncomplicated       .01 With delus ions       .03 With depres sed mood        S pe cify if: with behavioral dis turbance 1058 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 59 of 173

     F 00.xx Dementia of the Alzheimer's type, with onset (als o code G 30.1 Alzhe ime r's dis e as e , with ons e t, on Axis III) (154)       .10 Uncomplicated       .11 With delus ions       .13 With depres sed mood        S pe cify if: with behavioral dis turbance      F 01.xx V as cular dementia (158)       .80 Uncomplicated       .81 With delus ions       .83 With depres sed mood       S pe cify if: with behavioral dis turbance      F 02.4 Dementia due to HIV diseas e (als o B 22.0 HIV dis e as e res ulting in e nce phalopathy III) (163)      F 02.8 Dementia due to head trauma (als o S 06.9 intracranial injury on Axis III) (164)      S pe cify if: s ingle epis ode or recurrent 1059 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 60 of 173

     F 02.3 Dementia due to P arkinson's disease code G 20 P arkins on's dis eas e on Axis III) (164)      F 02.2 Dementia due to Huntington's dis eas e code G 10 Huntington's dis e as e on Axis III) (165)      F 02.0 Dementia due to P ick's dis ease (als o G 31.0 P ick's dis e as e on Axis III) (165)      F 02.1 Dementia due to C reutzfeldt-J akob (als o code A81.0 C re utzfe ldt-J akob dis e as e on (166)      F 02.8 Dementia due to… [indicate the gene ral me dical condition not lis ted above ] (als o code the ge neral me dical condition on Axis III) (167)      __._ S ubstance-induced persisting dementia to s ubs tance -re late d dis orde rs for s ubs tancecode s ) (168)      F 02.8 Dementia due to multiple etiologies code F 00.2 for mixed Alzheimer's and vas cular de me ntia) (170)      F 03 Dementia NOS (171)    Amnestic disorders (172)      F 04 Amnestic dis order due to… [indicate the 1060 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 61 of 173

ge neral me dical condition] (175)        S pe cify if: transient or chronic      __._ S ubstance-induced persisting amnestic disorder (re fe r to s ubs tance -re late d dis orders for s ubs tance-s pecific code s ) (177)      R 41.3 Amnestic dis order NOS (179)    Other cognitive disorders (179)      F 06.9 C ognitive disorders NOS (179) Mental dis orders due to a general medical condition not els ewhere clas s ified (181)    F 06.1 C atatonic disorder due to… [indicate the ge neral me dical condition] (185)    F 07.0 P ers onality change due to… [indicate the ge neral me dical condition] (187)  S pe cify type: labile type, disinhibited type, aggres sive type, apathetic type, paranoid type, type, combined type, or unspecified type    F 09 Mental dis order NOS due to… [indicate the ge neral me dical condition] (190)

1061 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 62 of 173

S ubs tanc e-related dis orders (191)     a T he following s pecifie rs may be applie d to de pendence:      S pe cify if: with phys iological dependence or without physiological dependence    C ode cours e of depe nde nce in fifth characte r:      0 = E arly full remis sion or early partial      0 = S ustained full remis sion or sustained remis sion      1 = In a controlled environment      2 = On agonis t therapy      4 = Mild, moderate, or s evere    T he following s pe cifie rs apply to s ubs tance dis orders as note d:       IWith onset during intoxication       W With onset during withdrawal    Alcohol-related dis orders (212)

1062 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 63 of 173

     Alcohol us e disorders (213)       F 10.2x Alcohol dependence a (213)       F 10.1 Alcohol abus e (214)      Alcohol-induced disorders (214)       F 10.00 Alcohol intoxication (214)       F 10.3 Alcohol withdrawal (215)        S pe cify if: with perceptual dis turbances       F 10.03 Alcohol intoxication delirium (143)       F 10.4 Alcohol withdrawal delirium (143)       F 10.73 Alcohol-induced pers isting dementia       F 10.6 Alcohol-induced pers isting amnes tic disorder (177)       F 10.xx Alcohol-induced psychotic disorder       .51 With delus ions I,W       .52 With hallucinations I,W       F 10.8 Alcohol-induced mood disorderI,W (405) 1063 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 64 of 173

      F 10.8 Alcohol-induced anxiety disorderI,W       F 10.8 Alcohol-induced s exual dysfunctionI       F 10.8 Alcohol-induced s leep disorderI,W (655)       F 10.9 Alcohol-related dis order NOS (223)    Amphetamine (or amphetamine-like)–related disorders (223)      Amphetamine use disorders (224)       F 15.2x Amphetamine dependence a (224)       F 15.1 Amphetamine abus e (225)      Amphetamine-induced disorders (226)       F 15.00 Amphetamine intoxication (226)       F 15.04 Amphetamine intoxication, with perceptual disturbances (226)       F 15.3 Amphetamine withdrawal (227)       F 15.03 Amphetamine intoxication delirium       F 15.xx Amphetamine-induced psychotic (338) 1064 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 65 of 173

      .51 With delus ions I       .52 With hallucinations I       F 15.8 Amphetamine-induced mood (405)       F 15.8 Amphetamine-induced anxiety disorderI (479)       F 15.8 Amphetamine-induced s exual (562)       F 15.8 Amphetamine-induced s leep (655)       F 15.9 Amphetamine-related dis order NOS    C affeine-related dis orders (231)      C affeine-induced disorders (232)       F 15.00 C affeine intoxication (232)       F 15.8 C affeine-induced anxiety disorderI       F 15.8 C affeine-induced s leep disorderI (655)       F 15.9 C affeine-related dis order NOS (234)

1065 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 66 of 173

   C annabis -related dis orders (234)      C annabis us e disorders (236)       F 12.2x C annabis dependence a (236)       F 12.1 C annabis abus e (236)      C annabis -induced disorders (237)       F 12.00 C annabis intoxication (237)       F 12.04 C annabis intoxication, with perceptual disturbances (237)       F 12.03 C annabis intoxication delirium (143)       F 12.xx C annabis-induced psychotic disorder       .51 With delus ions I       .52 With hallucinations I       F 12.8 C annabis -induced anxiety disorderI       F 12.9 C annabis -related dis order NOS (241)    C ocaine-related dis orders (241)      C ocaine us e disorders (242) 1066 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 67 of 173

      F 14.2x C ocaine dependence a (242)       F 14.1 C ocaine abus e (243)      C ocaine-induced disorders (244)       F 14.00 C ocaine intoxication (244)       F 14.04 C ocaine intoxication, with perceptual disturbances (244)       F 14.3 C ocaine withdrawal (245)       F 14.03 C ocaine intoxication delirium (143)       F 14.xx C ocaine-induced psychotic disorder       .51 With delus ions I       .52 With hallucinations I       F 14.8 C ocaine-induced mood disorderI,W       F 14.8 C ocaine-induced anxiety disorderI,W       F 14.8 C ocaine-induced s exual dysfunctionI       F 14.8 C ocaine-induced s leep disorderI,W       F 14.9 C ocaine-related dis order NOS (250) 1067 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 68 of 173

   Hallucinogen-related dis orders (250)      Hallucinogen use disorders (251)       F 16.2x Hallucinogen dependence a (251)       F 16.1 Hallucinogen abuse (252)      Hallucinogen-induced disorders (252)       F 16.00 Hallucinogen intoxication (252)       F 16.70 Hallucinogen pers is ting perception disorder (flas hbacks ) (253)       F 16.03 Hallucinogen intoxication delirium       F 16.xx Hallucinogen-induced psychotic (338)       .51 With delus ions I       .52 With hallucinations I       F 16.8 Hallucinogen-induced mood disorderI       F 19.8 P hencyclidine-induced anxiety disorderI (479)       F 16.9 Hallucinogen-related dis order NOS 1068 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 69 of 173

   Inhalant-related dis orders (257)       F 18.2x Inhalant dependence a (258)       F 18.1 Inhalant abus e (259)      Inhalant-induced disorders (259)       F 18.00 Inhalant intoxication (259)       F 18.03 Inhalant intoxication delirium (143)       F 18.73 Inhalant-induced pers isting dementia (168)       F 18.xx Inhalant-induced psychotic disorder       .51 With delus ions I       .52 With hallucinations I       F 18.8 Inhalant-induced mood disorderI (405)       F 18.8 Inhalant-induced anxiety disorderI (479)       F 18.9 Inhalant-related dis order NOS (263)    Nicotine-related dis orders (264)      Nicotine us e disorder (264) 1069 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 70 of 173

      F 17.2x Nicotine dependence a (264)      Nicotine-induced disorders (265)       F 17.3 Nicotine withdrawal (265)       F 17.9 Nicotine-related dis orders NOS (269)    Opioid-related dis orders (269)      Opioid us e dis orders (270)       F 11.2x Opioid dependence a (270)       F 11.1 Opioid abus e (271)      Opioid-induced disorders (271)       F 11.00 Opioid intoxication (271)       F 11.04 Opioid intoxication, with perceptual disturbances (272)       F 11.3 Opioid withdrawal (272)       F 11.03 Opioid intoxication delirium (143)       F 11.xx Opioid-induced psychotic disorder       .51 With delus ions I 1070 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 71 of 173

      .52 With hallucinations I       F 11.8 Opioid-induced mood disorderI (405)       F 11.8 Opioid-induced s exual dysfunctionI       F 11.8 Opioid-induced s leep disorderI,W (655)       F 11.9 Opioid-related dis order NOS (277)    P hencyclidine (or phencyclidine-like)–related disorders (278)      P hencyclidine us e disorders (279)       F 19.2x P hencyclidine dependence a (279)       F 19.1 P hencyclidine abus e (279)      P hencyclidine-induced disorders (280)       F 19.00 P hencyclidine intoxication (280)       F 19.04 P hencyclidine intoxication, with perceptual disturbances (280)       F 19.03 P hencyclidine intoxication delirium       F 19.xx P hencyclidine-induced psychotic (338) 1071 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 72 of 173

      .51 With delus ions I       .52 With hallucinations I       F 19.8 P hencyclidine-induced mood disorderI (405)       F 19.9 P hencyclidine-related dis order NOS    S edative-, hypnotic-, or anxiolytic-related (284)      S edative, hypnotic, or anxiolytic us e disorders (285)       F 13.2x S edative, hypnotic, or anxiolytic dependence a (285)       F 16.8 Hallucinogen-induced anxiety disorderI (479)       F 13.1 S edative, hypnotic, or anxiolytic abus e      S edative-, hypnotic-, or anxiolytic-induced disorders (286)       F 13.00 S edative, hypnotic, or anxiolytic intoxication (286)      Inhalant us e disorders (258) 1072 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 73 of 173

      F 13.3 S edative, hypnotic, or anxiolytic (287)        S pe cify if: with perceptual dis turbances       F 13.03 S edative, hypnotic, or anxiolytic intoxication delirium (143)       F 13.4 S edative, hypnotic, or anxiolytic delirium (143)       F 13.73 S edative-, hypnotic-, or anxiolyticpersis ting dementia (168)       F 13.6 S edative-, hypnotic-, or anxiolyticpersis ting amnestic disorder (177)       F 13.xx S edative-, hypnotic-, or anxiolyticps ychotic dis order (338)       .51 With delus ions I,W       .52 With hallucinations I,W       F 13.8 S edative-, hypnotic-, or anxiolyticmood dis orderI,W (405)       F 13.8 S edative-, hypnotic-, or anxiolyticanxiety dis orderW (479)

1073 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 74 of 173

      F 13.8 S edative-, hypnotic-, or anxiolyticsexual dys functionI (562)       F 13.8 S edative-, hypnotic-, or anxiolyticsleep dis orderI,W (655)       F 13.9 S edative-, hypnotic-, or anxiolyticdisorder NOS (293)    P olysubstance-related dis order (293)      F 19.2x P olysubstance dependence a (293)    Other (or unknown) s ubs tance-related (294)      Other (or unknown) s ubs tance use dis orders       F 19.2x Other (or unknown) s ubs tance dependence a (192)       S pe cify if: with pos tpartum ons et      Other (or unknown) s ubs tance-induced (295)       F 19.00 Other (or unknown) s ubs tance intoxication (199)       F 19.04 Other (or unknown) s ubs tance 1074 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 75 of 173

intoxication, with perceptual dis turbances (199)       F 19.3 Other (or unknown) s ubs tance (201)  S pe cify if: with perceptual disturbances       F 19.03 Other (or unknown) s ubs tancedelirium (code F 19.4 if ons e t during withdrawal)       F 19.73 Other (or unknown) s ubs tancepersis ting dementia (168)       F 19.6 Other (or unknown) s ubs tance-induced persis ting amnestic disorder (177)       F 19.xx Other (or unknown) s ubs tanceps ychotic dis order (338)       .51 With delus ions I,W       .52 With hallucinations I,W       F 19.8 Other (or unknown) s ubs tance-induced mood dis orderI,W (405)       F 19.8 Other (or unknown) s ubs tance-induced anxiety dis orderI,W (479)       F 19.8 Other (or unknown) s ubs tance-induced 1075 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 76 of 173

sexual dys functionI (562)       F 19.8 Other (or unknown) s ubs tance-induced sleep dis orderI,W (655)       F 19.9 Other (or unknown) s ubs tance-related disorder NOS (295) S chizophrenia and other ps ychotic dis orders (297)    F 20.xx S chizophrenia (298)      .0x P aranoid type (313)      .1x Dis organized type (314)      .2x C atatonic type (315)      .3x Undifferentiated type (316)      .5x R es idual type (316)    C ode cours e of s chizophre nia in fifth characte r:      2 = E pis odic with interepis ode res idual (s pecify if: with prominent negative symptoms)      3 = E pis odic with no interepis ode res idual symptoms 1076 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 77 of 173

     0 = C ontinuous (s pecify if: with prominent negative symptoms )      4 = S ingle epis ode in partial remis sion (s pecify with prominent negative s ymptoms)      5 = S ingle epis ode in full remiss ion      8 = Other or unspecified pattern      9 = Les s than 1 year s ince onset of initial phase symptoms    F 20.8 S chizophreniform dis order (317)  S pe cify if: without good prognos tic features/with good prognostic features    F 25.x S chizoaffective dis order (319)      .0 B ipolar type      .1 Depres sive type    F 22.0 Delusional dis order (323)  S pe cify type: erotomanic type, grandios e type, jealous type, persecutory type, somatic type, type, or unspecified type

1077 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 78 of 173

   F 23.xx B rief psychotic disorder (329)      .81 W ith marked s tres sor(s )      .80 W ithout marked s tres sor(s )       S pe cify if: with pos tpartum ons et    F 24 S hared ps ychotic disorder (332)    F 06.x P s ychotic disorder due to… [indicate the ge neral me dical condition] (334)      .2 W ith delusions      .0 W ith hallucinations    __._ S ubs tance-induced psychotic disorder s ubs tance-re late d dis orde rs for s ubs tance code s ) (338)  S pe cify if: with ons et during intoxication/with during withdrawal    F 29 P s ychotic dis order NOS (343) Mood dis orders (345)    T he following s pe cifie rs apply (for curre nt or re cent epis ode ) to mood dis orde rs as noted: 1078 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 79 of 173

      a S everity, ps ychotic, and remis sion s pecifiers       bC hronic       c With catatonic features       dWith melancholic features       e With atypical features       fWith postpartum onset    T he following s pe cifie rs apply to mood noted:       gWith or without full interepisode recovery       hWith s eas onal pattern       iWith rapid cycling    Depres sive dis orders (369)      F 32.x Major depres sive disorder, single episode a,b,c,d,e,f (369)      F 33.x Major depres sive disorder, recurrenta,b,c,d,e,f,g,h (369)      C ode curre nt s tate of major de pre s s ive 1079 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 80 of 173

fourth characte r:       0 = Mild       1 = Moderate       2 = S evere with ps ychotic features       3 = S evere with ps ychotic features       S pe cify: mood-congruent psychotic features mood-incongruent ps ychotic features       4 = In partial remis sion       5 = In full remis sion       9 = Uns pecified      F 34.1 Dysthymic disorder (376)        S pe cify if: early ons et or late onset        S pe cify: with atypical features       2 = S evere without psychotic features      F 32.9 Depress ive disorder NOS (381)    B ipolar disorders (382) 1080 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 81 of 173

     F 30.x B ipolar I disorder, single manic (382)  S pe cify if: mixed       C ode curre nt s tate of manic e pis ode in fourth characte r:       1 = Mild, moderate, or s evere without features       2 = S evere with ps ychotic features       8 = In partial or full remis sion      F 31.0 B ipolar I disorder, mos t recent episode hypomanic g,h,i (382)      F 31.x B ipolar I disorder, mos t recent episode manic a,c,f,g,h,i (382)      C ode curre nt s tate of manic epis ode in fourth characte r:       1 = Mild, moderate, or s evere without features       2 = S evere with ps ychotic features       7 = In partial or full remiss ion 1081 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 82 of 173

     F 31.6 B ipolar I disorder, mos t recent episode mixeda,c,f,g,h,i (382)      F 31.x B ipolar I disorder, mos t recent episode depres seda,b,c,d,e,f,g,h,i (382)      C ode curre nt s tate of major de pre s s ive fourth characte r:       3 = Mild or moderate       4 = S evere without psychotic features       5 = S evere with ps ychotic features       7 = In partial or full remiss ion      F 31.9 B ipolar I disorder, mos t recent episode unspecifiedg,h,i (382)      F 31.8 B ipolar II disordera,b,c,d,e,f,g,h,i (392)       S pe cify (curre nt or mos t re cent epis ode): or depress ed      F 34.0 C yclothymic disorder (398)      F 31.9 B ipolar disorder NOS (400)      F 06.xx Mood dis order due to… [indicate the 1082 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 83 of 173

ge neral me dical condition] (401)       .32 With depres sive features       .32 With major depres sive–like episode       .30 With manic features       .33 With mixed features      __._ S ubstance-induced mood dis order (re fe r s ubs tance-re late d dis orde rs for s ubs tance code s ) (405)  S pe cify type: with depress ive features , with features, or with mixed features  S pe cify if: with ons et during intoxication or with onset during withdrawal      F 39 Mood disorder NOS (410) Anxiety dis orders (429)    F 41.0 P anic dis order without agoraphobia (433)    F 40.01 P anic dis order with agoraphobia (433)    F 40.00 Agoraphobia without his tory of panic disorder (441) 1083 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 84 of 173

   F 40.2 S pecific phobia (443)  S pe cify type: animal type, natural environment blood-injection-injury type, situational type, or type    F 40.1 S ocial phobia (450)  S pe cify if: generalized    F 42.8 Obsess ive-compuls ive disorder (456)  S pe cify if: with poor ins ight    F 43.1 P os ttraumatic stress dis order (463)  S pe cify if: acute or chronic  S pe cify if: with delayed onset    F 43.0 Acute s tres s dis order (469)    F 41.1 G eneralized anxiety disorder (472)    F 06.4 Anxiety disorder due to… [indicate the ge neral me dical condition] (476)  S pe cify if: with generalized anxiety, with panic attacks, or with obses sive-compuls ive s ymptoms

1084 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 85 of 173

   __._ S ubs tance-induced anxiety disorder (re fe r s ubs tance-re late d dis orde rs for s ubs tance code s ) (479)  S pe cify if: with generalized anxiety, with panic attacks, with obs ess ive-compuls ive s ymptoms, or with phobic s ymptoms  S pe cify if: with ons et during intoxication or with onset during withdrawal    F 41.9 Anxiety disorder NOS (484) S omatoform dis orders (485)    F 45.0 S omatization dis order (486)    F 45.1 Undifferentiated somatoform disorder    F 44.x C onvers ion disorder (492)      .4 W ith motor s ymptom or deficit      .5 W ith seizures or convuls ions      .6 W ith sensory s ymptom or deficit      .7 W ith mixed presentation      F 45.4 P ain disorder (498) 1085 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 86 of 173

 S pe cify type: as sociated with ps ychological or ass ociated with ps ychological factors and a general medical condition  S pe cify if: acute or chronic    F 45.2 Hypochondrias is (504)  S pe cify if: with poor ins ight    F 45.2 B ody dysmorphic dis order (507)    F 45.9 S omatoform dis order NOS (511) Fac titious dis orders (513)    F 68.1 F actitious disorder (513)  S pe cify type: with predominantly ps ychological signs and s ymptoms, with predominantly physical signs and s ymptoms, or with combined ps ychological and phys ical s igns and s ymptoms    F 68.1 F actitious disorder NOS (517) Dis s ociative dis orders (519)    F 44.0 Dis sociative amnes ia (520)    F 44.1 Dis sociative fugue (523) 1086 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 87 of 173

   F 44.81 Dis sociative identity disorder (526)    F 48.1 Depersonalization dis order (530)    F 44.9 Dis sociative disorder NOS (532) S exual and gender identity dis orders (535)    S exual dys functions (535)      T he following s pecifie rs apply to all primary dys functions :       Lifelong type, acquired type, generalized situational type, due to ps ychological factors , or to combined factors      S exual des ire dis orders (539)       F 52.0 Hypoactive s exual des ire dis order       F 52.10 S exual avers ion dis order (541)      S exual arousal disorders (543)       F 52.2 F emale s exual arous al dis order (543)       F 52.2 Male erectile dis order (545)      Orgas mic disorders (547) 1087 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 88 of 173

      F 52.3 F emale orgas mic disorder (547)       F 52.3 Male orgas mic disorder (550)       F 52.4 P remature ejaculation (552)      S exual pain disorders (554)       F 52.6 Dyspareunia (not due to a general condition) (554)       F 52.5 V aginismus (not due to a general condition) (556)      S exual dys function due to a general medical condition (558)       N94.8 F emale hypoactive sexual desire due to… [indicate the gene ral me dical condition] (558)       N50.8 Male hypoactive sexual desire disorder to… [indicate the gene ral me dical condition] (558)       N48.4 Male erectile dis order due to… ge neral me dical condition] (558)       N94.1 F emale dyspareunia due to… [indicate ge neral me dical condition] (558)

1088 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 89 of 173

      N50.8 Male dyspareunia due to… [indicate ge neral me dical condition] (558)       N94.8 Other female s exual dys function due [indicate the gene ral me dical condition] (558)       N50.8 Other male s exual dys function due [indicate the gene ral me dical condition] (558)       __._ S ubstance-induced s exual dysfunction to s ubs tance -re late d dis orders for s ubs tance code s ) (562)  S pe cify if: with impaired des ire, with impaired arousal, with impaired orgasm, or with s exual  S pe cify if: with onset during intoxication       F 52.9 S exual dysfunction NOS (565)    P araphilias (566)      F 65.2 E xhibitionis m (569)      F 65.0 F etis his m (569)      F 65.8 F rotteurism (570)      F 65.4 P edophilia (571)

1089 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 90 of 173

 S pe cify if: sexually attracted to males, s exually attracted to females, or s exually attracted to both    S pe cify if: limited to incest  S pe cify type: exclusive type or nonexclusive type      F 65.5 S exual masochism (572)      F 65.5 S exual s adis m (573)      F 65.1 T ransves tic fetis his m (574)  S pe cify if: with gender dys phoria      F 65.3 V oyeurism (575)      F 65.9 P araphilia NOS (576)    G ender identity disorders (576)      F 64.x G ender identity disorder (576)       .2 In children       .0 In adolescents or adults  S pe cify if: sexually attracted to males, s exually attracted to females, sexually attracted to both, or sexually attracted to neither 1090 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 91 of 173

     F 64.9 G ender identity disorder NOS (582)      F 52.9 S exual disorder NOS (582) E ating dis orders (583)    F 50.0 Anorexia nervos a (583)  S pe cify type: res tricting type or binge-eating and purging type    F 50.2 B ulimia nervosa (589)  S pe cify type: purging type or nonpurging type    F 50.9 E ating disorder NOS (594) S leep dis orders (597)    P rimary s leep disorders (598)      Dys somnias (598)       F 51.0 P rimary insomnia (599)       F 51.1 P rimary hypersomnia (604)        S pe cify if: recurrent       G 47.4 Narcolepsy (609) 1091 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 92 of 173

      G 47.3 B reathing-related sleep dis order (615)       F 51.2 C ircadian rhythm s leep disorder (622)        S pe cify type: delayed s leep phase type, jet type, shift work type, or unspecified type       F 51.9 Dyss omnia NOS (629)      P aras omnias (630)       F 51.5 Nightmare disorder (631)       F 51.4 S leep terror disorder (634)       F 51.3 S leepwalking dis order (639)       F 51.8 P arasomnia NOS (644)    S leep dis orders related to another mental (645)      F 51.0 Insomnia related to… [indicate the Axis Axis II dis orde r] (645)      F 51.1 Hypers omnia related to… [indicate the or Axis II dis orde r] (645)    Other s leep disorders (651)

1092 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 93 of 173

     G 47.x S leep disorder due to… [indicate the me dical condition] (651)       .0 Ins omnia type       .1 Hypersomnia type       .8 P aras omnia type       .8 Mixed type      __._ S ubstance-induced s leep disorder (re fe r s ubs tance-re late d dis orde rs for s ubs tance code s ) (655)  S pe cify type: ins omnia type, hypersomnia type, parasomnia type/mixed type  S pe cify if: with ons et during intoxication or with onset during withdrawal Impuls e-control dis orders not els ewhere clas s ified (663)    F 63.8 Intermittent explosive disorder (663)    F 63.2 K leptomania (667)    F 63.1 P yromania (669)

1093 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 94 of 173

   F 63.0  P athological gambling (671)    F 63.3  T richotillomania (674)    F 63.9  Impulse-control disorder NOS (677) Adjus tment dis orders (679)    F 43.xx Adjus tment dis order (679)      .20 W ith depres sed mood      .28 W ith anxiety      .22 W ith mixed anxiety and depres sed mood      .24 W ith disturbance of conduct      .25 W ith mixed disturbance of emotions and conduct      .9 Unspecified  S pe cify if: acute or chronic Pers onality dis orders (685)    Note : T he s e are code d on Axis II.    F 60.0 P aranoid pers onality disorder (690) 1094 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 95 of 173

   F 60.1 S chizoid pers onality disorder (694)    F 21 S chizotypal personality disorder (697)    F 60.2 Antisocial personality disorder (701)    F 60.31 B orderline pers onality disorder (706)    F 60.4 His trionic pers onality disorder (711)    F 60.8 Narciss is tic pers onality disorder (714)    F 60.6 Avoidant personality dis order (718)    F 60.7 Dependent personality disorder (721)    F 60.5 Obsess ive-compuls ive personality (725)    F 60.9 P ers onality disorder NOS (729) Other c onditions that may be a foc us of attention (731)    P s ychological factors affecting medical (731)      F 54… [S pe cified ps ychological factor] [indicate the gene ral me dical condition]

1095 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 96 of 173

 C hoos e name bas e d on nature of factors : (731)  Mental disorder affecting medical condition  P s ychological symptoms affecting medical condition  P ers onality traits or coping style affecting condition  Maladaptive health behaviors affecting medical condition  S tress -related physiological respons e affecting medical condition  Other or unspecified ps ychological factors medical condition    Medication-induced movement disorders (734)      G 21.0 Neuroleptic-induced parkins onism      G 21.0 Neuroleptic malignant s yndrome (735)      G 24.0 Neuroleptic-induced acute dystonia      G 21.1 Neuroleptic-induced acute akathisia      G 24.0 Neuroleptic-induced tardive dys kines ia 1096 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 97 of 173

(736)      G 25.1 Medication-induced pos tural tremor      G 25.9 Medication-induced movement dis order NOS (736)    Other medication-induced dis order (736)      T 88.7 Advers e effects of medication NOS    R elational problems (736)      Z63.7 R elational problem related to a mental disorder or general medical condition (737)      Z63.8 P arent–child relational problem (code if focus of attention is on child) (737)      Z63.0 P artner relational problem (737)      F 93.3 S ibling relational problem (737)      Z63.9 R elational problem NOS (737)    P roblems related to abus e or neglect (738)      T 74.1 P hysical abuse of child (738)      T 74.2 S exual abuse of child (738) 1097 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 98 of 173

     T 74.0 Neglect of child (738)      T 74.1 P hysical abuse of adult (738)      T 74.2 S exual abuse of adult (738)    Additional conditions that may be a focus of clinical attention (739)      Z91.1 Noncompliance with treatment (739)      Z76.5 Malingering (739)      Z72.8 Adult antis ocial behavior (740)      Z72.8 C hild or adolescent antisocial behavior      R 41.8 B orderline intellectual functioning (740)      R 41.8 Age-related cognitive decline (740)      Z63.4 B ereavement (740)      Z55.8 Academic problem (741)      Z56.7 Occupational problem (741)      F 93.8 Identity problem (741)      Z71.8 R eligious or s piritual problem (741) 1098 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 99 of 173

     Z60.3 Acculturation problem (741)      Z60.0 P hase of life problem (742) Additional c odes (743)    F 99 Unspecified mental dis order (nonps ychotic) (743)    Z03.2 No diagnosis or condition on Axis I (743)    R 69 Diagnos is or condition deferred on Axis I    Z03.2 No diagnosis on Axis II (743)    R 46.8 Diagnosis deferred on Axis II (743)

     Note: An x appearing in a diagnostic code indicates that a specific code number is required. ellipsis (…) is us ed in the names of certain to indicate that the name of a specific mental disorder or general medical condition should be inserted when recording the name (e.g., F 05.0 Delirium Due to Hypothyroidis m). Numbers in parentheses are page numbers. If criteria are currently met, one of the following s everity may be noted after the diagnos is : mild, mode rate, s e ve re . If criteria are no longer met, one of the following s pecifiers may be noted: in partial 1099 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 100 of 173

re mis s ion, in full re mis s ion, or prior his tory. *HIV , human immunodeficiency virus ; NOS , not otherwis e s pecified. F rom American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. T ext rev. W as hington, American P s ychiatric Ass ociation; 2000, with permis sion.

I: Dis orders Us ually Firs t Diagnos ed Infanc y, C hildhood, or Adoles c enc e T he section of disorders us ually first diagnosed in childhood, or adoles cence is unique in DS M-IV -T R , the disorders grouped here are included bas ed on the that they are usually firs t diagnos ed rather than s hared phenomenological features. DS M-IV -T R notes that this separation is for convenience only, and it does not a clear distinction between thes e disorders and the in the manual.

Mental R etardation Mental retardation is characterized by significant, average intelligence (as demonstrated by a s core on a s tandardized, individually administered, tes t) and impairment in adaptive functioning in at least two areas . Adaptive functioning refers to how effective individuals are in achieving age-appropriate common demands of life in areas such as communication, s elfand interpersonal skills. Mental retardation is one of four disorders in DS M-IV -T R in which different 1100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 101 of 173

code numbers are provided for different levels of (mild, moderate, s evere, and profound).

L earning Dis orders T he three s pecific learning dis orders (reading, mathematics , and written express ion) are diagnos ed performance on standardized achievement tests are subs tantially below expectations bas ed on age, and intelligence, and these learning problems caus e significant impairment in functioning. Learning can be comorbid with mild mental retardation if the achievement is below that expected based on level. T he context of learning difficulties is cons idered insofar as learning disorders are not diagnosed if low of achievement is due to inadequate education.

Motor S kills Dis order DS M-IV -T R lists a single motor s kills disorder— developmental coordination dis order. Analogous to learning disorders , developmental coordination diagnosed when motor coordination is substantially expectations based on age and intelligence, and when coordination problem s ignificantly interferes with functioning. E xamples include delays in achieving developmental milestones s uch as crawling or walking, dropping things, and poor s ports performance. T he diagnosis is excluded if a s pecific general medical condition, s uch as cerebral palsy or mus cular accounts for the s ymptoms.

C ommunic ation Dis orders T he four specific communication dis orders (express ive 1101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 102 of 173

language disorder, mixed receptive-expres sive disorder, phonological disorder, and s tuttering) are characterized by speech or language difficulties . T he diagnosis of expres sive and mixed receptivelanguage dis orders depends on s tandardized tes ting (s imilar to mental retardation and learning disorders ), whereas the two articulation dis orders do not. T he communication disorders , s imilar to the learning and motor s kills disorders , are only diagnosed when they significant impairment in functioning. T he presence of subjective dis tres s in the absence of demons trable functional impairment would not warrant the diagnosis.

P ervas ive Developmental Dis orders T he four specific pervas ive developmental dis orders (autis tic disorder, R ett's s yndrome, childhood disintegrative disorder, and Asperger's s yndrome) are characterized by severe difficulties in multiple developmental areas , including social relatedness , communication, and range of activity and interests . T he diagnostic criteria for the s ocial interaction deficits and repetitive and stereotypical patterns of behavior and interes ts are identical for autistic dis order and syndrome. T hey differ in that concurrent deficits are required to diagnose autistic dis order and absent in Asperger's syndrome. Als o, to diagnose Asperger's s yndrome, a criterion is added that the symptoms mus t caus e clinically s ignificant impairment functioning; this criterion is not s pecified for autis tic disorder. P.1014 1102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 103 of 173

P.1015 P.1016 P.1017 P.1018 P.1019 P.1020

A ttention-Defic it/Hyperac tivity (A DHD) S ince the 1990s, ADHD has been one of the most discuss ed ps ychiatric disorders in the lay media the sometimes unclear line between age-appropriate normal and disordered behavior and because of the concern that nondisordered children are being and treated with medication. In fact, a lawsuit was filed agains t the AP A, charging it with being influenced by pharmaceutical industry to include the disorder in the T he central feature of the disorder is persistent or hyperactivity and impulsivity, or both, that cause clinically significant impairment in functioning in two or more s ettings . T he s ymptom criteria are polythetic— cons isting of two lis ts of nine criteria (one representing inattentive features and one repres enting the and impulsivity features) of which at least six criteria either lis t are neces sary for the diagnosis. Different 1103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 104 of 173

diagnostic code numbers are provided for different subtypes (combined type, predominantly inattentive and predominantly hyperactive-impulsive type).

C onduc t Dis order C onduct dis order, the childhood precursor of antis ocial personality disorder, is characterized by a behavior in which age-appropriate s ocietal norms and rules are violated. T he broad categories of the 15 diagnos tic are aggress ion toward people and animals , destruction property, deceitfulnes s or theft, and s erious violation of rules. C onduct dis order is the only dis order in DS M-IV which s pecific guidelines are provided for rating the disorder's s everity, but the s everity distinction is not captured by different diagnos tic code numbers . T he IV -T R text indicates that the context in which the of conduct disorder are expres sed s hould be when determining if the dis order is present. T hus, a growing up in an impoverished, violent neighborhood who joins a gang and manifes ts features of conduct disorder for self-protection should not receive the diagnosis. On the other hand, the criteria thems elves not indicate that context should be cons idered.

Oppos itional Defiant Dis order Oppositional defiant disorder is characterized by an ongoing pattern of negativistic, defiant, disobedient, hostile behavior toward authority figures . B ecaus e the features of oppositional defiant dis order occur in nondis ordered children (e.g., deliberate annoyance of others and refusal to comply with adults' reques ts), IV -T R includes a note in the diagnostic criteria 1104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 105 of 173

P.1021 that a criterion is met only when the behavior occurs frequently than that of other children of the same age developmental level. T he features of oppos itional disorder are us ually present in individuals with conduct disorder; thus , the diagnosis of oppos itional defiant disorder is not also made when conduct dis order criteria are met.

P ic a P ica refers to persistent eating of nonnutritive such as dirt, paint, plas ter, sand, and pebbles , that is inappropriate to developmental level and cultural P ica can be diagnosed when it is secondary to another mental disorder (e.g., delusional beliefs of a chronic ps ychotic dis order), as long as the eating behavior is enough to be an independent focus of clinical attention.

R umination Dis order T he core feature of rumination dis order is the repeated regurgitation and rechewing of food after a period of normal food cons umption. T he diagnosis is excluded if specific general medical condition, such as pyloric or esophageal reflux, accounts for the s ymptoms .

F eeding Dis order of Infanc y or E arly C hildhood F eeding disorder of infancy or early childhood, referred to as failure to thrive , is characterized by weight or a failure to make expected weight gain in an infant or young child due to inadequate food intake. T he 1105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 106 of 173

excluded if a s pecific general medical condition for the symptoms .

Tic Dis orders T he three s pecific tic dis orders (T ourette's s yndrome, chronic motor or vocal tic disorder, and trans ient tic disorder) are characterized by “sudden, rapid, nonrhythmic, stereotyped motor movements or vocalization.” T he three disorders are dis tinguis hed in terms of chronicity (T ourette's s yndrome and chronic tic disorder are of at leas t 12 months in duration; trans ient disorder is of at leas t 1 month in duration but less than months in duration) and range of tics (T ourette's has motor and vocal tics , chronic tic dis order has motor vocal tics , and transient tic disorder has motor or vocal or both). F or all three dis orders, a diagnosis is only the symptoms caus e marked dis tres s or significant impairment in functioning.

E limination Dis orders T he two s pecific elimination disorders (encopresis and enures is ) are characterized by repeated inappropriate pass ing of feces or urine, whether voluntary or T o diagnos e encopres is , the child must be at least 4 of age, and the inappropriate pass age of feces mus t at least once a month for 3 months or more. F or the child must be at least 5 years of age before a can be made, and the inappropriate voiding of urine occur at leas t twice a week for 3 months or more. are provided for each (encopres is—with or without cons tipation and overflow incontinence; enures is — nocturnal only, diurnal only, and nocturnal and diurnal), 1106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 107 of 173

although s eparate diagnos tic codes for the s ubtypes only provided for encopres is.

S eparation A nxiety Dis order S eparation anxiety disorder is characterized by anxiety about separation from home or attachment beyond that expected for the child's developmental DS M-IV -T R notes that clinical judgment mus t be us ed distinguish developmentally appropriate levels of separation anxiety from the excess ive and impairing or distress ing levels indicative of the disorder.

S elec tive Mutis m S elective mutis m is characterized by persistent refus al speak in s pecific s ituations in which speaking is despite the demonstration of s peaking ability in other situations. C ontext is cons idered ins ofar as the not made if the failure to speak is attributed to lack of knowledge of the spoken language (e.g., second of an immigrant).

R eac tive A ttac hment Dis order of or E arly C hildhood R eactive attachment dis order of infancy or early is characterized by one of two patterns of inappropriate s ocial relatednes s —excess ively inhibited disinhibited attachments—due to gros sly pathological caregiving.

S tereotypic Movement Dis order T he core feature of s tereotypic movement disorder is “repetitive, s eemingly driven, nonfunctional motor 1107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 108 of 173

behavior,” such as body rocking, hand waving, head banging, s elf-biting, and other s elf-mutilating behaviors . T he presence of mental retardation does not exclude diagnosis if the stereotypic behavior is sufficiently to be a focus of clinical attention.

II: Delirium, Dementia, and Amnes tic and Other C ognitive Dis orders In a break from DS M-III-R , the disorders in this s ection previous ly were included in a section entitled “Organic Mental S yndromes and Dis orders.” T he term organic me ntal dis order is not us ed in DS M-IV -T R , becaus e it incorrectly implies that other dis orders in other s ections the manual do not have an organic basis. T he former III-R organic disorders section included the disorders in section, the next section (Mental Dis orders Due to a G eneral Medical C ondition Not E ls ewhere C las sified), the S ubs tance-R elated Disorders section.

Delirium Delirium is characterized by a relatively rapid onset of problems in attention ass ociated with memory impairment, dis orientation, language impairment, hallucinations , or illusions . DS M-IV -T R presents discuss ions and criteria for delirium that is due to a medical condition, s ubs tance intoxication, or s ubs tance withdrawal, although the core features of impaired attention and cognitive deficits are the s ame across disorders . Delirium s uperimposed on a preexisting vascular dementia is clas sified as dementia with

Dementia 1108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 109 of 173

Dementia is characterized by memory impairment and or more other cognitive impairments (aphas ia, apraxia, agnos ia, and executive functioning dys function). DS MT R distinguis hes between five types (Alzheimer's vascular, due to other general medical condition, subs tance-induced, and due to multiple etiologies). Alzheimer's dementia and dementia due to a general medical condition are s ubtyped according to the or abs ence of clinically significant behavioral (which is reflected in the fifth digit of the diagnostic Alzheimer's disease is also subtyped according to the patients' age of ons et (which is not reflected in the diagnostic code). V as cular dementia is s ubtyped to the predominant clinical characteristic (with delirium, delus ions, depress ion, or none of the prior features) this is reflected in the fifth digit coding.

A mnes tic Dis order Amnes tic dis order is characterized by clinically memory impairment, similar to dementia, but without other cognitive impairments that define dementia. T wo specific amnes tic disorders are defined—amnes tic disorder due to a general medical condition (which is subtyped as trans ient or chronic) and substancepersis ting amnestic disorder. P.1022

III: Mental Dis orders Due to a Medic al C ondition Not E ls ewhere C las s ified T his s ection of mental dis orders due to a general 1109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 110 of 173

condition not elsewhere clas sified includes nine due to a general medical condition (delirium, dementia, amnes tic disorder, psychotic disorder, mood disorder, anxiety dis order, sexual dys function, s leep disorder, catatonic disorder, and pers onality change). T extual descriptions and diagnostic criteria are provided in this section only for catatonic dis order and personality T he other s even disorders are des cribed and defined in phenomenologically relevant section to facilitate differential diagnosis, although these dis orders are also listed in this s ection. F or example, the diagnos tic for mood disorder due to a general medical condition included in the mood disorders s ection to ensure that clinician cons iders this potential cause of the symptoms.

IV: S ubs tanc e-R elated Dis orders T he term s ubs tance in DS M-IV -T R includes what are commonly thought of as substances of abus e (alcohol, street drugs ), as well as medications and toxins. types of dis orders are described (dependence, abus e, intoxication with or without delirium, withdrawal with or without delirium, dementia, amnes tic disorder, mood dis order, anxiety, sexual dys function, and s leep disorder). T he s ection is organized according to the 11 specific clas ses of substances that may caus e these disorders (alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogen, inhalant, nicotine, opioid, phencyclidine [P C P ], and s edative-hypnotics). In a group of other s ubs tances is included for s ubs tances such as anabolic s teroids , nitrite inhalants , nitrous and over-the-counter and prescription drugs that are 1110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 111 of 173

covered by the 11 specific clas ses. T here is also a category for polysubstance which is diagnosed when dependence criteria are met during a 1-year period during which three or more of substances are us ed without a clear predominance any one s ubs tance, and the dependence criteria are for the substances as a group but not for any specific subs tance. T he subs tance-related dis orders section begins with provis ion of general criteria for diagnos ing abuse, intoxication, and withdrawal, which can be to many of the substances, although s ubs tance is manifest in the intoxication or withdrawal syndromes . T he s ubs tance-induced dis orders (ps ychosis , mood disorder, anxiety, s exual dysfunction, and s leep are lis ted with their corres ponding diagnostic code numbers in this section but are des cribed in detail in DS M-IV -T R s ections with which they share clinically features. T he initial s ection des cribing the general diagnostic for s ubs tance dependence, abuse, intoxication, and withdrawal is followed by a discus sion of the dis orders as sociated with each of the s pecific substances. T he section is organized by s ubs tance. T hus , all of the as sociated with alcohol use are grouped together, followed by the dis orders ass ociated with amphetamine us e, then caffeine, etc. T he dis order-specific abuse and dependence refer back to the general and dependence diagnos tic criteria. In contrast, specific criteria for withdrawal and intoxication are presented separately for each substance. 1111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 112 of 173

S ubs tanc e Dependenc e Dis orders E ach of the specific substances, except caffeine, can manifest a dependence s yndrome. T he s even criteria subs tance dependence (three of which are needed to make the diagnos is ) cover three major constructs : withdrawal, tolerance, and loss of control over use. tolerance nor withdrawal, s ometimes considered the hallmark of dependence, is neces sary or sufficient to the diagnostic criteria for s ubs tance dependence. However, based on the presence or absence of or tolerance, s ubs tance dependence is subtyped as without physiological dependence. S ubs tance dependence is one of the few dis orders in DS M-IV -T R which remiss ion is explicitly defined. C omple te requires the absence of all criteria for at least 1 month, whereas partial remis s ion refers to the presence of one two criteria. Unique to the substance dependence disorders , the duration of the period of remiss ion is specified. W hen the period of remiss ion is les s than 12 months, then it is s pecified as early re mis s ion. T his is contrast to s us taine d re mis s ion that has pers isted for at least 12 months.

S ubs tanc e A bus e Dis orders In contras t to DS M-III and DS M-III-R , DS M-IV -T R nonoverlapping criteria s ets for substance dependence and abuse. S ubstance abuse can be diagnosed for the specific subs tances , except caffeine and nicotine. S ubstance abuse is characterized by a maladaptive of use that res ults in recurrent psychosocial problems . S ubstance abuse is not diagnos ed if the criteria for dependence have ever been met. T he remiss ion 1112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 113 of 173

for s ubs tance dependence are not also applied to subs tance abus e.

S ubs tanc e-Induc ed Dis orders T he symptoms of many Axis I dis orders can be by subs tance us e; consequently, the differential of many psychiatric disorders includes ruling out that it subs tance induced. T he criteria for diagnos ing induced dis orders are therefore placed in the phenomenologically relevant section to facilitate differential diagnosis, although these dis orders are also listed in the substance-related dis orders section. F or example, the diagnostic criteria for s ubs tance-induced mood dis order are included in the mood disorders to ens ure that the clinician considers this potential of the presenting symptoms.

V: S c hizophrenia and Other Dis orders T he section on s chizophrenia and other ps ychotic disorders includes eight specific dis orders schizophreniform disorder, s chizoaffective dis order, delus ional dis order, brief ps ychotic dis order, shared ps ychotic dis order, ps ychotic dis order due to a general medical condition, and s ubs tance-induced psychotic disorder) in which psychotic symptoms are a prominent feature of the clinical picture. T he DS M-IV -T R text that other disorders may also be characterized at times ps ychotic features (e.g., major depres sive dis order or bipolar mania with psychotic features). T he grouping of disorders in this section was made to facilitate diagnosis and not to imply etiological links amongs t the 1113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 114 of 173

disorders in this section.

S c hizophrenia S chizophrenia is generally a chronic dis order in which prominent hallucinations or delusions are usually T he individual mus t be ill for at least 6 months, he or s he need not be actively psychotic during all of time. T hree phases of the dis order are defined. T he prodrome phas e refers to deterioration in function the ons et of the active psychotic phase. T he active symptoms (delusions , hallucinations , disorganized gross ly dis organized behavior, or negative s ymptoms, such as flat affect, avolition, and alogia) must be for at leas t 1 month. T he res idual phase follows the phase. T he features of the res idual and prodromal include functional impairment and abnormalities of cognition, and communication. If a manic or depress ive syndrome occurs , its duration mus t be brief relative to duration of the active phase of s chizophrenia. S chizophrenia is not diagnosed if the s ymptoms are the effects of s ubs tances or a general medical S chizophrenia is subtyped according to the mos t prominent symptoms present at the time P.1023 of the evaluation (paranoid, disorganized, catatonic, undifferentiated, and residual types ). T he subtypes different diagnostic code numbers. T he course of the disorder can als o be specified (e.g., continuous vers us episodic with or without interepisode residual although thes e are not reflected in diagnostic coding.

1114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 115 of 173

S c hizophreniform Dis order S chizophreniform dis order is characterized by the active phas e s ymptoms of s chizophrenia (delusions , hallucinations , dis organized speech, gross ly behavior, or negative symptoms ) but lasts between 1 6 months, and the prodromal or residual phase social or occupational impairment are absent. S imilar schizophrenia, schizophreniform dis order is ruled out if mood epis ode, if pres ent, is not brief relative to the duration of the psychotic s ymptoms. DS M-IV -T R does indicate how s hort the mood s yndrome must be to be cons idered brie f, and, given that s chizophreniform disorder mus t be les s than 6 months duration, there is uncertainty in how often this exclus ion criterion is S chizophreniform disorder is also excluded if the symptoms are due to the effects of substances or a medical condition. T he predicted cours e of the disorder can be s pecified (with or without good prognostic features), although this is not reflected in diagnos tic coding.

S c hizoaffec tive Dis order S chizoaffective dis order is also characterized by the active phas e symptoms of s chizophrenia (delusions , hallucinations , dis organized speech, gross ly behavior, or negative symptoms ), as well as the of a manic or depres sive syndrome that is not brief to the duration of the ps ychosis . Individuals with schizoaffective disorder, in contrast to a mood disorder with ps ychotic features, have delus ions or for at leas t 2 weeks without coexis ting prominent mood symptoms. As with the other nonfunctional ps ychotic 1115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 116 of 173

disorders , the symptoms are not attributable to us e or a general medical condition. S chizoaffective disorder is s ubtyped as bipolar or depress ive type, although this is not reflected in diagnostic coding.

Delus ional Dis order Delusional disorder is characterized by nonbizarre delus ions (i.e., delus ions about situations that could in real life, s uch as infidelity, being followed, or having illness ). T he pres ence of bizarre delus ions or the other active phas e ps ychotic symptoms of schizophrenia excludes the diagnosis of delus ional dis order. impairment is directly linked to the delusional s ys tem, the broad-based functional decline often as sociated schizophrenia is usually absent. If a manic or syndrome occurs , its duration mus t be brief relative to duration of the delusions . Delusional disorder is not diagnosed if the symptoms are due to the effects of subs tance us e or a general medical condition. disorder is s ubtyped according to the content of the delus ion, although this is not reflected in diagnostic coding.

B rief P s yc hotic Dis order B rief ps ychotic dis order requires the pres ence of hallucinations , dis organized speech, gross ly behavior, or catatonic behavior for at least 1 day but than 1 month. T he individual returns to his or her usual level of functioning. T he ps ychotic symptoms cannot be due to s ubs tance use or a general medical condition. ps ychotic dis order is s ubtyped based on the presence absence of markedly s tres sful life events or recent 1116 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 117 of 173

childbirth, although this is not reflected in diagnostic coding.

S hared P s yc hotic Dis order S hared psychotic dis order, also called folie à de ux, is characterized by a delusional belief that develops in an individual involved in a close relationship with s omeone who has an established delus ion. T he content of the delus ion is similar to the content in the pers on with the es tablis hed delusion.

P s yc hotic Dis order Due to a G eneral Medic al C ondition P sychotic disorder due to a general medical condition diagnosed when there is evidence that hallucinations delus ions are the direct cons equence of a general condition other than delirium or dementia. T he disorder subtyped according to whether delusions or predominate the s ymptom picture, and the s ubtypes coded differently.

S ubs tanc e-Induc ed P s yc hotic S ubstance-induced psychotic disorder is analogous to ps ychotic disorder due to a general medical condition, except the caus e of the hallucinations or delusions is subs tance intoxication, s ubs tance withdrawal, or a medication. T he dis order is subtyped according to the predominant s ymptom picture and the s pecific res ponsible for the s ymptoms. T he subtypes are in diagnostic coding.

VI: Mood Dis orders 1117 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 118 of 173

T he section on mood dis orders begins with the specification of the diagnostic criteria for mood (major depress ive epis ode, manic episode, hypomanic episode, and mixed episode). T he mood episode are the bas is for diagnosing the mood dis orders; by thems elves , the mood epis odes are not able to be T he next part of the section describes the s even mood disorders (major depress ive disorder, bipolar I disorder, bipolar II dis order, dysthymic disorder, cyclothymic dis order, mood dis order due to a general medical condition, and s ubs tance-induced mood disorder). T he final part of the mood disorders section describes the many methods of subtyping, s ome of are reflected in the diagnos tic code.

Major Depres s ive Dis order T he neces sary feature of major depres sive dis order is depres sed mood or loss of interest or pleas ure in usual activities. T he diagnos is of major depres sive dis order requires the presence of at least five of nine s ymptom criteria for at leas t 2 weeks , one of which is depress ed mood or loss of interest. All s ymptoms must be present nearly every day, except s uicidal ideation or thoughts death, which need only be recurrent. T o count toward diagnosis, the s ymptom mus t be a change from the person's us ual bas eline (e.g., chronic sleep difficulty of several years duration that did not change with the of depress ive s ymptoms 2 months ago does not make the diagnosis, the symptoms must cause significant dis tres s or impairment and mus t not be due subs tance use or a general medical condition. T he diagnosis is excluded if the symptoms are the res ult of normal bereavement and if there are ps ychotic 1118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 119 of 173

in the abs ence of mood s ymptoms . T he fourth digit of five-digit diagnos tic code indicates whether the experienced a previous episode of major depress ion single epis ode vers us recurrent epis odes ). T he fifth indicates current severity, the pres ence of ps ychotic features, and, if full criteria are not met at the time of evaluation, whether the episode is in partial or full remis sion. Other methods of subtyping major which are not reflected in the diagnos tic code, are chronicity (chronic subtype indicates an epis ode of at leas t 2 years ); presence of catatonic, melancholic, atypical features ; as sociation with recent childbirth postpartum onset, if the epis ode began within 4 weeks delivery); completenes s of the recovery between for individuals with two or more epis odes (with or full interepis ode recovery); and whether there is a pattern to the onset of recurrent epis odes .

Dys thymic Dis order Dys thymic disorder is a mild, chronic form of that lasts at least 2 years , during which, on the P.1024 majority of days , the individual experiences depres sed mood for mos t of the day and at leas t two other of depress ion. During the 2-year period, the s ymptoms never get s evere enough to meet criteria for a major depres sive epis ode, although many individuals with dysthymic dis order have s uperimpos ed major disorder (called double de pres s ion). T he disorder is excluded if there is a history of mania, hypomania, or cyclothymia. T he dis order is subtyped according to age 1119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 120 of 173

onset (early onset before 21 years of age, late onset 21 years of age) and the pres ence of atypical features , although neither method of s ubtyping is reflected by diagnostic coding.

B ipolar I Dis order T he neces sary feature of bipolar I disorder is a his tory manic or mixed manic and depres sive epis ode. Mania requires euphoric or irritable mood for at leas t 1 week any duration, if the individual is hos pitalized) and at three (if mood is euphoric) or four (if mood is irritable) seven s ymptom criteria. In contrast to major there is no indication that the s ymptoms mus t be nearly every day. T he diagnosis is excluded if the symptoms are the res ult of a general medical condition, subs tance use, antidepres sant medication, or if there ps ychotic symptoms in the abs ence of mood T he impairment-distress criterion for mania is different than the impairment-distress criterion for most other disorders . F or mos t disorders , s uch as major disorder, this criterion is worded “clinically significant distress or impairment.” F or a manic epis ode, there is reference to distress , and the impairment mus t be “marked.” DS M-IV -T R does not specify how “marked” differs from “clinically significant.” T he distress criterion for a manic epis ode is als o met if the neces sitate hos pitalization or if ps ychotic symptoms present. T he inclusion of these other components of impairment criterion sugges ts that marked impairment more s evere than clinically s ignificant impairment. disorder is s ubtyped in many ways : type of current (manic, hypomanic depress ed, or mixed), severity and remis sion s tatus (mild, moderate, severe without 1120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 121 of 173

ps ychos is , s evere with ps ychotic features , partial or full remiss ion), the s ame symptom and cours e as major depress ion when the current epis ode is depres sion, and whether the recent cours e is by rapid cycling (at least four epis odes in 12 months ).

B ipolar II Dis order B ipolar II disorder is characterized by a his tory of hypomanic and major depress ive epis odes. T he criteria for a hypomanic episode are the s ame as that manic epis ode, although hypomania only requires a minimum duration of 4 days . T he major difference between mania and hypomania is the s everity of the impairment ass ociated with the syndrome. Hypomania the only DS M-IV -T R disorder that is excluded if the impairment is too s evere. T he DS M-IV -T R criteria refer observable changes in functioning but do not s pecify a minimum level of impairment for the diagnos is. T he subtyping of bipolar II dis order is the same as bipolar I disorder, although none of the s ubtyping methods is reflected in diagnos tic coding.

C yc lothymic Dis order T he bipolar equivalent to dysthymic dis order, disorder, is a mild, chronic mood disorder with depres sive and hypomanic episodes over the cours e of least 2 years . T he depres sive periods never meet a major depres sive epis ode, and the hypomanic never meet criteria for mania, although they may meet criteria for hypomania.

Mood Dis order Due to a G eneral 1121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 122 of 173

C ondition Mood dis order due to a general medical condition is diagnosed when there is evidence that a significant disturbance is the direct cons equence of a general condition other than delirium. T he disorder is s ubtyped according to the pres ence of depress ive s ymptoms not meeting criteria for a major depress ive epis ode, symptoms meeting full major depress ion criteria, manic features, or mixed features .

S ubs tanc e-Induc ed Mood Dis order S ubstance-induced mood disorder is diagnosed when caus e of the mood dis turbance is s ubs tance withdrawal, or a medication. T he disorder is s ubtyped according to the s pecific substance res ponsible for the symptoms, which is reflected in diagnos tic coding, and type of mood s ymptoms, which is not reflected in the coding.

VII: Anxiety Dis orders T he section on anxiety dis orders includes ten s pecific disorders (panic disorder, agoraphobia, specific social phobia, OC D, posttraumatic s tres s disorder acute stress dis order, generalized anxiety disorder, disorder due to a general medical condition, and subs tance-induced anxiety dis order) in which anxious symptoms are a prominent feature of the clinical T he grouping of dis orders in this section was made to facilitate differential diagnosis and not to imply links amongst the disorders in this s ection. B ecaus e separation anxiety dis order occurs in childhood, it is included in the childhood dis orders s ection. 1122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 123 of 173

P anic Dis order A panic attack is characterized by feelings of intense terror that come on out of the blue in s ituations in which there is nothing to fear and that are accompanied by at least four of a lis t of 13 features , the most common heart racing or pounding, ches t pain, shortness of or choking, dizziness , trembling or s haking, feeling faint lightheaded, s weating, and naus ea. P anic disorder is diagnosed in an individual who has experienced at two attacks as sociated with 1 month or more of concern about having another panic attack, worrying about the implications of the attack, or a change in behavior becaus e of the attacks . P anic dis order is according to the pres ence or abs ence of agoraphobia, this is reflected in the fifth digit of the diagnostic code.

A goraphobia Agoraphobia is a frequent cons equence of panic although it can occur in the abs ence of panic attacks. Individuals with agoraphobia avoid (or try to avoid) situations that they think might trigger a panic attack (or panic-like symptoms ) or situations from which they es cape might be difficult if they have a panic attack. to the precedent of diagnos ing the cooccurrence of vascular dementia and delirium as a single dis order, panic dis order and agoraphobia are present, only a diagnosis is made (panic disorder with agoraphobia).

S pec ific P hobia S pecific phobia is characterized by an excess ive, unreas onable fear of specific objects or situations that occurs almost always on exposure to the feared 1123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 124 of 173

Ins ight that the fear is excess ive or unreasonable is required to make the diagnos is . T he phobic stimulus is avoided, or, when not avoided, the individual feels severely anxious or uncomfortable. T he anxiety or avoidance caus es clinically significant functional impairment or dis tres s. T he s ubtypes of specific based on the type of phobic stimulus (animal, environment, blood-injection-injury, or situation), are captured by different diagnos tic code numbers .

S oc ial P hobia S ocial phobia is characterized by the fear of being embarrass ed or humiliated in front of others . S imilar to specific phobia, insight that the fear is excess ive or unreas onable is required to make the diagnosis, and phobic s timuli are avoided, P.1025 or, when not avoided, the individual feels s everely or uncomfortable. T he anxiety res ponse or avoidance caus es clinically s ignificant functional impairment or distress . When the phobic s timuli include mos t social situations, then it is s pecified as generalized s ocial

Obs es s ive-C ompuls ive Dis order OC D is characterized by repetitive and intrus ive or images that are unwelcome (obs es sions ) or behaviors that the person feels compelled to do (compuls ions), or both. Mos t often, the compulsions done to reduce the anxiety ass ociated with the thought. S imilar to the diagnosis of s pecific and s ocial phobia, at some time during the course of the disorder, 1124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 125 of 173

individual mus t exhibit s ome insight that the compuls ions are excess ive or unreasonable. If, for the cours e of the disorder the individual does not recognize that the obses sions or compulsions are excess ive, then the s pecifier with poor ins ight is added. impairment-distress criterion for OC D is s omewhat different than this criterion for other dis orders , because can also be met in the absence of evidence of clinically significant impairment or distress if the obs es sions or compuls ions are time-cons uming (pres ent for more hour per day).

P os ttraumatic S tres s Dis order P T S D occurs after the occurrence of traumatic events which the individual believes that he or she is in danger or that his or her life is in jeopardy. P T S D can occur after witness ing a violent or life-threatening event happening to s omeone else. T he symptoms of P T S D us ually occur soon after the occurrence of the event, although, in s ome cases, the s ymptoms develop months or even years after the trauma. T he symptoms P T S D are grouped into four categories : reaction to the event, reexperiencing s ymptoms, symptoms of and s ymptoms of increased arousal. P T S D is when a person reacts to the traumatic event with fear experiences at least one reexperiencing symptom, more s ymptoms of avoidance, and two or more of hyperarousal. T he s ymptoms must persist for at month and cause clinically significant impairment in functioning or dis tres s. T he cours e of the dis order (i.e., acute if less than 3 months , chronic if greater than 3 months) and timing of symptom onset in relation to the occurrence of the symptoms (i.e., with delayed ons et if 1125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 126 of 173

symptoms ons et at least 6 months after the trauma) specified, although this is not reflected in diagnos tic coding.

A c ute S tres s Dis order Acute s tres s dis order occurs after the same type of stress ors that precipitate P T S D, although some of the symptom inclusion criteria are different than the ones us ed to diagnose P T S D. Acute stress dis order is not diagnosed if the s ymptoms las t beyond 1 month. Acute stress disorder is thus the third disorder in DS M-IV -T R is ruled out if the symptoms persist beyond a certain amount of time (s chizophreniform disorder and brief ps ychotic dis order are the other two). T he impairmentdistress criterion for acute stres s dis order is s omewhat different than the usual criterion, becaus e it can be met the absence of evidence of clinically significant impairment or dis tres s if the s ymptoms “impair the individual's ability to purs ue some necess ary task.”

G eneralized A nxiety Dis order G eneralized anxiety disorder is characterized by excess ive worry that occurs more days than not and is difficult to control. T he worry is as sociated with such as concentration problems, ins omnia, mus cle irritability, and physical res tles sness , and caus es significant dis tres s or impairment. G eneralized anxiety disorder is the only anxiety dis order that is not if the symptoms only occur during the cours e of depres sion.

A nxiety Dis order Due to a G eneral 1126 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 127 of 173

Medic al C ondition Anxiety disorder due to a general medical condition is diagnosed when there is evidence that s ignificant is the direct consequence of a general medical other than delirium or dementia. T he disorder is according to the pres ence of generalized anxiety, panic attacks, or obsess ive-compuls ive features, although not reflected in diagnostic coding.

S ubs tanc e-Induc ed A nxiety Dis order S ubstance-induced anxiety disorder is diagnosed when the cause of the anxiety is substance intoxication, subs tance withdrawal, or a medication. T he disorder is subtyped according to the s pecific s ubs tance for the s ymptoms, which is reflected in diagnos tic and the type of anxiety s ymptoms, which is not the coding.

VIII: S omatoform Dis orders T he section on s omatoform dis orders includes s ix disorders (s omatization disorder, undifferentiated somatoform disorder, convers ion disorder, pain hypochondriasis, and body dysmorphic dis order) in phys ical s ymptoms sugges tive of a general medical condition, but not accounted for by such a condition, prominent feature of the clinical picture. T he grouping disorders in this section was made to facilitate diagnosis (i.e., the need to rule out general medical disorders ) and not to imply etiological links amongst disorders in this section.

S omatization Dis order 1127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 128 of 173

S omatization dis order is characterized by multiple unexplained medical symptoms in diverse organ occurring over several years that are not explained by general medical conditions . T he s ymptoms are into four categories: pain, gastrointestinal (G I), sexual, ps eudoneurological. S ymptoms from each group must present, res ulting in functional impairment or treatment, beginning before 30 years of age.

Undifferentiated S omatoform Undifferentiated somatoform dis order is a residual category for conditions characterized by unexplained medical symptoms that are not as pervasive and longlasting as thos e of somatization dis order. T he precluded by another s omatoform dis order.

C onvers ion Dis order C onvers ion dis order is characterized by unexplained voluntary motor or sensory deficits that suggest the presence of a neurological or other general medical condition. P s ychological conflict is determined to be res ponsible for the s ymptoms. T he symptoms caus e clinically significant impairment or distress or medical evaluation. T he disorder is subtyped according to the of symptom (motor, sensory, seizure, or mixed), this is not reflected in diagnostic coding.

P ain Dis order T he core feature of pain dis order is impairing or pain that is the primary focus of attention. factors are determined to have an important role in the onset, severity, or maintenance of the pain. F ifth-digit 1128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 129 of 173

coding reflects the pres ence or abs ence of a general medical condition. In addition, the cours e of the (i.e., acute if les s than 6 months, chronic if greater than months) is s pecified, although this is not reflected in diagnostic coding.

Hypoc hondrias is Hypochondrias is is a distress ing and impairing preoccupation with the belief of having a s erious illnes s based on a misinterpretation of phys ical s ymptoms. thorough medical evaluation rules out the medical the preoccupation remains. Although not a diagnostic criterion, at s ome time during the P.1026 cours e of the dis order, the individual mus t exhibit some insight that the preoccupation is excess ive or unreas onable. If there is no insight, and the belief delus ional intensity, then the diagnosis would be delus ional dis order, somatic type rather than hypochondriasis. If, for mos t of the course of the the individual does not recognize that the is excess ive, then the s pecifier with poor ins ight is

B ody Dys morphic Dis order B ody dys morphic disorder is a dis tres sing and preoccupation with an imagined or slight defect in appearance. If the belief is held with delusional then delus ional dis order, somatic type, might also be diagnosed. T his contras ts with the decision rule for hypochondriasis that cannot be codiagnosed with delus ional dis order. 1129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 130 of 173

IX: Fac titious Dis order F actitious dis order refers to the deliberate feigning of phys ical or psychological symptoms to ass ume the s ick role. F actitious dis order is dis tinguished from in which s ymptoms are also fals ely reported; however, motivation in malingering is external incentives , such avoidance of res ponsibility, obtaining financial compens ation, or obtaining substances. F actitious disorder is s ubtyped according to whether the predominant s ymptoms are psychological, physical, or mixture of the two.

X: Dis s oc iative Dis orders T he section on diss ociative dis orders includes four disorders (dis sociative amnesia, diss ociative fugue, diss ociative identity disorder, and depersonalization disorder) characterized by a “disruption in the us ually integrated functions of cons cious nes s, memory, or perception.” T here is a hierarchical diagnos tic relations hip among the disorders , s uch that amnes ia is not diagnos ed when dis sociative fugue or diss ociative identity dis order is pres ent, diss ociative is not diagnosed when the criteria for diss ociative disorder are met, and depers onalization disorder is excluded when any of the other three diss ociative disorders are present. Diss ociative features, such as depers onalization, are s ometimes pres ent in other disorders and are part of the DS M-IV -T R diagnostic sets for panic attacks, P T S D, acute stress disorder, somatization disorder. DS M-IV -T R notes some in the class ification of convers ion dis order, because it cons idered to be a diss ociative phenomenon in some 1130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 131 of 173

clas sification schemes but is placed in the s omatoform disorders section in DS M-IV -T R “to emphas ize the importance of considering neurological or other general medical conditions in the differential diagnosis.” T his illus trates how different principles of clas sification might influence the organization of the clas sification s ys tem.

Dis s oc iative A mnes ia Dis sociative amnes ia is characterized by memory loss important personal information that is us ually traumatic nature. T he inability to remember is not due to normal forgetfulness , substance us e, or a general medical condition; does not occur only during the course of another dis sociative disorder, P T S D, or s omatization disorder; and caus es clinically significant impairment or distress .

Dis s oc iative F ugue Dis sociative fugue is characterized by s udden travel from home as sociated with partial or complete memory loss about one's identity. At times, there is confusion personal identity, and, at times , a new identity is T he diss ociation is not due to substance us e or a medical condition and caus es clinically significant impairment or dis tres s.

Dis s oc iative Identity Dis order Multiple P ers onality Dis order) T he es sential feature of diss ociative identity dis order is presence of two or more dis tinct identities that ass ume control of the individual's behavior.

1131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 132 of 173

Depers onalization Dis order T he es sential feature of depersonalization dis order is persis tent or recurrent episodes of depers onalization altered sense of one's physical being, including feeling that one is outside of one's body, phys ically cut off or distanced from people, floating, obs erving oneself from distance, like one is in a dream, or that one's body is phys ically changed in s hape or size). T he is not due to another psychiatric disorder, substance or a general medical condition, and it caus es clinically significant impairment or distress .

XI: S exual and G ender Identity Dis orders T he section on s exual and gender identity dis orders includes three groups of dis orders —sexual paraphilias, and gender identity disorder.

S exual Dys func tions T he group of sexual dys function disorders is organized the bas is of the phase of s exual respons e that is S exual pain disorders are als o included in this T he sexual dys function disorders are diagnos ed only they caus e marked dis tres s or interpers onal difficulty. two s exual desire disorders are hypoactive s exual disorder (lack of des ire for s exual activity) and sexual avers ion dis order (active avoidance of sexual contact). two s exual arousal disorders are female sexual arousal disorder (inability to attain or maintain adequate lubrication until completion of sexual activity) and male erectile dis order (inability to attain or maintain erection until completion of sexual activity). T he three 1132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 133 of 173

orgasmic disorders are female orgas mic disorder, male orgasmic disorder, and premature ejaculation. T he two sexual pain dis orders are dyspareunia (pain during intercours e) and vaginis mus (vaginal spasm interfering with sexual intercours e). S exual dysfunction due to a general medical condition and substance-induced dysfunction are als o included, the subtypes of which linked to the other s exual dys functions , so that these caus es of s exual dys function are ruled out as part of evaluation.

P araphilias T he characteristic features of paraphilias are recurrent, sexually arous ing fantasies, urges, or behaviors lasting least 6 months and involving nonhuman objects, or humiliation of oneself or one's partner, or children or other noncons enting partners. DS M-IV -T R includes specific paraphilias: exhibitionis m (exposure of genitals strangers), fetishism (us e of nonliving objects), (touching and rubbing agains t a noncons enting pedophilia (attraction to children), s exual mas ochis m (s uffering pain or humiliation), s exual sadis m (causing or humiliation to someone else), transves tic fetishism (cross -dress ing), and voyeuris m (observing individuals ).

G ender Identity Dis order T he characteristic feature of gender identity dis order is persis tent discomfort with one's own gender and s trong cross -gender identification. G ender identity disorder is subtyped according to the individual's current age, and the subtypes are dis tinguis hed by different diagnostic 1133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 134 of 173

codes .

XII: E ating Dis orders T he section on eating disorders includes two s pecific disorders —anorexia nervosa and bulimia nervosa— are characterized by abnormal eating behavior. Other disorders of eating that us ually are diagnos ed in and childhood P.1027 (i.e., pica, rumination disorder, and feeding disorder of infancy or early childhood) are included in the Usually F irst Diagnosed in Infancy, C hildhood, or Adoles cence section.

A norexia Nervos a T he core feature of anorexia nervos a is a strong fear of gaining weight or becoming fat, res ulting in deliberate maintenance of low body weight. Individuals are preoccupied with their weight and body image, and weight and perceived body shape markedly influence self-image. An additional diagnostic criterion is required for pos tmenarcheal women—amenorrhea for at leas t three cons ecutive mens trual cycles . Anorexia is based on whether the individual engages in bingeor purging behavior (binge-eating or purging type) or maintains low weight through res tricting food intake or excess ive exercise (res tricting type). T he s ubtypes are distinguished by s eparate diagnos tic codes .

B ulimia Nervos a Individuals with bulimia nervosa engage in recurrent 1134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 135 of 173

eating during which they eat an abnormally large of food over a short period of time. During the binge, person feels like he or s he cannot control his or her T o prevent weight gain from the overeating, the engages in compens atory behavior, such as s elfvomiting, excess ive exercise, laxative us e, or going on strict diets.

XIII: S leep Dis orders T he sleep dis orders are divided into four groups bas ed the presumed cause—primary, due to another mental disorder, due to a general medical condition, or due to subs tances . T he sleep dis orders are diagnosed only they caus e marked dis tres s or interpers onal difficulty. primary s leep disorders are subdivided into five dyss omnias (primary insomnia, primary hypersomnia, narcoleps y, breathing-related sleep dis order, and rhythm s leep disorder) and three paras omnias disorder, s leep terror disorder, and sleepwalking

XIV: Impuls e-C ontrol Dis orders Not E ls ewhere C las s ified F ive s pecific dis orders of impulse control are included this s ection on impuls e-control disorders not els ewhere clas sified—intermittent explosive dis order, pyromania, pathological gambling, and trichotillomania. T hese dis orders are characterized by the failure to urges to engage in behaviors that are harmful to the individual or others. T he diagnostic criteria for three disorders , kleptomania, pyromania, and are similar. T he first criterion refers to repeated performance of the harmful behavior. T he s econd 1135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 136 of 173

refers to a growing feeling of tension before performing the behavior, and the third criterion refers to tension or gratification after performing the behavior. F or all disorders in this section, if the behavior is attributable another ps ychiatric disorder, then the impuls e control disorder is not diagnosed.

Intermittent E xplos ive Dis order T his dis order is characterized by recurrent, dis crete, episodes of as saultive and violent behavior that is out proportion to poss ible precipitating factors . If the can be accounted for by another ps ychiatric disorder, as antis ocial or borderline pers onality disorder, bipolar disorder, or a s ubs tance use dis order, then a separate diagnosis of intermittent explos ive dis order is not also made. T hus , intermittent explos ive disorder is only after other ps ychiatric causes of the aggress ive behavior are ruled out.

K leptomania K leptomania is characterized by repeated s tealing of that are not needed for pers onal us e or for their value. T he stealing is not done for the purpos e of expres sing anger or revenge. B efore committing the the individual experiences an increasing s ens e of that diss ipates after the behavior. If the behavior is accounted for by conduct disorder, antis ocial disorder, or a manic epis ode, then a separate kleptomania is not als o made.

P yromania P yromania is characterized by recurrent setting of fires 1136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 137 of 173

because of a preoccupation or fascination with fire than being done for other purpos es such as financial political expres sion, revenge, or hiding of criminal behavior. B efore setting the fire, the individual an increasing s ense of tension that dis sipates after the behavior. If the behavior is better accounted for by conduct dis order, antisocial personality dis order, or a manic epis ode, then a s eparate diagnos is of pyromania not also made.

P athologic al G ambling P athological gambling is characterized by a pattern of gambling behavior. Although class ified as an impulse control dis order, many experts draw parallels between pathological gambling and addictive dis orders (i.e., s ubs tance use dis orders). Of the ten criteria for pathological gambling, one refers to tolerance, one to an inability to control gambling behavior, and one to withdrawal s ymptoms when cutting down on or stopping gambling. T he remaining criteria are a heterogeneous group of features , including cons equences of problem gambling, preoccupation gambling, and problematic gambling behaviors after loss es , gambling to es cape problems, or negative emotional states ).

Tric hotillomania T richotillomania is characterized by repeated hair caus ing noticeable hair los s. T he anticipatory tension criterion for trichotillomania is broader than the criterion for kleptomania and pyromania. F or trichotillomania, the criterion refers to an increasing 1137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 138 of 173

of tens ion before pulling or attempts to res is t pulling. T richotillomania is the only impuls e control disorder includes an impairment-distress criterion.

XV: Adjus tment Dis orders Many ps ychiatric dis orders are precipitated or by s tres sful life events. T he adjustment disorder res idual diagnos tic category that is us ed when the ps ychiatric symptoms that follow a psychosocial do not meet the criteria for a s pecific disorder. F or example, the development of depress ive symptoms stress ful event is diagnos ed as a major depress ive if the criteria for this dis order are met (i.e., at leas t five features of major depress ion for at least 2 weeks ). Adjustment disorder with depres sed mood, rather than depres sive dis order not otherwise s pecified (NOS ), is diagnosed only if the major depress ion criteria are not met. T hus, the diagnos is of a specific disorder the diagnosis of adjus tment dis order, and the diagnosis adjus tment disorder s upersedes the diagnosis of a nototherwis e-specified condition. Adjus tment disorders are diagnosed when the pers on's dis tres s in respons e to event is in exces s of a normative reaction to the when the symptoms caus e s ignificant impairment in functioning. Adjus tment dis order is not diagnos ed if the symptoms repres ent a bereavement reaction, although the conceptual justification for the distinction between this s tres sful event and other events that frequently in ps ychiatric symptoms is not provided. T he disorders are s ubtyped according to the predominant symptom picture (depres sed mood, anxiety, mixed and depres sion, dis turbance of conduct, mixed disturbance of emotions and conduct, uns pecified), and 1138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 139 of 173

this is reflected in their diagnostic code. P.1028

XVI: Pers onality Dis orders P ers onality refers to an individual's characteristic affect, emotional regulation, behavior, motivation, cognition about s elf, and interactions with others that long-standing, present s ince adolescence or early adulthood. Aspects of pers onality include the way tend to think about thems elves (e.g., s elf-confident or lacking confidence), how they relate to people (e.g., friendly), how they interpret and deal with events in the environment (e.g., paranoid people believe that others out to get them and may try to attack firs t before being attacked), and how an individual reacts emotionally to situation. It is not easy to define a he althy pe rs onality, in general, it allows one to cope with the normal s tres s life and to develop and to maintain satis fying and intimate relationships . When long-standing of thinking, behaving, and emotional response are inflexible, and caus e s ignificant dis tres s or impairment functioning, then a DS M-IV -T R personality dis order present. DS M-IV -T R includes ten s pecific personality disorders that are coded on Axis II.

P aranoid P ers onality Dis order Individuals with paranoid pers onality disorder are suspicious and distrustful of others . T hey may think others do things jus t to annoy or to hurt them, and they often read hidden threats or put-downs in the of others . T hey may worry that friends or coworkers are 1139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 140 of 173

really loyal or trustworthy and are often reluctant to confide in others , because they believe that there is a to pay when something pers onal is s hared. P ersons paranoid personality dis order may have problems with anger management. T hey are easily slighted and hold grudges . T hey often find that people s ay things to their character or ruin their reputation, even though it does not s eem that way to others. Individuals with paranoid personality dis order often read too much into things , take offense at things that were not meant to be critical, and often try to get back at the person they is attacking them. W hen involved in a relations hip, they often worry that their partner is unfaithful.

S c hizoid P ers onality Dis order S chizoid pers onality disorder is characterized by lack emotionality and social relations hips. Individuals with schizoid personality disorder are s ocially isolated, but does not bother them. T hey us ually prefer to work and things alone. T hey are emotionally cold and are neither bothered by criticis m from others nor joyful when complimented. Individuals with s chizoid personality disorder us ually do not get pleasure from many and often have little interes t in sexual experiences with another person.

S c hizotypal P ers onality Dis order Individuals with schizotypal pers onality disorder are and eccentric. T hey may dress , act, or speak in a manner. T hey are often s uspicious and paranoid and anxious in s ocial situations because of their distrust. B ecaus e of these beliefs , they have few friends. 1140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 141 of 173

with s chizotypal personality dis order frequently feel that others are talking about them behind their back and strangers are taking s pecial notice of them. W hen into a room, they sometimes think that people start or acting differently because they are there. Individuals with schizotypal personality dis order sometimes misinterpret reality. T hey may mis take nois es for and s hadows or objects for people. T hey may believe extras ens ory perception (E S P ), hexes, telepathy, and supers titions more s trongly than most people, and their behavior may be influenced by these beliefs .

A ntis oc ial P ers onality Dis order Antisocial personality dis order, the adult manifes tation childhood conduct dis order, is characterized by selfis h, irrespons ible, unlawful, and impuls ive behavior that a lack of regard for the rights of others . Individuals with antis ocial pers onality disorder often find it easy to lie if serves their purpose. P hysical aggress ion is common. T rouble at work may be the result of not arriving on miss ing too many days, not doing the work, or not following the rules . T here is a general failure to society's rules by engaging in illegal activities or not honoring obligations . E xamples of antisocial behavior include quitting a job without other work in s ight or spending money on things that one could do without, thus being unable to pay for household neces sities , as food, rent, or the utility bill. R eckless driving, tickets, driving under the influence of drugs or alcohol, ignoring recommended s afety precautions are of a lack of regard for the s afety of oneself or others. Individuals with antisocial personality dis order us ually not feel remors eful at having hurt others but instead 1141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 142 of 173

or rationalize their behavior.

B orderline P ers onality Dis order B orderline personality dis order is characterized by emotional dysregulation, unstable interpersonal relations hips , and unstable self-image. Individuals with borderline pers onality disorder have strong and intense emotions , often in reaction to how they perceive and believe others are treating them, and these emotions difficult to control. Not s urpris ingly, individuals who strong emotional reactions that are difficult to control often have problems in interpers onal relations hips and self-image. Interpersonal relations hips are affected by strong fears of being abandoned and going to keep others from leaving. At an extreme, suicide is threatened to keep someone from leaving. tend to be stormy, with many ups and downs, as the person alternates between having s trong positive and negative feelings . T he moods of the individual with borderline pers onality disorder are s trong and change. T here are often problems with controlling and anger outbursts are common. Individuals with borderline pers onality disorder frequently do not have a stable s ens e of their identity and feel empty ins ide the time. S elf-destructive behavior is common. with borderline pers onality disorder make recurrent suicide attempts, s uicide threats , or engage in s elfdamaging behavior, s uch as cutting or burning. T hey also do impuls ive things that can caus e problems , s uch gambling, spending excess ive money, s exual excess drug and alcohol use, stealing, eating binges , reckless driving. 1142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 143 of 173

His trionic P ers onality Dis order In contras t to some personality dis orders that are characterized by s ocial anxiety, inhibition, and individuals with his trionic personality dis order are loud, overly emotionally expres sive, and attention s eeking. act as if they are on stage. Individuals with histrionic personality dis order tend not to feel comfortable unles s they are the center of attention. T hey may be flirtatious and s exually s eductive and may us e phys ical to get people's attention. T hey often feel a close bond someone they have just met and are quick to s hare personal details of their life with new acquaintances. are often described by others as shallow.

Narc is s is tic P ers onality Dis order Individuals with narcis sis tic personality dis order have high of an opinion of thems elves and little regard for others , except as how others meet their needs. T hey thems elves as accomplishing great things that their s uperiority over others. T hey view thems elves as special and unique and that only similarly s pecial could unders tand them. T here is a s ens e of and they often feel that they have earned the right to special treatment or cons ideration because P.1029 of who they are or what they have done. Individuals narcis sistic pers onality disorder are often s o s elfthat they are intolerant of others, and they lack the capacity to understand how others feel. T he admiration others is us ually important, and they dream of attaining status . T hey may take advantage of others , if 1143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 144 of 173

get what is desired. Individuals with narciss istic disorder are often envious of others who have more they do or believe that others are jealous of them, or

A voidant P ers onality Dis order Avoidant personality dis order is characterized by social inhibition related to low s elf-es teem and s ens itivity to rejection and criticism from others . Individuals with avoidant pers onality disorder have difficulty making friends and feel uncomfortable in s ocial s ituations . It is difficult to s hare personal feelings and thoughts in relations hips because of the fear of being put down. Individuals with this personality dis order usually worry about making a bad impres sion and believe that they not interes ting or fun. T heir fears of criticis m and can influence the type of career they choos e (one that does not involve a lot of contact with people) or career advancement (turning down promotions or job opportunities that would require more contact with people).

Dependent P ers onality Dis order Individuals with dependent personality dis order have difficulty with self-sufficiency and have a s trong need to taken care of by others. E veryday decis ions often are made without the input of others , and others frequently make decis ions about important areas of their life. Individuals with dependent pers onality disorder may over backward to the point of doing unpleasant tasks others to get s upport and gratitude. It is difficult for the person with dependent personality dis order to start projects on their own, because they do not feel 1144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 145 of 173

in their own abilities , and it is hard to disagree with for fear of losing s upport or approval. Individuals with dependent pers onality disorder do not like being alone. T hey often believe that they cannot care for and, if a clos e relations hip ends, they may be get into another relationship right away, even if it is not the best pers on for them.

Obs es s ive-C ompuls ive P ers onality Dis order Obsess ive-compuls ive personality dis order is by a pattern of perfectionis m, stingines s, stubbornnes s, orderlines s, and inflexibility. Individuals with obsess ivecompuls ive personality dis order often s pend so much on small details that they los e s ight of the main thing were trying to do. T hey frequently are workaholics, who spend so much time working that they have little time family activities , friends hips, or entertainment. T hey are often interpers onally controlling because of their Individuals with obs ess ive-compuls ive personality have difficulty delegating tasks or working with others unles s things are done their way. Others often that they are too s trict about moral is sues and that they are cheap. Individuals with obsess ive-compuls ive personality dis order frequently find it difficult to throw things away, even when the object is old and worn and no sentimental value.

XVII: Other C onditions That May B e Foc us of C linic al Attention T he conditions included in the section on other that may be a focus of clinical attention are not 1145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 146 of 173

mental disorders but are included because they may the focus of clinical attention. T he reasons that these conditions fail to meet the DS M-IV -T R definition for a mental disorder are not s pecified. T wenty-nine s pecific problems are lis ted in s ix groups : ps ychological factors affecting medical conditions , medication-induced movement disorders , other medication-induced relational problems, problems related to abus e or and others . T hese problems are coded on Axis I.

P s yc hologic al P roblems A ffec ting Medic al C onditions T he category of ps ychological problems affecting conditions refers to those situations in which ps ychological factors negatively affect the cours e or outcome of a general medical condition or significantly increase the risk of an advers e outcome. T he and behavioral factors that may negatively impact on cours e and outcome of a medical condition include subthreshold symptoms and personality traits that do meet criteria for a s pecific mental disorder diagnos is , personality traits that undermine a therapeutic collaboration with health providers, and maladaptive behaviors , s uch as overeating and s edentary lifestyle.

Medic ation-Induc ed Movement Dis orders T he category of medication-induced movement is included because of its clinical importance in and differential diagnosis. F ive of the six s pecific movement disorders des cribed are related to the us e of neuroleptics (neuroleptic-induced parkins onism, acute 1146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 147 of 173

dystonia, acute akathisia, tardive dys kinesia, and neuroleptic malignant s yndrome). T he s ixth disorder is medication-induced pos tural tremor, which is most as sociated with antidepres sants and mood s tabilizers . DS M-IV -T R text includes brief descriptions of thes e disorders , with reference to DS M-IV -T R 's appendix for more detailed des cription of sugges ted diagnostic

Other Medic ation-Induc ed Dis orders T he category of other medication-induced dis orders is included so that clinicians could code medication side effects that are a focus of clinical attention (e.g., severe hypotens ion, priapis m, weight gain, and sexual dysfunction).

R elational P roblems R elational problems that caus e s ignificant s ymptoms or functional impairment are frequently the focus of attention. T hes e problems may be as sociated with a mental or general medical disorder in one of the of the relational unit. W hen the relations hip problem is primary focus of treatment, then the problem is coded Axis I. If not the primary focus of treatment, the can be listed on Axis IV .

P roblems R elated to A bus e or T he category of problems related to abus e or neglect includes five problems (physical abuse of child, sexual abuse of child, neglect of child, phys ical abus e of adult, and s exual abus e of adult) that frequently are the focus clinical attention. S eparate diagnos tic codes are used when the patient is the perpetrator or victim of the 1147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 148 of 173

or neglect.

Other C onditions That May B e a C linic al A ttention T he last group in this clas s of problems includes a heterogeneous collection of 13 problems that may the focus of treatment (noncompliance with treatment, malingering, adult antis ocial behavior, child or antis ocial behavior, borderline intellectual functioning, age-related cognitive decline, bereavement, academic problem, occupational problem, identity problem, religious or s piritual problem, acculturation problem, phase of life problem). E ach of thes e problems has its diagnostic code.

XVIII: Appendix Diagnos es DS M-IV -T R contains propos ed criteria for 20 specific disorders that were not included in the official clas sification but are included in an appendix, s o that P.1030 res earch can be conducted on their reliability, validity, potential clinical usefulnes s (T able 9.1-6). Many of disorders are currently captured by the clas sification not-otherwis e-specified designations (e.g., depress ive disorder NOS for minor depres sive dis order or premenstrual dys phoric disorder).

Table 9.1-6 Appendix Diagnos es the DS M-IV-TR 1148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 149 of 173

P os tconcuss ional dis order Mild neurocognitive disorder C affeine withdrawal P os tps ychotic depress ive disorder of S imple deteriorative disorder Minor depress ive disorder R ecurrent brief depres sive dis order P remens trual dysphoric disorder Mixed anxiety depress ive disorder F actitious disorder by proxy Dis sociative trance dis order B inge-eating dis order Depress ive personality dis order P as sive-aggres sive pers onality disorder personality dis order)

1149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 150 of 173

US ING DS M-IV-TR An 11-page introduction to DS M-IV -T R describes its history, methods of the revision process , definition of mental disorder, and iss ues in us ing a clas sification of mental disorders . T his is followed by a cautionary statement warning agains t reifying the diagnos tic and the clas sification. It is noted that the specified diagnostic criteria repres ent guidelines for making diagnoses based on consensus opinion of current knowledge. Als o, the clas sification may not cover all conditions for which pers ons seek treatment, and the inclusion of a diagnos tic category in the clas sification not have implications for legal decis ions. After the cautionary s tatement, an 11-page s ection des cribes us e of the manual, and a 7-page s ection des cribes T R 's multiaxial diagnostic approach. T he inclusion of latter two s ections is indicative of the complexity of the DS M-IV -T R clas sification and the potential difficulty in us ing it.

Multiaxial E valuation 1150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 151 of 173

T he DS M-IV -T R multiaxial system of evaluation, in different domains of information are described on five different axes , was introduced in DS M-III. P roper us e DS M-IV -T R does not require the use of the multiaxial format. T he purpose of multiaxial evaluation is to a comprehens ive, biops ychos ocial approach toward clinical as sess ment. Axis I cons ists of all clinical except for the pers onality disorders and mental retardation, both of which are reported on Axis II. P rominent maladaptive personality traits that do not criteria for a s pecific disorder and defense mechanis ms also noted on Axis II. Axis III is for general medical conditions that might be relevant to unders tanding or managing the patient's ps ychiatric dis order. In those in which the medical dis order caus es the mental then the medical disorder is listed on Axis III, and the mental disorder is listed on Axis I as due to a ge neral me dical condition. Axis IV is for noting psychosocial environmental problems that are relevant to the treatment, and prognos is of Axis I and Axis II disorders. When a ps ychosocial problem is the primary focus of treatment, then it is lis ted on Axis I as a condition that be the focus of clinical attention, although this is not cons idered a mental dis order. T he problem is also Axis IV . Axis V is the G AF s cale, a 100-point rating symptom severity, social functioning, and occupational functioning (s ee T able 7.9-2).

Multiple Dis orders Many patients have more than one psychiatric When more than one dis order is pres ent in a patient presenting for treatment, the clinician denotes one disorder as the principal diagnos is . S everal methods 1151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 152 of 173

been used by res earchers in identifying principal in patients with multiple ps ychiatric dis orders. S ome of factors us ed to designate a principal dis order include of ons et (i.e., the principal disorder is the one that first), relative degree of impairment (i.e., the principal disorder is the one res ponsible for the greatest degree ps ychos ocial dysfunction), and reas on for s eeking treatment (i.e., the principal disorder is the one that is chiefly respons ible for the treatment s eeking). In DS MT R , the determination of the principal diagnos is is on the reas on for the clinical service. W hen two are nearly equally res ponsible for the clinical s ervice, IV -T R acknowledges that the identification of one as the principal dis order is somewhat arbitrary.

Dis order S everity When the full criteria for a dis order are met, its s everity be s pecified as mild, moderate, or s evere. S everity are bas ed on the number and intensity of the the disorder and the impairment in occupational or functioning caus ed by the symptoms . Although the severity specifier can be applied to all disorders , guidelines for making this rating are provided only for mental retardation, conduct disorder, mania, mixed depres sive epis odes, and major depres sion. F or each these dis orders, except conduct dis order, the disorder's severity is captured by the diagnostic code.

R emis s ion S tatus When the s ymptoms of a dis order are pres ent, but the criteria of the dis order are no longer met, then the is cons idered in partial remis sion. According to DS M1152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 153 of 173

a dis order is in full remiss ion when no s ymptoms or of the dis order are pres ent. Although this s pecifier, to dis order severity, can be applied to all dis orders, guidelines for making this distinction are provided only manic and major depress ive epis odes and s ubs tance dependence. F or s ubs tance dependence, full requires that none of the diagnostic criteria has been for at leas t 1 month. T he definition of remiss ion from a manic and depres sive episode differs from the dependence remis sion definition in two ways . F irst, in contrast to a complete absence of diagnos tic criteria, DS M-IV -T R remis sion definition for mania and requires the absence of “s ignificant (italics added) symptoms of the disturbance.” No guidelines are for interpreting the meaning of “significant.” It is unclear if the pres ence of one or two mild s ymptoms is inconsistent with the definition of remiss ion. S econd, duration of the symptom-free interval mus t last at least months for depres sion and mania, in contrast to 1 for substance dependence. B ecause of the differences defining remiss ion for the mood and substance dependence disorders , it is unclear how to define remis sion for other disorders . F or example, to anorexia as being in remis sion, how much residual concern, if any, about body image can remain in a who has regained lost weight? Or, how much any, can remain in a patient with a public s peaking phobia who no longer avoids public pres entations? T he threshold used to determine dis order remis sion has important implications for characterizing the P.1031

1153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 154 of 173

longitudinal course of disorders and the effectivenes s treatment efforts and will hopefully be given more cons ideration in the next DS M revision. DS M-IV -T R also differentiates between full remiss ion recovery. A disorder in full remiss ion is listed as a disorder, becaus e it remains clinically relevant. After an unspecified period of time, bas ed on factors s uch as duration of the symptoms , the duration of the symptomfree interval, and the need for continued monitoring prophylactic treatment, the clinician might cons ider the patient as having recovered from the dis order, and the disorder is no longer class ified a current condition. In cases, the clinician can lis t the disorder by using the specifier prior his tory.

Diagnos tic Unc ertainty T here are s everal ways of coding diagnos tic DS M-IV -T R . T he diagnos is can be deferred, or a diagnosis can be rendered and identified as When s ome information is available, not enough to diagnose a s pecific disorder but enough to know which clas s of disorder is present, then the diagnos is is NO S .

C linic al C onditions Not Meeting S pec ified Diagnos tic C riteria C linically s ignificant presentations sometimes do not the threshold for a diagnosis . T his is particularly true disorders that are defined polythetically, whereby a minimum number of features from a list are needed to make a diagnosis. T o account for this , every DS M-IV diagnostic clas s has an NOS category. F or example, patients who present with fewer than five clinically 1154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 155 of 173

significant depress ive s ymptoms would be diagnos ed depres sive dis order NOS . B ecaus e the definition of mental dis order is based, in on impairment and dis tres s, and knowledge of dysfunction and etiological mechanisms is largely unknown, the DS M-IV -T R phenomenologically based clas sification system is unable to account for the wide divers ity of clinical presentations . S imilar to patients fall below s pecified diagnos tic thresholds, patients with atypical symptom pres entations are given an NOS diagnosis in the diagnostic class that most closely res embles the clinical picture. F or s ome NOS DS M-IV -T R provides specific examples of such presentations , and, in s ome ins tances , these symptom patterns have corres ponding res earch diagnos tic that are pres ented in the appendix.

P S YC HIA TR IC DIA G NOS IS IN P R A C TIC E Multiple opinions about the us e of the DS M s ys tem in clinical practice have been offered, two of which are described in this s ection. S ome authors have rais ed concerns that clinicians have become preoccupied with eliciting s igns and s ymptoms to make DS M psychiatric diagnoses to the exclusion of evaluating the and ps ychodynamic perspectives of the patient's In contras t, s ome res earchers have sugges ted that adherence to the DS M s ys tem is clinically important, they have raised concerns related to clinicians ' high diagnostic error rate. In their review of DS M-III, Arnold C ooper and R obert Michels s peculated that the antitheoretical approach 1155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 156 of 173

toward clas sification, without s uperordinate principles integrate biops ychosocial information with DS M diagnoses, would result in an overly narrow focus on determining whether diagnostic criteria are met. In their review of DS M-III-R 7 years later, they concluded that initial concern had been realized, particularly in the as sess ments done by the new generation of trainees . S imilarly, G ary J . T ucker s uggested that the improved diagnostic precision offered in the modern DS M era res ulted in narrowly focus ed evaluations of DS M that rule in or out diagnos es but neglect the patient's story. S igns and s ymptoms are accorded greater significance than coping style. T hese authors acknowledged that the multiaxial system of encourages a pers pective beyond the s igns and of Axis I dis orders but found, in their experience, that broader pers pective is not actually taken in clinical practice. T homas A. W idiger and S pitzer, res ponding to concerns expres sed in C ooper's and Michels ' review of DS M-III-R , indicated that the problem lies with the of the new generation of clinicians rather than the T hey reiterated the cautionary s tatement in DS M-III-R a diagnos is represents only one component of a comprehensive evaluation. Moreover, they added that their anecdotal experience in us ing DS M-III-R with was that it stimulated a broader perspective of ps ychopathology, becaus e its antitheoretical approach encouraged cons ideration of different models of and treatment. In contras t to concerns regarding an overly narrow on diagnosis, in the past few years , res earch by independent research groups has raised concerns 1156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 157 of 173

the adequacy of psychiatric diagnos tic evaluations conducted in routine clinical practice, becaus e the diagnostic as sess ment is not s ufficiently F or example, M. K atherine S hear and colleagues diagnostic accuracy in two community mental health centers, one in urban P itts burgh and the other in rural wes tern P enns ylvania. T hey found poor agreement between clinical ass es sments and evaluations by trained raters adminis tering the S tructured C linical Interview for DS M-IV (S C ID), a semi-structured interview commonly used by res earchers to make ps ychiatric diagnoses . In particular, they found that, whereas clinicians frequently diagnosed adjus tment disorder, the S C ID interviewers made specific mood or anxiety dis order diagnoses . T hey als o reported that diagnostic comorbidity was identified on the S C ID. In discuss ing their findings , S hear and colleagues whether patients ' outcomes were compromised by the failure to detect and to diagnos e correctly treatable conditions. In another s tudy of community mental health patients , one conducted in T exas , Monica R . B asco and adminis tered the S C ID to patients as a tes t of the us efulnes s of research diagnos tic procedures in clinical practice. T hey found that supplementing information the patients' charts with the information from the S C ID res ulted in more than five times as many comorbid conditions being diagnosed. A gold standard, all information, diagnos is was made for all patients, and level of agreement with this s tandard was higher for the S C ID than the clinical diagnoses. After feedback from S C ID interview was presented to the clinicians , a 1157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 158 of 173

patient care occurred in one-half of the cases . T he res ults of these two studies are cons is tent with the findings from the R hode Island Methods to Improve Diagnos tic Ass es sment and S ervices (MIDAS ) project, which diagnos tic frequencies were compared in two samples —one interviewed with the S C ID and the other interviewed by ps ychiatrists us ing an uns tructured interview. C onsistent with the findings of the T exas and P ittsburgh groups, it was found that many more were diagnos ed with two or more DS M-IV -T R Axis I disorders when research interviews were conducted when diagnoses were bas ed on the routine clinical evaluation. More than one-third of patients interviewed with S C ID received three or more diagnoses in contrast fewer than 10 percent of the patients ass es sed with an unstructured interview. F ifteen dis orders were more frequently diagnosed when the S C ID was us ed, and differences cut across mood, anxiety, eating, and impulse control dis order categories . Importantly, patients often desired treatment for the comorbid Axis I disorders that were P.1032 not the primary reason for s eeking treatment. T hus , detecting diagnostic comorbidity was important from a cons umer and patient perspective. Another report from the MIDAS project examined the is sue of diagnosing borderline pers onality disorder and found that res earch interviewers us ing the S tructured Interview for DS M-IV P ers onality were much more likely to diagnos e personality dis order than clinicians . Moreover, when information from the research interview was provided 1158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 159 of 173

the clinician, clinicians diagnos ed borderline disorder more frequently; thus, it was not simply a of clinicians being reluctant to diagnos e borderline personality dis order during the initial diagnos tic evaluation. Are thes e findings any caus e for alarm? T hat is hard to because no research has demonstrated the clinical significance of the gap between res earchers ' and diagnostic practices. S pecifically, there are currently no studies that have examined the important ques tion of whether the more accurate and comprehensive diagnostic evaluations improve outcomes. In fact, one could argue that patients ' outcomes are not more likely be worse, even if diagnoses are mis sed. C linicians currently have at their disposal agents with broad-based efficacy; consequently, diagnostic error might not be important. T he new generation of medications, s uch as s elective serotonin reuptake inhibitors (S S R Is ), have been found to be for depress ion, almost all anxiety disorders , eating disorders , impulse control dis orders, s ubs tance use disorders , attention deficit dis order, and some disorders . In s hort, most of the disorders for which individuals seek outpatient care have been found to be res ponsive to at least one of the new generation of antidepres sant medications . T hus , it is pos sible that accurate and comprehens ive DS M-IV -T R diagnoses critical after gros s diagnos tic clas s distinctions (e.g., ps ychotic dis order vs . mood dis order) are made. T his would be cons istent with the res ults of a s urvey of ps ychiatris ts' attitudes about DS M-III and DS M-III-R conducted 10 years ago that found that only a minority 1159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 160 of 173

ps ychiatris ts rated the DS Ms as being important for treatment planning, determining prognosis, patient management, and understanding patients ' problems . Whether or not improved diagnostic practice would in improved outcome, it is important to recall from the beginning of this chapter that diagnos is has more than one clinically relevant function. In addition to optimizing outcome, diagnos is is important for predicting outcome. It is the opinion of the authors of this chapter that a greater percentage of the variance in outcome would be predicted by comprehens ive evaluations than clinical diagnoses. Again, this is an unstudied question.

C L A S S IF IC A TION Dimens ional Vers us C ategoric al Approac hes toward C las s ific ation T he introduction to DS M-IV -T R makes it clear that, although a categorical class ification is des cribed in the manual, this should not be interpreted as sugges ting the categorical approach is more reliable or valid than dimensional approach toward class ification. P ut s imply, categorical s ys tem posits that there are clear between diagnos tic entities or between dis order and absence of disorder, whereas a dimens ional model lack of clear demarcation. Discus sions of the relative of categorical and dimens ional approaches toward the clas sification of mental disorders have persisted throughout the 20th century. F or example, in the E dward Mapother ques tioned the usefulness of depres sed patients as endogenous or neurotic the difficulty in placing many patients into one group or 1160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 161 of 173

the other. T hrough the years , several s tatistical have been used to evaluate the categorical vers us dimensional approaches toward clas sification. T hes e include plotting scores of symptom characteris tics and determining whether the plots were consistent with a bimodal or unimodal distribution or determining linear nonlinear relationships between s ymptom s cores and independent variables, s uch as laboratory tes ts, family history, or treatment respons e. More recently, interest grown in using P aul Meehl's taxometric methods to test latent categories . At present, the research community not unified in its opinion regarding the categoricaldimensional debate. Although it is apparent that there no clearly defined boundaries distinguishing dis orders from each other and from normality, much of the taxometric research is consistent with the categorical model. DS M-IV -T R 's categorical approach, which is the traditional method of medical clas sification, s eems appropriate at this time, becaus e it is more us eful in practice.

S eparate Dis orders Vers us Arthur C . Houts has been highly critical of the number of dis orders lis ted in each success ive edition of DS M and has sugges ted that this was indicative of a scientific progress . Moreover, he s ugges ted that were being created that had previous ly not been recognized as pathology. W akefield carefully examined caus es of diagnostic proliferation and concluded that greater number of diagnoses listed in s ucces sive represented greater s pecification rather than diagnos tic discoveries . In fact, he found that the increas e in the number of diagnos es paralleled the increas es found in 1161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 162 of 173

IC D clas sification of cardiac and G I diseases during the 30 years . Although the increased number of coded diagnos tic entities does not generally represent the discovery of diagnostic entities , this iss ue nonetheless warrants cons ideration, because it has generated debate within field between the s o-called lumpers, who favor broader categories , and the s plitters , who favor R es earchers are more likely to benefit from embracing splitters ' approach, as it is eas ier to publish findings demonstrating that a method of s ubclas sification is as sociated with s tatistically significant differences than to publis h null findings. T hus , there are many res earch articles sugges ting the validity of diagnos tic and (s ub) clas sification distinctions . However, the principles the incorporation of thes e distinctions into a of dis orders are unwritten. S ome resulting questions include the following: When is a syndrome s ufficiently distinct from its near neighbors to warrant being cons idered a s eparate dis order? When is the amongst members of a disorder s ufficient to warrant subdividing the group into more homogeneous subgroups (i.e., s ubtyping)? Is there a conceptual difference between dis tinguis hing between dis orders distinguishing between s ubtypes of a disorder? T he introduction to DS M-IV -T R does not dis cuss thes e questions . S ome examples illustrate the lack of conceptual in making thes e distinctions. T he dis tinctions between bipolar and unipolar depres sion and psychotic and nonps ychotic depress ion have been demons trated in multiple domains. Y et, unipolar and bipolar depress ion 1162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 163 of 173

cons idered different disorders , whereas determination the presence of ps ychotic features is a method of subtyping depres sion. B ody dysmorphic dis order is clas sified as a s omatoform dis order. It has been conceptualized as an obs ess ive-compuls ive s pectrum disorder, and research sugges ts that there are many similarities and few differences between patients with body dys morphic disorder and patients with OC D. C ons ider individuals with OC D who obs es sively was h hands and shower. S uch individuals are not clas sified body cleaning disorder. It is reasonable to sugges t that body dys morphic disorder is as repres entative of OC D body cleaning disorder. P.1033

Financ ial Implic ations of R evis ing C las s ific ation S ince DS M-III, the AP A has made millions of dollars the DS Ms . W hen plans were announced to publis h 5 years after DS M-III-R was published, concern was that profit motives were res ponsible, at leas t in part, for the short interval between DS M editions. reviews of DS M-III-R also rais ed s uch ques tions. It is disconcerting that financial cons iderations might have significantly influenced the timing of revis ions of the clas sification. P erhaps as a result of thes e criticisms, pace of DS M revis ions has slowed. At the time of the writing of this chapter, it has been 8 years since the publication of DS M-IV , and DS M-V is not anticipated the end of the decade. However, the iss ue of profiting from revising the DS M 1163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 164 of 173

manual renewed its elf with the publication of the DS MT R . On the one hand, the principal architects of the have ass erted that the manual is not a textbook. this caveat, the detailed clinical descriptions and discuss ions of differential diagnos is along with up-tosummaries of prevalence data, demographic familial patterns , and cours e of illness , give the DS Ms feel of a textbook, which has undoubtedly contributed their s ucces s. S eemingly incons is tent with the that the DS M s hould not be considered to be a the most recent vers ion of the DS M, DS M-IV -T R , is updating of the text without changes to the diagnostic criteria. T his follows the typical pattern of publishing editions of academic textbooks, such as the present every few years to have up-to-date s ummaries of knowledge. T hus , despite the declaration that the DS M not a textbook, the publication schedule sugges ts otherwis e. T he integrity of the revis ion proces s can be compromised by a conflict of interes t between the scientific jus tification for revising and updating the manual's text and nomenclature versus fiscal gains to AP A. A potential method of reducing the tension scientific and economic forces is to develop scientific guidelines regarding the level of s ignificant change needed in the clas sification s ys tem that should trigger revis ion.

S UG G E S TE D C R OS S T he ps ychiatric report is discuss ed in S ection 7.3, signs and s ymptoms are discus sed in S ection 7.4, neurops ychological as sess ment is discus sed in clinical manifestations of psychiatric disorders are discuss ed in C hapter 8, and international pers pectives 1164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 165 of 173

ps ychiatric diagnosis are discus sed in S ection 9.2.

R E F E R E NC E S Akiskal HS , McK inney W : P s ychiatry and ps eudops ychiatry. Arch G e n P s ychiatry. American Medical As sociation. S tandard C las s ifie d Nome nclature of Dis e as e . C hicago: American Ass ociation; 1935. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 1s t ed. Was hington, DC : American P s ychiatric Ass ociation; 1952. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 2nd ed. Was hington, DC : American P s ychiatric Ass ociation; 1968. *American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd ed. Was hington, DC : American P s ychiatric Ass ociation; 1980. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd revis ed Was hington, DC : American P sychiatric As sociation; 1987. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed, text 1165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 166 of 173

revis ion. W ashington, DC : American P sychiatric Ass ociation; 2000. B as co MR , B ostic J Q, Davies D, R us h AJ , W itte B , Hendricks e W , B arnett V : Methods to improve diagnostic accuracy in a community mental health setting. Am J P s ychiatry. 2000;157:1599–1605. B rill H. Nos ology. In: F reedman AM, K aplan HI, HS , eds. C omprehe ns ive T e xtbook of P s ychiatry. B altimore: W illiams & W ilkins ; 1967:581–589. C ooper A, Michels R : B ook review of Diagnos tic and S tatistical Manual of Mental Dis orders, 3rd ed, (DS M-III-R ). Am J P s ychiatry. 1988;145:1300–1301. C ooper J E , K endell R E , G urland B J , S harpe L, J R M, S imon R . P s ychiatric Diagnos is in Ne w Y ork L ondon. London: Oxford University P res s; 1972. E ndicott J , S pitzer R L: A diagnos tic interview: T he S chedule for Affective Disorders and S chizophrenia. Arch G e n P s ychiatry. 1978;35:837–844. *F eighner J P , R obins E , G uze S B , Woodruff R A, G , Munoz R : Diagnostic criteria for us e in ps ychiatric res earch. Arch G e n P s ychiatry. 1972;26:57–67. F irst MB , P incus HA: T he DS M-IV text revision: and potential impact on clinical practice. P s ychiatr 2002;53:288–292.

1166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 167 of 173

F irst MB , S pitzer R L, W illiams J B W, G ibbon M. C linical Inte rvie w for DS M-IV (S C ID). W ashington, American P s ychiatric Ass ociation; 1997. F ollette W C , Houts AC : Models of scientific progress the role of theory in taxonomy development: A case study of the DS M. J C ons ult C lin P s ychol. 1132. F rances AJ , W idiger T A, P incus HA: T he DS M-IV . Arch G e n P s ychiatry. 1989;46:373–375. F reud S . Introductory L e cture s on P s ycho-analys is . London: Hogarth P ress ; 1963. F ulford K W M: Nine variations and a coda on the of an evolutionary definition of dys function. J P s ychol. 1999;108:412–420. G ottesman II, G ould T D: T he endophenotype ps ychiatry: E tymology and strategic intentions. Am J P s ychiatry. 2003;160:636–645. G roup for the Advancement of P s ychiatry. P s ychopathological Dis orde rs in C hildhood: C ons ide rations and a P ropos ed C las s ification. New G roup for the Advancement of P s ychiatry; 1966. G ruenberg E M: How can the new diagnos tic manual help? Int J P s ychiatry. 1969;7:368. Houts AC : T he diagnos tic and statis tical manual's 1167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 168 of 173

white coat and circularity of plausible dys functions : R es pons e to W akefield, part 1. B ehav R e s T her. 2001;39:315–345. J effers on J W , T homps on T D: R hinotillexomania: P sychiatric dis order or habit? J C lin P s ychiatry. 1995;56:56–59. K endell R E . T he R ole of Diagnos is in P s ychiatry. B lackwell; 1975. K endell R , J ablens ky A: Dis tinguis hing between the validity and utility of ps ychiatric diagnoses . Am J P s ychiatry. 2003;160:4–12. K endler K S : S etting boundaries for psychiatric Am J P s ychiatry. 1999;156:1845–1848. K ihlstrom J F . T o honor K raepelin: F rom s ymptoms pathology in the diagnosis of mental illness . In: LE , Malik ML, eds . R ethinking the DS M. American P s ychological As sociation; 2002:279–303. K lerman G L, V aillant G E , S pitzer R L, Michels R : A on DS M-III. Am J P s ychiatry. 1984;141:539–542. K ramer M. T he history of the efforts to agree on an international clas sification of mental dis orders. In: American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 2nd ed. Was hington, DC : American P sychiatric As sociation; 1973. 1168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 169 of 173

Lilienfeld S O, Marino L: Mental dis order as a concept: A critique of W akefield's “harmful analysis. J Abnorm P s ychol. 1995;104:411–420. Lilienfeld S O, Marino L: E ss entialism revisited: E volutionary theory and the concept of mental disorder. J Abnorm P s ychol. 1999;108:400–411. Mapother E : Discus sion on manic-depres sive B r J P s ychiatry. 1926;2:872–876. Meehl P E : B ootstrap taxometrics . Am P s ychol. 1995;50:266–275. Menninger K : S heer verbal Mickey Mouse. Int J P s ychiatry. 1969;7:415. Menninger K , Mayman M, P ruys er P . T he V ital T he L ife P roces s in Mental He alth and Illnes s . New V iking P res s; 1963. Merikangas K R , R isch N: W ill the genomics revolutionize ps ychiatry? Am J P s ychiatry. 635. Narrow W E , R ae DS , R obins LN, R egier DA: prevalence estimates of mental disorders in the S tates. Arch G e n P s ychiatry. 2002;59:115–123. Office of G eneral R egister. A G los s ary of Me ntal London: Her Majesty's S tationery Office; 1968. 1169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 170 of 173

P eck MC , S cheffler R M: An analys is of the mental illness us ed in s tate parity laws. P s ychiatr 2002;53:1089–1095. P incus HA, F rances A, Davis WW, F irst MB , Widiger DS M-IV and new diagnostic categories: Holding the on proliferation. Am J P s ychiatry. 1992;149:112– R obins E , G uze S B . E s tablis hment of diagnostic in ps ychiatric illnes s: Its application to Am J P s ychiatry. 1970;126:983–987. R obins LN, Locke B Z, R egier DA. An overview of ps ychiatric disorders in America. In: R obins LN, DA, eds. P s ychiatric Dis orde rs in Ame rica: T he E pidemiologic C atchment S tudy. New Y ork: T he P res s; 1991. S hear MK , G reeno C , K ang J , Ludewig D, F rank E , HA, Hanekamp M: Diagnosis of nonps ychotic community clinics. Am J P s ychiatry. 2000;157:581– S pitzer R L: A proposal about homosexuality and the AP A nomenclature: Homosexuality as an irregular of sexual behavior and s exual orientation as a psychiatric disorder. A symposium: S hould homos exuality be in the AP A nomenclature? Am J P s ychiatry. 1973;130:1207–1216. S pitzer R L, E ndicott J , R obins E : R es earch criteria: R ationale and reliability. Arch G e n 1170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 171 of 173

1978;35:773–782. S pitzer R L, F leis s J : A re-analysis of the reliability of ps ychiatric diagnosis. B r J P s ychiatry. *S pitzer R L, W akefield J C : DS M-IV diagnos tic for clinical significance: Does it help s olve the fals e positives problem? Am J P s ychiatry. 1864. S role L, Langner T S , Michael S T , Opler MK , R ennie Me ntal H ealth in the Me tropolis . V ol 1. T he Midtown Manhattan S tudy. New Y ork: McG raw-Hill; 1962. S tengel E : C lass ification of mental disorders . B ull 1959;21:601. S zasz T S . T he Myth of Me ntal Illne s s : F oundations T he ory of P e rs onal C onduct. New Y ork: Harper & 1974. T ucker G J : P utting DS M-IV in perspective. Am J P s ychiatry. 1998;155:159–161. T uke H: F rench retros pective. J Me nt S ci. *Wakefield J C : Disorder as harmful dysfunction: A conceptual critique of DS M-III-R 's definition of disorder. P s ychol R e v. 1992;99:232–247. P.1034

1171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 172 of 173

Wakefield J C : Diagnosing DS M-IV part I: DS M-IV concept of disorder. B ehav R e s T her. 1997;35:633– Wakefield J C : W hen is development dis ordered? Developmental ps ychopathology and the harmful dysfunction analys is of mental disorder. Dev P s ychopathol. 1997;9:269–290. Wakefield J C . Meaning and melancholia: W hy the IV cannot (entirely) ignore the patient's intentional system. In: B arren J , ed. Making Diagnos is E nhancing E valuation and T reatme nt of Dis orde rs . W ashington, DC : American P sychological Ass ociation; 1998:29–72. Wakefield J C : E volutionary versus prototype the concept of disorder. J Abnorm P s ychol. 1999;108:374–399. Wakefield J C : T he myth of DS M's invention of new categories of dis order: Houts' diagnostic theses disconfirmed. B ehav R e s T her. Wakefield J C , P ottick K J , K irk S A: S hould the DS Mdiagnostic criteria for conduct dis order consider context? Am J P s ychiatry. 2002;159:380–386. Widiger T A, S pitzer R L: C riticis ms of DS M-III-R . Am P s ychiatry. 1989;146:566–567. World Health Organization. Manual of the C las s ification of Dis e as e s , Injurie s , and C aus e s of 1172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 173 of 173

G eneva: W orld Health Organization; 1948. *Zimmerman M: Why are we rus hing to publis h IV ? Arch G e n P s ychiatry. 1988;45:1135–1138. Zimmerman M, J ampala V C , S ierles F S , T aylor MA: III and DS M-IIIR : W hat are American ps ychiatris ts and why? C ompr P s ychiatry. 1993;181:360–364. Zimmerman M, Mattia J I: Differences between and res earch practice in diagnosing borderline personality dis order. Am J P s ychiatry. 1574. Zimmerman M, Mattia J I: P sychiatric diagnos is in practice: Is comorbidity being miss ed? C ompr P s ychiatry. 1999;40:182–191. Zimmerman M, Mattia J I: P rincipal and additional IV disorders for which outpatients s eek treatment. P s ychiatr S erv. 2000;51:1299–1304.

1173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

01/01/2009

Page 1 of 6

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 10 - Delirium, Dementia, and Amnes tic and O ther C ognitive and Mental Dis orders Due to a G eneral Medical C ondition > 10.1: C ognitive Dis orders : Introduction Overview

10.1: C ognitive Dis orders : Introduc tion and Overview K enneth L . Davis M.D. P art of "10 - Delirium, Dementia, and Amnestic and C ognitive Disorders and Mental Disorders Due to a Medical C ondition" C ognition includes memory, language, orientation, judgment, conducting interpers onal relations hips, and problem s olving. C ognitive dis orders not only reflect disruption in one or more of the above domains but are also frequently complicated by behavioral symptoms. C ognitive dis orders exemplify the complex interface between neurology, medicine, and ps ychiatry in that medical or neurological conditions often lead to disorders that are, in turn, as sociated with behavioral symptoms. It can be argued that of all psychiatric conditions, cognitive dis orders bes t demonstrate how biological ins ults res ult in behavioral s ymptomatology. phys ician mus t carefully as sess the his tory and context the presentation of these dis orders before arriving at a diagnosis and treatment plan. F ortunately, advances in molecular biology, diagnostic techniques , and management have significantly improved the ability to recognize and to treat cognitive dis orders. T he aging population has res ulted in a public health 1174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

01/01/2009

Page 2 of 6

regarding the diagnosis and management of dementia. More than 14 million Americans will develop dementia the year 2050. W ith illnes s progress ion, dementia eventually dis rupts all domains of cognition, thereby significantly impairing an individual's ability to function the most bas ic level. Although not included in the criteria, dementia is frequently complicated by symptoms, including agitation, delusions , and hallucinations . Not s urprisingly, a tremendous amount res earch has focused on the molecular biology, pathophys iology, epidemiology, phenomenology, and treatment of dementia. J udith Neugroschl and focus their review on Alzheimer's disease, the most common cause of dementia. Much progress has been made in the area of res earch that investigates the cognitive deficits as sociated with Alzheimer's disease. Many studies have elucidated the role of amyloid and neurofibrillary tangles, the pathological changes by Alois Alzheimer more than a century ago, in the pathophys iology of Alzheimer's dis eas e. Neuroimaging techniques have permitted vis ualization of the earlies t structural and functional correlates of cognitive decline. Molecular biology advances have identified at least genes that are ass ociated with Alzheimer's disease. F ood and Drug Administration (F DA) approval of cholines terase inhibitors has trans formed Alzheimer's disease from an untreatable illnes s less than 10 years to a condition for which there are effective pharmacological interventions . T he ability to better identify risk factors for the subsequent development of dementia will undoubtedly provide opportunities for interventions that could delay onset and perhaps 1175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

01/01/2009

Page 3 of 6

the development of this devas tating illness . Although cognitive disorders may cros s -sectionally present with s imilar symptoms , this heterogeneous of illnes ses may significantly differ in their etiologies, cours es, and treatments. As a case in point, delirium Alzheimer's disease may present with impaired recall, the former condition is epis odic and revers ible, the latter illness is a neurodegenerative process for there are only symptomatic treatments. S teven S amuels and Neugros chl review the pathophys iology, and management of delirium. Of the cognitive disorders , delirium can be particularly difficult diagnose becaus e of its waxing and waning symptomatology. G iven the high prevalence of delirium the acutely ill medical patient, it behooves the clinician anticipate the development of this condition and to aggres sively for the underlying etiology. However, a relative paucity of res earch regarding the pathophys iology and pharmacological management of delirium. In part, this fact is due to the difficulty in obtaining informed cons ent from delirious patients and the urgency to treat in an expedient fashion. with adequate recognition of the disorder, clinicians treat the caus ative factors and can appropriately the behavioral complications . Martin Allan Drooker reviews cognitive dis orders due to general medical condition and substances. T his extends previous chapters in this s ection through discuss ion of additional medical, neurological, or subs tance-induced causes of dementia and delirium. In contrast to other cognitive disorders , amnestic are characterized by a s ingle cognitive deficit, impaired 1176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

01/01/2009

Page 4 of 6

memory. However, these syndromes are commonly as sociated with s ocial and occupational functioning. G ross man reviews the range of illness es and that can result in amnes tic disorders. K ors akoff's provides a paradigm for recognizing how exposure to a subs tance (e.g., alcohol) results in focal brain injury turn, caus es an amnestic disorder. P atients often develop or are evaluated for cognitive disorders in the medical setting and are not evaluated ps ychiatris t unles s P.1054 there are significant behavioral disturbances that with day-to-day patient management. T he high prevalence of ps ychiatric symptoms and s yndromes in medically ill patients without prior ps ychiatric his tories saliently demonstrates the physician's obligation to anticipate cognitive complications in the medical or surgical s etting. Optimum treatment for cognitive disorders res ults from a collaborative effort between patient's primary phys ician and a psychiatrist.

S UG G E S TE D C R OS S P sychiatric clinical manifestations of specific and s ys temic dis orders are discus sed in C hapter 2. Neurops ychological and intellectual ass es sment of is presented in S ection 7.5, ass ess ment of children in S ection 7.7, and medical as sess ment and laboratory tes ting in S ection 7.8. Dis cuss ion of s ubstance-related disorders appears in C hapter 11, s chizophrenia in 12, psychotic dis orders in S ection 12.16, anxiety in C hapter 14, factitious dis orders in C hapter 16, 1177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

01/01/2009

Page 5 of 6

diss ociative dis orders (including diss ociative amnesia) C hapter 17, s exual dys functions in S ection 18.1a, disorders in C hapter 20, and personality dis orders in C hapter 23. T he ps ychiatric as pects of human immunodeficiency virus (HIV ) infection and acquired immune deficiency s yndrome (AIDS ) are pres ented in S ection 2.8. P s ychological changes in normal aging (including age-related cognitive decline) are dis cuss ed S ection 51.2c, and dementia of the Alzheimer's type other dementing disorders of late life are discus sed in S ection 51.3e.

R E F E R E NC E S *F ick DM, Agostini J V , Inouye S K : Delirium superimposed on dementia: A systematic review. J G e riatr S oc. 2002;50:1723–1732. *Hardy J , S elkoe DJ : T he amyloid hypothes is of Alzheimer's disease: P rogress and problems on the to therapeutics. S cience . 2002;297:353–356. *Helmes E , B owler J V , Merskey H, Munoz DG , V C : R ates of vognitive decline in Alzheimer's and dementia with Lewy bodies. Deme nt G e riatr Dis ord. 2003;15:67–71. *Morita T , T ei Y , Inoue S : Agitated terminal delirium as sociations with partial opioid s ubs titution and hydration. J P alliat Me d. 2003;6:557–563. *Wild R , P ettit T , B urns A: C holines terase inhibitors dementia with Lewy bodies. C ochrane Databas e 1178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

01/01/2009

Page 6 of 6

R ev. 2003;3:C D003672.

1179 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

01/01/2009

Page 1 of 167

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 11 - S ubstance-R elated Dis orders > 11.1: S ubs ta nce-R elated Introduction and O verview

11.1: S ubs tanc e-R elated Dis orders : Introduc tion and Overview J erome H. J affe M.D. J ames C . Anthony Ph.D., S C .M. P art of "11 - S ubstance-R elated Disorders " T his chapter on the s ubs tance-related dis orders is up of s eparate s ections organized around the as sociated with the use of each of the major groups of pharmacological agents that are commonly mis used (abused). T his section deals with is sues that are acros s categories of drugs : the nomenclature and diagnostic s chemes of the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV -T R ) and the tenth edition of the Inte rnational C las s ification of Dis e as e s and R e late d He alth 10), the his tory of substance us e and dependence, epidemiology, and the etiological factors and treatment principles that appear to be common to thes e

S UB S TA NC E -R E L A TE D DS M-IV, DS M-IV-TR , A ND IC D-10 DS M-IV -T R does not differ from DS M-IV in the us e disorders sections . DS M-IV -T R includes two broad categories of substance-related disorders : s ubs tance 1180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 2 of 167

disorders (substance dependence and s ubs tance and a diverse grouping of substance-induced dis orders (s uch as intoxication, withdrawal, ps ychotic dis order, mood dis orders). T hus , in DS M-IV -T R , the topic of subs tance-related dis orders goes beyond s ubs tance dependence and abus e and clos ely related problems include a wide variety of advers e reactions not only to subs tances of abus e but also to medications and T he medications as sociated with substance-induced disorders range from anes thetics to over-the-counter medications and include s uch diverse drug categories anticholinergics, antidepress ants , anticonvuls ants, antimicrobial drugs , antihypertens ive agents , corticos teroids, antiparkinsonian agents , chemotherapeutic agents , nonsteroidal drugs (NS AIDs ), and disulfiram (Antabuse). In addition, several categories of s ubs tance-induced disorders can as sociated with a wide range of nonmedicinal toxic materials , ranging from heavy metals and industrial solvents to ins ecticides and hous ehold cleaning DS M-IV -T R groups the diagnostic criteria for s ubs tance dependence, abus e, intoxication, hallucinogen perception disorder, and withdrawal s yndromes in a section titled s ubs tance -re late d dis orde rs , whereas the other s ubs tance-related dis orders (e.g., substancemood dis orders and s ubs tance-induced delusional disorders ) are des cribed in the s ections covering and other psychiatric s yndromes that they most closely res emble phenomenologically (T able 11.1-1).

Table 11.1-1 S ubs tanc e-Induc ed 1181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 3 of 167

Mental Dis orders Inc luded E ls ewhere in the Textbook S ubstance-induced dis orders caus e a variety of symptoms that are characteristic of other mental disorders . T o facilitate differential diagnos is, the and criteria for these other s ubs tance-induced disorders are included in the sections of DS M-IV and this textbook with disorders with which they share phenomenology.    S ubs tance-induced delirium (C hapter 10) is included in the “Delirium, Dementia, and and Other C ognitive Dis orders” section of DS MTR .    S ubs tance-induced pers isting dementia 10) is included in the “Delirium, Dementia, and Amnes tic and Other C ognitive Dis orders ” section.    S ubs tance-induced pers isting amnestic (C hapter 10) is included in the “Delirium, and Amnes tic and Other C ognitive Dis orders ” section.    S ubs tance-induced psychotic disorder is in the “Other P sychotic Disorders ” section 12.16). (In DS M-III-R , these dis orders were as organic hallucinos is and organic delusional 1182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 4 of 167

disorder.)    S ubs tance-induced mood disorder is included the “Mood Disorders ” chapter (C hapter 13).    S ubs tance-induced anxiety disorder is included the “Anxiety Dis orders” chapter (C hapter 14).    S ubs tance-induced s exual dysfunction is in the “Normal S exuality and S exual and G ender Identity Disorders” chapter (C hapter 18).    S ubs tance-induced s leep disorder (C hapter 20) included in the “S leep Dis orders ” section.    In addition, hallucinogen persisting perception disorder (flas hbacks ) (S ection 11.7) is included hallucinogen-related dis order.

Adapted from Diagnos tic and S tatis tical Manual Me ntal Dis orde rs . 4th ed. T ext rev. W as hington, American P s ychiatric Ass ociation; 2000. T he section dealing with substance dependence and subs tance abus e presents des criptions of the clinical phenomena as sociated with the use of 11 designated clas ses of pharmacological agents : alcohol; or s imilarly acting agents; caffeine; cannabis ; cocaine; hallucinogens; inhalants; nicotine; opioids; 1183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 5 of 167

(P C P ) or s imilar agents ; and a group that includes sedatives, hypnotics , and anxiolytics. A residual 12th category includes a variety of agents not in the 11 designated clas ses, s uch as anabolic steroids and oxide. IC D-10 considers the dis orders due to ps ychoactive subs tance use within the confines of an alphanumeric system that allows only nine categories of pharmacological agents , with one res idual category to cover both multiple drug use and use of psychoactive subs tances not included in the nine des ignated DS M-IV -T R and IC D-10 categorize substances with the following exceptions . C affeine and P C P are cons idered distinct categories in DS M-IV -T R , whereas 10 includes problems related to caffeine in the category other s timulants , such as amphetamine, and P C P mus t included with hallucinogens or in the res idual category. Als o, IC D-10 has a s pecial category for abuse of non– dependence-producing substances (T able 11.1-2). S pecifically mentioned are antidepress ants, antacids , vitamins , and s teroids or hormones .

Table 11.1-2 IC D-10 Diagnos tic C riteria for Abus e of NonDependenc e-Produc ing S ubs tanc es A wide variety of medicaments and folk remedies 1184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 6 of 167

may be involved, but the particularly important groups are: ps ychotropic drugs that do not dependence, s uch as antidepres sants , and and analgesics that may be purchased without medical prescription such as aspirin and paracetamol. Although the medication may have been medically pres cribed or recommended in first instance, prolonged, unnecess ary, and often excess ive dos age develops , which is facilitated the availability of the substances without medical prescription. P ers is tent and unjustified us e of these us ually ass ociated with unneces sary expense, involves unneces sary contacts with medical profes sionals or supporting staff, and is marked by the harmful phys ical effects of the subs tances . Attempts to dis courage or forbid the of the s ubs tance are often met with resistance; laxatives and analgesics , this may be in spite of warnings about (or even the development of) phys ical harm s uch as renal dys function or electrolyte disturbances. Although it is us ually that the patient has a strong motivation to take subs tance, no dependence or withdrawal develop, as in the cas e of the psychoactive subs tances specified in mental and behavioral disorders due to ps ychoactive substance us e. Identify the type of s ubs tance involved:

1185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 7 of 167

   Antidepres sants (such as tricyclic and antidepres sants and monoamine oxidase    Laxatives    Analgesics (such as aspirin, paracetamol, phenacetin, not s pecified as psychoactive mental and behavioral disorders due to psychoactive subs tance use)    Antacids    V itamins    S teroids or hormones    S pecific herbal or folk remedies    Other s ubs tances that do not produce (s uch as diuretics)    Unspecified

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

1186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 8 of 167

DE F INITIONS A ND DIA G NOS IS S ubs tanc e Dependenc e DS M-IV , DS M-IV -T R , and IC D-10 formulations for abuse and dependence closely follow the concepts and terminology developed in 1980 by an International Working G roup spons ored by the W orld Health Organization (WHO) and the Alcohol, Drug Abuse, and Mental Health Adminis tration (ADAMHA) of the United S tates, which defined s ubs tance dependence as A s yndrome manifested by a behavioral pattern in which the us e of a given ps ychoactive or class of drugs , is given a higher priority than other behaviors that once had higher value. T he term “syndrome” is taken to mean no more than a clus tering of phenomena so that not all the components need always be pres ent or not always present with the same T he dependence s yndrome is absolute, but is a quantitative phenomenon that exis ts in different degrees. T he intensity the syndrome is measured by behaviors that are elicited in relation to us ing the drug and by the other behaviors that are secondary to drug us e…. No 1187 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 9 of 167

cut-off point can be identified for distinguishing drug dependence P.1138 from non-dependent but recurrent drug us e. At the extreme, the dependence syndrome is as sociated with “compuls ive drug-us ing T hat central notion is continued in DS M-IV and DS Mwhich s tate: T he es sential feature of dependence is a cluster of cognitive, behavioral, and phys iological symptoms that the individual continues subs tance use des pite subs tance-related problems. T he central notion in IC D-10 is virtually the same: … a cluster of behavioural, cognitive, and phys iological phenomena that develop after repeated s ubs tance use and typically include a s trong desire take the drug, difficulties in controlling its use, pers is ting in us e despite harmful cons equences, a higher priority 1188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 10 of 167

given to drug use than to other activities and obligations, increased tolerance, and sometimes a phys ical state. Diagnos tic criteria for substance dependence are T able 11.1-3 (for DS M-IV -T R ) and T able 11.1-4 (for DS M-IV -T R us es seven criteria to des cribe a generic concept of dependence that applies acros s 11 clas ses pharmacological agents and requires three of s even criteria to be met if dependence is to be diagnosed. is based on a more dimens ional concept of the dependence s yndrome, but it s tates that a definite diagnosis of dependence s hould usually be made only three or more of six criteria have been met within the previous year. B oth s ys tems use a polythetic s yndrome definition in which no one specific criterion is required long as three or more are present. However, DS M-IV as ks the clinician to s pecify whether phys iological dependence—evidence of C riterion 1 (tolerance) or C riterion 2 (withdrawal)—is present or abs ent. indicates that phys iological dependence is ass ociated a more severe form of the disorder.

Table 11.1-3 DS M-IV-TR C riteria for S ubs tanc e

1189 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 11 of 167

A maladaptive pattern of s ubs tance use, leading clinically significant impairment or distress , as manifested by three (or more) of the following, occurring at any time in the same 12-month    (1) T olerance, as defined by either of the       (a) A need for markedly increased amounts of subs tance to achieve intoxication or des ired       (b) Markedly diminis hed effect with continued us e of the same amount of the s ubs tance    (2) Withdrawal, as manifes ted by either of the following:       (a) T he characteristic withdrawal s yndrome the substance (refer to C riteria A and B of the sets for withdrawal from the s pecific s ubs tances )       (b) T he s ame (or clos ely related) subs tance is taken to relieve or avoid withdrawal s ymptoms    (3) T he substance is often taken in larger or over a longer period than was intended.    (4) T here is a pers is tent des ire or unsuccess ful effort to cut down or control s ubs tance use.    (5) A great deal of time is spent in activities 1190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 12 of 167

neces sary to obtain the substance (e.g., vis iting multiple doctors or driving long distances), use subs tance (e.g., chain s moking), or recover from effects.    (6) Important s ocial, occupational, or activities are given up or reduced becaus e of subs tance use.    (7) T he substance us e is continued despite knowledge of having a pers is tent or recurrent phys ical or ps ychological problem that is likely to have been caused or exacerbated by the (e.g., current cocaine use des pite recognition of cocaine-induced depress ion or continued drinking despite recognition that an ulcer was made wors e alcohol cons umption). S pe cify if:    With phys iological dependence: evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present)    Without phys iologic al dependence: no of tolerance or withdrawal (i.e., neither item 1 nor is present) C ours e s pe cifiers :

1191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 13 of 167

   E arly full remis sion    E arly partial remiss ion    S ustained full remiss ion    S ustained partial remis sion    On agonis t therapy    In a controlled environment

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 11.1-4 IC D-10 Diagnos tic C riteria for Mental and Dis orders Due to Ps yc hoac tive S ubs tanc e Us e Mental and behavioral dis orders due to us e of alc ohol

1192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 14 of 167

Mental and behavioral dis orders due to us e of opioids Mental and behavioral dis orders due to us e of cannabinoids Mental and behavioral dis orders due to us e of s edatives or hypnotic s Mental and behavioral dis orders due to us e of coc aine Mental and behavioral dis orders due to us e of other s timulants , inc luding caffeine Mental and behavioral dis orders due to us e of hallucinogens Mental and behavioral dis orders due to us e of tobac co Mental and behavioral dis orders due to us e of volatile s olvents Mental and behavioral dis orders due to drug us e and us e of other ps yc hoactive s ubs tanc es Acute intoxication

1193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 15 of 167

G 1. T here mus t be clear evidence of recent us e ps ychoactive substance (or s ubs tances ) at sufficiently high dose levels to be cons istent with intoxication. G 2. T here mus t be symptoms or signs of compatible with the known actions of the subs tance (or s ubs tances ), as s pecified below, sufficient s everity to produce disturbances in the level of consciousness cognition, perception, or behavior that are of clinical importance. G 3. T he s ymptoms or s igns present cannot be accounted for by a medical disorder unrelated to subs tance use, and are not better accounted for another mental or behavioral dis order. Acute intoxication frequently occurs in persons have more pers is tent alcohol- or drug-related problems in addition. W here there are s uch problems , e.g., harmful us e, dependence or psychotic disorder, they should also be T he following may be used to indicate whether acute intoxication was as sociated with any complications :       Uncomplicated          S ymptoms are of varying severity, us ually dependent 1194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 16 of 167

      With trauma or other bodily injury       With other medical complications          E xamples are hematemesis , inhalation of       With delirium       With perceptual distortions       With coma       With convuls ions       P athological intoxication          Applies only to alcohol Acute intoxication due to us e of alc ohol A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior, as evidenced by at least one of the following:       (1) disinhibition       (2) argumentativenes s

1195 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 17 of 167

      (3) aggres sion       (4) lability of mood       (5) impaired attention       (6) impaired judgment       (7) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) uns teady gait       (2) difficulty in s tanding       (3) s lurred s peech       (4) nystagmus       (5) decreas ed level of consciousness (e.g., coma)       (6) flus hed face       (7) conjunctival injection C omment

1196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 18 of 167

When s evere, acute alcohol intoxication may be accompanied by hypotens ion, hypothermia, and depres sion of the gag reflex. If des ired, the blood alcohol level may be specified. Pathologic al alcohol intoxication Note . T he s tatus of this condition is being T hese res earch criteria mus t be regarded as tentative. A. T he general criteria for acute intoxication mus t met, with the exception that pathological intoxication occurs after drinking amounts of insufficient to cause intoxication in most people. B . T here is verbally aggres sive or phys ically behavior that is not typical of the pers on when sober. C . T he intoxication occurs very soon (usually a minutes) after consumption of alcohol. D. T here is no evidence of organic cerebral or other mental dis orders. C omment T his is an uncommon condition. T he blood levels found in this disorder are lower than those 1197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 19 of 167

that would caus e acute intoxication in mos t (i.e., below 40 mg/100 mL). Acute intoxication due to us e of opioids A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior, as evidenced by at least one of the following:       (1) apathy and s edation       (2) disinhibition       (3) psychomotor retardation       (4) impaired attention       (5) impaired judgment       (6) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) drowsines s       (2) s lurred s peech

1198 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 20 of 167

      (3) pupillary cons triction (except in anoxia severe overdose, when pupillary dilatation       (4) decreas ed level of consciousness (e.g., coma) C omment When s evere, acute opioid intoxication may be accompanied by res piratory depres sion (and hypoxia), hypotension, and hypothermia. Acute intoxication due to us e of c annabinoids A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, including at leas t one of the following:       (1) euphoria and disinhibition       (2) anxiety or agitation       (3) s uspicious ness or paranoid ideation       (4) temporal s lowing (a sense that time is very s lowly, and/or the person is experiencing a rapid flow of ideas) 1199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 21 of 167

      (5) impaired judgment       (6) impaired attention       (7) impaired reaction time       (8) auditory, visual, or tactile illusions       (9) hallucinations with pres erved orientation    (10) depers onalization    (11) derealization    (12) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) increas ed appetite       (2) dry mouth       (3) conjunctival injection       (4) tachycardia Acute intoxication due to us e of s edatives or hypnotic s

1200 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 22 of 167

A. T he general criteria for acute intoxication mus t met. B . T here is dys functional behavior, as evidenced at least one of the following:       (1) euphoria and disinhibition       (2) apathy and s edation       (3) abus iveness or aggress ion       (4) lability of mood       (5) impaired attention       (6) anterograde amnesia       (7) impaired ps ychomotor performance       (8) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) uns teady gait       (2) difficulty in s tanding       (3) s lurred s peech 1201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 23 of 167

      (4) nystagmus       (5) decreas ed level of consciousness (e.g., coma)       (6) erythematous s kin lesions or blis ters C omment When s evere, acute intoxication from s edative or hypnotic drugs may be accompanied by hypotens ion, hypothermia, and depres sion of the gag reflex. Acute intoxication due to us e of c oc aine A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) euphoria and s ens ation of increased       (2) hypervigilance       (3) grandios e beliefs or actions       (4) abus iveness or aggress ion 1202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 24 of 167

      (5) argumentativenes s       (6) lability of mood       (7) repetitive s tereotyped behaviors       (8) auditory, visual, or tactile illusions       (9) hallucinations , us ually with intact    (10) paranoid ideation    (11) interference with personal functioning C . At leas t two of the following s igns mus t be present:       (1) tachycardia (s ometimes bradycardia)       (2) cardiac arrhythmias       (3) hypertension (s ometimes hypotension)       (4) s weating and chills       (5) naus ea or vomiting       (6) evidence of weight los s       (7) pupillary dilatation 1203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 25 of 167

      (8) psychomotor agitation (sometimes retardation)       (9) mus cular weakness    (10) ches t pain    (11) convuls ions C omment Interference with pers onal functioning is mos t readily apparent from the s ocial interactions of cocaine users, which range from extreme gregarious nes s to social withdrawal. Acute intoxication due to us e of other inc luding caffeine A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) euphoria and s ens ation of increased       (2) hypervigilance

1204 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 26 of 167

      (3) grandios e beliefs or actions       (4) abus iveness or aggress ion       (5) argumentativenes s       (6) lability of mood       (7) repetitive s tereotyped behaviors       (8) auditory, visual, or tactile illusions       (9) hallucinations , us ually with intact    (10) paranoid ideation    (11) interference with personal functioning C . At leas t two of the following s igns mus t be present:       (1) tachycardia (s ometimes bradycardia)       (2) cardiac arrhythmias       (3) hypertension (s ometimes hypotension)       (4) s weating and chills       (5) naus ea or vomiting 1205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 27 of 167

      (6) evidence of weight los s       (7) pupillary dilatation       (8) psychomotor agitation (sometimes retardation)       (9) mus cular weakness    (10) ches t pain    (11) convuls ions C omment Interference with pers onal functioning is mos t readily apparent from the s ocial interactions of subs tance us ers , which range from extreme gregarious nes s to social withdrawal. Acute intoxication due to us e of A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) anxiety and fearfulnes s 1206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 28 of 167

      (2) auditory, visual, or tactile illusions or hallucinations occurring in a state of full and alertness    (3) depers onalization    (4) derealization    (5) paranoid ideation    (6) ideas of reference    (7) lability of mood    (8) hyperactivity    (9) impulsive acts    (10) impaired attention    (11) interference with personal functioning C . At leas t two of the following s igns mus t be present:       (1) tachycardia       (2) palpitations       (3) s weating and chills 1207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 29 of 167

      (4) tremor       (5) blurring of vision       (6) pupillary dilatation       (7) incoordination Acute intoxication due to us e of tobac c o nic otine intoxic ation] A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) insomnia       (2) bizarre dreams       (3) lability of mood       (4) derealization       (5) interference with personal functioning C . At leas t one of the following s igns must be present: 1208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 30 of 167

      (1) naus ea or vomiting       (2) s weating       (3) tachycardia       (4) cardiac arrhythmias Acute intoxication due to us e of volatile A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior, by at least one of the following:       (1) apathy and lethargy       (2) argumentativenes s       (3) abus iveness or aggress ion       (4) lability of mood       (5) impaired judgment       (6) impaired attention and memory       (7) psychomotor retardation

1209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 31 of 167

      (8) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) uns teady gait       (2) difficulty in s tanding       (3) s lurred s peech       (4) nystagmus       (5) decreas ed level of consciousness (e.g., coma)       (6) mus cle weakness       (7) blurred vision or diplopia C omment Acute intoxication from inhalation of s ubs tances other than s olvents s hould als o be coded here. When s evere, acute intoxication from volatile solvents may be accompanied by hypotens ion, hypothermia, and depres sion of the gag reflex. Acute intoxication due to multiple drug us e 1210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 32 of 167

us e of other ps ychoac tive s ubs tanc es T his category should be us ed when there is of intoxication caused by recent use of other ps ychoactive s ubs tances (e.g., phencyclidine) or multiple ps ychoactive s ubs tances where it is uncertain which s ubs tance has predominated. Harmful us e A. T here mus t be clear evidence that the us e was res ponsible for (or substantially to) physical or psychological harm, including impaired judgment or dys functional behavior, may lead to dis ability or have advers e for interpers onal relations hips. B . T he nature of the harm should be clearly identifiable (and specified). C . T he pattern of use has pers is ted for at least 1 month or has occurred repeatedly within a 12month period. D. T he disorder does not meet the criteria for any other mental or behavioral dis order related to the same drug in the s ame time period (except for intoxication). Dependenc e s yndrome 1211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 33 of 167

A. T hree or more of the following manifes tations should have occurred together for at leas t 1 or, if persisting for periods of les s than 1 month, should have occurred together repeatedly within 12-month period:       (1) a strong desire or sense of compuls ion to the substance       (2) impaired capacity to control substancebehavior in terms of its ons et, termination, or of use, as evidenced by: the s ubs tance being taken in larger amounts or over a longer period intended; or by a persis tent desire or efforts to reduce or control s ubs tance use       (3) a phys iological withdrawal state when subs tance use is reduced or ceas ed, as the characteristic withdrawal s yndrome for the subs tance, or by us e of the same (or clos ely subs tance with the intention of relieving or withdrawal s ymptoms       (4) evidence of tolerance to the effects of the subs tance, s uch that there is a need for increased amounts of the subs tance to achieve intoxication or the desired effect, or a marked diminis hed effect with continued us e of the same amount of the substance

1212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 34 of 167

      (5) preoccupation with subs tance use, as manifested by important alternative pleas ures or interes ts being given up or reduced becaus e of subs tance use; or a great deal of time being activities necess ary to obtain, take, or recover the effects of the substance       (6) pers istent s ubs tance use des pite clear evidence of harmful consequences , as evidenced continued us e when the individual is actually or may be expected to be aware, of the nature extent of harm Diagnos is of the dependence syndrome may be further s pecified by the following: C urrently abs tinent    E arly remiss ion    P artial remis sion    F ull remiss ion C urrently abs tinent but in a protected (e.g., in a hos pital, in a therapeutic community, in prison, etc.) C urrently on a clinically s upervis ed maintenance replacement regime (controlled dependence) 1213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 35 of 167

with methadone; nicotine gum or nicotine patch) C urrently abs tinent, but receiving treatment with avers ive or blocking drugs (e.g., naltrexone or disulfiram) C urrently us ing the substance (active    W ithout phys ical features    W ith physical features T he cours e of the dependence may be further specified, if desired, as follows: C ontinuous us e E pisodic use (dipsomania) Withdrawal s tate G 1. T here mus t be clear evidence of recent or reduction of substance us e after repeated, and us ually prolonged and/or high-dose, use of that subs tance. G 2. S ymptoms and s igns are compatible with the known features of a withdrawal s tate from the particular substance or s ubs tances (see below).

1214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 36 of 167

G 3. S ymptoms and s igns are not accounted for medical dis order unrelated to subs tance use, and not better accounted for by another mental or behavioral disorder. T he diagnosis of withdrawal state may be further specified by us ing the following: Uncomplicated With convuls ions Alcohol withdrawal s tate A. T he general criteria for withdrawal state mus t met. B . Any three of the following s igns mus t be       (1) tremor of the tongue, eyelids , or hands       (2) s weating       (3) naus ea, retching, or vomiting       (4) tachycardia or hypertension       (5) psychomotor agitation

1215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 37 of 167

      (6) headache       (7) insomnia       (8) malais e or weakness       (9) trans ient visual, tactile, or auditory hallucinations or illus ions    (10) grand mal convuls ions C omment If delirium is present, the diagnosis s hould be alcohol withdrawal s tate with delirium (delirium tremens). A. T he general criteria for withdrawal state mus t met. (Note that an opioid withdrawal state may be induced by adminis tration of an opioid antagonis t after a brief period of opioid us e.) B . Any three of the following s igns mus t be       (1) craving for an opioid drug       (2) rhinorrhea or s neezing       (3) lacrimation

1216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 38 of 167

      (4) mus cle aches or cramps       (5) abdominal cramps       (6) naus ea or vomiting       (7) diarrhea       (8) pupillary dilatation       (9) piloerection, or recurrent chills    (10) tachycardia or hypertens ion    (11) yawning    (12) restless s leep C annabinoid withdrawal s tate Note . T his is an ill-defined s yndrome for which definitive diagnostic criteria cannot be established the present time. It occurs following cess ation of prolonged high-dose us e of cannabis . It has been reported variously as lasting from s everal hours up to 7 days. S ymptoms and signs include anxiety, irritability, tremor of the outstretched hands, s weating, and muscle aches. 1217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 39 of 167

S edative or hypnotic withdrawal s tate A. T he general criteria for withdrawal state mus t met. B . Any three of the following s igns mus t be       (1) tremor of the tongue, eyelids , or hands       (2) naus ea or vomiting       (3) tachycardia       (4) pos tural hypotens ion       (5) psychomotor agitation       (6) headache       (7) insomnia       (8) malais e or weakness       (9) trans ient visual, tactile, or auditory hallucinations or illus ions    (10) paranoid ideation    (11) grand mal convuls ions 1218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 40 of 167

C omment If delirium is present, the diagnosis s hould be sedative or hypnotic withdrawal state with C oc aine withdrawal s tate A. T he general criteria for withdrawal state mus t met. B . T here is dys phoric mood (e.g., sadnes s or anhedonia). C . Any two of the following s igns mus t be       (1) lethargy and fatigue       (2) psychomotor retardation or agitation       (3) craving for cocaine       (4) increas ed appetite       (5) ins omnia or hypersomnia       (6) bizarre or unpleasant dreams Withdrawal s tate from other s timulants , inc luding c affeine

1219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 41 of 167

A. T he general criteria for withdrawal state mus t met. B . T here is dys phoric mood (e.g., sadnes s or anhedonia). C . Any two of the following s igns mus t be       (1) lethargy and fatigue       (2) psychomotor retardation or agitation       (3) craving for s timulant drugs       (4) increas ed appetite       (5) ins omnia or hypersomnia       (6) bizarre or unpleasant dreams Halluc inogen withdrawal s tate Note : T here is no recognized hallucinogen withdrawal state. Tobacc o withdrawal s tate A. T he general criteria for withdrawal state mus t met.

1220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 42 of 167

B . Any two of the following signs mus t be       (1) craving for tobacco (or other nicotinecontaining products )       (2) malais e or weakness       (3) anxiety       (4) dys phoric mood       (5) irritability or restles sness       (6) insomnia       (7) increas ed appetite       (8) increas ed cough       (9) mouth ulceration    (10) difficulty in concentrating Volatile s olvents withdrawal s tate Note : T here is inadequate information on states from volatile solvents for research to be formulated. Multiple drug withdrawal s tate 1221 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 43 of 167

Withdrawal s tate with delirium A. T he general criteria for withdrawal state mus t met. B . T he criteria for delirium mus t be met. T he diagnosis of withdrawal state with delirium be further s pecified by using the following: Without convuls ions With convuls ions Ps yc hotic dis order A. Ons et of ps ychotic symptoms must occur or within 2 weeks of s ubs tance use. B . T he psychotic symptoms mus t pers is t for more than 48 hours. C . Duration of the disorder mus t not exceed 6 months. T he diagnosis of ps ychotic disorder may be specified by us ing the following: S chizophrenia-like

1222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 44 of 167

P redominantly delusional P redominantly hallucinatory P redominantly polymorphic P redominantly depress ive s ymptoms P redominantly manic symptoms Mixed F or research purpos es it is recommended that change of the dis order from a nonpsychotic to a clearly psychotic state be further specified as abrupt (ons et within 48 hours ) or acute (onset in more than 48 hours but les s than 2 weeks ). Amnes ic s yndrome A. Memory impairment is manifest in both:    (1) a defect of recent memory (impaired new material) to a degree sufficient to interfere daily living    (2) a reduced ability to recall past experiences B . All of the following are abs ent (or relatively absent): 1223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 45 of 167

   (1) defect in immediate recall (as tested, for example, by the digit s pan)    (2) clouding of cons cious nes s and disturbance attention, as defined in delirium, not induced by alcohol and other ps ychoactive s ubs tances , A    (3) global intellectual decline (dementia) C . T here is no objective evidence from phys ical neurological examination, laboratory tests , or of a disorder or dis eas e of the brain (especially involving bilaterally the diencephalic and medial temporal s tructures), other than that related to subs tance use, that can reasonably be presumed be res ponsible for the clinical manifes tations described under C riterion A. R es idual and late-ons et ps ychotic dis order A. C onditions and disorders meeting the criteria the individual s yndromes lis ted below s hould be clearly related to s ubs tance use. Where onset of condition or dis order occurs s ubs equent to us e of ps ychoactive substances, strong evidence s hould provided to demonstrate a link. C omments

1224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 46 of 167

In view of the cons iderable variation in this the characteristics of s uch res idual states or conditions s hould be clearly documented in terms their type, severity, and duration. F or res earch purpos es full des criptive details should be If required, use as follows : F lashbacks P ers onality or behavior disorder B . T he general criteria for personality and disorder due to brain disease, damage and dysfunction must be met. R es idual affective disorder B . T he criteria for organic mood (affective) must be met. Dementia B . T he general criteria for dementia mus t be met. Other pers is ting cognitive impairment B . T he criteria for mild cognitive dis order must be met, except for the exclusion of ps ychoactive subs tance use in C riterion D. 1225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 47 of 167

Late-onset psychotic disorder B . T he general criteria for ps ychotic dis order met, except with regard to the onset of the which is more than 2 weeks but not more than 6 weeks after substance us e. Other mental and behavioral dis orders Uns pecified mental and behavioral dis order

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. C opyright, Health Organization, G eneva; 1993, with In addition to requiring the clus tering of three criteria in 12-month period, DS M-IV -T R includes a few other qualifications. It s tates s pecifically that the diagnos is of dependence can be applied to every clas s of except caffeine. T his point is admittedly controversial, some res earchers (including thos e who authored the section in this chapter) believe, on the bas is of the DS M-IV -T R generic criteria, that caffeine produces a distinct form of dependence, although it is us ually relatively benign. S ome people cons ume s everal categories of drugs concurrently and are clearly drug dependent according the generic criteria, but it may not be poss ible to 1226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 48 of 167

whether they are dependent on any one s pecific clas s drugs. W hen at leas t three groups of drugs are DS M-IV -T R calls the condition polys ubs tance (T able 11.1-5). DS M-IV -T R also makes provis ion for clas sifying s ubs tance-related dis orders that cannot be clas sified in any of the previous categories (e.g., oxide, anticholinergics, anabolic-androgenic P.1139 steroids) or for an initial diagnos is of dependence or when the specific drug is not known. A s imilar res idual category is included in IC D-10, but steroids are given a distinct code. T he DS M-IV -T R diagnostic criteria for (or unknown) s ubstance-related dis orders are listed in T able 11.1-6.

Table 11.1-5 DS M-IV-TR C riteria for Polys ubs tanc e Dependenc e T his diagnos is is res erved for behavior during the same 12-month period in which the pers on was repeatedly us ing at leas t three groups of (not including caffeine and nicotine), but no single subs tance predominated. F urther, during this period, the dependence criteria were met for subs tances as a group but not for any s pecific subs tance. 1227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 49 of 167

F rom Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. T ext rev. W as hington, DC : American P s ychiatric Ass ociation; 2000, with permis sion.

Table 11.1-6 DS M-IV-TR C riteria for Other (or Unknown) S ubs tanc e-R elated Dis orders T he other (or unknown) substance-related category is for clas sifying s ubs tance-related disorders ass ociated with subs tances not shown T able 11.1-4. E xamples of thes e s ubs tances , are des cribed in more detail below, include steroids, nitrite inhalants (“poppers ”), nitrous over-the-counter and prescription medications not otherwis e covered by the 11 categories (e.g., antihistamines , benztropine), and other that have ps ychoactive effects . In addition, this category may be us ed when the s pecific unknown (e.g., an intoxication after taking a bottle unlabeled pills ).

1228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 50 of 167

Anabolic s teroids s ometimes produce an initial of enhanced well-being (or even euphoria), which replaced after repeated use by lack of energy, irritability, and other forms of dysphoria. us e of these substances may lead to more symptoms (e.g., depress ive s ymptomatology) general medical conditions (liver disease). Nitrite inhalants (“poppers ”—forms of amyl, butyl, and is obutyl nitrite) produce an intoxication that is characterized by a feeling of fullnes s in the head, mild euphoria, a change in the perception of time, relaxation of smooth muscles , and a pos sible increase in s exual feelings. In addition to poss ible compuls ive us e, these substances carry dangers potential impairment of immune functioning, irritation of the res piratory system, a decrease in oxygen-carrying capacity of the blood, and a toxic reaction that can include vomiting, severe hypotens ion, and dizzines s. Nitrous oxide (“laughing gas ”) caus es rapid ons et an intoxication that is characterized by lightheadedness and a floating s ensation that in a matter of minutes after adminis tration is stopped. T here are reports of temporary but clinically relevant confusion and reversible states when nitrous oxide is us ed regularly. Other substances that are capable of producing

1229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 51 of 167

intoxication include catnip, which can produce states s imilar to those obs erved with marijuana which in high dos es is reported to res ult in acid diethylamide–type perceptions ; betel nut, which is chewed in many cultures to produce a euphoria and floating s ensation; and kava (a subs tance derived from the S outh P acific pepper plant), which produces sedation, incoordination, weight loss , mild forms of hepatitis , and lung abnormalities . In addition, individuals can develop dependence and impairment through repeated adminis tration of over-the-counter and drugs, including cortis ol, antiparkins onian agents that have anticholinergic properties, and antihistamines . T exts and criteria sets have already been define the generic as pects of s ubs tance dependence, s ubs tance abuse, s ubs tance intoxication, and s ubs tance withdrawal that are applicable acros s class es of s ubs tances . T he unknown) s ubs tance-induced dis orders are described in the sections of the manual with disorders with which they s hare phenomenology (e.g., other [or unknown] s ubs tance-induced disorder is included in the mood dis orders Listed below are the other (or unknown) us e disorders and the other (or unknown) induced disorders .

1230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 52 of 167

Other (or unknown) s ubs tance us e dis orders Other (or unknown) s ubs tance dependenc e Other (or unknown) s ubs tance abus e Other (or unknown) s ubs tance-induced Other (or unknown) s ubs tance intoxic ation    S pe cify if:       With perceptual disturbances Other (or unknown) s ubs tance withdrawal    S pe cify if:       With perceptual disturbances Other (or unknown) s ubs tance-induced Other (or unknown) s ubs tance-induced pers is ting dementia Other (or unknown) s ubs tance-induced pers is ting amnes tic dis order Other (or unknown) s ubs tance ps yc hotic with delus ions 1231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 53 of 167

   S pe cify if:       With onset during intoxication       With onset during withdrawal Other (or unknown) s ubs tance-induced dis order with halluc inations    S pe cify if:       With onset during intoxication       With onset during withdrawal Other (or unknown) s ubs tance-induced mood dis order    S pe cify if:       With onset during intoxication       With onset during withdrawal Other (or unknown) s ubs tance-induced dis order    S pe cify if:       With onset during intoxication 1232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 54 of 167

      With onset during withdrawal Other (or unknown) s ubs tance-induced dys func tion    S pe cify if:       With onset during intoxication Other (or unknown) s ubs tance-induced s leep dis order    S pe cify if:       With onset during intoxication Other (or unknown) s ubs tance-related not otherwis e s pecified

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

P atterns of R emis s ion and C ours e S pec ifiers B oth systems deal with remis sion by providing distinct modifying terms that can be appended to a diagnos is 1233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 55 of 167

subs tance dependence. DS M-IV -T R terms are more than those of IC D-10 (T able 11.1-7). T he DS M-IV -T R specifiers for remis sion require a period of at leas t 1 month, after a period of active dependence, during no criteria of dependence are present. If a patient has met any criteria for dependence for at least 1 month fewer than 12 months , the cours e s pecifier is early full remis sion. If the period during which no criteria of dependence are met exceeds 12 months , the s pecifier s us taine d full remis sion can be used. If the full criteria dependence or abuse have not been met for less than year, but one or more criteria have been present, early partial remis sion may be des ignated. If the period 12 months , s us taine d partial remis sion may be us ed. additional remis sion s pecifiers should be used when appropriate: on agonis t the rapy (includes partial and in a controlle d e nvironment. T hus , a heroinpatient or client success fully enrolled in a methadone maintenance program for 12 months is described as in remis sion on agonis t therapy, as are those maintained succes sfully on buprenorphine, a partial agonis t.

1234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 56 of 167

S everal factors , s uch as duration of remiss ion and of a period of dependence, must be cons idered when deciding that a person has fully recovered and no warrants a diagnosis of dependence. T he modifiers describe the course of dependence in IC D-10 are but specific criteria for selecting them are not provided (T able 11.1-4). T he DS M-IV -T R does not use the term “in recovery” to describe any part of the course of remis sion from subs tance use dis orders. It is a term commonly used among patients who are currently abstinent while participating in 12-step programs . Many profess ionals are interacting with such patients also us e it. who were formerly dependent on drugs or alcohol and 1235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 57 of 167

have been s tably abs tinent for many years may also to themselves as being “in recovery,” typically to the idea that they are vulnerable to relaps e.

S ubs tanc e Abus e DS M-IV -T R defines the ess ential features of s ubs tance abuse as follows : A maladaptive pattern of subs tance use manifes ted by recurrent and s ignificant advers e cons equences related to the repeated us e of subs tances …. T hese problems mus t occur recurrently during the s ame 12month period…. [T ]he criteria for S ubstance Abus e do not include tolerance, withdrawal, or a of compulsive use and instead include only the harmful cons equences of repeated us e. diagnosis of S ubs tance Abus e is preempted by the diagnos is of S ubstance Dependence if the individual's pattern of substance us e has ever met the criteria for Dependence for that class of subs tances . E xpert committees of the W HO have rejected the term “abuse” when applied to drug problems . However, IV -T R task panels have chosen to retain the concept of 1236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 58 of 167

“subs tance abus e” to des cribe s ocially maladaptive behavior in connection with drug use in the absence of history of drug dependence. T hat is , the progres sion toward drug dependence is defined by DS M-IV -T R to include the poss ibility of drug abuse, but once a pers on meets criteria for drug dependence, the pos sibility of abuse is abs ent with respect to each drug clas s by the DS M-IV -T R . T he DS M-IV -T R criteria for abuse are shown in T able 11.1-8.

Table 11.1-8 DS M-IV-TR C riteria for S ubs tanc e Abus e A. A maladaptive pattern of s ubstance us e clinically significant impairment or distress , as manifested by one (or more) of the following, occurring within a 12-month period:    (1) R ecurrent substance us e res ulting in an to fulfill major role obligations at work, s chool, or home (e.g., repeated abs ences or poor work performance related to substance us e; related abs ences , s uspens ions, or expuls ions school; neglect of children or hous ehold)    (2) R ecurrent substance us e in s ituations in is phys ically hazardous (e.g., driving an or operating a machine when impaired by us e) 1237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 59 of 167

   (3) R ecurrent substance-related legal problems (e.g., arrests for substance-related dis orderly conduct)    (4) C ontinued s ubs tance use des pite having persis tent or recurrent social or interpers onal problems caus ed or exacerbated by the effects of the substance (e.g., arguments with spous e cons equences of intoxication, phys ical fights ) B . T he s ymptoms above never met the criteria for subs tance dependence for this class of

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. Although rejecting the concept of drug “abuse,” the 10 includes a category of harmful us e, which differs from the DS M-IV -T R concept of “abuse.” T he concept of “harmful us e” is limited to mental and health (e.g., hepatitis and overdose or episodes of depres sive dis order res ulting from heavy alcohol use). concept s pecifically excludes s ocial impairment, “T he fact that a pattern of us e of a particular s ubs tance disapproved of… or may have led to s ocially negative cons equences s uch as arrest or marital arguments is its elf evidence of harmful use.” F our diagnostic criteria 1238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 60 of 167

must be met to make the IC D-10 diagnosis of harmful P.1140 P.1141 P.1142 P.1143 P.1144

S ubs tanc e Withdrawal S ubstance withdrawal, as used in DS M-IV -T R , is a diagnostic term rather than a technical one. T hus , symptoms that technically are due to cess ation of the of a drug (e.g., the coffee drinker's early morning lethargy or minor headache) do not by thems elves fulfill the criteria for substance withdrawal unles s they are accompanied by a maladaptive behavior change and caus e s ome clinically significant distress or impairment social, occupational, or other important areas of functioning. DS M-IV -T R does not recognize withdrawal from caffeine, cannabis , or P C P , although some believe that specific signs and symptoms can be when those agents are abruptly dis continued after a period of heavy use. IC D-10 does describe a withdrawal state; accumulating evidence sugges ts that cannabis withdrawal s yndrome will be recognized in future revisions of the DS M-IV -T R . Withdrawal is commonly, but not invariably, as sociated 1239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 61 of 167

with the dependence s yndrome. T he s igns and of withdrawal vary with the specific clas s of drug. In general, the s everity of withdrawal is related to the amount of the substance us ed and the duration and patterns of us e. W ithdrawal is s een not only when the of the substance is stopped but also when reduced change in metabolis m, or the adminis tration of an antagonis t res ults in lower levels of the drug at the relevant s ites of action. T able 11.1-9 s hows the DS Mgeneric criteria for subs tance withdrawal; the IC D-10 general criteria are shown in T able 11.1-4. S pecific diagnostic criteria for withdrawal from each category of drugs, to be us ed when the general criteria have been are als o s hown.

Table 11.1-9 DS M-IV-TR C riteria for S ubs tanc e A. T he development of a subs tance-specific syndrome due to the ces sation of (or reduction in) subs tance use that has been heavy and B . T he s ubs tance-specific s yndrome caus es significant dis tres s or impairment in social, occupational, or other important areas of functioning. C . T he s ymptoms are not due to a general condition and are not better accounted for by 1240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 62 of 167

another mental disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. Was hington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

S ubs tanc e Intoxic ation Intoxication is defined more narrowly in DS M-IV -T R might be in a pharmacology text. A variety of drugs produce unwanted phys iological or ps ychological that could be construed as intoxication (e.g., exces sive sleepiness after the us e of an antihis tamine), but they are as sociated with maladaptive behavior, thos e effects do not constitute s ubs tance-induced intoxication as DS M-IV -T R defines it. F urthermore, whether a effect is maladaptive depends on the social and environmental context in which it occurs. W hen alcohol makes a pers on unus ually sociable, a bit garrulous , little uncoordinated at a family celebration, it may not maladaptive drinking behavior; the same behavior at a formal bus iness meeting probably is . S imilarly, IC D-10 specifies that intoxication mus t produce disturbances in the level of cons cious nes s, cognition, perception, behavior that are of clinical importance. However, clinicians are to further specify which of s everal complications of intoxication (e.g., trauma, delirium, convuls ions) are also present. In addition, IC D-10 1241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 63 of 167

specific s ets of diagnos tic criteria for each of the drug categories and for multiple drugs to be used once the generic criteria for intoxication have been met. T he IV -T R general criteria for s ubs tance intoxication are in T able 11.1-10. Also s ee T able 11.1-4 for the IC D-10 additional s pecifiers for complications of intoxication.

Table 11.1-10 DS M-IV-TR Diagnos tic C riteria for Intoxic ation A. T he development of a revers ible s ubs tancespecific s yndrome due to recent ingestion of (or expos ure to) a substance. Note: Different may produce similar or identical s yndromes. B . C linically significant maladaptive behavioral or ps ychological changes that are due to the effect the substance on the central nervous s ys tem belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or functioning) and develop during or s hortly after of the s ubs tance. C . T he s ymptoms are not due to a general condition and are not better accounted for by another mental disorder.

1242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 64 of 167

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

S ubs tanc e-Induc ed Dis orders In addition to dependence, abuse, intoxication, and withdrawal, certain psychoactive P.1145 drugs can induce syndromes that used to be called me ntal dis orders . T o avoid implying that other disorders do not have an organic bas is , DS M-IV -T R designates thes e s yndromes as s ubs tance -induce d and recognizes the following categories : s ubs tance intoxication, s ubs tance withdrawal, s ubs tance-induced withdrawal delirium, s ubs tance-induced intoxication delirium, substance-induced pers isting dementia, subs tance-induced pers isting amnes tic dis order, subs tance-induced mood disorder, s ubs tance-induced anxiety dis order, substance-induced psychotic subs tance-induced s exual dysfunction, and substanceinduced s leep disorder. When recording a diagnosis of s ubs tance-related the clinician should indicate the s pecific agent causing disorder, if known, rather than the broad drug category. 1243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 65 of 167

F or example, the diagnos is should be s ubs tanceintoxication, pentobarbital (Nembutal), rather than subs tance-induced intoxication, sedative-hypnotics. However, the diagnos tic code s hould be s elected from list of clas ses of substances provided in sets of criteria the substance-induced dis order being recorded. F or of the s ubs tance-induced dis orders (other than intoxication and withdrawal), the clinician should whether the onset occurred during intoxication or withdrawal. T hus, a s pecific s ubs tance-induced has a three-part name delineating (1) the specific subs tance, (2) the context (whether the dis order during intoxication or during withdrawal or occurs or persis ts beyond those stages ), and (3) the phenomenological presentation (e.g., diazepam induced anxiety disorder with onset during withdrawal). P.1146 T able 11.1-11 s hows the various disorders induced by major categories of drugs recognized by DS M-IV -T R indicates which dis orders are s een during intoxication which during withdrawal. Although they are not specifically in the table, anabolic-adrenergic s teroids also induce ps ychotic mood, anxiety, and sleep and disorders , and their withdrawal can also be ass ociated mood and sleep disorders . Although the current the table in DS M-IV (DS M-IV -T R ) does not s how a withdrawal syndrome, future revis ions may do so.

Table 11.1 1244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 66 of 167

  Dependenc e Abus e

Intoxic ation

Alcohol

X

X

X

Amphetamines

X

X

X

C affeine

 

 

X

C annabis

X

X

X

C ocaine

X

X

X

Hallucinogens

X

X

X

Inhalants

X

X

X

Nicotine

X

 

 

Opioids

X

X

X

P hencyclidine

X

X

X

S edatives , hypnotics, or anxiolytics

X

X

X

1245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 67 of 167

P olys ubs tance

X

 

 

Other

X

X

X

Note: X, I, W , I/W , or P indicates that the category is rec Delirium); W indicates that the s pecifier With Ons et Duri With Ons et During W ithdrawal may be noted for the cate aAls o

hallucinogen persisting perception disorder (flas hb

F rom American P sychiatric As sociation. Diagnos tic and IC D-10 takes a distinctly different approach to these drug-related dis orders. W ith the firs t and s econd digits after the letter committed to designating the drug category, additional ps ychiatric syndromes are by the us e of the third and fourth digits. F or example, persis tent mood (affective) dis order as sociated with hallucinogens is des ignated F 16.72. F or the diagnosis made, the mood disorder needs to meet the criteria for mood disorders .

E volving Terminology T he terminology used to des cribe the s ubs tancedisorders has been repeatedly revised as concepts the nature of drug-us ing behavior have evolved. In the 1980 third edition of the DS M (DS M-III), drug us e were divided into two major categories, drug abuse and drug dependence, and s pecific criteria for diagnosis 1246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 68 of 167

provided. In DS M-III-T R , adopted in 1987, the two categories were retained, P.1147 but the diagnostic criteria were modified. F urther were made for DS M-IV -T R , which adopted the terms “subs tance abus e” and “subs tance dependence,” to eliminate the use of the more cumbers ome term “alcohol and drug dependence including tobacco.” F or similar reasons, IC D-10 adopted the term subs tance dependence.” In much of the world literature on drug dependence, term “dependence” is us ed to convey two distinct (1) a behavioral s yndrome, and (2) physical or dependence. P hys iological de pe ndence can be defined an alteration in neural systems that is manifes ted by tolerance and the appearance of withdrawal when a chronically adminis tered drug is dis continued displaced from its receptor. B ecause the dual us e of word causes confusion, a 1980 ADAMHA-WHO group recommended us ing “dependence” only to the behavioral syndrome and s ubs tituting the term “neuroadaptation” for physical dependence. S uch a subs titution would have emphas ized s everal points . the continued us e of many drugs, including some antidepres sants, some selective serotonin uptake inhibitors (S S R Is), and β-adrenergic receptor caus es neuroadaptive changes followed by withdrawal phenomena but not by drug-seeking behavior when are dis continued. S econd, neuroadaptive changes with the first dose of an opioid or sedative drug, and, therefore, s uch changes in and of thems elves are not a 1247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 69 of 167

sufficient caus e (or definition) of drug dependence as a behavioral s yndrome.

Why Us e “A ddic tion”? T he words “addict” and “addiction” often have connotations . Often, they are trivialized and are used to refer to frequently engaging in ordinary activities s uch exercising or solving cross word puzzles . However, “addiction” continues to have the core connotation of decreased control, and s ome chapters in this book retained s uch terms as “opioid addict” simply becaus e are les s awkward than “severely opioid-dependent person.” Here, the word “dependent,” unmodified, is to mean behaviorally dependent. T he term de pendence or phys ical de pe ndence is us ed to refer to phys iological changes that res ult in withdrawal when drugs are discontinued.

C OMP A R A TIVE NOS OL OG Y DS M-IV-TR and IC D-10 T he generic concept of dependence is virtually DS M-IV -T R and IC D-10. B y requiring the clinician to whether tolerance and withdrawal are pres ent, DS Mappears to recognize a s pecial s ignificance for and phys iological dependence. S ome data indicate among alcoholics , the pres ence of phys ical and, to a less er degree, tolerance, is as sociated with a severe variety of the syndrome. In practice, however, requiring evidence of these criteria does not reduce the number of cas es meeting the criteria for dependence in most drug categories, with the of hallucinogens , a class of drugs for which DS M-IV -T R 1248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 70 of 167

does not lis t phys iological dependence as a criterion. T here is generally a high level of agreement between IV -T R and IC D-10 for making a diagnosis of although the descriptions of the criteria for determining the presence and severity of the syndrome differ. T hey both require that three elements of the syndrome have been present in a 12-month period. T he DS M-IV -T R categorization of drug class es differs somewhat from one us ed by IC D-10, which, constrained by a new alphanumeric system, uses only nine drug categories including caffeine with amphetamine-like stimulants P C P with other psychoactive agents . T he word abus e is also commonly us ed in ways that significantly from the definitions developed for use in DS M-IV -T R . In popular and legis lative contexts, drug means any use of an illegal s ubs tance or any nonpres cribed us e of a drug intended as a medicine as well as the harmful or excess ive use of legally available subs tances such as alcohol and tobacco. In this the authors have chosen to use the term ille gal in lieu illicit wherever pos sible because illicit carries with it a moral connotation that is not carried by the term illegal. S ome exceptions appear in figures taken from works. Des pite the reliability of DS M-IV -T R and IC D-10 criteria dependence in many E uropean and Anglo-American cultures, several criteria (e.g., narrowing of drinking repertoire, time spent obtaining the drug, and even tolerance for the drug) have pos ed difficulties in other cultures, es pecially when dealing with alcohol. often mis understood when applied to alcohol; in some cultures, holding one's liquor is a s ign of manhood. 1249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 71 of 167

C linicians are more likely to make a diagnos is of drug dependence than alcohol dependence even when behavioral s igns are comparable. In several cultures , or no distinction is recognized among us e, abus e, and harmful us e of illegal drugs .

Other Pers pec tives T he criteria for diagnos is in DS M-IV -T R and IC D-10 developed from what is es sentially a biopsychosocial model of drug dependence. In such a model, multiple factors —genetic, psychological, sociological, and pharmacological—contribute to the observed clinical syndromes. S uch apparent unanimity about drug dependence s hould not obscure the existence of diss enting perspectives, which take s everal forms. In the biops ychos ocial model is criticized as giving too weight to biological factors and too little recognition to the notion of human will and responsibility, of medicalizing deviant behavior for the benefit of profes sionals, and of creating universal exculpation for those who do not live up to reas onable societal expectations . B ut some profess ionals have implicitly criticized the P.1148 P.1149 same biopsychos ocial model for not giving s ufficient weight to the ideas that substance dependence is a specific primary disease (i.e., not a s ymptom of other ps ychiatric difficulties ), that those who develop the have no control over their intake of certain substances, 1250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 72 of 167

and that denial of the pres ence of a problem can be a major characteris tic of the disease. C oncepts about substance dependence can be along several dimensions that are not entirely independent or orthogonal: broad versus narrow, versus learned behavior, and social vers us medical. narrow concept of substance dependence accepts as disorders thos e maladaptive behaviors as sociated primarily, if not exclus ively, with the inges tion of subs tances generally accepted as pharmacological C ompulsive eating, gambling, running, hair pulling, and repetitive exces sive sexual activities are not included among the dependence disorders , although thos e problems may s hare certain features that resemble a decreased ability to choos e and are s ometimes ameliorated by participation in support groups founded on principles s imilar to those of Alcoholics Anonymous (AA). A broad approach creates a superclas s of that include a number of s uch behaviors not involving pharmacological agents . At the disease end of the dis eas e-versus -behavioral syndrome dimension is a belief that dependence is not learned behavior that can be modified or ameliorated relearning but is a primary disorder caus ed by an interaction between a drug and a pers on with s ome genetic vulnerability and that only total abstinence can arrest the progress ion of the disease. T he medicalsocial dimens ion typically describes a range of views how bes t to res pond to problems with s ubs tances , than differences about the es sential nature of the problems . T he medical model s tres ses iss ues of as sess ment—treatment, planning, and record 1251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 73 of 167

and s ometimes treatment that can be rendered only by those with profess ional training (not necess arily phys icians ). T he s ocial model emphas izes the of social s upports and integrating the person with a problem into a network of recovering people who can offer continuing s upport. T he ass ess ment and progres s and outcome as generally practiced by credentialed profess ionals are minimized.

HIS TOR Y T he most commonly us ed drugs have been part of exis tence for thous ands of years. F or example, opium been used for medicinal purpos es for at least 3,500 references to cannabis (marijuana) as a medicinal can found in ancient C hinese herbals , wine is mentioned frequently in the B ible, and the indigenous people of Wes tern Hemisphere were s moking tobacco and coca leaves generations before the arrival of the S ome of the problems caused by alcohol and other such as drunkennes s, are described in the B ible and in writings of the ancient G reeks and R omans . As new more concentrated forms of drugs were discovered or invented or new routes of adminis tering them were developed, new problems related to their us e emerged. 18th-century E ngland, for example, the alcohol-related problems seen after the introduction of cheap gin were cons idered more serious than those as sociated with and wine. Although, in As ia, opium s moking was a problem in the 18th and 19th centuries, new problems related to opium were seen there and in other parts of world after morphine, its most active alkaloid, was in 1806. W ith the introduction of the hypodermic needle the mid-19th century, morphine could be injected and 1252 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 74 of 167

became s ubject to mis us e by that route. Intravenous morphine and heroin us e began to spread in the early of the 20th century. T echnology also influenced the us e tobacco and the problems related to it. Although us e was common by the 19th century, the serious medical consequences as sociated with it did not until the 20th century, when new methods of curing the leaves produced a mild smoking tobacco, and were introduced. C igarettes made common the inhaling tobacco smoke deeply into the lungs . B y the 20th century, cigarette s moking was a popular practice, and lung cancer was recognized as a consequence of cigarette use. It took an additional 20 years for it to become generally accepted that tobacco has the to induce dependence.

Medic alizing E xc es s ive Drug Us e In 1810, B enjamin R ush, who is often credited as the American phys ician to s uggest that exces sive use of alcohol was a dis eas e rather than exclus ively a moral defect, propos ed the establishment of a sober hous e; 1835, S amuel W oodward, a pioneer in the as ylums for the ins ane, advocated s imilar as ylums for inebriates . C ontemporaneous with those early moves involve medicine in dealing with exces sive alcohol us e the emergence of the temperance movement and the Was hingtonians—groups of reformed drunkards concerned with helping others to adopt and maintain sobriety. In the process , the W ashingtonians many of the principles of s elf-help that were by AA almost a century later. W hen the ideas of voluntarism and s elf-help, as exemplified by Was hingtonian s ocieties, failed to eliminate the 1253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 75 of 167

drunkenness , physicians began to debate more the idea of coerced treatment in inebriate as ylums supported by public funds. In 1870, advocates of the approach established the American As sociation for the C ure of Inebriates (AAC I), dedicated to setting up for such people, conducting res earch, and teaching medical students and phys icians how to treat inebriety. first, thos e phys icians who believed in a more s piritual, voluntary approach to the problem (neowere part of the AAC I, but, gradually, the more oriented factions , which advocated medically as ylums (and compuls ory treatment when needed), gained as cendancy. F urthermore, the focus of concern no longer limited to thos e who abused alcohol. T homas C rothers, the secretary of AAC I, s aw inebriate asylums places to treat all those who used any variety of or narcotic to exces s. However, very few publicly supported inebriate as ylums ever opened.

E arly Attitudes T he clos ing years of the 19th century s aw growing about the excess ive and inappropriate use of drugs , including alcohol and tobacco, as well as opiates and cocaine. F irs t isolated from the coca leaf in 1860, came into wides pread us e in 1885 when companies began s elling it in the United S tates and E urope. In 1884, S igmund F reud published a review of potential therapeutic uses of cocaine. S ome medical authorities in the United S tates shared his enthus ias m, cocaine was recommended by the Hay F ever as a remedy for that malady. W ithin a few years, it was recognized that cocaine had the capacity to toxic ps ychos is as well as “habitual” or compulsive use 1254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 76 of 167

other features of a dependence syndrome. It was also recognized that long-term opiate us e had dependenceinducing effects . Nevertheles s, in the United S tates, the beginning of the 20th century, the opium alkaloids cocaine were s till found in patent medicines that were over the counter without pres cription for a wide variety indications , and their labeling often did not reveal their contents. Although achieving long-term cure of morphinis m was reported to be exceedingly difficult, neither the public the medical profess ion viewed the habitual user of or morphine as invariably having a moral deficit. T hose who had developed the morphine habit repres ented the entire socioeconomic s pectrum, with women outnumbering men by approximately two to one. political and literary figures were known to us e opiates to lead otherwis e productive and exemplary lives. with emotional problems and thos e who had formerly us ed alcohol to exces s were probably als o overrepres ented among opium us ers because it was unusual at the time for phys icians to pres cribe opiates control emotional problems and alcoholis m. However, cocaine use and the morphine habit were als o common among gamblers, petty thieves , prostitutes , and other disreputable members of society. T he problem of us ing the same institution for the treatment of drug us ers who had antisocial tendencies those who led more conventional lives P.1150 was jus t as vexing to early advocates of medical as it is to present-day practitioners . Many proponents 1255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 77 of 167

inebriate asylums did not want to take responsibility for people who had frequent or serious encounters with police because it was believed that s uch people made impos sible to create an atmos phere conducive to recovery. P artly to cope with the problem, even some the proponents of a dis ease model of inebriety the distinction between “inebriety the dis eas e” and “intemperance the vice.”

E arly C ontrol E fforts : E volution of C riminal Model B y the late 1890s, the public and the medical were no longer indifferent to drug use and habituation. 1893, the Anti-S aloon League was founded, a temperance movement that advocated the total prohibition of alcohol. Medical texts in E ngland, and the United S tates contained descriptions of morphinis m, theories of its causation, and recommendations for withdrawal and pos twithdrawal treatment. S ome texts als o described problems of cocainism. Medical authorities in the United S tates cautioned agains t overly liberal prescribing of cocaine opiates by phys icians and express ed great concern the presence of those drugs in unlabeled proprietary the-counter medicines. S tate laws were pas sed that at controlling the sale of opiates and cocaine, patent medicines . In 1903, the cocaine in C oca-C ola replaced by caffeine. P artly to s upport the efforts of the C hines e government control opium us e in C hina, repres entatives of the S tates government led the movement to negotiate an international treaty to control traffic in opium, cocaine, 1256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 78 of 167

and related drugs. T he firs t such treaty was signed in Hague in 1912. Negotiators from the United S tates also interested in the international control of cannabis could not get other nations to view the s ubs tance as sufficiently problematic to warrant it. (S uch control was achieved in 1925 at the S econd G eneva C onvention.) Hague C onvention required the s ignatories to pass domes tic legis lation controlling opiates and cocaine. Harrison Act of 1914, the firs t federal legislation to opiates and cocaine in the United S tates, was res trict access to opiates and cocaine to doctors, pharmacists , and legitimate importers and it brought the United S tates into compliance with the convention. Within the United S tates, state regulations concerning sale of opiates and cocaine, the introduction of aspirin the barbiturates , and the P ure F ood and Drug Act of which required labeling of patent medicines , were having an impact on the us e of opiates in medicine the Harrison Act was pas sed in 1914. Although many medical and political leaders in the United S tates that much of the problem of drug dependence resulted from careless prescribing by phys icians, the Harrison was not originally intended to interfere with the practice of medicine or to caus e s pecial hardship for already dependent on opiates . F or several years after Harrison Act was pass ed, a few cities operated clinics prescribed morphine to people with es tablis hed habits . Mos t of thos e dependent on opiates before the Harrison Act became abs tinent within a few years after was pass ed, although generally not as a res ult of at the clinics . 1257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 79 of 167

Fluc tuating Attitudes Major changes had taken place in American attitudes practices by the 1920s . T he 18th Amendment to the C ons titution, which prohibited the s ale of alcohol, law in 1920 and radically changed drinking behavior in United S tates . W ithin a year after alcohol prohibition enacted, 14 s tates also pas sed cigarette prohibition E ven less popular than alcohol prohibition, thos e antitobacco laws were all repealed by 1927, and by the 1920s , Americans were s moking 80 billion cigarettes a year. However, cocaine us e, so prevalent at the turn of century, was no longer wides pread. Dis illusioned by the reluctance of morphine addicts at clinics to detoxify and by repeated relaps es among who did, doctors began to recommend (not for the firs t time) compulsory treatment with confinement until cure. As the new laws curtailed legitimate s upplies of illegal traffic developed to provide them to morphine addicts who could not or would not us e the clinics. Increasingly, the drug s old was heroin, which had been introduced for medical use in 1898 but was quickly by drug us ers to have effects quite similar to those of morphine. Many who patronized the illegal traffickers us ed the clinics had his tories of delinquency and activity, and, eventually, that subgroup came to predominate. R eformers, moralists, and the popular found in the opiate habit, and in the reputation of thos e who continued to us e morphine, proof of the evils inherent in those drugs. Negative publicity, lurid stories, medical and press ure from law enforcement agents combined 1258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 80 of 167

label the morphine clinics as medical folly and brought about their closing, the las t in 1923. At the s ame time, series of U.S . S upreme C ourt decis ions implied that prescribing even s mall amounts of opiates or cocaine addict for treatment of addiction was not proper practice and was thus an illegal sale of narcotic drugs. S everal physicians were imprisoned, and numerous were tried, reprimanded, or otherwise harass ed. B y the early 1920s, people addicted to opiates were not in doctor's offices , and they were often refus ed at hos pitals . Dope addict and dope fiend had become common terms, and the average laypers on, as well as some otherwise well-informed members of the medical profes sion, appeared to believe that the opiate was inherently evil. In the late 1930s , cannabis similar reputation, and in 1937, the U.S . C ongress tax legis lation prescribing criminal penalties for its us e, sale, or poss es sion. Alcohol prohibition had been in 1933.

New Drug Problems T he firs t of the barbiturate s edatives , barbital, was introduced into clinical medicine in 1903, followed over the next 30 years by scores of congeners that differed primarily in their duration of action. Within a few years after the introduction of each new compound, the first case reports of mis use, dependence, and withdrawal appeared in the medical journals , a pattern that was repeated with the nonbarbiturate s edatives, such as glutethimide (Doriden), ethchlorvynol (P lacidyl), and meprobamate (Miltown), in the 1950s . Amphetamine, firs t synthesized in 1887, was put into 1259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 81 of 167

clinical us e in 1932 as a drug to s hrink mucous membranes. B y 1935, its central stimulant effects had recognized and found us eful for treating narcolepsy, dozens of other suggested us es soon followed. that amphetamine was being used as a euphoriant to appear in the late 1930s , but the full s ignificance of potential to caus e harm was not appreciated until the post–World W ar II epidemic of IV methamphetamine addiction in J apan. T hat epidemic, precipitated by the of surplus methamphetamine tablets intended for troops , involved millions of people. Other like drugs, which have also been s ubject to mis use, introduced during the 1950s and early 1960s . T he ps ychological effects of mes caline were already known and written about at the end of the 19th century. However, public concern about hallucinogens did not reach a high level until the 1960s, when the use of a discovered and exceedingly potent compound, lys ergic acid diethylamide (LS D), evolved from experimentation the intellectual elite and a few college s tudents to more widespread use by even younger people. P C P , a anesthetic developed in the 1950s , also became a drug abuse in the 1960s and 1970s . Des pite repeated reports of abus e and dependence as sociated with barbiturates, barbiturate-like sedatives , and amphetamines and related s timulants and in spite concerns about experimentation with LS D and related hallucinogens, there were no federal criminal sanctions related to thes e drugs until 1964, when authority for control was as signed to the F ood and Drug (F DA). In contrast, in the 1950s , concern about heroin addiction had led to ever harsher criminal penalties for 1260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 82 of 167

sale or poss ess ion. Although law enforcement efforts aimed at controlling heroin use were increas ed, both number of new heroin us ers and the crime rates to increas e throughout the late 1960s . At about that there was also a s harp increas e in the nonmedical us e other s ubs tances , s uch as cannabis and LS D, and a epidemic of amphetamine mis us e and dependence. In addition to amphetamines diverted from medical channels , s upplies came P.1151 from clandes tine laboratories. Drug us e, es pecially cannabis , became linked to antiestablishment attitudes, politics , and lifes tyles . T hrough the mid-1970s in the United S tates, there was subs tantial increase in experimentation with cocaine followed by increases in heavy cocaine us e. S tarting in late 1980s , there was an upsurge in methamphetamine us e that was driven by a proliferation of illegal laboratories. S ubsequently, there has been an increas e the popularity of drugs s uch as 3,4methylenedioxymethamphetamine (MDMA) and γhydroxybutyrate (G HB ), now often referred to as club because they are typically us ed at marathon-like dance parties (“raves ”).

E volving Treatment Approac hes T reatment for drug- and alcohol-related problems underwent several dramatic changes during the 20th century. T he large specialized as ylums that were advocated in the 19th century never materialized. the end of the 19th century, physicians were primarily 1261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 83 of 167

concerned with how to manage withdrawal s yndromes and whether longer compuls ory treatment was needed. With the advent of prohibition, the impetus to develop treatments for alcoholis m declined s harply. Interes t in treating opioid-dependent patients also declined as phys icians became dis couraged by their patients ' tendency to relapse after being detoxified and as opioid us e and dependence came to be seen more as behaviors than as medical dis orders. A few private sanatoriums continued to provide treatment for opioid dependence. B y 1930, after a change in federal policy drug-addicted pris oners began to fill the penitentiaries , the federal government es tablis hed two hospitals, at Lexington, K entucky, and F ort W orth, T exas , to provide treatment for that population and also to conduct on opiates and opiate addiction. T reatment for and amphetamine dependence took place largely in mains tream of medical practice and in s tate hos pitals , there was no consensus on what constituted effective posthospital care. In the mid-1930s , two recovering alcoholics the principles of the W ashingtonians, added s ome new principles, and initiated the s elf-help movement now known as AA. B y the 1950s , this movement had begun inspire analogous s elf-help efforts among other types drug us ers . T he situation changed again in the early 1960s . W ith outbreaks of heroin use by young people and crime, the federal government and individual states attempted to respond to the problem. C alifornia civil commitment program for addicts under the adminis trative control of the Department of C orrections ; 1262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 84 of 167

New Y ork C ity reopened R ivers ide Hospital to treat heroin addicts. T he first follow-up studies of patients treated at the federal hospital at Lexington, K entucky, revealed exceedingly high rates of relaps e after B oth the medical community and the general public demanded new ideas and s olutions, including a recons ideration of providing opiate addicts with opioids through medical channels . F rom 1958 to 1967, several major new approaches to treating opioid dependence were developed. S ynanon, prototype therapeutic community for treatment of drug dependence, was s tarted in C alifornia in 1958 and was s oon replicated in New Y ork with the Daytop V illage and P hoenix House. V incent Dole and Nys wander s howed that maintaining s elected longheroin addicts on large daily doses of methadone (Dolophine) was effective in reducing crime and heroin us e. S everal research groups demons trated that heroin addicts voluntarily tried treatment with narcotic antagonis ts. In the mid-1960s , New Y ork S tate and the federal government legis lated civil commitment modeled after the program in C alifornia, with an initial period of prolonged ins titutional care as a key element. Although many treatment programs initiated in the 1960s continued to focus on the treatment of opioid dependence, others , especially the therapeutic communities, viewed all nonmedical drug us e as stemming from s imilar defects in character s tructure offered a generic approach to treating drug E ach of these general approaches has evolved and incorporated findings from an unprecedented of government-funded res earch on treatment methods 1263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 85 of 167

and outcome. Among the methods that found their way into both publicly s upported programs and individual practices was the us e of cognitive-behavioral and prevention techniques.

A lc ohol and Nic otine In the 1950s, clinicians at Wilmar S tate Hos pital in Minnesota developed a treatment program for built on a synthesis of the medical model and the experiences of individuals recovering from alcohol dependence us ing the 12-step principles of AA. T hat treatment approach was refined and expanded at the J ohns on Ins titute and Hazelden F oundation, als o in Minnesota. T he modified programs , widely adopted by others , are often referred to as 28-day programs , 12programs , or the Minne s ota mode l. In the early 1970s, effort to recognize alcoholism as a dis eas e gained momentum, and the decision of medical ins urance to provide coverage for detoxification and inpatient treatment fueled an unprecedented growth of privatesector facilities offering treatment for alcoholism. without exception, they were res idential programs the Minnesota model. T he decriminalization of public intoxication spurred a parallel increase in alcohol treatment programs supported by the public s ector. T he S urgeon G eneral's R eport of 1964 linked cigarette smoking to lung cancer and concluded that tobacco smoking was a form of dependence, although not an addiction. B y the 1970s, tobacco dependence was widely accepted as a valid clinical entity, and various treatments for it were developed. B y the late 1980s , as smoking was becoming socially unacceptable, many 1264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 86 of 167

buildings were declared s moke free, smoking was on most airplane flights and in many hospitals , and pharmaceutical companies began to market new for delivering nicotine (e.g., nicotine chewing gum and transdermal patches) as aids for smoking cess ation. B y late 1990s , the tobacco companies were negotiating settlements in multiple civil lawsuits by states and by individuals who had been injured by their tobacco use, and C ongres s had debated major tax increases on and regulation by the F DA.

Two-Tiered S ys tem As the cocaine epidemic of the 1970s and 1980s s truck middle clas s, much of the large, private-sector system treating alcoholism evolved into chemical dependency units offering similar treatments to people with alcohol problems and thos e with other varieties of subs tance dependence. B y 1990, it was es timated that more than 8,000 recognized programs exis ted that dealt with alcoholism and other s ubs tance dependence. (T he es timate at the turn of the 21s t century was 12,000.) treatment methods us ed varied widely in terms of costs , philosophical underpinnings , and populations served. New categories of drug treatment profes sionals had emerged, and psychiatrists who once had the problems to be a low-status area s ucces sfully for the creation of a recognized s ubs pecialty in ps ychiatry. T reatment capacity was described as a tiered system with private and public s ectors in which private s ector served 40 percent of the population but received 60 percent of the total expenditures for treatment. One res ponse to the es calating cos t of drug treatment s ervices among thos e with private medical 1265 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 87 of 167

insurance was the ris e of a managed care industry to control cos ts on behalf of employers who pay for insurance, generally by severely limiting the length of in hos pital s ettings . Managed care, by refusing to recognize (and pay for) the medical neces sity of treatment for most cas es of drug or alcohol largely dismantled the “28-day” inpatient alcohol and treatment programs that had serviced patients with insurance. B y the mid-1990s , managed care principles were routine in the public s ector as well, and little remained of the res idential component of the two-tiered system. T here are s till two tiers of treatment in that some individuals with private res ources or insurance have to a wider variety of treatment opportunities . T hose do have insurance or their own funds mus t rely on the availability of publicly supported programs . T hese programs are often unable to accept new patients in a timely way. T he 1990s s aw increased effort to provide treatment to incarcerated individuals with drug dependence problems . Als o, there was subs tantial expansion of “drug courts ” in which judges with s pecial interes t us ed their authority to motivate (or coerce) us ing offenders to P.1152 accept treatment. In s ome cases, the treatment was coerced abstinence in which the court mandated drug testing (usually urine tests ) and s pecified periods of incarceration for continued drug use.

L egis lation and National S trategies 1266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 88 of 167

In 1969, C ongres s recognized the need to give greater attention to the problem of alcoholism and es tablished National Ins titute on Alcohol Abuse and Alcoholis m (NIAAA) in the National Ins titute of Mental Health In 1970, new federal controlled s ubstances legis lation pass ed, reorganizing the jumble of drug regulatory statutes that had evolved s ince the pass age of the Act, increasing the res ources for controlling the of illegal drugs . S hortly thereafter, the task of was given to a new agency, the Drug E nforcement (DE A), which incorporated elements of the F DA and B ureau of Narcotic and Dangerous Drugs. All drugs to special controls were included in one of several categories of the C ontrolled S ubstances Act (C S A). In 1971, when U.S . troops in V ietnam were reported to us ing heroin heavily, the S pecial Action Office for Drug Abuse P revention (S AODAP ) was es tablis hed in the executive office of the pres ident to coordinate government activities and policies relating to drug and to develop and publish an overall national drug strategy. T he creation of that office and the ass ociated legis lation marked a turning point in U.S . drug policy. notion that opioid dependence was an incurable which jus tified the harshest of penalties in the name of prevention, was supers eded by a policy that that a s ubs tantial proportion of drug-dependent individuals could eventually reenter the mainstream of society. New commitments were made to basic epidemiology, development of new treatment methods , and evaluation of existing treatment approaches . Methadone maintenance was moved, by executive fiat, from the legal limbo of experimental s tatus to a 1267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 89 of 167

that recognized its legitimacy. R egulations intended to prevent inappropriate prescribing of opioids were developed. F ederal s upport for the expans ion of community treatment programs was also greatly increased. T he legis lation that es tablished S AODAP provided the legislative framework for the National Ins titute on Drug Abus e (NIDA) in the Department of Health, E ducation, and W elfare (HE W). W hen it was es tablis hed in 1974, NIDA became the lead agency for implementing federal policy on treatment, research, prevention. S AODAP was ended in 1974 but was succeeded by s everal similar drug policy coordinating offices (currently the Office of National Drug C ontrol [ONDC P ]) located within the executive office of the president. B y the early 1980s , treatment for opioid dependence generally accepted to have demonstrable impact. However, for most patients in treatment programs, the primary drugs of choice were no longer opioids but, typically, cannabis, stimulants, or sedatives. In the and mid-1970s , some groups had argued for the decriminalization or legalization of cannabis. T he arguments los t much of their force when it was found in 1979 almost 10 percent of high s chool students were us ing cannabis on a daily bas is . In res ponse to what perceived as tolerance toward cannabis use, a number parents ' organizations were formed that were to making all drug us e unacceptable. T hos e groups NIDA to review and remove from all its publications any statements that could be interpreted as tolerating drug us e. T his decreas ed tolerance for drug us e grew in with a more general cons ervative s hift in public 1268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 90 of 167

F or example, in the 1970s , the public and the courts rejected the use of urine testing as a means of drug us e in an effort to interrupt the heroin epidemic; starting in 1986, federal employees were required by presidential order to undergo s uch tes ts . S imilar drug tes ting was encouraged in private indus try, giving ris e new indus tries for detecting the pres ence of drugs, interpreting tes t results, and placing drug users in treatment. B y the 1970s, it was obvious that the major drug in the United S tates in terms of s ocial and economic impact and health costs were alcoholism and tobacco dependence. Although the S urgeon G eneral's R eport 1964 linking cigarettes to cancer had not produced any dramatic immediate decreas e in s moking, the rate of increase in cigarette cons umption among men had to level out. In 1988, the S urge on G e neral's R eport on Health C ons e que nce s of S moking officially defined dependence as analogous to other varieties of drug dependence. In 1994, the F DA held hearings on the appropriatenes s of regulating the nicotine in tobacco as addictive drug. S hortly thereafter, with backing from the president, the F DA as sumed authority to regulate advertising of tobacco products ; the W hite House C ongres s to pas s legislation that would limit advertis ing and increase federal taxes on tobacco. Legislation was pass ed. T he U.S . S upreme C ourt rejected the F DA's as sertion of authority, s tating that s pecific authority to regulate tobacco would be required. In the major tobacco manufacturers negotiated a with 46 of the 50 states (the Master S ettlement Agreement), which awarded the s tates more than $200 1269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 91 of 167

billion over 20 years , provided that they pass legis lation that prevents any tobacco manufacturers that did not the agreement from selling cigarettes without paying a special tariff. T his allowed the major tobacco increase their prices to pay the s tates the agreed-on B y the mid-1980s , increasing demand for the treatment cocaine dependence, the s udden cocaine-induced of several prominent athletes , and concern about the spread of human immunodeficiency virus (HIV ) and acquired immune deficiency s yndrome (AIDS ) among drug us ers led to additional legis lation that authorized government to spend nearly $4 billion to intensify agains t drugs and drug problems. Although most of money was allocated to law enforcement activities , res ources for the treatment of drug dependence and res earch were also substantially increased. T hereafter, federal government created a s eries of offices that into the S ubstance Abus e and Mental Health S ervices Administration (S AMHS A) with s everal cons tituent including the C enter for S ubs tance Abus e T reatment (C S AT ) and the C enter for S ubs tance Abus e (C S AP ). C ritics of the emphas is on s upply control public attention when they were supported by s everal prominent conservative writers and economists and garnered the financial support of several well-endowed foundations. Although the more thoughtful of these have stopped calling for outright legalization of drugs , they have called for greater emphas is on reducing the harm related to drug us e by medically pres cribing and other psychoactive drugs and more support for needle-exchange programs. Despite s ome evidence suggesting that availability of s terile needles can 1270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 92 of 167

HIV transmis sion, the federal government continues to the us e of federal money for s uch programs. Although largely rejected at the federal level, the thrust toward harm reduction has gained s ome momentum in some states in which penalties for poss ess ion of cannabis have been reduced, and its medical purposes has been approved. In 2000, C ongres s pass ed legislation that allows with s pecial training to provide office-based treatment to pres cribe an opioid for opioid-dependent patients . C urrently, the only opioid that meets the legis latively specified criteria is buprenorphine, a partial opioid

E P IDE MIOL OG Y Most of epidemiology's contributions to the unders tanding of the drug dependence s yndromes can sorted in relation to five main s ubs tantive rubrics plus a separate rubric for theoretical and methodological res earch on core concepts, measurements , and other details of res earch approach. T he five main substantive rubrics and examples of the as sociated research are s hown in T able 11.1-12.

Table 11.1-12 E pidemiology's R ubric s F ive main s ubject matter rubrics and examples of res earch ques tions 1271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 93 of 167

   Quantity: How many in the population are becoming drug dependent for the first time each year?    Location: W here, within the population, are we more and less likely to find people becoming drug dependent?    C auses: W hat accounts for s ome people drug dependent, whereas others remain    Mechanis ms : What is the pathogenesis , natural history, and clinical course of drug dependence observed in drug-dependent people identified in community, compared with those identified when they are incarcerated for drug-related crimes or when they otherwis e come to official attention?    P revention and control: W hat can be done to prevent or delay the onset of drug dependence to shorten or ameliorate the burden of drug dependence when it occurs ?

Adapted from Anthony J H, V an E tten ML. E pidemiology and its rubrics. In: B ellack A, eds. C omprehe ns ive C linical P s ychology. Oxford, E ls evier; 1998. In the field of drug dependence res earch, epidemiology 1272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 94 of 167

may be known best for contributions under the rubric of quantity.” E pidemiological field s urveys to quantify the burden of inebriety and habitual use of opiate drugs added to community surveys of mental illness in the quarter of the 19th century during the era of P.1153 increasing concern about drunken behavior and the misuse of over-the-counter patent medicines opiates and cocaine. B eginning in the 1960s , a number of distinct methods designed to gauge the extent and consequences of subs tance use, abuse, and dependence have been developed and have been progres sively improved. C urrently, the major recurring s urveillance ins truments the United S tates are the National Household S urvey Drug Abus e (NHS DA), the Drug Abuse Warning (DAWN), Arres tee Drug Abus e Monitoring S ys tem formerly known as the Drug Us e F orecas ting [DUF ] program), and the Monitoring the F uture S tudy (MT F ), known as the High S chool S urvey. In addition, data on availability and purity of illegal drugs , drug seizures , arrests for drug offenses are collected nationally from DE A and the F ederal B ureau of Investigation (F B I) and locally from municipal police departments . E ach of data s ources has strengths and limitations . T he (recently renamed the National H ous e hold S urve y on Us e and He alth) annually interviews a repres entative sample of individuals aged 12 years and older living in households, college dormitories, homeless shelters, rooming hous es. It overs amples minority populations certain large urban areas and focuses in detail on drug1273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 95 of 167

us ing behaviors . It does not interview military individuals who are living on the s treet or in institutions (jails or hospitals). S ince 2000, it has als o included questions designed to measure s ubs tance dependence and abuse bas ed on DS M-IV criteria and to determine whether res pondents believe they need treatment, and as ks what type of treatment, if any, they have received the pas t year. Other developments have included an increase in s ample size, from less than 8,000 in the survey in the 1970s to more than 50,000 in more years , and the deliberate probabilis tic overs ampling of certain metropolitan areas and disadvantaged minority groups . B ecause of the new sample sizes and NHS DA can now produce remarkably precise some years, there has been ass es sment of s uspected determinants or cons equences of drug taking, s uch as major depres sion. Analys is of the 2001 NHS DA indicates that 16.6 million people in the United S tates aged 12 years or older (7.3 percent of the population) could be considered to be abusing or dependent on alcohol (but not illegal drugs); 2.4 million, abusing or dependent on both alcohol and illegal drugs ; and 3.2 million, abusing or dependent on illegal drug (but not alcohol). T hese es timates are illus trated in F igure 11.1-1. Approximately one-half of 16.6 million people (8.2 million) were considered subs tance dependent. Of those, 4.5 million were dependent on alcohol only, 2.7 million were dependent illegal drugs but not alcohol, and 0.9 million were dependent on both alcohol and illegal drugs. W hen the analysis is limited to those who have used a given drug the pas t year, the proportion with dependence or abus e 1274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 96 of 167

increases. F or example, 9.3 percent of past-year users alcohol, approximately 50 percent of pas t-year heroin us ers , and 25 percent of past-year cocaine us ers are clas sified with dependence or abus e of thos e drugs . past-year users of marijuana, dependence or abuse is cons idered present in only 16.5 percent, but because the total number of marijuana users, the number of with cannabis dependence or abuse (3.5 million) the number dependent on heroin and cocaine

FIGUR E 11.1-1 E s timates of past-year s ubs tance dependence or abuse among people 12 years of age or older in the United S tates , 2000 and 2001. (F rom Hous ehold S urvey of Drug Abuse; 2001, with

C orrelates of G ender, E duc ation, 1275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 97 of 167

E mployment, and Age of Firs t Us e Men are twice as likely as women to be considered dependent on or abus ers of alcohol or illegal drugs , 10 percent; women, 4.9 percent). T here is little gender difference with respect to tobacco dependence. Adults who did not complete high s chool are more likely than college graduates to have become dependent on illegal drugs (3.7 percent for those with les s than a high education, 0.9 percent for college graduates ), although alcohol dependence or abuse is not particularly with educational level. T he unemployed are almost as likely as thos e employed full time to be categorized dependent on illegal drugs or alcohol (15.4 percent, compared with 7.9 percent). Adults who first used a younger age are more likely to have developed dependence or abuse than thos e who s tarted later. F or example, 12 percent of thos e who tried marijuana by years of age are clas sified as dependent on or abusers an illegal drug, compared with 2 percent of those who us ed at 18 years of age or older. T he Monitoring the F uture s urvey has obtained information each year s ince 1975 from selfforms returned anonymous ly by high s chool s eniors. It includes former s eniors now in college and students in eighth and tenth grades. In addition to drug use, the survey taps sus pected caus es and cons equences of such as perceived availability of drugs and perceived harmfulnes s. Although the survey depends on s elfthe trend information it provides is useful. F igure 11.1-2 shows the changes in annual us e of illegal drugs by , tenth-, and 12th-grade s tudents through 2002. 1276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 98 of 167

FIGUR E 11.1-2 T rends in annual prevalence of an drug us e index for eighth, tenth, and 12th graders : percentage of s tudents who reported use. (C ourtesy of J ohns ton LD, O'Malley P M, B achman J G . Monitoring F uture N ational R es ults on Drug Us e: O ve rview of K ey F indings , 2002. [NIH P ubl. No. 03-5374]. B ethesda, National Ins titute on Drug Abus e; 2003.) T he ADAM s ys tem interviews and obtains anonymous urine s pecimens from a sample of arres tees in 1277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 99 of 167

sized cities in the United S tates . B y design, people with sale or pos sess ion of drugs cannot make up P.1154 more than 25 percent of the sample. Although it does depend on self-reports to meas ure us e, the ADAM cannot be eas ily extrapolated to a national population, and the information that can be derived from a single urine test is limited. Nevertheless , the system obtains from a population in which illegal drug use is high and thus provides trend data not readily available from sources. In general, current drug us e among arrestees several times higher than among those s ampled and as sess ed in s elf-reports for the national surveys. F ield survey approaches of nationally representative samples tend to be more us eful and informative than incident or event reporting approaches s uch as DAW N. T he DAW N system involves abs tracting and reporting drug-related emergency room and medical examiner death event data each month of the calendar year. T he DAWN s ys tem is now designed so that the reporting emergency rooms cons titute a representative sample such facilities in the continental United S tates . T he data provide useful information on trends in the as sociated with various illegal drugs ; but these data to be interpreted with caution because the DAW N reports only epis odes in which a drug is part of the presenting clinical picture. F or example, an increas ing number of emergency room episodes ass ociated with heroin could mean that more heroin us ers with AIDS related problems are s eeking primary medical care in emergency department facilities rather than that more 1278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 100 of 167

individuals are us ing heroin. S imilarly, reports by examiners of more violent deaths ass ociated with may s ignal an escalation of competition among drug dealers rather than more people using cocaine. T he analytical methods do not reveal the nature of the between drug use and the pres enting problem, which drugs (if any) played a causal role in the episode, or whether the user was a novice or a chronic user.

C omorbidity S urveys In addition to the recurring data-gathering efforts, important epidemiological information is available from two national studies that s ys tematically interviewed representative samples of the population and used or DS M-III-R criteria to develop es timates of current lifetime prevalence of ps ychiatric disorders, including subs tance abus e and s ubs tance dependence. T hes e studies are the NIMH E pidemiological C atchment Area (E C A) S tudy, conducted in the early 1980s , and the National C omorbidity S urvey (NC S ), conducted 1990 and 1992. T he E C A interviews in five areas of the United S tates included individuals in institutions hospitals , jails, nurs ing homes, and s o forth) and used DS M-III criteria to develop es timates of prevalence. NC S interviews of a nationally representative sample of people not res iding in institutions us ed DS M-III-R Although the E C A was conducted before the cocaine epidemic of the 1980s cres ted, and criteria for us ed were altered somewhat in DS M-III-R , it remains a landmark study of the extent of drug abuse dependence and cooccurring ps ychiatric disorders . T he E C A study found that 16.7 percent of the U.S . 1279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 101 of 167

population aged 18 years and older met the DS M-III for a lifetime diagnos is of either abus e or dependence some substance, with 13.8 percent meeting the criteria an alcohol-related dis order, and 6.2 percent meeting criteria for abuse or dependence of a drug other than alcohol or tobacco. T he NC S found a 26.6 percent prevalence of substance abus e and dependence, subs tantially higher than the 16.7 percent found in the E C A. S ome of this is probably due to ques tions in the about pres cription drugs that were posed when a reported symptoms of dependence and on differences criteria (DS M-III vs . DS M-III-R ). However, there may have been real increases in prevalence. F or illegal and the nonmedical use of prescription drugs, the history of dependence in the NC S was 7.9 percent, a much closer to the 6.2 percent found for s uch drugs in E C A study. T he NC S found a 12-month prevalence for any drug us e disorder (including dependence and abuse) of 8.2 percent, 4.5 percent alcohol dependence, and 1.8 percent drug dependence. E xcept for tobacco, men are far more likely than women to use drugs and alcohol and are corres pondingly more likely to have developed dependence. F or example, lifetime and 12month prevalence of alcohol dependence is 20.1 and percent for men but only 8.2 and 2.2 percent for res pectively. Among the major achievements of the NC S analyses the findings on the proportions of people who had us ed drugs at any time in their lives (lifetime us ers) who dependent (overall and for each drug category); the demographic factors ass ociated with us e, dependence, and persis tence of dependence; and the prevalence 1280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 102 of 167

significance of multiple psychiatric diagnoses. Dependence cannot develop if a drug is never us ed; presenting data on the prevalence of dependence in population as whole, including thos e who never used, obscure the likelihood of dependence developing those who do use a particular drug. In the NC S , of lifetime dependence on the broad range of illegal nonpres cribed medications was 14.7 percent, with us ers only s lightly more likely (16.4 percent) than us ers (12.6 percent) to develop dependence. In a analysis of the 12-month prevalence of dependence on these drugs, the rate for the population as a whole was percent. However, the 12-month prevalence was 3.5 percent for thos e who had us ed any of these drugs at time in their lives, 10.3 percent for thos e who had us ed them in the past 12 months, and 23.8 percent among those who had a lifetime history of dependence. T he likelihood of being drug dependent within the pas t 12 months, given a lifetime history of dependence, was similar for men (24.9 percent) and women (22.2 Lower educational and income levels predicted a history of dependence (odds ratios greater than 2), but race, ethnicity, or living in an urban environment did T here were als o differences in the likelihood that users particular drug would become dependent on it. F or example, for heroin, the estimated probability of having developed opioid dependence was 23 percent; for tobacco, 32 percent; for cocaine, 16.7 percent; for P.1155 15.4 percent; but only 4.9 percent for ps ychedelics . who used alcohol were more likely to have become 1281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 103 of 167

dependent (21.4 percent) than women (9.2 percent), poss ibly because they drink more than women, but genetics may also play a role. A comparable comorbidity s tudy conducted in E ngland and W ales in the 1990s found, like s tudies in the S tates, that substance-related disorders are among the most common psychiatric disorders . Alcohol was found in 5 percent of the household s ample (8 of men, 2 percent of women), in 7 percent of an institutional sample, and in 21 percent of the homeles s sample. S ubs tance use was s ignificantly as sociated higher rates of ps ychological morbidity. Among thos e dependent on any substance, 12 percent were having a psychiatric dis order. Among thos e dependent nicotine, 22 percent were as sess ed as having another ps ychiatric disorder. T he rates for psychiatric were 30 percent and 45 percent for thos e dependent alcohol and other drugs, respectively. T he newest vers ions of NHS DA now provide s ome comorbidity and confirm the findings of the NC S that serious mental illnes s is s trongly correlated with illegal drug us e and cigarette us e. Individuals with a s erious mental illness are more than twice as likely to have illegal drug and to have been cigarette smokers. mental illness is even more strongly correlated with the presence of drug abus e or dependence. T his illus trated in F igure 11.1-3. In 2001, it was es timated million adults had both a s erious mental illnes s and subs tance dependence or abuse in the past year. Of million, 1.6 million met criteria for abus e of or on alcohol alone; 0.7 million for abus e of or on both drugs and alcohol; and 0.7 million for abuse of 1282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 104 of 167

dependence on an illegal drug.

FIGUR E 11.1-3 S ubstance dependence or abuse adults by serious mental illnes s, 2001. (F rom National Hous ehold S urvey of Drug Abus e; 2001, with C omorbidity is also considered below as an etiological factor in the development of s ubs tance abuse and dependence.

E pidemic s S everal major overlapping drug epidemics have over the past 30 years , affecting somewhat different populations. C annabis us e, which had been endemic among certain minority groups and jazz musicians , to increas e in the 1960s , es pecially among young and then s pread to other segments of the population. its peak in the mid- to late 1970s , 10 percent of high seniors were us ing marijuana on a daily bas is . Daily 1283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 105 of 167

declined to 5 percent by 1984, to 2 percent by 1991, then revers ed direction and again increased, according the Monitoring the F uture s urvey. S imilar changes in rates were reflected in the NHS DA. An epidemic of heroin us e also began in the early and incidence peaked between 1969 and 1971. T he population of active heroin users reached its highest in the early 1970s , but periodic ups urges have supplies became more available, law enforcement waxed and waned, and relapse rates increased among former users. In 1977, the U.S . government estimated there were 500,000 opioid abusers and dependent and more recently, it revised the es timate to 320,000 occasional us ers and 810,000 chronic users. In heroin-us ing population is an aging one, with a high still growing prevalence of HIV in s ome areas. In 1996, NHS DA estimated that approximately 2.3 million had tried heroin at leas t once and that 245,000 had in the pas t year. However, it was believed that a large percentage of heroin us ers were outs ide the population interviewed by the s urvey. Data from the more recent NHS DA indicate that heroin us e increased during the 1990s to levels nearly as high as those of the 1970s . annual number of new us ers was estimated to range 55,000 to 69,000 between 1989 and 1992. B y 2000, number of new heroin us ers per year appeared to have increased to 146,000. T he cocaine epidemic that began in the late 1960s to have reached its peak by 1980. In the early 1980s, according to the NHS DA, an es timated 5.8 million in the United S tates (2.9 percent of the population) had us ed cocaine in the month before the survey. T here 1284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 106 of 167

an es timated 1.5 million new users in 1983. T he pass ed its peak in most s egments of society by the 1980s , with the number of new us ers declining s teadily until 1992. Among the heavies t users (weekly or almost weekly), us e did not decline significantly, although among arres tees decreas ed in 1995. F or the a whole, the number of new us ers has been increasing modes tly s ince 1992. T here were approximately 0.9 new users in 2000. In the early 1990s , fueled by abundant s upplies of methamphetamine produced illegally in many s mall laboratories, methamphetamine us e began to increas e number of cities in the west, southwes t, and northwes t the United S tates . F or the country as a whole, the of new us ers increased from 164,000 per year at that to 344,000 in 2000. C hanges in the annual rate of new users of various over the past 30 years as deduced from the NHS DA database are s hown in F igure 11.1-4.

1285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 107 of 167

FIGUR E 11.1-4 Annual number of new us ers (in of various drugs, 1965 to 2000. A: Marijuana. B : lysergic acid diethylamide (LS D), and phencyclidine C : Nonmedical users of psychotherapeutics. D: (Adapted from National Hous ehold S urvey of Drug 2001.)

E TIOL OG Y T he model of drug dependence from which the DS Mand IC D-10 criteria were derived conceptualizes dependence as a result of a process in which multiple interacting factors influence drug-us ing behavior and loss of flexibility with res pect to decisions about using a given drug. Although the actions of a given drug are critical in the process , it is not ass umed that all people become dependent on the same drug P.1156 experience its effects in the s ame way or are motivated the same set of factors. F urthermore, it is postulated different factors may be more or less important at stages of the process . T hus, drug availability, social acceptability, and peer pres sures may be the major determinants of initial experimentation with a drug, but other factors, s uch as personality and individual probably are more important in how the effects of a drug are perceived and the degree to which repeated us e produces changes in the central nervous system S till other factors, including the particular actions of the drug, may be primary determinants of whether drug 1286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 108 of 167

progres ses to drug dependence, whereas still others be important influences on the likelihood that drug us e leads to adverse effects or the likelihood of s ucces sful recovery from dependence. It has been as serted that addiction is a “brain dis eas e,” the critical proces ses that transform voluntary drugbehavior to compuls ive drug use are changes in the structure and neurochemistry of the brain of the drug T here is now more than enough evidence that s uch changes in relevant parts of the brain do occur. T he perplexing and unans wered question is whether these changes are both necess ary and sufficient to account the drug-us ing behavior. Many argue that they are not, that the capacity of drug-dependent individuals to their drug-us ing behavior in res ponse to positive reinforcers or avers ive contingencies indicates that the nature of addiction is more complex and requires the interaction of multiple factors. F igure 11.1-5 illus trates how various factors might in the development of drug dependence. T he central element is the drug-us ing behavior itself. T he decision us e a drug is influenced by immediate s ocial and ps ychological situations as well as by the person's remote his tory. Us e of the drug initiates a sequence of cons equences that can be rewarding or aversive and which, through a proces s of learning, can res ult in a greater or less er likelihood that the drug-us ing behavior will be repeated. F or s ome drugs, use also initiates the biological process es as sociated with tolerance, dependence, and (not s hown in the figure) turn, tolerance can reduce some of the advers e effects the drug, permitting or requiring the us e of larger 1287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 109 of 167

which then can accelerate or intensify the development phys ical dependence. Above a certain thres hold, the avers ive qualities of a withdrawal s yndrome provide a distinct recurrent motive for further drug use. of motivational systems may increase the s alience of related stimuli.

FIGUR E 11.1-5 W orld Health Organization s chematic model of drug use and dependence. (F rom E dwards G , A, Hodgs on R : Nomenclature and class ification of drugalcohol-related problems. A WHO memorandum. B ull 1981;99:225, with permiss ion.) F or simplicity, F igure 11.1-5 s hows drug us e alone as initiating that chain of consequences , but the choices a person makes over and over again are more complex. decis ion is whether to us e one drug or another or to engage in some behavior that does not involve drug 1288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 110 of 167

E ach of those decis ions can initiate positive and cons equences. C hanges in the availability, cos ts, and cons equences of alternative behaviors can als o what appears to be compuls ive use of a agent. F or example, patients in a methadone program who were us ing cocaine despite negative cons equences (no take-home methadone) reduced cocaine use when vouchers for goods and s ervices awarded for clean (negative for cocaine) urine

S oc ial and E nvironmental Fac tors C ultural factors , social attitudes , peer behaviors, laws, drug cost and availability all influence initial experimentation with s ubs tances , including alcohol and tobacco. T hes e factors als o influence initial use of socially disapproved drugs, such as cocaine and but personality factors as sume a more important role. S ocial and environmental factors also influence us e, although individual vulnerability and ps ychopathology are probably more important determinants of the P.1157 development of dependence. In general, the us e of the less socially disapproved substances (alcohol, tobacco, cannabis ) precedes the use of opioids and cocaine, those antecedent substances are s ometimes referred gateway drugs .

A lc ohol and Tobac c o S ubstantial evidence indicates that changes in price availability can alter the consumption of alcohol and 1289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 111 of 167

tobacco. W hen an increas e in sales outlets or an of sales hours increases the availability of alcohol, cons umption tends to increase. W hen the cost of either alcohol or tobacco is increas ed in relation to disposable income (e.g., by increas ed taxes ), cons umption T hese factors even influence the behavior of people, although perhaps not to the s ame degree as those who are not dependent. Availability can be independently of cos t, and alterations can be limited to selected populations (e.g., prohibiting sale of alcohol tobacco to those younger than a specific age). S ocial, cultural, and economic factors do not always operate s ynergis tically but may sometimes influence cons umption in opposite directions. F or example, in the late 1980s , increased public awareness of how alcohol advers ely affects health resulted in a decline in its cons umption. T hat decline occurred even though was more freely available, its cos t relative to income remained constant or actually decreas ed, and social press ures agains t women drinking (unles s pregnant) decreased.

Illegal Drugs S ocial and cultural factors, including beliefs about the effects of a drug, frequently exert more influence on us e patterns than the laws that s upposedly reflect such factors . F or example, cannabis use increased among school s tudents from the early 1970s to 1979 and then decreased steadily over the next decade, although us e poss ess ion were illegal throughout the entire 18-year period, and nothing indicates that it became more expensive or less available during the 1980s (F ig. 11.11290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 112 of 167

An upward trend in us e was noted from 1993 to 1997, although perhaps the values never reached the peak of 1979. S ome experts believe the decline in use s een during the 1980s was linked to changing perceptions about the toxic effects of cannabis on health. T he beginning in the 1990s was correlated with a decline in perception of the risk of harm from regular us e. cocaine use increased in the 1970s des pite high prices the drug and high risk of criminal penalties ; but after several well-publicized deaths from cocaine in the mid1980s , prevalence of active cocaine us e declined high s chool seniors and in the general population even the price of the drug declined. S ocial and cultural factors profoundly influence the availability of illegal drugs ; availability, in turn, which groups within a s ociety are mos t likely to us ers . C urrently, illegal opioids and cocaine are more available in the inner cities of large urban areas than in other parts of the country. S uch availability influences only initial and continued drug us e but also affects the relaps e rates after treatment of thos e who live in highavailability areas . When a significant number of users illegal drugs live in one area, a s ubculture evolves that supports experimentation and continued us e. Many of areas in which illegal drugs are readily available are characterized by a high crime rate, high and demoralized s chool systems —all of which s erve to reduce the sense of hope and sense of s elf-es teem as sociated with resistance to use. S ocial and factors also affect the likelihood for s uccess ful recovery from drug dependence; thos e who find satis fying alternatives are more likely to abs tain from drug use. 1291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 113 of 167

VIE TNAM T he experience of U.S . s ervice pers onnel who us ed in V ietnam provided a unique natural experiment in the influences of availability, vulnerability, and s ocial norms could be observed. F rom 1970 to P.1158 1972, high-grade heroin at very low cost was readily available to young people in V ietnam s eparated from families and us ual s ocial norms. Among army enlisted personnel, approximately one-half of those who tried heroin became dependent (at leas t they developed withdrawal s ymptoms when they attempted to s top heroin). Of those who us ed heroin at leas t five times, percent became dependent. T he background factors predicted heroin use in the general civilian early deviant behavior, s uch as fighting, drunkenness , arrest, and school expulsion—also predicted drug us e V ietnam, but they were not the bes t predictors of after the s oldiers returned to the United S tates . was related to being white, being older, and having parents who had criminal his tories or were alcoholic.

A vailability and Health P rofes s ionals T he important role of availability is also illus trated by repeated observation that physicians, dentis ts, and have far higher rates of dependence on DE A-controlled subs tances , such as opioids , s timulants , and than other profes sionals of comparable educational achievement (e.g., accountants or lawyers) who do not have such easy access to the drugs . C ompared with controls, physicians appear to be four to five times as 1292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 114 of 167

to take s edatives and minor tranquilizers without supervis ion by a profes sional other than themselves. even in that s ituation, other factors play a role. who had unhappy childhoods are more likely to selfprescribe than those who are healthier psychologically.

Drugs as R einforc ers Different drugs produce dis tinctive s ubjective states , extensive laboratory evidence shows that people with experience can dis tinguis h one drug clas s from another and can even rank different clas ses and doses on the of how much they like the effects . Y et, the hold that can eventually exert on a us er's behavior is not entirely function of its initial likable or euphorigenic actions. F or example, the effects of cocaine are typically described most users as powerfully euphorigenic, producing increased s elf-es teem, alertnes s, energy, and wellT he effects of nicotine, as described by many tobacco us ers , are more subtle, producing some mixture of and relaxing. T he subjective effects of alcohol are more likely to be described as relaxing, but are more and appear to be more dependent on personality and underlying genetic variability traits and genetically influenced ethanol metabolism. Des pite those dependence (or addiction) can occur with each, and appear to have shared or overlapping neural their reinforcing properties . Almos t all of the drugs that are us ed for their s ubjective effects and are as sociated with the development of dependence induce s ome degree of tolerance. In some cases, the tolerance to the toxic and aversive effects is more pronounced than the tolerance to the reinforcing 1293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 115 of 167

and mood-elevating effects. F or example, most opioid us ers quickly develop tolerance to opioid-induced and vomiting. T his may allow users to increas e the and thus experience greater euphoric effects . those who continue to experience aversive drug effects (s uch as severe flushing with alcohol) may be less persis t in us ing the drug and are at lower risk for developing dependence. T olerant opioid users do not continue to s elf-adminis ter opioids s olely to prevent the highly avers ive withdrawal phenomena. Interviews with heroin users have indicated that, despite s ome to many of the drug's effects, they continue to a brief euphoric effect immediately after an IV injection. Among nonalcoholic sons of alcoholic fathers, intrinsic tolerance may be a marker of biological vulnerability to developing alcohol dependence. S ons of alcoholic who were more tolerant to a test dos e of alcohol were more likely to have developed alcohol dependence at 8 years ' follow-up than those who were les s tolerant. With a few notable exceptions , animals in experimental situations s elf-adminis ter mos t of the drugs that tend to us e and abuse. Included among the drugs are and δ-opioid agonis ts , cocaine, amphetamine and amphetamine-like agents, substituted amphetamines, such as MDMA, alcohol, barbiturates, many benzodiazepines, a number of volatile gases and (e.g., nitrous oxide and ether), P C P , and nicotine. C annabinoid self-adminis tration, which has been to demons trate with natural cannabinoids, has been shown with s ome synthetics. LS D-like drugs are not generally found to be reinforcing in preclinical studies. 1294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 116 of 167

B iologic al S ubs trates K nowledge about the neurobiology of drug and the mechanisms underlying tolerance and dependence has continued to increase. P athways and structures critical for the reinforcing actions of a dependence-producing drugs, s uch as opioids, amphetamine, cocaine, and, to some degree, nicotine alcohol, have their origins in dopaminergic neurons cell bodies in the ventral tegmental area (V T A) and projections to the nucleus accumbens and the related structures that make up the “extended amygdala.” T he extended amygdala compris es several neural structures , including the central nucleus of amygdala, bed nucleus of the s tria terminalis, as well as the s hell of the nucleus accumbens . T he extended amygdala receives input from the limbic cortex, hippocampus , basolateral amygdala, midbrain, and lateral and projects axons to the ventral pallidum, the medial and the lateral hypothalamus . T he medial part of the nucleus accumbens (shell) is a particularly important site; dopamine releas e here is for the reinforcing effects of cocaine and is also important for the reinforcing effects of opioids, there are opioid receptors on neurons in the nucleus accumbens, and opioids can exert reinforcing effects at that s ite even when the dopaminergic terminals are destroyed. S ome researchers have propos ed that all positive reinforcement, including the reinforcement as sociated with food reward and sex, critically depends this dopaminergic circuit. Dopamine release from mes olimbic dopaminergic 1295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 117 of 167

may play more than one role in the genes is of drug seeking and drug dependence. Dopamine releas e has been postulated to facilitate learning what events and behaviors lead to important consequences for the organism and to alert the organis m to pay greater attention to s uch events . In this way, drug-induced dopamine release leads to a greater salience of drugopportunities and is linked to wanting and craving. However, the diverse categories of drugs that activate mesolimbic dopaminergic system do s o by distinct mechanisms, and mos t have actions on many other systems . R einforcing mechanisms are also briefly in the chapters devoted to s pecific drugs . Only a few examples are given here. T he V T A dopaminergic have both nicotinic and γ-aminobutyric acid (G AB A) receptors. T hes e neurons normally are inhibited by G AB Aergic activity. T he G AB Aergic neurons acting on V T A express μ and δ-opioid receptors . When these receptors are activated by μ opioids, G AB Aergic transmis sion is inhibited, and the dopaminergic V T A neurons become more active and releas e dopamine in nucleus accumbens. However, opioids can als o act on neurons in the nucleus accumbens , independent of dopamine action. As a reinforcing drug, cocaine acts primarily at the endings of the serotonergic, dopaminergic, and noradrenergic neurons. W hen transmitters are from those neurons into the s ynapse, they are back into the nerve endings by transporter proteins . B y occupying thes e transporter sites, cocaine prevents the reuptake of the transmitters, thus increasing their concentration in the synaps e. C ocaine's binding to the 1296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 118 of 167

dopamine transporter is primarily res ponsible for its reinforcing effects, but the actions on other neurotransmitters als o influence its s ubjective effects. C ocaine adminis tration P.1159 also produces glutamate releas e within the mesolimbic accumbens system, an action that is probably relevant its capacity to change behavior becaus e glutamate antagonis ts interfere with learning to as sociate cocaine effects to environmental stimuli. Amphetamine als o increases dopamine levels at the synapse and binds to the dopamine trans porter to degree. B ut amphetamine actions at the dopamine transporter are not as important as its major action, is to displace dopamine and norepinephrine from their storage s ites in the neuron and thereby lead to their releas e. Alcohol, at clinically relevant concentrations, exerts its actions relatively s electively on s pecific receptors and neurotransmitter s ys tems. T hes e actions include enhancing the inhibitory action of G AB Aergic neurotransmitters (by increasing the s ens itivity of the G AB A receptor) and reducing the excitatory actions of glutamatergic neurotransmitters (by altering the of the N-methyl-D-as partate [NMDA] receptors). B y its blocking actions at the NMDA receptor, ethanol can indirectly alter the release of other neurotransmitters serotonin, dopamine, norepinephrine, glutamate, as partate, and G AB A). Low doses of alcohol increas e dopamine levels in the nucleus accumbens and elevate brain s erotonin concentration. V arious regions of the 1297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 119 of 167

differ in their s ensitivity to these actions of ethanol. T he endogenous opioid s ys tem may be involved in some as pects of the mood-elevating effects of alcohol the opioid antagonis t naloxone reduces alcohol selfadminis tration in animals , and the antagonis t (R eV ia) reduces relapse rates in treated alcoholics. Mesolimbic dopaminergic neurons have multiple cholinergic receptors on their cell bodies and terminals the nucleus accumbens. W hen activated, thes e increase dopamine release. Nicotine also increas es glutamatergic activity, thereby tending to increase the activity of V T A dopaminergic neurons. T his action las ts longer than nicotine's G AB Aergic effects, which mesolimbic dopaminergic activity. Interes tingly, regular expos ure to nicotine-containing tobacco smoke may be more reinforcing than nicotine its elf becaus e other chemical entities in tobacco inhibit brain monoamine oxidase type A (MAO A ) and MAO B , which are involved the regulation of intraneuronal stores of dopamine. P res umably, this inhibition increas es the amount of dopamine available for release when the dopaminergic neurons are activated. Drugs can also act as reinforcers by terminating states . S ome of these actions involve dopaminergic systems , but others do not. S ome res earchers argue compuls ive drug us e can be explained on the basis of positive reinforcing effects of drugs without any need to invoke alleviation of withdrawal distress or any obvious source of antecedent pain or dys phoria. F urthermore, argue, craving is primarily as sociated not with cues that evoke withdrawal but with thos e that evoke memories positive reinforcement (euphoria). However, evidence 1298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 120 of 167

indicates that even when there are no obvious and dramatic withdrawal s ymptoms (e.g., cocaine, nicotine) adaptive changes in the reward system result in a dopaminergic deficiency state (meas urable as dopamine levels in the nucleus accumbens ) when drug us e is s topped or its action ceases. T his deficiency experienced as dys phoria or anhedonia. Quite often, same drug-us ing behavior that terminates this moves the s ys tem to a hyperdopaminergic s tate as sociated with positive reinforcement (euphoria). In the behaviors as sociated with chronic drug us e are typically driven by both the avoidance of dysphoria (negative reinforcement) and the purs uit of euphoria (positive reinforcement). In animal models, s uch as the rat, the sensitivity of systems to reinforcing drugs, s uch as cocaine and is enhanced by corticos teroids . In animal models, a of stress es acting through release of corticotropinreleas ing factor (C R F ) and the hypothalamic-pituitaryadrenal axis can s ens itize neural s ys tems and trigger reinitiation of drug taking. T here is ample clinical that s uch stress es can act s imilarly in drug-dependent individuals immediately after withdrawal and for long periods thereafter. In addition, some drugs may neural systems to the reinforcing effects of the drug.

L earning and C onditioning Drug use, whether occasional or compulsive, can be viewed as behavior maintained by its cons equences. event that strengthens an antecedent behavior pattern can be cons idered a reinforcer of that behavior. In that sens e, certain drugs reinforce drug-taking behavior. 1299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 121 of 167

can also reinforce antecedent behaviors by terminating some noxious or aversive state s uch as pain, anxiety, depres sion. In s ome social s ituations, the use of the quite apart from its pharmacological effects, can be reinforcing if it res ults in s pecial status or the approval friends . S ocial reinforcement can maintain drug us e the effects of primary reinforcement or reinforcement alleviation of withdrawal s ymptoms come into play. us e of the drug evokes rapid pos itive reinforcement, as a result of the rush (the drug-induced euphoria), alleviation of disturbed affects , alleviation of withdrawal symptoms, or any combination of these effects. In addition, some drugs may s ens itize neural systems to reinforcing effects of the drug. With s hort-acting subs tances , such as heroin, cocaine, nicotine, and such reinforcement occurs s everal times a day, day in day out, creating powerfully reinforced habit patterns . E ventually, the paraphernalia (needles , bottles, packs) and behaviors ass ociated with substance us e become s econdary reinforcers , as well as cues availability of the substance, and in their pres ence, or a desire to experience the effects increases . W ith acceptable s ubs tances , s uch as tobacco, use becomes woven into the matrix of daily functioning that s ome are reminded of the substances when performing tas ks . S tress es can also act as cues that induce drug particularly in the postwithdrawal period. R es earchers have used positron emiss ion tomography (P E T ) and functional magnetic res onance imaging study brain activity in both drug users and controls presented with drug-related stimuli (paraphernalia or video tapes). Drug users res pond to the drug-related 1300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 122 of 167

stimuli with increas ed activity in limbic regions, the amygdala and the anterior cingulate, but do not res pond this way to neutral stimuli. C ontrol s ubjects res pond minimally to both types of s timuli. S uch drugrelated activation of limbic areas has been with a variety of drugs , including cocaine, opioids, and cigarettes (nicotine). Interes tingly, the same regions activated by cocaine-related stimuli in cocaine us ers activated by sexual s timuli in both normal controls and cocaine users.

C las s ic al C onditioning In addition to the operant reinforcement of drug-us ing and drug-seeking behaviors, other learning probably play a role in dependence and relapse. Opioid and alcohol withdrawal phenomena can be conditioned (in the P avlovian or clas sical sense) to environmental interoceptive stimuli. S uch conditioning has been demonstrated in both laboratory animals and abs tinent and methadone-dependent human volunteers. F or a time after withdrawal (from opioids , nicotine, or the addict exposed to environmental s timuli previous ly linked with subs tance use or withdrawal may conditioned withdrawal, conditioned craving, or both. increased feelings of craving are not necess arily accompanied by symptoms of withdrawal. T he most intens e craving is elicited by conditions as sociated with the availability or use of the s ubs tance, such as someone els e us e heroin or light a cigarette or being offered some drug by a friend. S ome workers now that the cues that induce memories of P.1160 1301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 123 of 167

drug-induced euphoria are more important for craving and in predis posing to relapse than either protracted or conditioned withdrawal. T hos e learning conditioning phenomena can be s uperimposed on any preexisting psychopathology, but preexisting difficulties are not required for the development of powerfully reinforced substance-seeking behavior.

Withdrawal S yndromes and R einforc ement Although positive reinforcement is a powerful factor in the genes is of cocaine, amphetamine, and (in some cases ) opioid dependence, for a number of other drugs, aversive withdrawal phenomena and negative reinforcement may be equally important, or even dominant, factors . F or example, in people who become dependent on benzodiazepines in the cours e of for anxiety syndromes , when drug us e is interrupted, seem to experience a reappearance of the original symptoms, whereas others have new distress ing symptoms indicating withdrawal. T he use of benzodiazepines alleviates both kinds of aversive either cas e, the drug is acting as a negative reinforcer perpetuating drug us e. B enzodiazepines can induce euphoria in alcoholic patients or in people with his tories sedative abuse, but they are not reliably euphorigenic normal, nonalcoholic people. B enzodiazepine anxiolytic agents may induce euphoria in people who are not dependent and not anxious, but s uch instances are relative to the number who experience only relief of anxiety. 1302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 124 of 167

In mos t clinical s ituations, even among us ers of highly euphorigenic illegal drugs, the dis tinction between positive and negative reinforcing effects does not exist. T he alcoholic, the heavy s moker, and the heroin us er experience, s imultaneous ly or sequentially, relief of withdrawal, a s ense of ease, and perhaps alleviation of dysphoria and depres sion. S ome of the dys phoria may res ult of long-lasting dys function in s ys tems s ubs erving hedonic tone. With IV drugs , there may als o be a rus h of intens e pleas ure.

L ong-L as ting C hanges A s s oc iated C hronic Drug Us e After long-term us e, mos t drugs of abus e produce adaptive changes in the brain that are manifested as and chronic withdrawal s yndromes when drug use Other drug-induced changes in the brain appear to be related to the proces ses by which the memories of action are stored and by which drug-related stimuli acquire and retain salience. How these changes are produced, how long they persis t after ces sation of drug us e, and how they contribute to relapse are still being explored. B ut much progres s has occurred, as is by the example of recent changes found with chronic opioids.

OPIOIDS T olerance and dependence on opioids involve several mechanisms. Opioid agonis t binding to the opioid receptors results in an inhibition of adenylyl cyclas e lower intracellular cyclic adenosine monophosphate (cAMP ) concentrations. Long-term exposure elicits 1303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 125 of 167

compens atory upregulation of the cAMP pathway, internalization of μ and δ receptors, and a decrease in number of G proteins, which couple the receptors to second mes sengers and ion channels . Upregulation of adenylyl cyclas e is mediated by the trans cription factor C R E B (cAMP respons e element–binding protein), also plays a role in the generation of dis tinct and F os -like proteins . T hese are believed to be involved in tolerance and sensitization. T he s ens itization may F os -like proteins that alter the s ens itivity of an α-aminohydroxy-5-methyl-4-is oxazolepropionic acid (AMP A) glutamate receptor s ubunit. As a res ult of upregulation cAMP , G AB Aergic neurons innervating the V T A hyperactive when opioids are withdrawn, thus inhibiting dopaminergic neurons. S uch a mechanism may part, for the dys phoria and anhedonia of opioid withdrawal. In addition, chronic opioid use reduces the size of dopamine neurons in the V T A; increased production of dynorphin may als o s erve to inhibit dopaminergic activity at the V T A and nucleus T he glutamatergic s ys tem is als o involved in opioid adaptation becaus e NMDA receptor s ens itivity is by opioids, and NMDA antagonis ts can alter the development of opioid tolerance and phys ical dependence. T he opioid-induced changes des cribed believed to be only a s ubs et of a wide range of cellular molecular changes induced by chronic drug use.

C onditioned Withdrawal and S tres s S ens itivity In addition to the direct contribution of withdrawal phenomena to the perpetuation of drug us e are the indirect effects exerted through learning mechanisms. 1304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 126 of 167

regular recurrence of withdrawal-induced aversive provides ample opportunity for thos e states to become linked through learning to environmental cues and mood states, and the rapid relief of withdrawal by drug res ults in repeated reinforcement of drug-taking Long after there are meas urable manifes tations of withdrawal, certain moods or environmental cues can evoke components of the original withdrawal s tate with urges to us e the drug again. C ons iderable shows that in former opioid addicts , stress can trigger craving and relapse, and dysregulation of the hypothalamic-pituitary-adrenal axis pers is ts for long periods after drug cess ation. How long withdrawal phenomena, stres s sensitivity, or both continue to contribute to risk of relapse is not S ubstantial evidence s upports a withdrawal s yndrome period for alcohol, opioids, and certain sedatives with subtle disturbances of mood, s leep, and cognition that persis ts for many weeks or months after the acute syndrome subsides . W hether the dysregulation of the hypothalamic-pituitary-adrenal axis is causally related protracted withdrawal or has a s imilar time cours e is uncertain.

Integrating Neurobiology and S everal res earch groups have attempted to integrate most recent findings from neurobiology and the role of learning to better explain how drugs gain control of behavior to produce compuls ive drug use and the tendency to relaps e after withdrawal. G eorge K oob and Michel LeMoal des cribe the proces s as a “cycle of spiraling dysregulation of brain 1305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 127 of 167

reward systems .” T hey des cribe in detail the of the hedonic regulatory system of the brain and its interaction with systems regulating res pons e to the pituitary-adrenal axis and extrahypothalamic C R F system. T he adaptive changes to chronic drug us e are believed to lead to deviations in hedonic homeostasis such magnitude that the s ys tem cannot be maintained within the normal range. C ontinued apparent reward function requires the mobilization of different systems, and in this s ens e, the s ys tem functions at a new setwhich thes e res earchers describe as an allos tatic s tate. C entral to this pers pective is the dysregulation of tone that results from a counter-adaptive respons e to drug-induced excess ive activation of the reward When drug action is withdrawn, prolonged hypoactivity follows . F ailed efforts to cope with this dysregulation to emotional dis tres s, which brings further negative and (mediated by increased levels of glucocorticoids) increased sens itivity to the rewarding effects of the At the s ame time, drug use alleviates the dys phoric of the hypofunction of the reward system. A strength of this des cription of the addictive proces s is the the interaction of various neural s ys tems s ubs erving reinforcement, motivation effects of withdrawal, learned as sociations with drug effects, thos e s ys tems (such as cortico-striatal-thalamic circuits ) involved in reinforcer evaluation, cognitive functioning and active inhibitory mechanisms, and the hypothalamic-pituitary-adrenal P.1161 Another important contribution is the role as signed to extrahypothalamic C R F system as well as other 1306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 128 of 167

neuropeptide transmitters such as neuropeptide Y During opiate, cocaine, or alcohol withdrawal, C R F increases in the central nucleus of the amygdala; microinjection of a C R F antagonis t revers es the effects of opioid or alcohol withdrawal. K oob and point out that, although adrenocorticotropic hormone (AC T H)–stimulated high levels of glucocorticoids the synthesis of C R F at the paraventricular nucleus, can actually increase C R F activity at the level of the nucleus of the amygdala. T erry R obins on and K ent B erridge have elaborated on role of drug-induced s ensitization and alteration of structure in the development of addiction. T he major points that form this general thes is are that addictive drugs share the ability to alter brain organization, particularly the organization of s ys tems that subserve incentive motivation and reward. T he alteration critical the development of addiction is the s ens itization of reward systems to drugs and drug-related stimuli. T his hypers ens itivity develops in those subcomponents of brain reward s ys tem involved with as signing s alience (drug wanting) to drugs to related s timuli rather than those more directly mediating drug reward or euphoria. Within this incentive-sens itization pers pective, drug-seeking behavior does not require the pres ence subs tantial or even subtle withdrawal dys phoria or the desire to obtain drug-induced euphoria. R ather, with repeated expos ure, drug-related stimuli become more attractive, acquiring greater incentive value, and “grab attention” of the drug user. In animals, drug-induced neural s ens itization can be long lasting and has the long-lasting drug-seeking behavior that outlasts 1307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 129 of 167

observable withdrawal phenomena. S ensitization (like development of drug-dependent behavior) is not a cons equence of drug administration but is powerfully influenced by learning and environmental context. T his view helps to explain the waxing and waning long persis tence of drug craving or wanting among drugdependent individuals attempting to function in their home environments. It does not explain why the so often leads to behavior even in the face of highly probably adverse cons equences. T he case for inhibitory control is better put by R ita G oldstein and V olkow. G oldstein and V olkow elaborate a pers pective that cons iderable us e of data from s tudies of neuroimaging. T his effort goes beyond the now generally accepted the mesolimbic dopaminergic system in accounting for the hedonic effects of addicting drugs , the role of the hippocampus and amygdala in the organization and storage of the drug experience, the hedonic deficiency (dysthymia) states that ens ue after drug ces sation, the biochemical and morphological dendritic changes to result from repeated drug adminis tration, and the res ulting salience of drug-related stimuli. W hat they these elements of addictive neurobiology are the importance of the activation of the thalamo-orbitofrontal circuit and the anterior cingulate in the experience of craving and the decreased inhibitory control over drug salient s timuli (impulsivity) due to inherent or druginduced impairment of function of the frontal cortex, particularly the anterior cingulate.

B iologic al Fac tors —Vulnerability 1308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 130 of 167

T he children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. T he higher ris k for alcoholism manifests itself even when children are adopted by nonalcoholic families s oon after birth. Dependence on other drugs also shows a familial T he increased ris k is partly due to early environmental factors (parental modeling, neglect, early child abus e) later exposure to drugs , but genetic factors also play important role. Numerous studies of laboratory animals have revealed genetically transmitted differences in the reinforcing effects of alcohol and various drugs, s uch cocaine and opioids, and s how that genetic factors powerfully influence s ensitivity to toxic effects. T he evidence for genetic factors in human vulnerability to alcoholism and other drug dependence is derived mos t convincingly from twin and adoption studies, but family studies are also revealing. S everal studies of twins found a higher concordance rate for alcoholis m among identical twins than among fraternal twins. Although identical twins are generally believed to have more contact than fraternal twins , when the effects of environmental factors are adjus ted statis tically, genetic factors are still found to have a major influence on the likelihood of becoming dependent. In one populationbased twin s tudy, 48 to 58 percent of the variation in liability to dependence was attributable to genetic the remainder was due to general environmental influences not s hared by family members . All of the twin s tudies have found that genetically vulnerability contributes s ubstantially to the likelihood us ing drugs and to becoming drug or alcohol 1309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 131 of 167

including dependence on nicotine and caffeine. One that has not been entirely settled is whether the genetic vulnerability is a general, nonspecific vulnerability or is subs tance s pecific. A s tudy of male twins in V irginia only a nonspecific genetic vulnerability. However, a of V ietnam–era veteran twin pairs us ing a s omewhat different analytical approach identified both common drug-specific genetic vulnerability factors . In that study, the importance of the nons pecific factors vers us the specific factors varied cons iderably for different drug categories . F or most drugs , the variance was mos tly a nons pecific vulnerability factor. B ut in the cas e of 54 percent of total variance was due to genetic factors , 70 percent of this genetic variance was due to drugspecific factors. T he differences concerning drug between thes e twin studies may be due to differences method or to the unusual experiences with heroin in V ietnam of that study population. T he C ollaborative on the G enetics of Alcoholis m als o found some in transmiss ion of cocaine and marijuana dependence. seems that the exis tence of nons pecific genetic vulnerability factors is well es tablis hed, but the role, if of drug-specific genetic vulnerability requires further study. S tudies of boys adopted s oon after birth have shown higher rates of alcoholism among those whose fathers were alcoholics than among thos e whose biological fathers were not. S ome adoption studies toward s ubtypes of alcoholis m among men: One is a onset dis order that is less severe and far more environmental factors (type I), and the other is with early-onset, antisocial behavior and criminality in 1310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 132 of 167

biological fathers and a stronger genetic basis for the increased vulnerability (type II). T he hypothes is that genetically dis tinct types of alcoholism (type I and type exis t has been criticized on the grounds that it is es sentially a relabeling of the older primary-secondary categorization. In the latter, alcohol-dependent people who do not have antisocial personality dis order are designated as having primary alcoholis m; thos e who exhibit antis ocial pers onality disorder and later develop alcoholism are designated antis ocial pers onality with s e condary alcoholis m. More recent s tudies of have shown that, compared with adoptees who have biological risk or a parent with only alcoholis m or only antis ocial pers onality disorder, risk for both drug abuse dependence is increased when subs tance abus e and antis ocial pers onality disorder are present in the same biological parent. Although s everal research groups been unable to us e the type I and type II criteria to categorize patients with alcohol dependence accurately clinical s tudies, arguments about the validity of the type I/type II categorization do not diminis h the importance genetic factors in vulnerability to developing alcohol dependence. As many as one-third of people with alcohol have no family his tory of the disorder. Men are more than women to develop alcoholism (four- to fivefold in United S tates ). T his is true across every culture probably reflecting in part s tronger s ocial s anctions on drug us e and deviant behavior by women. B ut it P.1162 is also pos tulated that women are les s likely to drink 1311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 133 of 167

heavily becaus e they are les s tolerant to alcohol. who do drink heavily run the s ame ris k as men of developing alcoholis m, and women who us e illegal are about as likely as men to become dependent. S ome s tudies have found that alcohol-dependent are at far greater ris k for developing other varieties of dependence. A more cons is tent finding is that drugdependent people are at high risk for alcoholis m and have a family history of alcoholism. S uch findings are cons istent with data from the twin s tudies that have general vulnerability factors. Most researchers believe that no s ingle gene will be to account for the complexities of inherited ris k for drug and alcohol dependence. S ome genetic factors may increase vulnerability to alcoholis m but decrease it. A genetically determined variation in the activity of that metabolize alcohol (alcohol dehydrogenase and aldehyde dehydrogenase [ALDH]), common among Asian groups, results in high levels of acetaldehyde in res ponse to alcohol ingestion. T he effect is to caus e alcohol flus h reaction and to exert s ome deterrent on alcohol inges tion. Alcoholism is lower among many Asian groups than among whites . F urther, Asians with alcoholism are much less likely to have the inactive the ALDH enzyme. Als o, genetically determined differences in nicotine metabolis m can influence the likelihood of becoming a smoker.

B iologic al and B ehavioral S tudies exploring how people with and without family histories of alcoholism might differ have involved meas ures of pers onality, drug and alcohol us e 1312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 134 of 167

ps ychomotor and cognitive performance, electrical of the brain, and endocrine respons es to challenges alcohol and other substances as well as meas ures of receptor numbers and affinities and enzyme activities MAO) in peripheral tis sues (e.g., blood platelets and lymphocytes). S imilar s tudies have been conducted offspring of men with histories of other s ubs tance use disorders . One finding that has been replicated is that, under s ome conditions, the electrical res ponse of the that occurs approximately 300 millis econds after a stimulus (the P 300 wave) has a s maller amplitude in nondrinking s ons and daughters of alcoholic fathers in control s ubjects without family histories of T he decreased amplitude is believed to reflect a capacity to recognize and interpret complex environmental s timuli. It has als o been considered an indicator of low phys iological inhibition and reflective of maturational lag. Mos t s tudies have found no in intelligence among subjects with and without family histories of alcoholis m. However, the res ults of studies are conflicting; some find no differences , and others find greater impuls ivity, adventurousness , and sens ation s eeking among thos e with a pos itive family history. S tudies of offspring of fathers with substance dependence have found, in addition, irritability, affect, and a difficult temperament. S tudies of the patterns of adoles cent and young adult sons of people also have not yielded consistent res ults; some not all) s tudies show that s ons of alcoholic parents are heavier drinkers. Other s tudies have compared the subjective, motoric, and endocrine res ponses of young men with and without family his tories of alcoholism challenge expos ures to alcohol and other potentially 1313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 135 of 167

euphoriant drugs (s uch as benzodiazepines). S ons of alcoholic fathers s eem to be more tolerant to the intoxicating effects of modes t doses of alcohol, and in some (but not all) studies, higher doses of alcohol produced s maller changes in their prolactin and cortis ol concentrations. F urthermore, one s tudy found that who had smaller res ponses to tes t doses of alcohol at years of age (i.e., were more tolerant) were fourfold likely to have developed alcoholism 8 years later. study of sons of alcoholic parents found that thos e who had exhibited smaller electroencephalographic (E E G ) alpha frequency res ponses to alcohol were more likely be alcohol dependent at 10 years ' follow-up. T he res ults of studies using benzodiazepine challenges also not cons is tent; one showed a greater euphoric res ponse to alprazolam (Xanax) in sons of alcoholic parents , and another showed no difference between positive and negative family history groups after a dos e diazepam. A number of studies have shown that conduct dis order and early childhood aggres sion are ass ociated with a subs tantial increas e in the likelihood of early with illegal drug use and development of dependence alcohol and illegal drugs. C ons iderable evidence a role for both genetics and environmental factors in development of conduct disorder. Antis ocial pers onality disorder repres ents an independent additional risk for addictive dis orders. T he effects of antisocial disorder and family his tory of a substance-related appear to be additive rather than s ynergis tic. It seems poss ible that, in s ome of the s tudies of children and people at high ris k for later drug dependence, the 1314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 136 of 167

electrophysiological differences , cognitive deficits , and personality differences reflect the presence of conduct disorder or antisocial personality disorder rather than a family history of alcoholism per se. In a s tudy of offs pring of fathers with s ubs tance use disorders , a high compos ite score of neurobehavioral disinhibition (derived from measures of affect, and cognition) when measured at 10 to 12 years of age was a predictor of s ubs tance use dis order at 19 years age. A high score at 16 years of age was a better of substance us e disorder than frequency of s ubs tance cons umption. Interes tingly, it was the presence of indicators of neurobehavioral dis inhibition that was predictive and not s ocioeconomic s tatus or being the of a father with a substance us e disorder.

Ps yc hodynamic Fac tors and Ps yc hopathology E arly psychoanalytical formulations pos tulated that us ers , in general, had either a s pecial form of affective dysregulation (tense depress ion) that was alleviated by drug us e or a disorder of impulse control in which the search for pleasure was dominant. More recent formulations pos tulate ego defects, which are evinced the addict's inability to manage painful affects (guilt, anger, anxiety) and to avoid preventable medical, legal, and financial problems . T he newer formulations postulating ego defects are to s ome degree the older formulations with a modes t change in terminology that gives greater weight to the inability to cope with painful affects than to the intens ity or abnormality of the affects per se. It is postulated that s ome s ubs tances 1315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 137 of 167

pharmacologically and symbolically aid the ego in controlling thos e affects and that their use can be as a form of s elf-medication. F or example, it has been suggested that opioids help us ers control painful anger, that alcohol helps alcoholics control panic, and that nicotine may help s ome cigarette smokers control symptoms of depres sion. Although it is conceded that some of thos e observations may reflect problems produced by long-term us e, the psychodynamic perspective is that the psychopathology is the motivation for initial us e, dependent us e, and relapse a period of abs tinence. However, traditions of pas sivity uncovering techniques derived from the neuros is are poorly s uited to the treatment of most addicts. F urther, s ome addicts have great difficulty differentiating and describing what they feel, a difficulty that has been called ale xithymia (i.e., no words for feelings). P.1163

F amily Dynamic s One family member's subs tance abus e is often by s ubs tance-us ing behaviors of others in the family, these complex interrelations hips can profoundly affect their lives. An unders tanding of the relations hips subs tance-us ing patients and their families is relevant unders tanding the etiology of subs tance dependence its treatment and for helping other family members to cope with problems as sociated with the s ubs tancebehavior. More has been written about the families of alcohol1316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 138 of 167

dependent people and heroin us ers than about families affected by users of other drugs. S imilarities between family dynamics in thes e two prototypical have led researchers and clinicians to ass ume that general principles apply to all varieties of s ubs tance dependence. T he observation that alcoholis m is commonly found in the families of those seeking treatment for other types of dependence, that alcoholdependent people are often dependent on other subs tances as well, and that those addicted to illegal are often alcoholic s uggests that there are common features among families with an addicted member. However, there are few data to sugges t that the those dependent on tobacco or benzodiazepines are dysfunctional as thos e affected by alcohol, opioids, or cocaine. It is not always clear to what degree one family behavior is the caus e of the substance-us ing behavior another or is primarily a res ponse to that behavior. writers emphas ize that the addiction is a s ymptom that provides a displaced focus for conflict among other members and that the us er (the designated patient) be playing a role in maintaining the homeostasis of a dysfunctional family. At the s ame time, addiction often arises in families in which one or both parents (and sometimes grandparents ) have drug or alcohol and other psychopathology. S ome characteristics commonly observed both in families of people who are alcohol dependent and of those addicted to illegal are multigenerational drug dependence; a high of parental los s through divorce, death, abandonment, incarceration; overprotection or overcontrol by one 1317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 139 of 167

(us ually the mother) whose life is inordinately on the behavior of the addicted offspring (s ymbiotic relations hips ); distant, cold, disengaged, or absent (when the father is alive); and defiant drug-us ing child appears to be engaged with peers but remains dependent on the family well into adult life (ps eudoindependence). T he actual family dynamics difficult to characterize because the family members' reports about their relations hips do not reliably corres pond to what outs iders observe. S uch families typically do not describe thems elves in the way that therapists s ee them. S ome workers have proposed that unresolved family grief plays a role in the genes is of addiction in a family member and that such families cannot deal effectively with s eparation because of previous los ses. Despite the pathological between the addict and other family members , the is often described as pass ive, dependent, withdrawn, unable to form close relationships . Des pite all the apparent pathology found in families , in many instances, the family brings the substance us er treatment, and the patient often believes that it is the family that is mos t likely to be helpful in recovery. F urthermore, clinicians now generally believe that involving families in treatment is important, if not es sential, to effective intervention. One as pect of families is dealing with the tendency of s ome members shield the patients from the consequences of their subs tance use, a behavior us ually labeled by clinicians enabling but us ually experienced by the family member loving, s upporting, accepting, and protecting. A on family therapy, s ometimes called ne twork the rapy, 1318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 140 of 167

involves enlis ting family members and clos e friends as allies of the therapis t to provide s ocial s upport and reinforcement of drug-abstaining behaviors. T he selected to fulfill this role function as part of a treatment team rather than as patients.

C ODE PE NDE NC E T he term code pe nde nce came into vogue to describe behavioral patterns of family members who have been significantly affected by another family member's subs tance use or addiction. T he term has been used in various ways , and there are no established criteria for codependence, a concept that s ome writers have expanded far beyond its origins to encompas s any personality trait that involves difficulty in expres sing emotions . However, many have criticized the expanded concept of codependence as a largely invalid notion solely on anecdote. T he following s ummary of some characteristics frequently des cribed as aspects of codependence is not meant to imply the validity of a unitary s yndrome. One of the more agreed-on characteris tics of codependence is enabling behavior. F amily members sometimes feel that they have little or no control over enabling acts. E ither becaus e of social press ure to and s upport family members or becaus e of interdependencies, or both, enabling behavior often res is ts modification. Other characteristics of codependence include an unwillingnes s to accept the notion of addiction as a disease. F amily members to behave as if the s ubs tance-us ing behavior were voluntary and willful (if not actually s piteful), and the 1319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 141 of 167

cares more for alcohol and drugs than for the members the family. T his res ults in feelings of anger, rejection, failure. In addition to thos e feelings , the family may feel guilty and depress ed becaus e the addict, in effort to deny los s of control over drugs and to shift the focus of concern away from their use, often tries to the res ponsibility for s uch us e on the other family members who often seem willing to accept s ome or all it. Like the s ubstance us ers themselves, family members often behave as if the substance us e that is caus ing obvious problems is not really a problem—that is , they engage in denial. T he reas ons for the unwillingness to accept the obvious vary. S ometimes denial is s elfprotecting in that the family members believe that, if is a drug or alcohol problem, then they are res ponsible. Like the addicts thems elves , codependent family seem unwilling to accept the notion that outside intervention is needed and, des pite repeated failures, continue to believe that greater willpower and greater efforts at control can restore tranquility. W hen efforts at control fail, they often attribute the failure to thems elves rather than to the addict or the dis eas e proces s, and along with failure come feelings of anger, lowered s elf-es teem, and depress ion.

Other Fac tors T here are other factors that influence the pattern of use and cess ation of any given s ubs tance. F or example, decis ion not to use a s ubs tance als o has that can be avers ive or reinforcing, and evidence that when the rewards of not us ing the substance are 1320 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 142 of 167

the likelihood of us e is reduced. In addition, many of subs tances as sociated with dependence act directly on systems that s ubs erve both motivation and decision making, rais ing questions about whether use is always influenced s olely by its cons equences (learning T he cognitive proces ses and s kills that ordinarily decis ion making appear to be impaired by alcohol, barbiturates , cannabis, and s everal other categories of adminis tered agents . T hus , whereas substance us e is influenced by learning, the substances also alter the its elf. T his sugges ts additional problems and for intervention. E vidence is accumulating that limited cognitive s kills reduce the likelihood of s ucces sful from s ubs tance use and that coping skills can help a person avoid or deal with avers ive affective s tates , environmental s tres ses , and s ituations that are with a high risk for substance us e. T he presence of ps ychiatric disorders has a powerful influence on both development and course of s ubs tance use disorders discuss ed separately below. Other factors that influence the course of s ubs tance and dependence are difficult to operationalize or teach prescribe, but they deserve mention. S tudies of the history of substance us e P.1164 indicate that recovery is powerfully influenced by the support of family and friends . Many people report that hope, faith, formal religious affiliation, or the s ustaining love of s ome significant person are more important to their recovery than any s pecific treatment. 1321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 143 of 167

C omorbidity C omorbidity is the cooccurrence of two or more disorders in a single patient. As noted earlier, a high prevalence of additional ps ychiatric dis orders is found among people seeking treatment for alcohol, cocaine, opioid dependence. Although opioid, cocaine, and abusers with current ps ychiatric problems are more to seek treatment, it s hould not be as sumed that those who do not s eek treatment are free of comorbid ps ychiatric problems; such people may have s ocial supports that enable them to deny the impact that drug us e is having on their lives. T wo large epidemiological studies have s hown that even among representative samples of the population, thos e who meet the criteria alcohol or drug abuse and dependence (excluding tobacco dependence) are far more likely to meet the criteria for other psychiatric disorders also. In the NC S , percent of thos e who met the criteria for a lifetime addictive disorder received at least one additional disorder diagnosis; in the earlier E C A s tudy, the comparable figure was 38 percent. In the E C A study, among those diagnos ed with drug dependence, the common additional diagnos is was alcohol abuse/dependence, followed in frequency by antisocial personality dis order, phobic disorders , and major depres sion for men and phobic disorders , major depres sion, and dys thymia for women. Almost every ps ychiatric diagnosis was more common among thos e who met the criteria for drug dependence, with notable increases in odds ratios for alcoholism, antis ocial personality dis order, and mania among women and for mania, antis ocial pers onality disorder, and dys thymia 1322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 144 of 167

among men. B oth men and women with drug abus e dependence are at a s ubs tantially higher risk for schizophrenia. In general, the probability of comorbidity is higher for those with a lifetime diagnosis of an opioid or cocaine disorder than for those with a diagnosis of cannabis Among people in prison, the comorbidity rates were higher than in the general population; addictive were found in 92 percent of pris oners with 90 percent of thos e with antisocial personality dis order, and 89 percent of thos e with bipolar disorders. Among people with mental dis orders s eeking treatment in ps ychiatric specialty s ettings , 20 percent have a subs tance abus e disorder diagnos is. More recently, it become apparent that cigarette smoking is as sociated with higher probability of additional ps ychiatric es pecially mood disorders . T he findings from the NC S largely confirm the observations of the E C A s tudy that those with us e disorders are substantially more likely to other mental disorders and that those with other mental disorders are far more likely to develop s ubs tance use disorders . T he NC S als o unders cored the finding that, although 52 percent of res pondents had never experienced any DS M-III-R disorder and 21 percent one s uch dis order, 13 percent had two disorders , and percent had three or more disorders . F urthermore, the month prevalence of a dis order was more likely among those with more than one disorder: 59 percent of all of month dis orders occurred in the 14 percent with a history of three or more dis orders, and 89 percent of severe 12-month dis orders occurred in the s ame 1323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 145 of 167

T hese findings describe rather than explain T hey do not s hed much light on the ques tion of or in which cas es , drug us e is at least initially an effort at self-medication or whether thos e with a variety ps ychiatric disorders are less able to cope with the of s ubs tance use and so are more likely to become dependent. It is also not clear whether psychiatric disorders increas e the vulnerability to drug abuse and drug dependence or whether s ome common factor contributes to both. In some cas es , however, there appear to be a causal link between drug us e and s ome ps ychiatric disorders. F or example, evidence indicates subs tance abus e (es pecially alcohol) can cause or the ris k for depres sive dis order; cocaine can increase frequency of panic disorder; and cannabis, cocaine, amphetamine us e can aggravate or precipitate schizophrenic symptomatology. S ome of these are induced dis orders (particularly some of the depres sive symptoms s een in alcoholics) and clear with cess ation alcohol use. However, s ome ps ychiatric dis orders (e.g., mood dis order and antisocial personality disorder) antedate s ubs tance use and can be viewed as risk or predictors for substance abuse and dependence. particularly true of conduct dis order and adult antis ocial behavior, in which the symptoms often begin before the onset of problematic drug us e. T he NC S found that the odds of developing alcohol or drug dependence fivefold in the presence of conduct dis order without antis ocial behavior and 10- to 14-fold if only adult antis ocial behavior or both conduct disorder and behavior were present. Of the Axis I disorders , bipolar I disorder is more s trongly related to dependence on alcohol or drugs than any other mood or anxiety 1324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 146 of 167

In general, approximately 24.5 percent of thos e with a month addictive dis order had a mood disorder as well, 35.6 percent had an anxiety dis order. Overall, 42.7 of thos e with a 12-month addictive dis order had at least one 12-month Axis I mental dis order. In terms of disorders , 41.0 to 65.5 percent of those with a lifetime addictive disorder have a lifetime history of at least one Axis I mental dis order, whereas 51 percent of those one or more lifetime mental disorders (Axis I or II) have history of one or more addictive disorders . F or lifetime conduct dis order or adult antisocial behavior, the rate lifetime substance us e disorder increas es to 82 Although the poss ibility of recall bias exis ts, those with both an affective and an addictive disorder us ually that depres sion began earlier than s ubs tance use. However, temporal relationship between two dis orders does not prove causality, even when the development the firs t disorder is a predictor of both the likelihood cours e of the subsequent disorder. T here is the as has been sugges ted for s moking and depres sion, both disorders are linked to s ome third common factor. the NC S , a more chronic cours e of an addictive was found for those who reported earlier development primary anxiety dis order, conduct dis order, or adult antis ocial behavior but was not found with earlier onset other mental disorders . As noted above, several views of the etiology of drug dependence place on preexis ting (genetically determined) or s ubstanceinduced deficits in the function of the prefrontal cortex only in inhibiting respons es to drug-related stimuli but impulsivity in general. In the NC S , cooccurring mental disorders als o 1325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 147 of 167

likelihood of s eeking treatment and the treatment from which service is s ought. As mentioned, those who had a s ubstance dependence problem were far more to seek and receive treatment if they also had a cooccurring mental disorder. Approximately one-third people with a 12-month his tory of affective disorder received some treatment; but those who also had an addictive disorder were more likely to have received it specialty addiction treatment program. A collaborative s tudy of the genetics of alcoholism extensive s tructured interviews to s eparate mood and anxiety disorders from those that occurred within the context of active P.1165 drinking or withdrawal. T his s tudy found that over a lifetime, independent mood dis order was les s common alcoholics (14 percent) than in controls (17.1 percent), although more than twice as many alcoholics (2.3 as controls (1 percent) met criteria for bipolar disorder. P anic dis order and social phobia were als o more common as independent disorders among alcoholics . In general, in this study, the large majority alcohol-dependent men and women did not have independent mood or anxiety dis orders. T his s uggests the higher rates of cooccurrence of most anxiety and affective dis orders found in epidemiological s tudies or clinical populations probably reflect s ubs tance induced anxiety and mood disorders that res olve special intervention once drug use ceas es .

Multiple Fac tors 1326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 148 of 167

T he biops ychos ocial general model of s ubs tance dependence presented here does not attempt to ass ign weight or special significance to any one factor or interaction. T he implication is that for different of drugs , different factors may play more or less caus al roles in perpetuating s ubs tance use or relaps e. F or example, pos itive reinforcing effects may more important for the development of cocaine dependence, whereas acute and protracted withdrawal phenomena may be more important in the return to opioid us e after withdrawal. E ven with the s ame subs tance, different factors may be more or les s for different people. T hus, the emergence of symptoms may make it difficult for some cigarette to quit, particularly thos e with a his tory of major depres sive disorder, and thos e people may be helped antidepres sants. S uch a multifactorial model implies certain treatments or interventions may be more for one substance category than another and that, among people us ing the same substances, different treatments may be indicated. F igure 11.1-5 implies that the notion of dependence is a property of any one element but, rather, an inferred from the relations among the elements of the system. Although it is convenient (and required by IV -T R ) to see dependence as a dis order located within person, any interpretation that overemphas izes one the system, whether the biology of the pers on, changes the brain, s ocial influences, or behavior, is miss ing part the nature of dependence.

TR E A TME NT 1327 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 149 of 167

Many people who develop substance-related problems recover without formal treatment. F or those who do help or advice, particularly those patients with les s disorders , relatively brief interventions are often as effective as more intens ive treatments . B ecause thes e interventions do not change the environment, alter induced brain changes, or provide new skills, a change the patient's motivation (cognitive change) probably explains their impact on the drug-us ing behavior. F or those individuals who do not res pond or whos e dependence is more severe, a variety of interventions appear to be effective. Although each section in this chapter discuss es treatment relevant to the particular subs tance use dis order, the clinician s ees few drugdependent people who use only one drug. (Nicotine dependence may be an exception.) F or example, patients using an illegal drug, the mos t common additional diagnosis is alcohol dependence. It is useful to distinguish among specific procedures or techniques (e.g., individual cognitive-behavioral family therapy, group therapy, relaps e prevention, and pharmacotherapy) and treatment programs. Mos t programs us e a number of s pecific procedures and several profes sional disciplines as well as who have s pecial skills or personal experience with the subs tance problem being treated. T he bes t treatment programs combine s pecific procedures and disciplines meet the needs of the individual patient after a careful as sess ment. However, there is no generally accepted clas sification either for the s pecific procedures us ed in treatment or for programs making us e of various combinations of procedures . T his lack of s tandardized 1328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 150 of 167

terminology for categorizing procedures and programs presents a problem, even when the field of interes t is narrowed from substance problems in general to treatment for a s ingle substance such as alcohol, or cocaine. E xcept in carefully monitored research even the definitions of specific procedures (e.g., couns eling, group therapy, and methadone tend to be so imprecise that one us ually cannot infer what transactions are s upposed to occur. descriptive purpos es , programs are often broadly on the bas is of one or more of their s alient whether the program is aimed at merely controlling withdrawal and consequences of recent drug us e (detoxification) or is focus ed on longer-term behavioral change; whether the program makes extensive use of pharmacological interventions ; and the degree to which the program is bas ed on individual ps ychotherapy, AA, other 12-step principles or therapeutic community principles. B road program des criptions mas k as much they reveal, tend to confuse the setting with the procedures , and obscure differences in the etiological models underlying the treatments used in different programs. F urther, s ervices actually provided by the types of programs can vary greatly in intens ity and in specific problems (legal, medical, vocational) they are intended to ameliorate. B as ed on the NHS DA, approximately 3.1 million people years of age or older reported receiving some form of treatment for a drug- or alcohol-related problem in S ome reported treatment at more than one location. most common treatment reported was participation in a self-help group (1.6 million). T he next mos t frequent 1329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 151 of 167

setting was treatment at an outpatient rehabilitation facility (1.2 million). T hen, in des cending order, were inpatient rehabilitation (0.87 million), mental health (0.73 million), hospital inpatient (0.71 million), private doctor's office (0.44 million), an emergency room (0.38 million), and pris on or jail (0.18 million). F igure 11.1-6 shows the drug for which people reported receiving treatment. S ome of the treatments received were for induced conditions other than dependence.

FIGUR E 11.1-6 Number of U.S . community res idents received services for treatment of alcohol and other problems in the year before as sess ment, as estimated each drug category under s tudy. (Data from U.S . Hous ehold S urvey of Drug Abus e, 2001, with Not all interventions are applicable to all varieties of subs tance us e or dependence, and s ome of the more coercive interventions us ed for illegal drugs are not applicable to s ubs tances that are legally available, 1330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 152 of 167

tobacco. C hanges in addictive behaviors do not occur abruptly but rather through a series of s tages. F ive in this gradual process have been proposed: precontemplation, contemplation, preparation, action, and maintenance. F or some types of addiction, the therapeutic alliance is enhanced when the treatment approach is tailored to the patient's s tage or readines s change. F or some drug use dis orders , a specific pharmacological agent may be an important of an intervention—for example, dis ulfiram, naltrexone, acampros ate (C ampral) for alcoholis m; methadone, levomethadyl acetate (Orlaam) (als o called L- αacetylmethadol [LAAM]), or buprenorphine (B uprenex, S ubutex) for heroin addiction; nicotine delivery devices bupropion (Zyban) for tobacco dependence. Not all interventions are likely to be useful as res ources for care profes sionals. F or example, young offenders with histories of drug use or dependence may be remanded special facilities under the juris diction of the criminal justice system. S ome P.1166 programs for offenders (and sometimes for employees) rely almost exclus ively on the deterrent effect of urine testing. In contrast to the numerous studies suggesting s ome value for brief interventions for and for problem drinking, there are few controlled of brief interventions for thos e s eeking treatment for dependence on illegal drugs . In general, for people who are severely dependent on illegal opioids, brief interventions (s uch as a few weeks detoxification, whether in or out of a hos pital) have 1331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 153 of 167

effect on outcome meas ured a few months later. F or dependent on cocaine or heroin, treatment las ting as 3 months is much more likely to result in s ubs tantial reductions in illegal drug us e, antisocial behaviors , and ps ychiatric distres s. S uch a time-in-treatment effect is acros s very different modalities, from res idential therapeutic communities to ambulatory methadone maintenance programs . Although s ome patients benefit from a few days or weeks of treatment, a subs tantial percentage of users of illegal drugs drop (or are dropped) from treatment before they have achieved significant benefits . S ome of the variance in outcome of treatment can be attributed to differences in the characteristics of patients entering treatment and events and conditions after treatment. However, based on similar philosophical principles and us ing seem to be s imilar therapeutic procedures vary greatly effectivenes s. S ome of the differences among that s eem to be s imilar reflect the range and intensity services offered. P rograms with profess ionally trained staffs that provide more comprehens ive s ervices to patients with more severe psychiatric difficulties are likely to be able to retain thos e patients in treatment to help them to make pos itive changes. Differences in skills of individual counselors and profes sionals can powerfully affect outcomes. P atients who have low of psychiatric problems tend to do well in mos t and for thes e patients , the impact of specialized skills services is more difficult to demons trate. S uch generalizations concerning programs s erving illegal us ers may not hold for programs dealing with thos e seeking treatment for alcohol or tobacco or even problems uncomplicated by heavy us e of illegal drugs . 1332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 154 of 167

such cases , relatively brief periods of individual or couns eling can produce long-lasting reductions in drug us e. T he outcomes us ually considered in programs with illegal drugs have typically included meas ures of social functioning, employment, and criminal activity as well as decreases in drug-us ing behavior. T reatment alcoholism and other mental health problems generally has more limited expectations (e.g., reduction in us e and s ymptoms of psychiatric disorders ), although reduced us e of health care res ources subs equent to treatment is s ometimes an additional meas ure of treatment effectiveness .

Meas uring Treatment Outc ome In a large multis ite study of treatment, the Drug Abuse T reatment Outcome S tudy (DAT OS ; carried out from to 1993) patients were interviewed at intake and 1, 3, 12 months after treatment. (F or s ome types of drug data are now available for outcomes 5 years after treatment entry.) As in previous multis ite studies, s ites selected were s table repres entatives of four major program types : drug-free outpatient, methadone maintenance, s hort-term res idential (chemical dependency), and long-term res idential (therapeutic community). E xcept at the methadone programs, which us ed group and individual counseling approximately equally, group couns eling was the common element of other treatments . S ome antidepress ant and agents were us ed in the nonmethadone programs , but they were incidental. T his s tudy found a lower level of services available to patients s eeking treatment than a decade earlier. Als o, 1333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 155 of 167

patients were older and more likely to have a variety of special medical problems (HIV , psychiatric disorders ) social needs (homeles sness ). T reatment outcomes generally cons is tent with thos e of previous s tudies of treatment in the public s ector. One year after there were substantial decreas es in drug use. Levels of weekly or daily cocaine us e at 1 year were, on approximately 50 percent of pretreatment levels , with greater reduction for those who participated in for 3 months or more. Daily heroin use was lower patients who remained in methadone maintenance treatment than among thos e who left. Although cocaine us e among patients treated with methadone was somewhat lower, the reduction could not be attributed treatment. Alcohol and marijuana us e did not decline significantly. T here was als o no apparent decrease in suicidal thoughts or increase in employment, and, in contrast to a number of previous multis ite studies, multivariate analys is in this s tudy did not confirm the widely reported reduction in predatory or high-ris k behaviors , or both, for those in methadone programs . T hose who s tayed in long-term res idential treatment for months or more showed a major decreas e in drug us e from preadmis sion levels for all categories of drugs — to 22.0 percent for cocaine; 17.2 to 5.8 percent for alcohol and marijuana use reduced by more than oneT hese individuals als o reported a 50 percent decrease illegal activities and approximately a 10 percent full-time employment. T he outpatient drug-free and short-term inpatient programs s urveyed by DAT OS had very few which heroin was the major drug problem; the most 1334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 156 of 167

common pres enting drug problem for both was P.1167 cocaine, followed by alcohol and marijuana. in the outpatient drug-free programs for 3 months or was as sociated with a greater decreas e in cocaine use year (approximately 50 percent, compared with those stayed 3 months or less ). B ut even 58 percent of those stayed less than 3 months reported some decreas e in cocaine use over preadmis sion levels . P atients who entered short-term inpatient programs also reported major decreas es in drug use at 1 year, but there was difference between those who s tayed more than 2 and those who s tayed les s than 2 weeks . G enerally, level of drug use at 1 year was predictive of drug us e at 5-year follow-up. T his s us tained improvement at 4 to 5 years was als o noted in a follow-up of treatment in the United K ingdom. Although adolescents are generally reluctant to seek treatment without some external or family press ure, follow-up studies of specializing in adolescent treatment have found subs tantial and sus tained decreas es in drug use. B ecaus e the decision to enter any of the programs in DAT OS is made by the patient, the study does not much guidance to a clinician weighing a for a s pecific patient. More guidance comes from a scale, random-as signment study of the treatment of alcoholics , which found that three dis tinct methods of delivering individual therapy over a 12-week period— step facilitation, cognitive-behavioral coping s kills , and motivational enhancement (four ses sions only)— produced comparable and generally quite favorable 1335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 157 of 167

outcomes . P atient characteristics interacted with the treatment in only one area, alcoholics with lowlevel ps ychiatric problems had better outcomes in days of abstinence if ass igned to 12-step facilitation than cognitive-behavioral therapy. P atients who individual therapy after a brief period of inpatient and intens ive day care treatment (aftercare) had better 1outcomes than those who began individual treatment outpatients, even though their problem level at bas eline was more s evere. C urrently, entry into treatment rarely reflects a truly informed choice aimed at matching the characteris tics needs of the patient with the capacities and skills of a provider. F indings from s tudies of public sector serving drug users with relatively few social s upports that more intensive s ervices, such as vocational, and mental health services , increase retention and produce better outcomes at follow-up. P atients who expres s more satis faction with the treatment received to remain in treatment longer. In general, acros s drug categories , participation in self-help groups s uch as AA correlates with better s hort-term and long-term

Influenc e of P hilos ophic al T he kinds of therapeutic procedures that treatment profes sionals deem valuable or es sential are affected by philosophical orientation. F or example, one study found that many profes sionals who adhere to a “disease model” of substance dependence view of denial, acceptance of disease, need for lifelong abstinence, commitment to recovery, and affiliation AA as the most important elements of intervention. In 1336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 158 of 167

contrast, dealing with res ponsibility, instilling motivation and confidence, teaching relaps e prevention, and high-ris k situations were rated highes t by ps ychologists es pousing a behavioral model of dependence. Until recently, even physicians were unlikely to view pharmacological interventions as having s ignificant in treating alcoholis m or most other forms of drug dependence, although some phys icians did prescribe various forms of nicotine for tobacco dependence. Many controlled studies over many years have shown the us e of illegal opioids (heroin) can be markedly by supervis ed adminis tration of oral opioid agonists (methadone or LAAM) or partial agonis ts B ecaus e of government regulations, the use of full agonis ts is limited to practitioners and programs that obtained s pecial licenses. Data also show that can reduce relaps e rates for alcoholics after C ontrolled s tudies conducted in E urope show that acampros ate, a drug believed to act via actions on the glutamatergic system, can also reduce alcoholis m rates. At pres ent, however, there s eems to be only a modes t correlation between the evidence s howing that given intervention or procedure is effective and the likelihood that it will be widely used.

Treatment of C omorbidity— vers us C onc urrent T he treatment of the severely mentally ill (primarily with s chizophrenia and schizoaffective dis orders) who also drug dependent continues to pos e problems for clinicians . Although s ome special facilities have been developed that us e both antipsychotic drugs and 1337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 159 of 167

therapeutic community principles, for the mos t part, specialized addiction agencies have difficulty treating these patients. G enerally, integrated treatment in which the same staff can treat both the psychiatric dis order the addiction is more effective than either parallel treatment (a mental health and a s pecialty addiction program providing care concurrently) or s equential treatment (treating either the addiction or the disorder first and then dealing with the comorbid condition).

S ervic es and Outc ome T he extens ion of managed care into the public sector produced a major reduction in the us e of hospitaldetoxification and virtual disappearance of longer-term res idential rehabilitation programs for alcoholics . However, s ome managed care organizations tend to as sume that the relatively brief courses of outpatient couns eling that are effective with private s ector patients are also effective with patients who are dependent on illegal drugs and who have minimal supports. F or the present, the trend is to provide the that costs leas t over the s hort term and to ignore showing that, for some patients , more services can produce better long-term outcomes. T reatment is often a worthwhile s ocial expenditure. F or example, treatment of antis ocial illegal drug us ers in outpatient settings can produce decreases in antis ocial behavior and reductions in rates of HIV seroconversion that more than offs et the treatment cos t. T reatment in a prison setting can produce favorable decreases in postreleas e cos ts ass ociated with drug us e and 1338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 160 of 167

Des pite such evidence, there are problems maintaining public s upport for treatment of substance dependence, both in the public and private s ectors. T his lack of suggests that these problems continue to be viewed, at least in part, as moral failings rather than as medical disorders .

S UG G E S TE D C R OS S Individual s ections discus s in detail the relevant subs tances and treatment for their related disorders : alcohol-related dis orders in S ection 11.2; related dis orders, S ection 11.3; caffeine-related S ection 11.4; cannabis -related dis orders, S ection 11.5; cocaine-related dis orders, S ection 11.6; hallucinogenrelated dis orders, S ection 11.7; inhalant-related S ection 11.8; nicotine-related disorders , S ection 11.9; opioid-related dis orders, S ection 11.10; P C P -related disorders , S ection 11.11; s edative-hypnotic–related disorders , S ection 11.12; and anabolic-androgenic abuse, S ection 11.13. B rief psychotherapy is covered S ection 30.9; alternative therapies , in S ection 30.10; methadone (and other maintenance therapies) in 31.22. Drug and alcohol abus e among elderly people is discuss ed in S ection 51.3i.

R E F E R E NC E S Anthony J C . E pidemiology of drug dependence. In: G alanter M, K leber HD, eds. T e xtbook of S ubs tance T re atme nt. 3rd ed. W ashington, DC : T he American P sychiatric P ress , Inc.; 2003. P.1168 1339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 161 of 167

Anthony J C , W arner LA, K ess ler R C : C omparative epidemiology of dependence on tobacco, alcohol, controlled subs tances , and inhalants : B asic findings from the National C omorbidity S urvey. C lin E xp P s ychopharmacol. 1994;2:244. Anthony J H, V an E tten ML. E pidemiology and its In: B ellack A, Hers en M, eds. C omprehe ns ive P s ychology. Oxford, UK : E lsevier; 1998. B eirut LJ , Dinwiddie S H, B egleiter H, C rowe R R , Hes selbrock V , Nurnberger J I J r, P orjes z B , R eich T : F amilial transmis sion of subs tance dependence: Alcohol, marijuana, cocaine, and smoking. Arch G e n P s ychiatry. 1998;55:982. B oys A, F arrell M, T aylor C , Mars den J , G oodman B rugha T , B ebbington P , J enkins R , Meltzer H: P sychiatric morbidity and s ubs tance use in young people aged 13–15 years: R esults from the C hild Adoles cent S urvey of Mental Health. B r J 2003;182:509. E dwards G , Arif A, Hodgs on R : Nomenclature and clas sification of drug- and alcohol-related problems. WHO Memorandum. B ull W HO . 1981;99:225. F arrell M, Howes S , B ebbington P , B rugha T , Lewis G , Mars den J , T aylor C , Meltzer H: Nicotine, alcohol and drug dependence, and ps ychiatric comorbidity—res ults of a national household survey. 1340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 162 of 167

Int R e v P s ychiatry. 2003;15:50. F arrell M, Howes S , T aylor C , Lewis G , J enkins R , B ebbington P , J arvis M, B rugha T , G ill B , Meltzer H: S ubstance misus e and ps ychiatric comorbidity: An overview of the OP C S National P s ychiatric Morbidity S urvey. Int R e v P s ychiatry. 2003;15:43. *G erstein DR , Harwood HJ , eds. T re ating Drug V ol 1. C ommittee for the S ubs tance Abuse S tudy, Divis ion of Health C are S ervices , Institute of Medicine. W ashington, DC : National Academy 1990. G oldstein R Z, V olkow ND: Drug addiction and its underlying neurobiological bas is : Neuroimaging evidence for the involvement of the frontal cortex. P s ychiatry. 2002;159:1642. G oss op M, Mars den J , S tewart D, K idd T : T he T reatment Outcome R es earch S tudy (NT OR S ): 4–5 follow-up res ults . Addiction. 2003;98:291. Hser Y -I, G rella C E , Hubbard R L, Hs ieh S -C , B rown B S , Anglin MD: An evaluation of drug for adoles cents in 4 US cities. Arch G e n P s ychiatry. 2001;58:689. Hubbard R L, C raddock S G , Anderson J : Overview year follow-up outcomes in the Drug Abuse Outcome S tudies (DAT OS ). J S ubs t Abus e 2003;25:125. 1341 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 163 of 167

Hubbard R L, C raddock S G , F lynn P M, Anderson J , E theridge R M: Overview of 1-year follow-up in the Drug Abuse T reatment Outcome S tudy P s ychol Addict B e hav. 1997;11:261. Humphreys K . C ircle s of R e cove ry: S e lf-Help for Addictions . C ambridge, UK : C ambridge P res s; 2004. *Ins titute of Medicine. B roadening the B as e of for Alcohol P roblems . W ashington, DC : National Academy P ress ; 1990. Ins titute of Medicine. P athways of Addiction. Was hington, DC : National Academy P res s; 1996. J affe J H. C urrent concepts of addiction. In: O'B rien J affe J H, eds. Addictive S tate s . V ol 70. R es earch P ublications : As sociation for R esearch in Nervous Mental Dis eas e. New Y ork: R aven; 1992. J ohns ton LD, O'Malley P M, B achman J G . F uture National S urve y R es ults on Drug Us e 1975– V ol I: S econdary S chool S tudents (NIH P ubl. No. 5106). B ethesda, MD: National Institute on Drug 2002. J ohns ton LD, O'Malley P M, B achman J G . F uture National R e s ults on Drug Us e : O vervie w of F indings , 2002. (NIH P ubl. No. 03-5374). B ethesda, National Ins titute on Drug Abus e; 2003. 1342 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 164 of 167

K endler K S , J acobson K C , P res cott C A, Neale MC : S pecificity of genetic and environmental risk factors us e and abus e/dependence of cannabis , cocaine, hallucinogens, sedatives , s timulants , and opiates in male twins . Am J P s ychiatry. 2003;160:687. *K es sler R C , C rum R M, W arner LA, Nelson C B , S chulenberg J , Anthony J C : Lifetime co-occurrence DS M-III-R alcohol abus e and dependence with other ps ychiatric disorders in the national comorbidity Arch G e n P s ychiatry. 1997;54:313. K es sler R C , McG onagle K A, Zhao S , Nelson C B , M, E s hleman S , W ittchen H-U, K endler K S : Lifetime 12-month prevalence of DS M-III-R ps ychiatric in the United S tates. Arch G en P s ychiatry. K oob G F , LeMoal M: Drug addiction, dysregulation reward, and allos tas is . Neurops ychopharmacology. 2001;24:97. K reek MH, K oob G F : Drug dependence: S tress and dysregulation of brain reward pathways. Drug Depe nd. 1998;51:23. McLellan AT , G riss om G R , Zanis D, R andall M, B rill O'B rien C P : P roblem-service “matching” in addiction treatment. Arch G e n P s ychiatry. 1997;54:730. Miller W R : W hy do people change addictive T he 1996 H. David Archibald lecture. Addiction. 1343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 165 of 167

1998;93:163. Musto DF . T he Ame rican Dis eas e . O rigins of C ontrol. New Y ork: Oxford University P ress ; 1987. Musto DF , ed. O ne Hundre d Y ears of He roin. C T : Auburn Hous e; 2002. *Nestler E J : Molecular neurobiology of addiction. Addictions . 2001;10:201. Office of Applied S tudies . R es ults from the 2001 Hous ehold S urve y on Drug Abus e . V ol I: S ummary National F indings (DHHS P ubl. No. S MA 01-3758, NHS DA S eries H-17). R ockville, MD: S ubstance and Mental Health S ervices Administration; 2002. P arran T V J r, Liepman MR , F arkas K . T he family in addiction. In: G raham AW , S chultz T K , Mayo-S mith R ies R K , W ilford B B , eds. P rinciple s of Addiction 3rd ed. C hevy C hase, MD: American S ociety of Addiction Medicine; 2003. P rochas ka J O, DiC lemente C C , Norcross J C : In how people change. Applications to addictive behaviours. Am P s ychol. 1992;47:1102. P roject MAT C H R es earch G roup: Matching treatment to client heterogeneity: P roject MAT C H posttreatment drinking outcomes. J S tud Alcohol. 1997;58:2.

1344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 166 of 167

R egier DA, F armer ME , R ae DS , Locke B Z, K eith LL, G oodwin F K : C omorbidity of mental disorders alcohol and other drug abus e. J AMA. R obins on T W , B erridge K C : Incentive-sens itization addiction. Addiction. 2001;96:103. R ounsaville B J , B ryant K , B abor R , K ranzler H, C ros s s ys tem agreement for s ubs tance use DS M-III-R , DS M-IV and IC D-10. Addiction. S chuckit MA, S mith T L: An 8-year follow-up of 450 of alcoholic and control s ubjects . Arch G e n 1996;53:202. S chuckit MA, T ipp J E , B ucholz K K , Nurnberger J I J r, Hes selbrock V M, C rowe R R , K ramer J : T he life-time of three major mood disorders and four major disorders in alcoholics and controls . Addiction. 1997;92:1289. *S impson DD, J oe G W , B roome K M: A national 5follow-up of treatment outcomes for cocaine dependence. Arch G en P s ychiatry. 2002;59:538. S imps on DD, J oe G W , B rown B S : T reatment and follow-up outcomes in the Drug Abuse Outcome S tudy (DAT OS ). P s ychol Addict B e hav. 1997;11:294. T arter R E , K irisci L, Mezzich A, C ornelius J R , P ajer V anyukov M, G ardner W , B lackson T , C lark D: 1345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 167 of 167

Neurobehavioral dis inhibition in childhood predicts early age at onset of substance us e disorder. Am J P s ychiatry. 2003;160:1078. T s ai G E , R agan P , C hang R , C hen S , Linnoila MI, Increased glutamatergic neurotransmis sion and oxidative s tres s after alcohol withdrawal. Am J P s ychiatry. 1998;155:726. T s uang MT , Lyons MJ , Meyer J M, Doyle T , E isen G oldberg J , T rue W , Lin N, T oomey R , E aves L: C ooccurrence of abuse of different drugs in men. Arch P s ychiatry. 1998;55:967. Weisner C , Matzger H, K askutas LA: How important treatment? One-year outcomes of treated and untreated alcohol-dependent individuals . Addiction. 2003;98:901.

1346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

01/01/2009

Page 1 of 79

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 12 - S chizophrenia and O ther P s ychotic Dis orders > 12.1 S chizophrenia

12.1 C onc ept of S c hizophrenia R obert W. B uc hanan M.D. William T. C arpenter J r. M.D. P art of "12 - S chizophrenia and Other P s ychotic S chizophrenia is a clinical s yndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. T he express ion of thes e manifes tations acros s patients and over time, but the effect of the always severe and is us ually long-lasting.

HIS TOR Y Written des criptions of s ymptoms commonly observed today in patients with s chizophrenia are found recorded history. E arly G reek phys icians described delus ions of grandeur and paranoia and deterioration cognitive functions and personality. B ecaus e these symptoms are not unique to s chizophrenia, it is whether thes e behaviors were ass ociated with what is currently called schizophrenia. Indeed, s everal have argued that s chizophrenia is of relatively recent origin. S chizophrenia emerged as a medical condition worthy study and treatment in the 18th century. B y the 19th 1347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 2 of 79

century, the various psychotic disorders were generally viewed as ins anity or madness , and the movement to conceptualize thes e disorders as regrettable afflictions replaced the view of insanity as a reprehens ible Many clinical categories were des cribed during the to late 19th century, but a general approach capable of integrating the divers e manifes tations of mental illnes s into distinguis hable clinical s yndromes was lacking. A major impediment to dis tinguishing schizophrenia other forms of ps ychos es was the exis tence of another common illnes s, general pares is of the insane. T he manifestations of general pares is were quite divers e overlapped extensively with schizophrenic symptomatology. T he caus e of s yphilitic insanity was subs equently traced to a spirochetal infestation, and malaria-induced fever therapy proved partially Antibiotics were eventually found to provide effective treatment and prevention. T he identification and treatment of general paresis is one of the great s tories medical science. T he identification of syphilitic insanity reduced the heterogeneity of madnes s and enabled K raepelin to delineate the two other major patterns of insanity—manic-depres sive psychosis and dementia praecox (or dementia of the young)—and to group together under the diagnostic category of dementia praecox the previous ly dis parate categories of insanity, such as hebephrenia, paranoia, and catatonia. In differentiating dementia praecox from manicdisorder, K raepelin emphas ized what he believed to be characteristic poor long-term prognosis of dementia praecox, as compared to the relatively nondeteriorating cours e of manic-depres sive illnes s. K raepelin went on 1348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 3 of 79

describe the two principal pathophys iological or proces ses occurring in dementia praecox (Deme ntia P rae cox and P araphre nia, 1919): On the one hand we obs erve a weakening of those emotional activities which permanently the mains prings of volition. In connection with this, mental activity and instinct for become mute. T he res ult of this part of the process is emotional dullness , failure of mental activities, loss of mas tery over volition, of endeavor, and of for independent action. T he es sence of pers onality is destroyed, the bes t and mos t precious part of its being, as G ries inger once expres sed it, from her.… T he second group of disorders , which gives dementia praecox peculiar stamp… cons ists in the loss of the inner unity of the activities of intellect, emotion, volition in themselves and one another. S transky speaks of annihilation of the “intraps ychic co-ordination”… this annihilation presents its elf to us in the disorders of ass ociation 1349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 4 of 79

by B leuler, in incoherence of the train of thought, in the sharp change of moods as well as in desultorines s and derailments in practical work. B ut further, the near connections between thinking and feeling, between deliberation and emotional activity on the one hand, and practical work on the other is or les s lost. E motions do not corres pond to ideas. T he description of the des truction of the pers onality provides a conceptual framework for the avolitional or negative symptom component of the illness , and the description of “the loss of the inner unity of activities” proces s provides a conceptual framework for the symptoms of s chizophrenia. In 1911, E ugen B leuler, recognizing that dementia was a usual characteristic of dementia praecox, s uggested term s chizophre nia (s plitting of the mind) for the B leuler introduced the concept of primary and schizophrenic symptoms ; his four primary symptoms four As) were abnormal ass ociations , autis tic behavior thinking, abnormal affect, and ambivalence. Of thes e symptoms, B leuler viewed as central to the illness the of ass ociation between thought process es and among thought, emotion, and behavior. E xamples of thes e of as sociations are a P.1330 1350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 5 of 79

patient laughing on receiving news of the death of a one, the introduction of magical thinking and peculiar concepts into an ordinary discus sion, and the s udden display of angry behavior without experiencing anger an understandable provocation). B leuler's view that a dis sociative proces s is schizophrenia and that this proces s underlies a wide variety of the symptom manifes tations of s chizophrenia has provided a major paradigm for conceptualizing the illness , that is , that in spite of its various schizophrenia is a single disease entity in which there extensive s imilarity in etiology (caus e) and pathophys iology (mechanism) across all patients with disorder. In this view, a neurophys iological disturbance indeterminate origin and nature occurs that is as diss ociative process es adversely influencing the development of mental capacities in the areas of emotion, and behavior. Depending on the individual's adaptive capacity and environmental circums tances , fundamental process could lead to s econdary disease manifestations, such as hallucinations , delus ions, withdrawal, and diminis hed drive. T here are many parallels in medicine for the previously mentioned s ingle-disease model. P atients with type I diabetes mellitus share an impairment in insulin metabolism, but the secondary manifestations may cons iderably, depending on which organ s ys tems are involved. S imilarly, patients with temporal lobe epileps y share a common pathophysiological mechanis m but present with a myriad of different s igns and s ymptoms. T he divers e manifes tations of syphilitic insanity best illustrate the us efulness of this dis ease entity 1351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 6 of 79

approach for schizophrenia. T he major alternative etiopathophys iological model conceptualizes s chizophrenia as a clinical s yndrome than as a single dis eas e entity. T his view holds that, although patients with schizophrenia s hare a s ufficient commonality of signs and symptoms to validly differentiate them from patients with other forms of ps ychos is (e.g., affective disorders and toxic more than one dis eas e entity is eventually found within this s yndrome. T his view is s upported by the existence numerous ris k factors, the implication of multiple and the heterogeneity in clinical pres entation, res ponse, and clinical cours e. T he demonstration over past 50 years that mental retardation is a clinical comprised of multiple dis eas e entities rather than a disease entity bes t illus trates this construct. currently maintains the status of a clinical syndrome in absence of evidence for the existence of a s ingle entity. T here are other competing models for conceptualizing schizophrenia, that, although seriously debated in the past, are presently dismis sed as demonstrably invalid seriously reductionis tic as to not account for major observations as sociated with the illness . Nondis eas e models, such as the s ocietal reaction theory (a sane reaction to an ins ane world) or T homas S zas z's theory schizophrenia is a myth enabling s ociety to manage deviant behavior, cannot adequately account for the distribution of s chizophrenia among biological relatives , the range of early developmental ris k factors, the as sociated functional and s tructural brain the normalizing effects of drug treatment, or the 1352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 7 of 79

similarity and lifetime prevalence and clinical manifestations of s chizophrenia across widely cultures. Narrow framework disease models that to account for the illnes s s olely at the level of ps ychological mechanis ms are als o demons trably inadequate in accommodating the known facts of the illness . G enetic or immunovirological caus al factors be address ed by reductionis tic theories operating at ps ychological or s ocial levels. T he many biological, ps ychological, and s ocial factors relevant to the unders tanding and treatment of the pers on with schizophrenia requires a broad medical model and es chews reduction to any single level of the functioning organism. R ecent scientific advances have confirmed current concepts of s chizophrenia and sugges ted that the nosology of psychotic illness will continue to evolve. F amily s tudies have provided an important validation of K raepelin's original formulation of dementia praecox manic-depres sive psychosis as s eparate dis orders . studies have repeatedly shown that biological relatives patients with s chizophrenia have an increased ris k of schizophrenia and s chizophrenia spectrum disorders , whereas biological relatives of patients with a major affective dis order have an increas ed risk for affective disorders . T he s eparation is not complete, but it is supportive of the two disorders as independent dis eas e entities. T win studies indicate that the genetic between schizophrenia and major affective dis orders is even more robust when cons idering concordance rates among monozygotic twins. T here is als o evidence that presence of the deficit form of s chizophrenia (i.e., 1353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 8 of 79

schizophrenia with primary negative symptoms) the relative risk of s chizophrenia and decreases the ris k for other mental illnes s in biological relatives. res ults s uggest that some subtypes of s chizophrenia breed true. In contrast, there are emerging data from linkage analys es conducted in families s elected for the presence of bipolar disorder, other major affective disorders , or schizophrenia that s uggest that there is remarkable overlap of chromosomal areas suspected the location of genes contributing to disease liability. It now appears likely that a number of genes confer for major ps ychiatric disorders and that these genes overlap acros s current diagnostic boundaries. Initial expres sion findings from postmortem tiss ue als o this overlap, and nos ologis ts will soon be challenged to reconceptualize clas sification of these illnes s In summary, schizophrenia is appropriately and conceptualized as a disease proces s. Although it is that a unifying etiology and pathophys iology will eventually be uncovered that will account for all, or all, cas es, it s eems more likely that more than one entity exis ts within the clinical syndrome of with each having a distinguishable etiology and pathophys iology. Any reductionistic approach to the description or explanation of the disorder cannot adequately account for the range of relevant and facts . A broad medical model that integrates ranging from the molecular to the psychosocial level of organization is necess ary to describe schizophrenia, to account for the range of pathogenic influences, and to provide for treatment and rehabilitation. W ith of extensive overlap in genetic vulnerability acros s 1354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

01/01/2009

Page 9 of 79

schizophrenia and affective disorder disease class es , a remarkable reconceptualization of nos ology may be required in the near future.

E P IDE MIOL OG Y S chizophrenia is a leading worldwide public health problem that exacts enormous personal and economic costs . S chizophrenia affects just les s than 1 percent of world's population. If schizophrenia s pectrum disorders are included in the prevalence estimates , then the of affected individuals increases to approximately 5 percent. T he concept of s chizophrenia s pectrum is derived from observations of ps ychopathological manifestations in the biological relatives of patients schizophrenia. Diagnos es (and approximate lifetime prevalence rates [percent of population]) for these disorders are s chizoid pers onality disorder (fractional percentage), s chizotypal personality dis order (1 to 4 percent), s chizoaffective psychosis (3.09, P T able of C ontents > V olume I > 15 - S omatoform Dis orders > 15 - S omatoform Dis order

15 S omatoform Dis orders Mic hael A. Hollifield M.D. T here are s even s omatoform disorders in the revised fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ), two of which are subs yndromal or nonspecific disorders (T able 15-1). nosology overlaps with the tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and Health P roble ms (IC D-10) class ification (T able 15-2), there are important differences that are apparent from criteria. T he DS M-IV -T R has convers ion disorder and dysmorphic dis order in its class ification, whereas the 10 does not, but instead s pecifies somatoform dysfunction and other s omatoform disorders . In the 10, conversion is clas sified as a dis sociative disorder, somatoform autonomic dys function is s imilar to the symptoms ass ociated with anxiety and depress ive disorders in the DS M-IV -T R . In the IC D-10, body dysmorphic dis order is subsumed under disorder. Nonetheles s, the two class ification systems more s imilar than different in how they represent the phenomenology and the history that links the disorders together. S omatization disorder is the and has the best evidence for being a discrete, and s table illness over time. T he other somatoform disorders are linked together by certain core features , 1525 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 2 of 176

also have features that call into question their fit in this category of illness . F or example, there is s upport for clas sifying convers ion dis order as a diss ociative and s ubs ets of hypochondriacs and body dysmorphics monos ymptomatic delusional disorders or anxiety disorders . T he his tory and phenomenology of the somatoform disorders have much in common.

Table 15-1 DS M-IV-TR Dis orders Diagnos tic C riteria 300.81 S omatization dis order    A. A history of many physical complaints before 30 years of age that occur over a period of several years and res ult in treatment being significant impairment in s ocial, occupational, or other important areas of functioning.    B . E ach of the following criteria must have been met, with individual symptoms occurring at any during the course of the disturbance: 1. F our pain s ymptoms . A history of pain related at leas t four different sites or functions (e.g., head, abdomen, back, joints , extremities , rectum, during menstruation, during sexual intercours e, or during urination). 2. T wo gas trointes tinal s ymptoms . A history of 1526 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 3 of 176

least two gas trointes tinal s ymptoms other pain (e.g., naus ea, bloating, vomiting other during pregnancy, diarrhea, or intolerance of several different foods). 3. O ne s exual s ymptom. A his tory of at least sexual or reproductive symptom other than (e.g., s exual indifference, erectile or dysfunction, irregular mens es, exces sive mens trual bleeding, or vomiting throughout pregnancy). 4. O ne ps e udone urological s ymptom. A history least one s ymptom or deficit suggesting a neurological condition not limited to pain (conversion s ymptoms , s uch as impaired coordination or balance, paralys is or localized weaknes s, difficulty s wallowing or lump in throat, aphonia, urinary retention, loss of touch or pain sens ation, double vision, blindnes s, deafnes s, and s eizures; symptoms, s uch as amnes ia; or loss of cons ciousnes s other than fainting).    C . E ither (1) or (2): 1. After appropriate investigation, each of the symptoms in C riterion B cannot be fully explained by a known general medical or the direct effects of a s ubstance (e.g., a of abus e, a medication). 2. When there is a related general medical condition, the phys ical complaints or resulting 1527 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 4 of 176

social or occupational impairment are in of what would be expected from the history, phys ical examination, or laboratory findings .    D. T he symptoms are not intentionally feigned (as in factitious disorder or malingering). 300.81 Undifferentiated s omatoform dis order    A. One or more phys ical complaints (e.g., loss of appetite, or gastrointestinal or urinary complaints ).    C . E ither (1) or (2): 1. After appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a subs tance (e.g., a drug of abuse or a 2. When there is a related general medical condition, the phys ical complaints or resulting social or occupational impairment is in excess what would be expected from the his tory, phys ical examination, or laboratory findings .    C . T he symptoms caus e clinically s ignificant distress or impairment in s ocial, occupational, or other important areas of functioning.    D. T he duration of the disturbance is at least 6 months. 1528 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 5 of 176

   E . T he dis turbance is not better accounted for another mental dis order (e.g., another disorder, s exual dysfunction, mood disorder, disorder, s leep disorder, or ps ychotic dis order).    F . T he symptom is not intentionally produced or feigned (as in factitious disorder or malingering). 300.11 C onvers ion dis order    A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest neurological or other general medical condition.    B . P sychological factors are judged to be with the symptom or deficit, becaus e the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stress ors .    C . T he symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).    D. T he symptom or deficit cannot, after inves tigation, be fully explained by a general medical condition or by the direct effects of a subs tance, or as a culturally s anctioned behavior experience.    E . T he symptom or deficit caus es clinically 1529 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 6 of 176

significant dis tres s or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.    F . T he symptom or deficit is not limited to pain sexual dys function, does not occur exclus ively during the course of s omatization dis order, and is not better accounted for by another mental    S pe cify the type of s ymptom or deficit:    

With motor symptom or deficit With s ens ory symptom or deficit With s eizures or convulsions With mixed presentation

Pain dis order    A. P ain in one or more anatomical s ites is the predominant focus of the clinical pres entation and of sufficient severity to warrant clinical attention.    B . T he pain caus es clinically s ignificant dis tres s impairment in s ocial, occupational, or other important areas of functioning.    C . P sychological factors are judged to have an important role in the onset, s everity, maintenance of the pain.    D. T he symptom or deficit is not intentionally 1530 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 7 of 176

produced or feigned (as in factitious disorder or malingering).    E . T he pain is not better accounted for by a anxiety, or ps ychotic dis order and does not meet criteria for dyspareunia.    C ode as follows : 307.80 Pain dis order as s oc iated with ps ychologic al fac tors : P s ychological factors are judged to have the major role in the ons et, exacerbation, or maintenance of the pain. (If a general medical condition is pres ent, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) T his of pain disorder is not diagnosed if criteria are met for somatization disorder.    S pe cify if:  

Acute: duration of less than 6 months C hronic : duration of 6 months or longer

307.89 Pain dis order as s oc iated with both ps ychologic al fac tors and a general medic al condition: B oth ps ychological factors and a medical condition are judged to have important roles in the onset, s everity, exacerbation, or maintenance of the pain. T he ass ociated general medical condition or anatomical site of the pain 1531 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 8 of 176

the following discus sion) is coded on Axis III.    S pe cify if:  

Acute: duration of less than 6 months C hronic : duration of 6 months or longer

Note: T he following is not cons idered to be a disorder and is included here to facilitate diagnosis. Pain dis order as s ociated with a general condition: A general medical condition has a role in the onset, s everity, exacerbation, or maintenance of the pain. (If ps ychological factors present, they are not judged to have a major role the ons et, severity, exacerbation, or maintenance the pain.) T he diagnos tic code for the pain is selected bas ed on the as sociated general condition if one has been es tablis hed or on the anatomical location of the pain if the underlying general medical condition is not yet clearly es tablis hed—for example, low back (724.2), (724.3), pelvic (625.9), headache (784.0), facial (784.0), chest (786.50), joint (719.4), bone abdominal (789.0), breast (611.71), renal (788.0), (388.70), eye (379.91), throat (784.1), tooth and urinary (788.0). 300.7 Hypochondrias is

1532 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 9 of 176

   A. P reoccupation with fears of having, or the that one has, a serious diseas e based on the misinterpretation of bodily symptoms .    B . T he preoccupation pers is ts despite medical evaluation and reass urance.    C . T he belief in C riterion A is not of delusional intens ity (as in delusional disorder, somatic type) and is not res tricted to a circumscribed concern about appearance (as in body dys morphic    D. T he preoccupation causes clinically distress or impairment in s ocial, occupational, or other important areas of functioning.    E . T he duration of the disturbance is at least 6 months.    F . T he preoccupation is not better accounted generalized anxiety disorder, obsess ivedisorder, panic disorder, a major depress ive separation anxiety, or another s omatoform S pe cify if: 

With poor ins ight: if, for mos t of the time during the current episode, the pers on does recognize that the concern about having a serious illness is excess ive or unreasonable

1533 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 10 of 176

300.7 B ody dys morphic dis order    A. P reoccupation with an imagined defect in appearance. If a s light phys ical anomaly is the person's concern is markedly exces sive.    B . T he preoccupation causes clinically distress or impairment in s ocial, occupational, or other important areas of functioning.    C . T he preoccupation is not better accounted by another mental dis order (e.g., diss atisfaction body shape and s ize in anorexia nervosa). 300.81 S omatoform dis order, not otherwis e s pecified    T his category includes dis orders with symptoms that do not meet the criteria for any specific s omatoform disorder. E xamples include 1. P seudocyesis: a false belief of being that is as sociated with objective signs of pregnancy, which may include abdominal enlargement (although the umbilicus does not become everted), reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, naus ea, breas t engorgement and secretions, and labor pains at the expected of delivery. E ndocrine changes may be but the syndrome cannot be explained by a 1534 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 11 of 176

general medical condition that causes changes (e.g., a hormone-secreting tumor). 2. A disorder involving nonpsychotic hypochondriacal symptoms of less than 6 months' duration. 3. A disorder involving unexplained phys ical complaints (e.g., fatigue or body weakness ) less than 6 months' duration that are not due another mental dis order.

Adapted from American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal 4th ed. T ext rev. W as hington, DC : American P sychiatric P ublishing; 2000.

Table 15-2 IC D-10 S omatoform Dis orders Diagnos tic C riteria F45.0 S omatization dis order    A. T here must be a his tory of at leas t 2 years ' complaints of multiple and variable physical symptoms that cannot be explained by any detectable phys ical disorders . (Any phys ical disorders that are known to be present do not 1535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 12 of 176

explain the s everity, extent, variety, and of the physical complaints , or the ass ociated disability.) If s ome symptoms clearly due to autonomic arous al are present, they are not a feature of the disorder in that they are not particularly pers istent or dis tres sing.    B . P reoccupation with the s ymptoms caus es persis tent distress and leads the patient to s eek repeated (three or more) cons ultations or s ets of inves tigations with primary care or specialist In the abs ence of medical s ervices within the financial or physical reach of the patient, there be persistent s elf-medication or multiple cons ultations with local healers.    C . T here is pers is tent refusal to accept medical reass urance that there is no adequate physical for the physical symptoms. (S hort-term of such reass urance, i.e., for a few weeks during immediately after investigations , does not this diagnos is .)    D. T here must be a total of six or more from the following lis t, with symptoms occurring in at leas t two s eparate groups: 

G as trointes tinal s ymptoms 1. Abdominal pain 2. Naus ea 3. F eeling bloated or full of gas 1536

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 13 of 176







4. B ad tas te in mouth or excess ively coated tongue 5. C omplaints of vomiting or regurgitation of food 6. C omplaints of frequent and loose bowel motions or discharge of fluids from anus C ardiovas c ular s ymptoms 1. B reathless nes s without exertion 2. C hes t pains G enitourinary s ymptoms 1. Dys uria or complaints of frequency of micturition 2. Unpleas ant sensations in or around the genitals 3. C omplaints of unus ual or copious vaginal discharge S kin and pain s ymptoms 1. B lotchines s or discoloration of the skin 2. P ain in the limbs , extremities, or joints 3. Unpleas ant numbness or tingling

   E . Mos t commonly us ed e xclus ion claus e . do not occur only during any of the s chizophrenic related dis orders (F 20 through F 29), any of the (affective) disorders (F 30 through F 39), or panic disorder (F 41.0). F45.1 Undifferentiated s omatoform dis order    A. C riteria A, C , and E for s omatization disorder

1537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 14 of 176

(F 45.0) are met, except that the duration of the disorder is at least 6 months.    B . One or both of C riteria B and D for disorder (F 45.0) are incompletely fulfilled. F45.2 Hypochondriac al dis order    A. E ither of the following must be present: 



A persistent belief, of at leas t 6 months ' of the presence of a maximum of two s erious phys ical diseases (of which at least one mus t specifically named by the patient). A persistent preoccupation with a presumed deformity or disfigurement (body dys morphic disorder).

   B . P reoccupation with the belief and the caus es pers istent dis tres s or interference with personal functioning in daily living and leads the patient to seek medical treatment or (or equivalent help from local healers).    C . T here is pers is tent refusal to accept medical reass urance that there is no physical cause for symptoms or phys ical abnormality. (S hort-term acceptance of s uch reass urance, i.e., for a few during or immediately after investigations does exclude this diagnosis.)

1538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 15 of 176

   Mos t commonly us ed e xclus ion claus e . T he symptoms do not occur only during any of the schizophrenic and related dis orders (F 20 through F 29, particularly F 22) or any of the mood disorders (F 30 through F 39). F45.3 S omatoform autonomic dys func tion    A. T here must be s ymptoms of autonomic that are attributed by the patient to a phys ical disorder of one or more of the following s ys tems organs :  

  

Heart and cardiovas cular s ys tem Upper gas trointestinal tract (es ophagus and stomach) Lower gas trointestinal tract R es piratory system G enitourinary system

   B . T wo or more of the following autonomic symptoms mus t be pres ent:     

P alpitations S weating (hot or cold) Dry mouth F lushing or blus hing E pigas tric dis comfort, “butterflies ,” or in the s tomach

   C . One or more of the following s ymptoms mus t 1539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 16 of 176

present: 

  

  

C hes t pains or dis comfort in and around the precordium Dys pnea or hyperventilation E xces sive tirednes s on mild exertion Aerophagy, hiccough, or burning s ens ations ches t or epigastrium R eported frequent bowel movements Increased frequency of micturition or dysuria F eeling of being bloated, dis tended, or heavy

   D. T here is no evidence of a disturbance of structure or function in the organs or s ys tems which the patient is concerned.    Mos t commonly used exclusion clause. T hes e symptoms do not occur only in the presence of phobic disorders (F 40.0 through F 40.3) or panic disorder (F 41.0).    A fifth character is to be us ed to clas sify the individual dis orders in this group, indicating the organ or system regarded by the patient as the origin of the s ymptoms:    F 45.30 Heart and cardiovas cular s ys tem       Includes : cardiac neurosis, neurocirculatory as thenia, and Da C os ta's s yndrome.

1540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 17 of 176

   F 45.31 Upper gastrointestinal tract       Includes : ps ychogenic aerophagy, hiccough, gastric neuros is .    F 45.32 Lower gastrointestinal tract       Includes : ps ychogenic irritable bowel ps ychogenic diarrhea, and gas s yndrome.    F 45.33 R es piratory system       Includes : hyperventilation.    F 45.34 G enitourinary s ys tem       Includes : ps ychogenic increas e of frequency micturition and dys uria.    F 45.38 Other organ or system F45.4 Pers is tent s omatoform pain dis order    A. T here is persis tent s evere and distress ing (for at leas t 6 months , and continuously on most days ), in any part of the body that cannot be explained adequately by evidence of a proces s or a physical dis order and that is the main focus of the patient's attention.

1541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 18 of 176

   Mos t commonly us ed e xclus ion claus e . T his does not occur in the pres ence of s chizophrenia related dis orders (F 20 through F 29), or only any of the mood (affective) disorders (F 30 F 39), s omatization disorder (F 45.0), somatoform disorder (F 45.1), or hypochondriacal disorder (F 45.2). F45.8 Other s omatoform dis orders    In these dis orders, the pres enting complaints not mediated through the autonomic nervous system and are limited to specific s ys tems or the body, such as the s kin. T his is in contrast to multiple and often changing complaints of the origin of s ymptoms and dis tres s found in somatization disorder (F 45.0) and somatoform disorder (F 45.1). T is sue damage is involved.    Any other dis orders of sens ation not due to phys ical disorders , which are clos ely as sociated time with stress ful events or problems or which res ult in significantly increased attention for the patient, personal or medical, should also be clas sified here. F45.9 S omatoform dis order, uns pec ified

1542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 19 of 176

Adapted from IC D-10 C las s ification of Me ntal and B ehavioural Dis orde rs . G eneva: World Health Organization; 1993:105–109.



B R IE F HIS T OR Y



G E NE R AL P HE NOME NOLOG Y



G E NE R AL E T IOLOG IE S



T R E AT ME NT P R INC IP LE S



S OMAT IZAT ION DIS OR DE R



HY P OC HONDR IAS IS



C ONV E R S ION DIS OR DE R



B ODY DY S MOR P HIC DIS OR DE R



P AIN DIS OR DE R



UNDIF F E R E NT IAT E D S OMAT OF OR M



S OMAT OF OR M DIS OR DE R NOT OT HE R WIS E



S P E C IAL C ONS IDE R AT IONS



F UT UR E DIR E C T IONS



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > B R IE F HIS T OR

1543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 20 of 176

B R IE F HIS TOR Y P art of "15 - S omatoform Dis orders" S omatoform means taking the form of (or in) soma, implies that these illnes ses are nonsomatic. thus a misnomer and reflects the historical and current of knowledge about the physiology of these dis orders. With res pect to the epistemological problems of mind– body dualis m, the general category of s omatoform disorders is better thought of as une xplained clas s of illnes ses that have changed in their presumed etiology over time. T he earlies t notions about symptoms were focus ed on disturbances of organs and body systems . Hippocrates and the G reeks believed abdominal organs were the s ource of emotional T he word hypochondrium, being the part of the body caudal to the rib cage, arose from this era. T his body was to be distinguished from the prae cordia, which was the ches t over the heart. T he G reek view, prominent into the s econd millennium, held that the pertained to diges tive s ymptoms and emotional disturbances and that the praecordia was the s eat of melancholia, which had little connection to depres sive illness as it is now known. B efore the R enais sance, was a disorder of the uterus , which could wander the body and even caus e s uffocation by press ing on organs of respiration. T reatment included physical manipulation of the uterus and applications of to vulvar tis sues. T he 1600s brought increas ed understanding of the 1544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 21 of 176

nervous s ys tem (C NS ) and ideas that unexplained symptoms were a product of the brain. T he father of neurology, T homas W illis (1621 to 1675), regarded in women and hypochondrias is in men as nervous disorders of the brain and advocated hitting affected patients with a stick to the head as one treatment. S ydenham (1624 to 1689) may have had the most on the shift to consider hysteria and hypochondrias is ps ychological diseases of the mind and not the body. However, he did recommend treatments integrating phys ical and ps ychological modalities, consisting of regular exercise, ps ychological s trengthening, and purification of the blood, as well as tending to the welfare of the patient. T he 1700s saw continued sophistication of terms to describe unexplained as nervous disorders . G eorge C heyne (1671 to 1743) coined the term E nglis h malady, and many great about this disorder were produced. Debate raged about the mechanis m of hypochondriasis in men and hys teria women, which continued to be cons idered nervous disorders of the brain or mind, or both. William C ullen (1712 to 1790) is widely quoted as coined the term ne uros is , and he wrote that all cons idered to be related to hypochondriasis and were of just one primary, idiopathic species, namely hypochondrias is me lancholia. Hysteria, he held, was a separate disorder that had been confused with hypochondriasis. Later, in the 1800s, hypochondrias is cons idered to be a form of ins anity, which could begin the abdominal organs but would progres s to caus e a general inflammation of all organs, including the brain. P os tmortem cases s uggested that hypochondriasis 1545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 22 of 176

be as sociated with cortical plaques and s oftening of the brain. However, when pathological studies in the 19th century failed to demons trate anatomical abnormalities the body or brain, hypochondriasis and hys teria began be considered subtle or functional. J ean-Martin and his pupils were certain that hys teria in women and hypochondriasis in men were dis orders of the nervous system and it centers throughout the body, but they not sure of its nature or location. P hys ical therapies , as manipulation of the hypochondrium or press ure on ovaries, paralleled this line of thinking. Other writers to consider this set of dis orders as problems of in which the combined mind and body had s ome in overfeeling or oversensing. T he early 20th century brought about a paradoxical which unexplained physical s ymptoms were thought of primarily ps ychological. It was paradoxical becaus e it the students of C harcot, including S igmund F reud, who were the impetus for this s hift. T hey were certain that these were disorders of the C NS and were P.1801 P.1802 due to repress ed phys ical energy caus ed by conflict. T he paradoxical s hift occurred becaus e of the of good physical treatments and the development of ps ychological treatments , including psychoanalys is , demonstrated treatment success . Once the province of general medicine and neurology, unexplained medical symptoms now became entrenched in the burgeoning field of ps ychiatry. With ps ychiatry's movement away 1546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 23 of 176

the res t of somatic medicine in the early 20th century, too moved the dis orders of unexplained symptoms. F ormal ps ychiatric class ification divided unexplained phys ical s ymptoms in the s econd edition of the DS M (DS M-II) (1968) into the categories ne uros e s , ps ychophys iologic dis orde rs (ten types ), and s pecial s ymptoms . Neuros es were further divided into ne uros e s (divided into conversion and diss ociative ne uras the nia, depe rs onalization, hypochondrias is , and ne uros e s . T here was also a hys te rical pe rs onality T he third edition of the DS M (DS M-III) (1980) made the shift to s eparating the dis orders with phys ical (s ubtyped organic me ntal dis orders and s omatoform dis orders ) from the dis s ociative dis orde rs , a new Hys terical personality dis order was replaced with pe rs onality dis orde r. C onversion disorder was with somatization, ps ychogenic pain, and under s omatoform dis orders . T here remains a fair debate about the relevance of the category of s omatoform dis orders , the way in which diagnoses are cons tructed, and the us efulness of diagnostic entities . S omatoform dis orders overlap with anxiety, affective, dis sociative, and personality S omatic s ymptoms are more common manifestations anxiety, depress ion, and trauma syndromes throughout the world than are ps ychological symptoms . Inclusion broader range of international and cultural conceptualization is needed. However, there is not debate about the importance of this s et of disorders to ps ychiatry and the res t of medicine. Unexplained symptoms ass ociated with high distress and high care use are a common problem for clinical medicine. 1547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 24 of 176

More than one-half of the most common symptoms in primary care are not adequately explained by a current biomedical paradigm. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > G E NE R AL P H E NO ME NO LO

GE NE R AL P art of "15 - S omatoform Dis orders"

E mbodiment E xpres sing general distress bodily is common P sychologizing of general dis tres s s eems to be a born of W es tern intellectual commitments to mind– dualism. Many body s ys tems are us ed to determine the source of dis tres s and the requisite action to counter it. S ensory and motor systems are activated during appraisal, and res olution of threat. During normal conditions, a person accurately appraises the s ource of threat and the behavior needed to counter it, and succes sful res olution quiets s ys tems back to normal. although s ens ory systems are always active, they are cons ciously felt if there is an appraisal of no threat. V arious elements of human ps ychobiology create conditions in which a pers on perceives ongoing threats that are felt in the body. T emperament may influence degree to which a child is focus ed on s ens ory systems cue for danger. F or example, young children of parents with panic dis order are more likely than children of without panic dis order to inhibit their exploring behavior in novel situations . S econd, there is s trong evidence 1548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 25 of 176

young children learn how to expres s their dis tres s. inves tigators describe case reports and cas e s tudies in which a child comes to medical care talking about pain one or another body system that is similar to how a expres ses his or her dis tres s. T hird, psychiatric are as sociated with an increase in bodily sensation, succes sful treatment of the disorder, s uch as an affective illnes s, can markedly reduce the somatic preoccupation and distress . F ourth, ongoing life coupled with poor coping s kills lead to generalization P.1803 P.1804 acros s multiple situations of the general s tres s and the flight, fight, or freeze respons e. T his phenomenon is s trongly conditioned by the intermittent and random nature of the life s tres sors and is mitigated res olution of the fear respons e by adequate coping. early-life adverse experiences may cause changes in ps ychobiology, s uch as pers is tent hyperadrenalis m hyper- or hypocortis olism, which have an impact on sens ory perception and reflex behavior. T here is good evidence in animal and human res earch indicating that advers e experiences , s uch as maternal s eparation, is olation, and deprivation, and overt forms of trauma influence the development and functioning of central peripheral nervous s ys tem components and the system and are ass ociated with worse health and wors e health by objective meas ures . T he phenomenon of reexperiencing in posttraumatic s tres s disorder (P T S D) is perhaps the best example of how 1549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 26 of 176

trauma becomes embodied. It has been known since late 1980s that there is a heightened autonomic to general threat cues in people with P T S D and that res ponse is incrementally larger to greater specificity of trauma cue. R ecently, inves tigators have determined the sensory cortex as sociated with specific body areas stimulated as s een on pos itron emis sion tomography in res pons e to a cue of a pas t trauma to that body T he integration of memory of pas t events with of current events occurs in s ens ory pathways just as it in cognitive pathways. T hes e memories are designed protective but, as in all organic s ys tems, can become pathological and maladaptive. In any cas e, as pas t are learned and stored in brain, they are als o learned stored in thos e s ens ory circuits that extend from brain are called body.

P erc eption and C ognition Many studies have demons trated that certain and cognitive s tyles are ass ociated with somatoform disorders . P eople with s omatization and have a lower threshold for perceiving certain proces ses and think that minor physical complaints be catas trophic phys ical events. T hey often have high negative self-appraisal and s elf-concepts of being and unable to tolerate stress . P eople with s omatoform disorders generally are more accurate in dis tinguishing between s maller increments of sensory s timuli than people without thes e disorders , although there are a mitigating s tudies about this. P eople with these tend to overreport s ymptoms during minor illnes ses during medical tests , s uch as pulmonary function tests , and notice s ymptoms more often when they read about 1550 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 27 of 176

them. P eople with hypochondriasis differ from normal subjects and anxiety patients in their perception and misinterpretation of normal bodily s ens ations , and this may be due to fluctuations in emotion.

A mplific ation B odily sensations are felt, thought about, appraised for meaning, and acted on. Many investigators have noted interactive relations hip and mutual reinforcement between sensation, cognitive appraisal, and behavior people with somatoform disorders. T hese reinforcing interactions have been termed s omatos e ns ory amplification, a proces s in which a pers on learns to feel body sensations more acutely, s ometimes more and may catastrophically dis tort the meaning of thos e sens ations by equating them with illness . T his phenomenon is likely part of a cognitive style of self-observation coupled with selective perception and amplification of phys ical s ens ations , which lead to excess ive perception of body vulnerability and overes timation of the likelihood of being ill.

Interac tion with A nxiety and Depres s ion Unexplained s omatic symptoms are highly prevalent in anxiety and affective disorders and diminish with adequate treatment of the anxiety or depres sive disorder. T here are numerous hypothes es about how occurs, including selective perception, amplification, increased autonomic nervous system activity. E ightyto 95 percent of people who come to primary care around the world and who are subsequently diagnosed 1551 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 28 of 176

with an anxiety or depres sive disorder pres ent with somatic symptoms as their chief complaint. T his may because somatic s ymptoms are actually prominent in these dis orders becaus e of their ps ychobiology or people us e s omatic s ymptoms as the mos t acceptable currency to obtain care, or both.

P rimary and S ec ondary Dis orders It is thought that C . F . Michea (1815 to 1882) was the to postulate an idiopathic (primary or true) form and a secondary form of hypochondriasis, which he called tris te (s ad monomania). T hes e forms are important conceptually for purpos es of clas sification and for determining treatment and predicting outcomes. forms are when the s omatoform dis order is the only condition of concern or, when there is comorbidity, the somatoform disorder precedes the other disorder and res ponsible for the unexplained physical symptoms. secondary form occurs when another dis order the ons et of the s omatoform disorder, and the unexplained physical symptoms are thought to be due or s econdary to, the other illness . S omatoform P.1805 may be s econdary to other ps ychiatric or other medical illness . T here is empirical s upport for the importance of both forms .

R elations hip to F ac titious and Malingering Dis orders T here is often confus ion about the relations hip somatoform disorders and factitious and malingering 1552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 29 of 176

disorders . T his is partly because they are all viewed as faking of symptoms in common medical parlance. However, they are different process es , with overlap between them, with features that are critical for the general ps ychiatris t to be familiar with. A concept that helps dis tinguis h between them is how symptom is produced and whether it is really being felt and not faked. It is not a critical feature of thes e that the phys ician believe in the authenticity of the symptoms, as this is not a reliable feature for P hysicians often only cons ider symptoms authe ntic if can be meas ured in the context of the biomedical In fact, the realnes s of a given symptom has to do with whether it is produced cons cious ly or uncons ciously by patient. In somatoform disorders , symptoms are unconsciously and are thus as authentic as a symptom diabetes mellitus. T he somatoform-disordered patient not making the s ymptom up for any reas on for which she is aware, and he or s he is rightfully offended when suggested that the s ymptom is being faked. In disorders , the patient has some awarenes s that he or intentionally produces the symptom, although this awarenes s is us ually les s than complete. In disorders , the pers on is clearly and cons cious ly the symptom to obtain external incentives. T he other concept that helps dis tinguis h thes e is the reason for, or the gain produced by, the regardless of the nature of s ymptom production. In somatoform disorders , the patient has no awarenes s of why this symptom has been produced, even if ps ychological factors are res pons ible for its production. this regard, the reas on for the s ymptom is s aid to be for 1553 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 30 of 176

primary gain. T his implies that the patient has no incentives for the s ymptoms, which may be due to ps ychophys iological variables that are out of the awarenes s of the patient. T he gain in s omatoform disorders is generally primitive—the patient who has symptoms s imply hopes that there is s omeone who help him or her feel better. However, because the somatoform patient feels sick, he or s he often reques ts phys ical or social benefits of illness , s uch as time off duties or dis ability benefits. In factitious dis orders, the reason for the s ymptoms is als o generally unconscious is thought to be due to the need to ass ume the s ick and to obtain the benefits that go along with being ill. T hese benefits are us ually primary, or about the self, but these needs and benefits may als o extend to phys ical or social world of the patient. As long as this remains partially or fully uncons cious to the patient, a factitious, not a malingering, disorder is pres ent. In malingering, the person is fully aware of why he or s he producing the illnes s, and the gain is said to be or external, to the s elf. T he malingering pers on is cons cious of using s ymptoms to obtain money or medications or to avoid duties. One problem for the clinician is that all three conditions can result in the as king for as sistance with things external to the s elf, thus, all three often get equated with being faked for external gain. T he difference is that the s omatoform factitious patient thinks they des erve what they are reques ting to gain bas ed on an illness , whereas the malingerer has no illus ions that s ymptoms are the for the attempted gain. F igure 15-1 demonstrates the relationship of s ymptom 1554 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 31 of 176

production and gain between these three dis orders. C linically, there is a spectrum between these dis orders how symptoms are produced and for what gain, and it the expertise of the clinician that allows him or her to clas sify a pers on who has s ymptoms that are not by known biomedical caus e. S omatoform and factitious disorders imply the pres ence of ps ychopathology or illness , whereas malingering implies the abs ence of ps ychopathology and the presence of s ociopathy.

FIGUR E 15-1 S omatoform, factitious, and malingering disorders : a comparison of s ymptom production, gain, phys iological bas is . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

1555 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 32 of 176

> T able of C ontents > V olume I > 15 - S omatoform Dis orders > G E NE R AL E T IO LOG

GE NE R AL E TIOL OG IE S P art of "15 - S omatoform Dis orders" T he etiologies of all somatoform disorders are T here are theories and some phys iological data to some of thes e theories.

G enetic T here is no direct evidence of a genetic etiology for any the s omatoform dis orders . T he few family and twin that have been conducted s upport a familial etiology for somatization disorder but not for hypochondriasis. support for a familial component for somatic anxiety a general population twin s tudy. Adoption s tudies demonstrate a weak, but present, familial relations hip the somatization phenomenon. T aken as a whole, it appears that a small amount of the variance for developing a preoccupation with body s ensation or a propens ity to amplify bodily sensations is genetically determined.

L earning and S oc ioc ultural A large body of research s upports the idea that early experiences and learning are the primary etiological factors of somatic s ensitivity and bodily preoccupation. C hildren's s ymptoms are often a copy of other family members' s ymptoms . Adult s omatoform s ymptoms are similar to those symptoms that were given attention by parents in childhood. Habitual attention to a given body 1556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 33 of 176

part improves the ability of a person to detect in that body part. R es earch has demons trated that can be trained to improve perception of bodily S ociocultural construction of body and mind has an impact on how people feel emotion and how it T here is evidence for differential conditioning of phys iological arousal acros s different cultural groups. C ulture also teaches people what is acceptable to and what is not, and this influences the manifes tation emotion and body sensation. S ocioeconomic class , education level, and subculture influence the rates of expres sing emotional distress as somatic complaint. P.1806

P s yc hodynamic F ac tors It is recommended that the reader consult cross material for comprehensive reading on this complicated is sue. T he most compelling theory with some empirical evidence is that the development of narciss is m is into bodily preoccupation. W hen a young child begins make the trans ition to unders tanding that there is something other than self, and thus begins the process separation and identity formation, parental figures can continue to be present and to acknowledge the needs the child during this transition, or they can be intermittently present and absent, creating in the child a sens e of anxiety, fear of abandonment, and betrayal. the latter occurs, the child becomes afraid of the other and is not yet certain of self. Ambivalent anger at other is turned inward as guilt in a defens ive maneuver protect the s elf–other complex, for, if that complex is 1557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 34 of 176

good, then neither can be the child. T he child does not learn to trus t other or self and begins a proces s of selffocus , s elf-criticis m, and increas ed mis trus t of self. T his abnormal focus on the self through self-reproach and mistrust occurs well before cognition has s ubs tantially developed and thus becomes ass ociated with body sens ations and perception, as well as with affect. T he other complex has betrayed the child, and there fear throughout life that the body as s elf may abandon betray the individual at any time. T he individual, who learned how to focus on the body s elf, begins to do s o more often as a defens e against a catas trophe of body betrayal.

S tres s ors and C oping T he late 20th century brought improved unders tanding the relations hip between life events , trauma, and subs equent s omatic s ymptoms and phys ical health. Advers e life events provide multiple s timuli to which a person res ponds , and that res ponse, often s omatic due autonomic nervous s ys tem and endocrine activation, become conditioned as memory. T his memory is to serve the person to remember the event and to learn avoid other s uch events. However, in pathological syndromes in which memory systems are altered, body memory may be reexperienced in res ponse to s timuli are reminders of earlier s tres sors and trauma. T his phenomenon is cons idered more fully later in the Day-to-day s tres sors also create s omatic experiences may be learned by continued selective perception to sens ation. C oping style then predicts individual to stress ors. If s tres sors are many, pers is tent, or of 1558 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 35 of 176

impact quality, somatic respons es occur and may be learned. If one's coping s tyle is inadequate to res olve phys iological consequences of the s tres sors , then persis tent s omatic res pons es may be learned. who are burdened with an unusually high number of persis tent and high-impact s tres sors and poor coping mechanisms are at the highest ris k of somatoform disorders , as well as s ome other ps ychiatric disorders. Anger, impulsivity, hos tility, is olation, and lack of in others are s ome coping s tyles that have been with an increas ed risk for somatic s ymptoms and somatoform disorders . T here are many empirical that link anger and hostility to somatization. Hos tility, in particular, is as sociated with cardiovascular reactivity greater increas e in blood pres sure in res pons e to compared to nonhostile s ubjects and, along with is the component of the type A personality that is predictive of developing cardiovascular dis eas e. T his provides indirect evidence that this coping style is to physiological reactivity, which is as sociated with somatic sensation and amplification. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > T R E AT ME NT P R INC IP

TR E ATME NT PR INC IPL E S P art of "15 - S omatoform Dis orders"

P atient–P hys ic ian R elations hip S truc ture of Treatment P erhaps there is no set of dis orders that better 1559 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 36 of 176

the importance of the therapeutic relationship between doctor and patient and of treatment structure than the somatoform disorders . T he doctor–patient relations hip the primary element of diligent and committed and is the foundation of all medical practice. It partly imbues the phys ician with power to hurt or to heal, dependent on how the relationship unfolds . P articularly with the somatoform-disordered patient, there are three elements of this relationship that make or break other specific treatment effects. T he firs t of these elements is attention. It has been that one difference between doctors of today and of the past is that, with the advent of and reliance on phys icians today have forgotten how to attend to and to s e e the patient. It is not the dis eas e, but the man or the woman, who needs to be s een and treated. Attending primarily to laboratory values or to the abdomen or the heart only leads to wors ening of the patient with a somatoform disorder and failure on the part of the phys ician. Attention—that s imple yet hard-to-conduct behavior of looking, watching, and listening—if pres ent, allows doctor and patient to move toward care and treatment and, if absent, promotes dislike and anger between doctor and patient and disallows any effective care. T he second important element is unconditional care. It the role of the physician to understand the illnes s and patient who has the illnes s and to provide care. It is not job of the patient to unders tand and to care for the In a patient with a s omatoform dis order, the as tute phys ician unders tands that he or she must know the patient to provide unconditional care, which is 1560 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 37 of 176

characterized by [black right-pointing arrowhead]Acceptance and res pect for the person, his or her symptoms , and the symptoms are adversely affecting the person, which is why he or s he comes to the doctor as a patient. [black right-pointing arrowhead]Hearing what is said by listening to words , s killfully eliciting words are not said, and intentional watching of body movement, and affect. [black right-pointing arrowhead]R eflecting back to patient what has been s aid via all forms of communication and letting him or her know that he she is attended to. [black right-pointing arrowhead]Not expecting or needing appreciation, as many patients with somatoform disorders as sumed a parental role life for parent or other authority figure. R equiring of a s omatoform patient may make his or her symptoms worse. T he third element is skillful treatment. S pecific are cons idered later in this chapter in each s ection. treatment elements in all s omatoform dis orders are es sential to encourage the patient to engage in s pecific treatments . S ome of these elements are referred to as nons pe cific variables of treatment. However, some are general modalities that are more specific to disorders than to other ps ychiatric illness . [black right-pointing arrowhead]Attend to 1561 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 38 of 176

transference and countertransference. T he former allows treatment to occur, and the latter can treatment. P atients with s omatoform dis orders generally do not appreciate their providers , are unsatisfied with care, are not loyal patients , and are attached to their s ymptoms and not to their doctor and his or her caring. E ffective treatment begins by doctor managing his or her countertransference, which, if not done effectively, may res ult in the phys ician avoiding or firing the patient or res cuing him. [black right-pointing arrowhead]F ormulate without labels when the diagnosis is uncertain. T he somatoform patient is s tanding ready to hear the doctor tell him or her that “it is all in your head.” Unfortunately, the s omatoform patient is easily able interpret that this is being s aid, regardless of behavior. T his cue likely acts as the s timulus that recreates scenes in which the patient was not heard, not respected, and not cared for. P.1807 [black right-pointing arrowhead]E valuate appropriately with s tandard and limited workup. the history. C onduct an examination. Order tests one might order for any patient with the s igns and symptoms of the patient being treated. C ons ider ordering a test that is requested by a patient, but it if one would otherwise. Do not pursue the symptom. Do not order repeat tes ts before they are reasonably due. 1562 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 39 of 176

[black right-pointing arrowhead]F rame and make boundaries . Once diagnosed, it is in the bes t the patient to know his or her diagnosis and the treatment plan of the phys ician. It is important to conduct the ps ychos ocial his tory and to dis cuss its relevance to the dis order in a s low, deliberate, and rational way. T his helps the phys ician to restrain impulse to rapidly trans late the phys ical into the ps ychological and gradually allows the patient to unders tand and to integrate information about the role of ps ychos ocial factors in his or her disorder. [black right-pointing arrowhead]C onnect for the patient the languages of ps yche and s oma. T his is perhaps the s ingle mos t important general s kill that allows the therapeutic relationship to move on to specific treatment. Mos t people do not have a with the idea that the mind and body are and, in fact, patients generally wish that doctors think this way more often. However, most people have a hard time unders tanding how the mind and body are connected and how symptoms are Draw pictures of brain centers and how they are connected to and influence peripheral organ functioning. G ive patients homework, cons is tent their educational level, to better unders tand thes e relations hips and to teach the doctor about them. the patient to keep diaries and logs about the relations hip of body symptoms to external events. G ive them s cientific information about ps ychophys iology and s omatic symptom Als o, do not be afraid to discuss what is not known about his or her disorder; just do s o in a competent 1563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 40 of 176

and confident way. [black right-pointing arrowhead]R eass ure appropriately and s paringly. T his topic is dis cus sed more in this chapter's section on hypochondriasis. R eas sured too much, the s omatoform-disordered patient is certain that the phys ician is not attending the so-called real illness , and, if reass ured too little, patient is convinced that the doctor is hiding information about the ominous medical disorder is lurking. [black right-pointing arrowhead]C ommunicate V olumes have been written on this subject. S uffice say that the phys ician needs to be clear with the somatoform patient on what is said and what is heard without being pedantic or demeaning. T ake time to hear from the patient what is sues were discuss ed during each sess ion, and reframe this information for the patient if it is incorrect. F inally, the structure of treatment is an ess ential part of treatment of the somatoform patient. F ollow-up appointments should be time contingent, not s ymptom contingent. Dis cuss ing the follow-up schedule, its intervals , and its changes is neces sary. E ach might bes t begin by discus sing gains in functioning or changes in emotion or life events . T ime s hould be s et to attend to symptoms with history or physical examination, or both. E ach appointment should end by verifying the next s cheduled appointment and how to urgent care systems . Once diagnosed properly, referral other s pecialis ts s hould be prudently res trained. T here always an urge to refer, and this urge should always be 1564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 41 of 176

viewed in relation to the countertransference. T hus, the best thing that the doctor can do for the s omatoform patient is to commit to the therapeutic relations hip than to zealous workup or treatment of individual symptoms.

R eas s uranc e R eas surance is discus sed in this chapter's s ection on hypochondriasis, and the reader is als o referred to the reference s ection. R eass urance is a general technique all of medicine and is als o a specific technique to be skillfully with the s omatoform-disordered patient.

C ognitive-B ehavioral and Other P s yc hotherapies T he value of the psychotherapies for somatoform disorders are jus t beginning to be understood. T he should be aware that the rubric cognitive -be havioral the rapy (C B T ) repres ents many modalities that are delivered over a relatively brief period of time, s uch as 20 sess ions . P s ychoanalys is was, as dis cus sed in the history, partly res ponsible for the categorization of the hysterias because of its s ucces s in the hands of some. T here have been more than 30 controlled trials to date designed to evaluate the efficacy of C B T in patients somatization or symptom syndromes . Most of thes e studies targeted a specific s yndrome, s uch as chronic fatigue or irritable bowel dis order, although eight on more general somatization or hypochondriasis. T he most common outcomes meas ured were physical symptoms, ps ychological distress , and functional P hysical symptoms appeared to be the most 1565 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 42 of 176

treatment, as the C B T -treated patients had greater improvement than control subjects in more than twothirds of the s tudies , and there were trends toward improvement in approximately 10 percent of the P sychological dis tres s was definitely improved by C B T compared to control s ubjects in approximately 40 of the studies , with trends toward improvement in approximately 10 percent of the studies . F unctional was definitely helped by C B T in approximately 50 of the studies , and trends toward improvement were shown in approximately 25 percent of the studies. care use seems to be decreased by approximately 25 percent in two s tudies . In s tudies that followed up participants, gains were generally maintained at 12 to months after treatment completion. R andomized, controlled s tudies to date als o s upport efficacy of individual C B T for the treatment of hypochondriasis, body dysmorphic dis order, and undifferentiated s omatoform disorders , which include medically unexplained s ymptoms, chronic fatigue syndrome, and noncardiac ches t pain. G roup C B T has shown effective for the treatment of body dys morphic disorder and s omatization disorder. Long-term and dynamic therapies were the first treatments available for dis orders of unexplained symptoms in the late 19th century and early 20th T here is s ome modern empirical evidence that their use in s omatoform dis orders , and s ome s uggest dynamic therapy is a contraindication (i.e., in disorder) until more basic ps ychosocial is sues have addres sed. One problem with ass es sing outcomes of group of therapies is that there is a range of modalities 1566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 43 of 176

labeled as dynamic, and thes e therapies als o variably overlap with modalities called C B T . Methods sections some s tudies of s omatoform dis orders often do not describe the kind of therapy conducted or, better, what was actually done and for how long. It will be critical in coming decade to identify the specific and nonspecific ingredients of therapies that are useful for somatoform disorders .

P harmac otherapy T here is mounting evidence for the usefulness of antidepres sant medications in somatoform disorders . C onvers ely, it has been argued that, in these studies, somatoform s ymptoms are often secondary to mood or anxiety disorders , and these comorbid dis orders are effectively treated, decreasing the s omatoform One critical diagnostic feature to determine the choice pharmacotherapy is whether the somatoform disorder primary or s econdary and, if primary, whether there is a comorbid psychiatric condition present. Information is presented in individual dis order s ections of this chapter current pharmacological P.1808 approaches, which should be interpreted in light of the problems with class ification and diagnos is .

C ombination Therapies As in all of medicine, a prudent clinical approach that does no harm is always warranted. S omatoform are dis tres sing, impairing, and costly but are usually emergencies . T his gives the clinician time to diagnose, 1567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 44 of 176

formulate, and to plan treatment. In most cas es , given epidemiology, comorbidity, and current treatment knowledge, combination therapies of modalities previous ly are used. F urthermore, there are emerging that combination therapies are likely to be the most efficacious for the treatment of somatoform disorders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S OMAT IZAT ION DIS O R D

S OMATIZATION DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition S omatization dis orde r is an illnes s of multiple somatic complaints in multiple organ systems that occurs over period of several years and res ults in s ignificant impairment or treatment s eeking, or both. S omatization disorder is the prototypic s omatoform disorder and has the best evidence of any of the somatoform disorders being a s table and reliably meas ured entity over many years in individuals with the disorder.

His tory T he term s omatization was firs t used by W ilhelm S tekel 1943. B riquet's s yndrome was the DS M-III predecess or current somatization dis order, which was named in the revis ed third edition of the DS M (DS M-III-R ).

C omparative Nos ology In the IC D-10, somatization s yndromes of the DS M-IV 1568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 45 of 176

are distributed among the s omatoform disorders (F 45), diss ociative dis orders (F 44), and neurasthenia (F 48).

E pidemiology S tudies report widely variable lifetime prevalence rates somatization disorder, ranging from 0.2 to 2.0 percent among women and less than 0.2 percent in men. there is evidence that less res trictive diagnos tic criteria than the current DS M-IV -T R criteria carry prevalence of as great as 5 percent with s imilar levels of this population. Approximately 5 percent of primary patients meet diagnostic criteria for the disorder, but more s omatize psychosocial distress . R ecent work demonstrated that 9 percent of hos pitalized general medical patients had s omatization disorder, and 12 percent of chronic pain patients and 17 percent of outpatients with irritable bowel s yndrome met the diagnostic criteria. Differences in prevalence rates on whether the interviewer is a phys ician, on the of ass es sment, and on the demographic variables in samples studied. In epidemiological s tudies , interviewers diagnose somatization disorder more frequently than phys icians . T he onset is before 25 age in 90 percent of people with the dis order, but initial symptoms generally develop during adolescence. R isk factors for children to develop s omatization dis order living with a family member who has the dis order and parental s ubs tance abus e and antis ocial symptoms . female to male ratio ranges from 5 to 1 to 20 to 1. S omatization dis order is relatively more common in areas and in people who are nonwhite and unmarried who have less education. T he type and frequency of 1569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 46 of 176

somatic symptoms in s omatization disorder, as in and anxiety dis orders, may differ across cultures. F or example, burning hands and feet or nondelusional symptoms of insects crawling under the s kin are symptoms that may be more common in Africa and Asia than in North America. Accordingly, diagnosis take into account cultural norms. T he DS M-IV -T R lists symptoms in order of frequency as found in res earch within the United S tates . C ultural factors may also influence the gender ratio, as there is a higher reported frequency in G reek and P uerto R ican men than in American men. S omatization dis order is obs erved in 10 to 20 percent female first-degree biological relatives of women who have the dis order. T he male relatives of women with somatization disorder s how an increased ris k of personality dis order and substance-related dis orders. Having a biological or adoptive parent with any of these three disorders increases the risk of developing personality dis order, a s ubs tance-related disorder, or somatization disorder. S omatization dis order is not highly prevalent but is proportionally costly. T hese patients seek care approximately three times more often than the U.S . and they incur between 6 and 14 times the national average for health care expenditures for physician and hospital services .

E tiology T he etiology for s omatization disorder is considered in section G eneral E tiologies. 1570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 47 of 176

A 34-year-old female temporary clerk pres ented with chronic and intermittent dizziness , pares thes ias , pain in multiple areas of her body, and intermittent naus ea and diarrhea. On further his tory, the patient said that the symptoms had been pres ent most of the time, although they had been undulating s ince s he was approximately years of age. In addition to the s ymptoms previous ly mentioned, s he had mild depres sion, was disinterested many things in life, including sexual activity, and had to many doctors to try to find out what was wrong with her. E ven though she had s een many doctors and had many tests , s he s tated that “no one can find out what's wrong” with her. S he wanted another opinion. S he commented that s he had been “sick a lot” since and had been on various medications on and off. examination revealed a normotens ive, s lightly female in no acute distress . S he had diffus e and mild abdominal tendernes s, without true guarding or tenderness . Her neurological examination was normal. winced when physical examination was conducted on various parts of her body, although this wincing went away when the phys ician was s peaking with her while conducting the examination.

Diagnos is and C linic al F eatures T he es sential feature of s omatization dis order is or recurring s omatic complaints in multiple organ that caus e medical treatment or significant impairment social, occupational, or other important areas of functioning. P hys ician-rated legitimacy of the not an es sential criterion of the disorder. T he begin before 30 years of age and occur over s everal 1571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 48 of 176

(C riterion A), although the type and severity of may change over time. T he multiple s ymptoms are not fully explained by another medical condition or by a subs tance, or, if they do occur as part of another condition, the phys ical complaints or resulting is in excess of what would be expected from the phys ical examination, or laboratory tes ts (C riterion C ). F urther diagnos tic criteria include pain in at leas t four different anatomical sites, at leas t two gas trointes tinal symptoms other than pain, at least one sexual or reproductive s ymptom other than pain, and at leas t one symptom, other than pain, that P.1809 suggests a neurological condition (C riterion B ). T he common pain symptoms in U.S . populations are the head, the back, the abdomen, the joints or the chest, and the rectum, and pain is often present mens truation and with intercourse. T he most common symptoms are naus ea and abdominal bloating, but vomiting, diarrhea, and food intolerance are les s S exual and reproductive s ymptoms may consist of irregular mens es, menorrhagia, or vomiting throughout pregnancy in women. Men are mos t likely to have or ejaculatory dysfunction. Women and men may have sexual indifference. T he ps eudoneurological symptoms commonly include impaired coordination or balance described by the patient as dizzines s, paralysis, paresthes ias or localized weaknes s, difficulty aphonia, urinary hesitancy or retention, hallucinations , diminis hed or loss of touch or pain sensation, double vision, diminished hearing, amnesia, or los s of 1572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 49 of 176

cons ciousnes s other than fainting. As mentioned previously, a les s restrictive form of somatization that requires fewer s ymptoms for more prevalent than DS M-IV -T R s omatization disorder. T his abridged form has moderate to s trong empirical support for being a sound diagnos is by demons trating similar levels of impairment and health care use as the DS M-IV -T R disorder. T his also highlights the s pectral of somatization and the resultant diagnostic difficulties . P eople with s omatization dis order consider themselves be ill and are us ually reluctant to entertain the idea that the cause of their symptoms arises from psychological social dis tres s. P artly becaus e of the undulating nature the disorder, people with somatization are us ually poor historians, and they seem to exaggerate various each at different times. T hey often defy good medical by attending various clinics and by getting multiple opinions from different doctors. F urthermore, people this dis order often do not report overall improvement, even when s pecific s ymptoms have been address ed by phys ician and have improved. In fact, the improved symptom seems to be forgotten, and the patient moves being bothered by another s ymptom. T his has led to idea that s ymptom s ubs titution occurs in these which one s ymptom develops in place of another that improved. T hese clinical features of the patient do not engender the affection of phys icians. In fact, one study indicated that patients who s omatize are among the illness types who are the least liked by doctors , the being people with s ubs tance abuse, with neurological deficits , and with pers onality disorders . One common feature of these four dis orders is that they are not as 1573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 50 of 176

unders tood and treated by W estern medicine as are other disorders . T he s omatizing patient often frustrates phys icians , as if the patient is challenging the and good s kill of the doctor. T his frustration alludes to a weaknes s in the s cientific clinical medical education of U.S .-trained physicians , is the lack of education about how mind and body are integrated in their function. As discuss ed previous ly, general distress can be embodied as s omatic which is more common around the world than is ps ychological distress . T he embodiment of distress is cultural odds with much of W estern medical care, views bodily s ymptoms as evidence that there should an identifiable illness in peripheral organs. W hen the search for this propos ed illnes s ends without the symptoms and the patient are logically deemed to inauthentic. T his clinical feature, which becomes part of the countertransference of physician to patient, can an advers arial relations hip between doctor and patient. P sychiatric comorbidity is high in s omatization dis order. P rominent anxiety and mood s ymptoms are common are us ually the reasons for being s een in mental health settings . Major depress ive disorder, panic disorder, subs tance-related dis orders are commonly as sociated I disorders , and histrionic, borderline, and antis ocial personality dis orders are the most commonly Axis II disorders . T here may be impuls ive behavior, threats and attempts, and marital dis cord. T he lives of these individuals are often as chaotic and complicated their s ymptoms . F requent and intermittent us e of medications may lead to s ide effects and s ubs tancedisorders . P eople with somatization dis order are at 1574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 51 of 176

relatively high risk of iatrogenic harm owing to their increased health care us e, numerous medical examinations, diagnostic procedures, surgeries, and hospitalizations.

P athology T here is no known tiss ue pathology in s omatization disorder. E xperimental studies demonstrate that somatizing patients are more s omatically s ens itive and often are more accurate in dis tinguishing between differences in s timuli compared to normal control F or example, s omatizing subjects are more likely to pain at less er amounts of barium in the colon and can detect smaller volumes of inflation of a balloon at the of an es ophageal endos cope than normal control S omatic amplification is thus the primary pathological finding in this dis order, but thes e phenomena are not easily used in clinical medicine for diagnos is . P hysical examination elicits different s igns on different examinations and is remarkable for the abs ence of objective findings to fully explain the degree of the subjective complaints of patients with this disorder. Laboratory tes t res ults are remarkable for the absence findings to s upport the s ubjective complaints.

Differential Diagnos is T able 15-3 s hows the vas t differential diagnosis for somatization phenomena. T here are three features that most sugges t a diagnos is of somatization dis order of anothe r me dical dis orde r, and thos e are the of multiple organ s ys tems, early onset and chronic without development of physical s igns or s tructural 1575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 52 of 176

abnormalities , and absence of laboratory abnormalities that are characteristic of the s uggested medical In the process of diagnos is , the as tute clinician other medical disorders that are characterized by multiple, and confus ing s omatic symptoms, s uch as dis e as e , hyperparathyroidis m, inte rmittent porphyria, multiple s cle ros is (MS ), and s ys te mic lupus cours e, other medical disorders may be comorbid with somatization disorder and, in fact, are risk factors for developing s omatization. T he onset of multiple phys ical symptoms late in life must be cons idered to be another medical condition until proven otherwis e.

Table 15-3 Differential Diagnos is the S omatizing Patient P sychophys iological symptoms    P s ychological factors affecting phys ical illness    Nonpathological, transient ps ychogenic s omatic symptoms (all are acute but may become       G rief and bereavement, with physical       F ear, with phys ical s ymptoms       E xaggeration or elaboration of physical

1576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 53 of 176

symptoms (e.g., pos taccident, when litigation or compens ation is involved)       S leep deprivation, with phys ical symptoms       S ensory overload or deprivation, with physical symptoms P sychiatric syndromes (other than s omatoform disorders )    Mood disorders (e.g., major depres sion and dysthymia)    Anxiety dis orders (e.g., panic disorders )    S ubs tance use, abus e, and withdrawal    P s ychotic dis orders (e.g., s chizophrenia, depres sion, and monosymptomatic hypochondriasis)    Adjus tment dis orders with anxiety or or both    P ersonality dis orders    Dementias S omatoform dis orders 1577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 54 of 176

   S omatization disorder    Hypochondriasis    B ody dys morphic dis order    S omatoform pain dis order    C onversion disorder    S omatoform disorder, not otherwise s pecified V oluntary psychogenic symptoms or s yndromes    F actitious , with physical symptoms (e.g., Munchaus en syndrome)    Malingering, with physical s ymptoms

Adapted from R ubin R H, V os s C , Derks en DJ , et eds. Me dicine : A P rimary C are Approach. WB S aunders; 1996:390. G iven the nature of the multiple somatic complaints in somatization disorder, there are many other pos sible somatoform and psychiatric disorders in the differential diagnosis. W hen full criteria are not met, s omatoform dis order is diagnosed if the duration of the syndrome is 6 months or longer, and s omatoform 1578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 55 of 176

not othe rwis e s pecifie d (NOS ) is diagnosed for of shorter duration. As noted in the previous discus sion the core phenomenology of s omatoform dis orders , is overlap between these dis orders and factitious and malinge ring disorders , dependent on whether the symptom production is volitional and on the nature of gain. W hen these elements are mixed, s omatization disorder and a factitious dis order or malingering can be diagnosed. Mood and anxie ty dis orders often, but not always , have prominent s omatic s ymptoms, which do exis t separately from the mood or anxiety dis order. However, s omatization disorder may be diagnos ed as comorbid condition with mood and anxiety disorders . S chizophre nia and other ps ychotic dis orde rs with somatic delusions need to be differentiated from the nondelus ional s omatic complaints of individuals with somatization disorder. Hallucinations can occur as ps eudoneurological symptoms and mus t be from the typical hallucinations s een in P.1810 schizophrenia. S omatization disorder s ymptoms are us ually eas ier to distinguis h from ps ychotic dis orders is the case for hypochondrias is , the disease fears of can reach delusional quality.

C ours e and P rognos is S omatization dis order is a chronic, undulating, and relaps ing disorder that rarely remits completely. It is unusual for the individual with s omatization disorder to free of symptoms or help seeking for greater than 1 R es earch has indicated that a pers on diagnos ed with 1579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 56 of 176

somatization disorder has approximately an 80 percent chance of being diagnos ed with this dis order 5 years Although patients with this dis order cons ider to be medically ill, there is good evidence that they are more likely to develop another medical illnes s in the 20 years than people without s omatization disorder.

Treatment T he primary mainstay of treatment is managing and helping the patient unders tand that symptom does not equal dis eas e. P romoting function is a key of education and treatment. An early s tudy that s ending a cons ultation letter to primary care phys icians suggesting how to treat identified patients somatization disorder resulted in increas ed physical functioning and decreas ed health care cos ts for those patients. R ecent work s hows promis e for cognitive and behavioral therapies . One uncontrolled study us ing C B T that focus ed on patient education and s tres s reduction demonstrated moderate but significant improvement of phys ical s ymptoms , s omatic preoccupation, hypochondriasis, and health care use compared to a control group of untreated patients. Another uncontrolled trial of ten sess ions of individual demonstrated patient-reported significant improvement in symptomatology and phys ical functioning between baseline and pos ttreatment, as well as between and follow-up 8 months later. One randomized clinical trial of group therapy with 70 patients demonstrated significantly better patient-reported phys ical and mental health in a 1-year period during after therapy. T he more group sess ions attended, the greater the improvement in general and mental health. 1580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 57 of 176

T here was also a 52 percent net savings in health care charges in the year after treatment compared to the before. P harmacological treatment for somatization dis order is well unders tood. In one pros pective, 8-week, openstudy, 15 patients diagnos ed with full or abridged somatization disorder were treated with nefazodone (S erzone). F ourteen of the 15 patients achieved the dosage of 300 mg per day and completed the trial, and percent of the patients were rated as globally improved and s ignificantly improved on functional abilities as meas ured by the Medical Outcomes S tudy S hort F orm(S F -36). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > HY P OC HO NDR IAS

HYPOC HONDR IAS IS P art of "15 - S omatoform Dis orders"

Definition Hypochondrias is is characterized by 6 months or more general and nondelus ional preoccupation with fears of having, or the idea that one has, a s erious dis eas e the person's mis interpretation of bodily symptoms. T his preoccupation caus es significant distress and in one's life, it is not accounted for by another or medical disorder, and a s ubs et of individuals with hypochondriasis has poor ins ight about the presence of this dis order. 1581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 58 of 176

His tory C onfusion and conceptual change epitomize the hypochondriasis. Is sy P ilowsky was the first modern inves tigator to identify the three dimens ions of bodily preoccupation, disease phobia, and disease conviction with a failure to res pond to medical evaluation and reass urance that now compris e hypochondriasis. inves tigators have replicated the validity of these dimensions .

C omparative Nos ology IC D-10 hypochondriacal dis orde r is s imilar to DS M-IV hypochondriasis, but also includes body dysmorphophobia as one potential “A” criterion, which not pos sible by DS M-IV -T R criteria. DS M-IV -T R hypochondriasis highlights the element of misinterpretation of body s ymptoms.

E pidemiology T here are no good community epidemiological data hypochondriasis. T he E pidemiological C atchment Area S tudy and the National C omorbidity S urvey failed to include hypochondrias is. T his reinforces the notion that hypochondriasis is cons idered les s important than ps ychiatric disorders or that it is cons idered invalid or unreliable, or that both are true. F or whatever reason, this has rendered knowledge of the of this disorder deficient. E arly researchers sugges ted community prevalence rates between 4 and 25 R obert K ellner pioneered the Illness Attitudes S cales determined a 2 to 13 percent prevalence of disease in many nonclinical settings, including employee 1582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 59 of 176

community samples, and medical and law students. current es timates are that there is a 1.1 to 4.5 percent prevalence of hypochondriasis in the community and additional 10 percent of people who have hypochondriacal fears and beliefs . P.1811 Data from nonps ychiatric medical s ettings have relied primarily on s creening instruments for prevalence and have used both dimens ional and categorical to determine rates . Hypochondrias is is probably more common in these settings with a prevalence between and 10.3 percent. Medical s pecialty clinics, such as gastroenterology, otolaryngology, neurology, and endocrinology, have a higher rate of hypochondriacs. prevalence is approximately 12 to 22 percent in outpatients and 30 to 45 percent in ps ychiatric although people with other psychiatric disorders are uncommonly diagnosed with hypochondrias is . T he onset of the disorder is mos t commonly in the third fourth decade of life, and the s ymptoms at different do not differ s ignificantly, except for a higher depres sion in the elderly. Hypochondriasis is equally common in men and women. S tudies s uggest a s lightly higher prevalence in people with lower education and income levels and in African Americans after for socioeconomic status . P hysical dis ease does not to be as sociated with hypochondrias is . Dis eas e does predict the onset nor do people with hypochondriasis develop more physical disease over many years after diagnosis. Little is known about other factors people to hypochondriasis, although there is a 1583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 60 of 176

that certain personality features and adverse life events may contribute to the genesis of this dis order.

E tiology T he etiology of hypochondriasis is cons idered in the section G eneral E tiologies.

Diagnos is and C linic al F eatures T he critical diagnos tic feature of hypochondriasis is at 6 months of impairment caus ed by preoccupation with fears of having, or the idea that one has, a s erious based on a misinterpretation of one or more bodily or s ymptoms (C riteria A, D, and E ), and the persis ts despite medical reass urance (C riterion B ). F or hypochondriasis to be diagnos ed when another condition is present, the phys ical s igns or symptoms cannot fully account for the person's preoccupation disease. T he dis eas e phobia present in not of delusional intens ity and is not res tricted to a circums cribed concern about appearance, as s een in dys morphic dis orde r (C riterion C ). T he preoccupation better accounted for by other ps ychiatric disorders cons idered in the following discus sion of differential diagnosis (C riterion F ). T he W hiteley Index and the Attitude S cales have demons trated 71/80 percent and 72/79 percent, res pectively, to diagnosis. T here are rational doubts about hypochondrias is as a distinct entity. Inves tigators have established internal validity bas ed on DS M criteria and external and validity to measures of fear, anxiety, depress ion, vulnerability to illnes s, somatic amplification, and health 1584 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 61 of 176

care s ervice us e. T hree s tudies have demons trated predictive validity, demonstrating that 50 to 70 percent hypochondriacs continue to have the diagnos is after 1 years and that those who no longer meet diagnos tic criteria s till have more bodily preoccupation than subjects . However, family and twin studies have failed demonstrate a genetic basis for hypochondrias is . hypochondriacal probands have a s tronger family as sociation to s omatization dis order. Dis criminant for hypochondriasis is less s ound than internal and concurrent validity. T he preoccupation in hypochondrias is may be with functions , minor physical abnormalities , or ambiguous phys ical s ens ations . T he pers on attributes these or s igns to a sus pected disease and is concerned with meaning and cause. T he concerns may involve several body systems or may be about a s pecific organ or a disease. E xaminations , diagnostic tests , and from the phys ician do not generally reass ure the hypochondriac, es pecially in chronic conditions and these examinations and tes ts are conducted in a perceived as flippant by the patient. F or example, an individual preoccupied with having MS may not be reass ured by the repeated lack of findings on phys ical examination or neuroimaging studies. In fact, showing radiological pictures to a hypochondriacal patient may elicit heightened distress when the patient sees a structure and firmly interprets it as being abnormal. T he actual preoccupation with dis ease may be so that s pecific s ymptoms are not the central concern or absent. However, hypochondriacal patients do report more s ymptoms than healthy control s ubjects. P eople 1585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 62 of 176

hypochondriasis are also highly thanatophobic, and degree of death fear is greater than in people with s omatization dis order. T hanatophobia is a central clinical feature of hypochondriasis and highlights the relations hip to and embodiment of personality features . Hypochondriacs focus so much on their own body that there is a decrease of interes t in other people or other matters outside of their body. T hey obsess ionally focus on thoughts about having a dis eas e, first this one and then maybe that one to the exclusion of, or marked in, thoughts about anything other than s elf. have noted this conflictual relations hip of the hypochondriac to his or her body, having s evere fears somatic uncertainty coupled with rigid certainty about state of his or her health. T his manifests in help s eeking and attention to details of s ymptoms that irrelevant to their overall health coupled with rejecting help for real health problems and inattention to health behaviors . F or example, a hypochondriac may certain that he or s he has heart disease, even when a reasonable evaluation is negative, yet he or s he may ignore sugges tions to prevent pos sible heart disease through exercise, a low-fat diet, and cholesterolmedications . T hey are persistent s eekers of rather than of treatment, are largely uns atis fied with medical care, and often feel that physicians have not recognized their needs. In this way, hypochondriasis is embodiment of neurotic, obs ess ional, and narcis sistic personality features, which are the pers onality traits the most empirical s upport in their relations hip to hypochondriasis. C lass ical and contemporary authors 1586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 63 of 176

emphasized how hypochondrias is develops from, or is of, a defective ego s tructure, pos sibly as a result of object relations and insecure attachments during development, and how narciss is tic injury res ults in a defens ive focus on the body s elf. T his defensive with perfect health res ults in amplified and s elective somatic perception, cognitive distortions about the meaning of s ymptoms, and fear of illness and death because of the belief that inner badness may cause the body to s uddenly and perhaps fatally betray the at any time.

P athology T here is no known s omatic pathology s pecific to hypochondriasis. Nineteenth-century investigators who conducted postmortem examinations on debated whether there was inflammation and in the upper G I tract. T his was refuted.

Differential Diagnos is T he most common condition in the differential of hypochondriasis is trans ie nt preoccupation with the of having a dis eas e . T his is a commonly dis cuss ed phenomenon that may occur during the course of training, known as the me dical s tude nt s yndrome . T his syndrome has been reported in two s tudies to occur 70 to 79 percent prevalence in medical students. another study compared medical students with law students, who had the s ame level of hypochondriacal and beliefs and took only s lightly less precautions their P.1812 1587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 64 of 176

health and paid only slightly les s attention to s omatic symptoms. T hus , trans ie nt fe ars of having a dis eas e limited to medical students but are most likely to occur when a person has s ome experience with major disease, or death, such as when one's family member or when one's friend contracts a s erious illnes s. T he most important s et of conditions to consider in the differential diagnosis of hypochondriasis is another me dical condition. B efore the use of improved techniques and instruments , it may have been common for early, undetected medical disorders to be thought to be a form of hypochondriasis , perhaps in as many as percent of people diagnosed as hypochondriacal. approximately 2 to 5 percent of people diagnosed with hypochondriasis are symptomatic of another medical disorder that is s ubs equently diagnos ed. However, are no good pros pective s tudies on this is sue, and the purported hypochondriacal s ymptoms could be symptoms of many subsequent medical conditions, at least one of which everyone, at some time, acquires . are no typical diseases that s hould be cons idered in differential diagnosis. T he physician is implored to think clearly about other ins idious dis eas es that could be the caus e of the patients ' symptoms , s uch as those in the endocrine, neurological, autoimmune, and malignant categories . However, a phys ician s hould als o not iatrogenic harm by conducting tes ts without good rationale. T he pres ence of another medical condition not rule out coexisting hypochondrias is . In fact, people with chronic medical illnes s are more likely than those without chronic illness to have a comorbid somatoform 1588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 65 of 176

disorder, usually hypochondriasis or somatization E ven if the patient has a known medical illness , the diagnosis of hypochondriasis can be made if it can be definitively es tablis hed that the symptoms and preoccupation with the fear of having dis ease are out proportion to the seriousness of the organic pathology. However, given the variability in normal respons e to and disease, the diagnosis of hypochondrias is in the context of other known medical pathology s hould be res erved for individuals who are able to benefit from diagnosis by having an explanation for the degree of suffering and by being able to benefit from treatment hypochondriasis. Other somatoform dis orders are in the differential diagnosis. S omatization dis orde r occurs in 7 to 40 of individuals diagnosed with hypochondriasis . Much of the des criptive literature to date cons iders s omatization disorder and hypochondriasis together in their genes is and phenomenology. A few recent studies conclude they are s eparate entities and that people with somatization disorder are more concerned with actual symptoms, have more abnormal personality and more depres sion and anxiety, and are more likely seek treatment, whereas people with hypochondriasis more afraid of death. F igure 15-2 depicts a model of hypochondriasis P.1813 and s omatization that helps identify s hared and characteristics , as well as places to intervene with treatment. P eople with body dys morphic dis order and hypochondriasis s hare elements of obsess ive 1589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 66 of 176

preoccupation with their body as sociated with specific overvalued ideas . However, the difference is that with body dys morphic disorder focus on specific, presumed defects , are not as fearful of having a of death, and are more likely to s eek s pecific medical such as cos metic surgery or dermatological advice.

1590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 67 of 176

FIGUR E 15-2 S omatization and hypochondriasis. (Data from Hollifield M, T uttle L, P aine S , K ellner R : Hypochondrias is and somatization related to and attitudes toward s elf. P s ychos omatics . 1591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 68 of 176

Other psychiatric dis orders are also in the differential diagnosis of hypochondrias is . A ps ychotic dis orde r, a de lus ional dis orde r, a major affective dis order with ps ychotic fe atures , and s chizophre nia, mus t be ruled before establishing the diagnosis of hypochondriasis. It may be difficult to dis tinguis h between disease phobia, disease conviction, and a ps ychotic process . Many with hypochondriasis have a firm conviction that they have a disease, and there is a fair debate about delus ional thoughts are part of hypochondriasis. an individual with hypochondriacal delus ions has a unfounded belief that a dis eas e is present. those with hypochondriacal delus ions often have explanations for their belief or gross impairment of or both, such as being convinced they have been poisoned, that their organs have somehow moved, or someone or s omething outside of s elf has agency over their organs and health. Hypochondriacal beliefs accompany de pres s ion in at leas t a great minority of people with s ignificant depress ive s ymptoms . T here good s tudies that determine whether hypochondriacal beliefs are more common in major depress ion than in dysthymia or depres sion in the context of bipolar disorder. A diagnosis of a major affective disorder is likely if the hypochondriacal preoccupations begin in life. T reatment of depress ion is likely to diminis h or to ablate hypochondriacal fears that are s econdary to the depres sion, whereas comorbid primary much les s likely to abate with s uccess ful treatment of comorbid depress ion. Anxie ty dis orders are highly 1592 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 69 of 176

comorbid with hypochondrias is. Individuals with hypochondriasis have intrusive thoughts about the fear having a dis eas e and also may have as sociated behaviors (e.g., checking their blood press ure). T he relations hip between hypochondriasis and obsess ional personality is well known. However, although this preoccupation in hypochondrias is is distress ing, the patient believes that he or s he has a disease, and, in sens e, the disease conviction is not ego-dystonic. separate diagnos is of obs e s s ive -compuls ive dis order is warranted only when the obses sions or compulsions not res tricted to concerns about illnes s and meet other criteria for the dis order, including that the s ymptoms ego-dystonic. S pe cific phobias are generally not limited the body but s hould be cons idered in the person with hypochondriasis. P anic dis orde r and ge neralize d dis order are highly comorbid with hypochondrias is . Approximately 50 percent of patients diagnosed with panic dis orde r have significant hypochondriacal preoccupations. C onversely, one study demonstrated more than 50 percent of patients with hypochondriasis had panic disorder. G e ne ralize d anxie ty dis orde r is less common in hypochondriasis than in panic but studies about this comorbidity are scarce. T hese anxiety dis orders s hare common features with hypochondriasis, s uch as pathological fear and worry behaviors designed to diminish anxiety. However, in people with hypochondrias is , the fear and worry are limited to the idea of disease, and they do not have the autonomic s ymptoms ass ociated with panic or generalized anxiety disorder. Malinge ring and pe rs onality dis orde rs are in the 1593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 70 of 176

diagnosis of hypochondriasis and are cons idered more fully in other parts of this chapter.

C ours e and P rognos is T he cours e of hypochondrias is is us ually intermittent chronic. Approximately two-thirds of people diagnos ed with hypochondrias is continue to have the dis order 1 later, and thos e who are not diagnos able have hypochondriacal symptoms. P oor prognostic factors include s everity and duration of symptoms, comorbid ps ychiatric disorders, and neuroticis m, including instability and interpers onal vulnerability. Acute onset, medical comorbidity, the abs ence of a current or past or II ps ychiatric disorder, and the abs ence of gain are favorable prognos tic indicators . R is k factors developing trans ient hypochondriasis are a past ps ychiatric history, pers onality pathology, and an underlying s ens itivity to somatic s ens ations . Well-devis ed reas surance, cons is ting of the of a s hared explanatory model between doctor and patient, education, and the rational use of examination and laboratory tes ting can improve the prognosis in than one-half of people with hypochondrias is , those with trans ient or s hort duration of s ymptoms and with other positive prognos tic factors .

Treatment R eas s uranc e A thorough description of the definition and us e of reass urance in hypochondriasis has recently been well discuss ed. Discus sion with the hypochondriacal patient 1594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 71 of 176

about the fals e nature of his or her illnes s is not However, reass urance that is delivered confidently by a competent doctor us ing multiple modalities , including skillful examination, effective communication, and education, is the corners tone of treatment of the hypochondriacal patient. W ithout s ucces sful more s pecific treatments are not likely to be accepted adhered to by the patient. Important elements of reass urance are s hown in T able 15-4.

Table 15-4 E lements of E ffec tive R eas s uranc e in Hypoc hondrias is T horough examination of medical records and history Acceptance of the patient, his or her complaints , their legitimacy S cheduling regular visits with a clear goal Using clear and s imple language with terms P roviding relevant information and explanations F os tering the patient's respons ibility for his or her treatment

1595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 72 of 176

S hifting attention from physical symptoms to underlying ps ychological and s ocial problems and focus ing on patient as sets Adjusting a reass uring s tyle in a way that is for a given patient P roviding repeated reas surance P erforming appropriate examinations and tests adequate explanation

Adapted from S tarcevic V . R eas surance in the treatment of hypochondriasis . In: Lipsitt D, V , eds. Hypochondrias is : Modern P ers pective s Ancie nt Malady. Oxford, UK : Oxford University 2001:299-308. It is important that all therapies work to diminis h the preoccupation with the fear of having a dis ease. T hus , reass urance is effective when preoccupation and is harmful when it gets wors e. T his can happen, for example, when examinations and tes ts iatrogenically reinforce the notion that a dis eas e is present. Another example is when the patient believes that a doctor is competent to find the dis eas e that is believed to be present or that the doctor is dis miss ing the patient's concerns by shifting attention to emotional or social is sues. However, when there is a therapeutic 1596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 73 of 176

that is trusting due to the competence and s kill of the phys ician, then examinations, tes ts, and shifting to important ps ychosocial is sues in the patient's life encourage the patient to focus on relevant features of illness and not on the diseas e phobia. P.1814

C ognitive-B ehavioral Therapy (C B T) Uncontrolled case series have demons trated promis ing res ults of C B T in hypochondriasis . T wo controlled are als o s upportive for C B T being effective in hypochondriasis. P s ychoeducation and cognitive aimed at changing the thoughts that there is a disease present have been the standard of treatment for many years . P oor prognos tic factors for success ful C B T wors e hypochondriasis, more somatic s ymptoms , ps ychiatric comorbidity, more dysfunctional thoughts about body functions , and higher levels of health care and s ocial impairment.

Pharmac ologic al S elective serotonin reuptake inhibitors (S S R Is) and serotonin norepinephrine reuptake inhibitors (S NR Is ) been s hown to be us eful for hypochondriasis in a few small, open-label studies. Larger clinical trials were way at this writing. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > HY P OC HO NDR IAS

HYPOC HONDR IAS IS 1597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 74 of 176

P art of "15 - S omatoform Dis orders"

Definition Hypochondrias is is characterized by 6 months or more general and nondelus ional preoccupation with fears of having, or the idea that one has, a s erious dis eas e the person's mis interpretation of bodily symptoms. T his preoccupation caus es significant distress and in one's life, it is not accounted for by another or medical disorder, and a s ubs et of individuals with hypochondriasis has poor ins ight about the presence of this dis order.

His tory C onfusion and conceptual change epitomize the hypochondriasis. Is sy P ilowsky was the first modern inves tigator to identify the three dimens ions of bodily preoccupation, disease phobia, and disease conviction with a failure to res pond to medical evaluation and reass urance that now compris e hypochondriasis. inves tigators have replicated the validity of these dimensions .

C omparative Nos ology IC D-10 hypochondriacal dis orde r is s imilar to DS M-IV hypochondriasis, but also includes body dysmorphophobia as one potential “A” criterion, which not pos sible by DS M-IV -T R criteria. DS M-IV -T R hypochondriasis highlights the element of misinterpretation of body s ymptoms.

1598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 75 of 176

E pidemiology T here are no good community epidemiological data hypochondriasis. T he E pidemiological C atchment Area S tudy and the National C omorbidity S urvey failed to include hypochondrias is. T his reinforces the notion that hypochondriasis is cons idered les s important than ps ychiatric disorders or that it is cons idered invalid or unreliable, or that both are true. F or whatever reason, this has rendered knowledge of the of this disorder deficient. E arly researchers sugges ted community prevalence rates between 4 and 25 R obert K ellner pioneered the Illness Attitudes S cales determined a 2 to 13 percent prevalence of disease in many nonclinical settings, including employee community samples, and medical and law students. current es timates are that there is a 1.1 to 4.5 percent prevalence of hypochondriasis in the community and additional 10 percent of people who have hypochondriacal fears and beliefs . P.1811 Data from nonps ychiatric medical s ettings have relied primarily on s creening instruments for prevalence and have used both dimens ional and categorical to determine rates . Hypochondrias is is probably more common in these settings with a prevalence between and 10.3 percent. Medical s pecialty clinics, such as gastroenterology, otolaryngology, neurology, and endocrinology, have a higher rate of hypochondriacs. prevalence is approximately 12 to 22 percent in outpatients and 30 to 45 percent in ps ychiatric 1599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 76 of 176

although people with other psychiatric disorders are uncommonly diagnosed with hypochondrias is . T he onset of the disorder is mos t commonly in the third fourth decade of life, and the s ymptoms at different do not differ s ignificantly, except for a higher depres sion in the elderly. Hypochondriasis is equally common in men and women. S tudies s uggest a s lightly higher prevalence in people with lower education and income levels and in African Americans after for socioeconomic status . P hysical dis ease does not to be as sociated with hypochondrias is . Dis eas e does predict the onset nor do people with hypochondriasis develop more physical disease over many years after diagnosis. Little is known about other factors people to hypochondriasis, although there is a that certain personality features and adverse life events may contribute to the genesis of this dis order.

E tiology T he etiology of hypochondriasis is cons idered in the section G eneral E tiologies.

Diagnos is and C linic al F eatures T he critical diagnos tic feature of hypochondriasis is at 6 months of impairment caus ed by preoccupation with fears of having, or the idea that one has, a s erious based on a misinterpretation of one or more bodily or s ymptoms (C riteria A, D, and E ), and the persis ts despite medical reass urance (C riterion B ). F or hypochondriasis to be diagnos ed when another condition is present, the phys ical s igns or symptoms cannot fully account for the person's preoccupation 1600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 77 of 176

disease. T he dis eas e phobia present in not of delusional intens ity and is not res tricted to a circums cribed concern about appearance, as s een in dys morphic dis orde r (C riterion C ). T he preoccupation better accounted for by other ps ychiatric disorders cons idered in the following discus sion of differential diagnosis (C riterion F ). T he W hiteley Index and the Attitude S cales have demons trated 71/80 percent and 72/79 percent, res pectively, to diagnosis. T here are rational doubts about hypochondrias is as a distinct entity. Inves tigators have established internal validity bas ed on DS M criteria and external and validity to measures of fear, anxiety, depress ion, vulnerability to illnes s, somatic amplification, and health care s ervice us e. T hree s tudies have demons trated predictive validity, demonstrating that 50 to 70 percent hypochondriacs continue to have the diagnos is after 1 years and that those who no longer meet diagnos tic criteria s till have more bodily preoccupation than subjects . However, family and twin studies have failed demonstrate a genetic basis for hypochondrias is . hypochondriacal probands have a s tronger family as sociation to s omatization dis order. Dis criminant for hypochondriasis is less s ound than internal and concurrent validity. T he preoccupation in hypochondrias is may be with functions , minor physical abnormalities , or ambiguous phys ical s ens ations . T he pers on attributes these or s igns to a sus pected disease and is concerned with meaning and cause. T he concerns may involve several body systems or may be about a s pecific organ or a 1601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 78 of 176

disease. E xaminations , diagnostic tests , and from the phys ician do not generally reass ure the hypochondriac, es pecially in chronic conditions and these examinations and tes ts are conducted in a perceived as flippant by the patient. F or example, an individual preoccupied with having MS may not be reass ured by the repeated lack of findings on phys ical examination or neuroimaging studies. In fact, showing radiological pictures to a hypochondriacal patient may elicit heightened distress when the patient sees a structure and firmly interprets it as being abnormal. T he actual preoccupation with dis ease may be so that s pecific s ymptoms are not the central concern or absent. However, hypochondriacal patients do report more s ymptoms than healthy control s ubjects. P eople hypochondriasis are also highly thanatophobic, and degree of death fear is greater than in people with s omatization dis order. T hanatophobia is a central clinical feature of hypochondriasis and highlights the relations hip to and embodiment of personality features . Hypochondriacs focus so much on their own body that there is a decrease of interes t in other people or other matters outside of their body. T hey obsess ionally focus on thoughts about having a dis eas e, first this one and then maybe that one to the exclusion of, or marked in, thoughts about anything other than s elf. have noted this conflictual relations hip of the hypochondriac to his or her body, having s evere fears somatic uncertainty coupled with rigid certainty about state of his or her health. T his manifests in help s eeking and attention to details of s ymptoms that 1602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 79 of 176

irrelevant to their overall health coupled with rejecting help for real health problems and inattention to health behaviors . F or example, a hypochondriac may certain that he or s he has heart disease, even when a reasonable evaluation is negative, yet he or s he may ignore sugges tions to prevent pos sible heart disease through exercise, a low-fat diet, and cholesterolmedications . T hey are persistent s eekers of rather than of treatment, are largely uns atis fied with medical care, and often feel that physicians have not recognized their needs. In this way, hypochondriasis is embodiment of neurotic, obs ess ional, and narcis sistic personality features, which are the pers onality traits the most empirical s upport in their relations hip to hypochondriasis. C lass ical and contemporary authors emphasized how hypochondrias is develops from, or is of, a defective ego s tructure, pos sibly as a result of object relations and insecure attachments during development, and how narciss is tic injury res ults in a defens ive focus on the body s elf. T his defensive with perfect health res ults in amplified and s elective somatic perception, cognitive distortions about the meaning of s ymptoms, and fear of illness and death because of the belief that inner badness may cause the body to s uddenly and perhaps fatally betray the at any time.

P athology T here is no known s omatic pathology s pecific to hypochondriasis. Nineteenth-century investigators who conducted postmortem examinations on debated whether there was inflammation and 1603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 80 of 176

in the upper G I tract. T his was refuted.

Differential Diagnos is T he most common condition in the differential of hypochondriasis is trans ie nt preoccupation with the of having a dis eas e . T his is a commonly dis cuss ed phenomenon that may occur during the course of training, known as the me dical s tude nt s yndrome . T his syndrome has been reported in two s tudies to occur 70 to 79 percent prevalence in medical students. another study compared medical students with law students, who had the s ame level of hypochondriacal and beliefs and took only s lightly less precautions their P.1812 health and paid only slightly les s attention to s omatic symptoms. T hus , trans ie nt fe ars of having a dis eas e limited to medical students but are most likely to occur when a person has s ome experience with major disease, or death, such as when one's family member or when one's friend contracts a s erious illnes s. T he most important s et of conditions to consider in the differential diagnosis of hypochondriasis is another me dical condition. B efore the use of improved techniques and instruments , it may have been common for early, undetected medical disorders to be thought to be a form of hypochondriasis , perhaps in as many as percent of people diagnosed as hypochondriacal. approximately 2 to 5 percent of people diagnosed with hypochondriasis are symptomatic of another medical disorder that is s ubs equently diagnos ed. However, 1604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 81 of 176

are no good pros pective s tudies on this is sue, and the purported hypochondriacal s ymptoms could be symptoms of many subsequent medical conditions, at least one of which everyone, at some time, acquires . are no typical diseases that s hould be cons idered in differential diagnosis. T he physician is implored to think clearly about other ins idious dis eas es that could be the caus e of the patients ' symptoms , s uch as those in the endocrine, neurological, autoimmune, and malignant categories . However, a phys ician s hould als o not iatrogenic harm by conducting tes ts without good rationale. T he pres ence of another medical condition not rule out coexisting hypochondrias is . In fact, people with chronic medical illnes s are more likely than those without chronic illness to have a comorbid somatoform disorder, usually hypochondriasis or somatization E ven if the patient has a known medical illness , the diagnosis of hypochondriasis can be made if it can be definitively es tablis hed that the symptoms and preoccupation with the fear of having dis ease are out proportion to the seriousness of the organic pathology. However, given the variability in normal respons e to and disease, the diagnosis of hypochondrias is in the context of other known medical pathology s hould be res erved for individuals who are able to benefit from diagnosis by having an explanation for the degree of suffering and by being able to benefit from treatment hypochondriasis. Other somatoform dis orders are in the differential diagnosis. S omatization dis orde r occurs in 7 to 40 of individuals diagnosed with hypochondriasis . Much of the des criptive literature to date cons iders s omatization 1605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 82 of 176

disorder and hypochondriasis together in their genes is and phenomenology. A few recent studies conclude they are s eparate entities and that people with somatization disorder are more concerned with actual symptoms, have more abnormal personality and more depres sion and anxiety, and are more likely seek treatment, whereas people with hypochondriasis more afraid of death. F igure 15-2 depicts a model of hypochondriasis P.1813 and s omatization that helps identify s hared and characteristics , as well as places to intervene with treatment. P eople with body dys morphic dis order and hypochondriasis s hare elements of obsess ive preoccupation with their body as sociated with specific overvalued ideas . However, the difference is that with body dys morphic disorder focus on specific, presumed defects , are not as fearful of having a of death, and are more likely to s eek s pecific medical such as cos metic surgery or dermatological advice.

1606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 83 of 176

FIGUR E 15-2 S omatization and hypochondriasis. (Data from Hollifield M, T uttle L, P aine S , K ellner R : Hypochondrias is and somatization related to and attitudes toward s elf. P s ychos omatics . 1607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 84 of 176

Other psychiatric dis orders are also in the differential diagnosis of hypochondrias is . A ps ychotic dis orde r, a de lus ional dis orde r, a major affective dis order with ps ychotic fe atures , and s chizophre nia, mus t be ruled before establishing the diagnosis of hypochondriasis. It may be difficult to dis tinguis h between disease phobia, disease conviction, and a ps ychotic process . Many with hypochondriasis have a firm conviction that they have a disease, and there is a fair debate about delus ional thoughts are part of hypochondriasis. an individual with hypochondriacal delus ions has a unfounded belief that a dis eas e is present. those with hypochondriacal delus ions often have explanations for their belief or gross impairment of or both, such as being convinced they have been poisoned, that their organs have somehow moved, or someone or s omething outside of s elf has agency over their organs and health. Hypochondriacal beliefs accompany de pres s ion in at leas t a great minority of people with s ignificant depress ive s ymptoms . T here good s tudies that determine whether hypochondriacal beliefs are more common in major depress ion than in dysthymia or depres sion in the context of bipolar disorder. A diagnosis of a major affective disorder is likely if the hypochondriacal preoccupations begin in life. T reatment of depress ion is likely to diminis h or to ablate hypochondriacal fears that are s econdary to the depres sion, whereas comorbid primary much les s likely to abate with s uccess ful treatment of comorbid depress ion. Anxie ty dis orders are highly 1608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 85 of 176

comorbid with hypochondrias is. Individuals with hypochondriasis have intrusive thoughts about the fear having a dis eas e and also may have as sociated behaviors (e.g., checking their blood press ure). T he relations hip between hypochondriasis and obsess ional personality is well known. However, although this preoccupation in hypochondrias is is distress ing, the patient believes that he or s he has a disease, and, in sens e, the disease conviction is not ego-dystonic. separate diagnos is of obs e s s ive -compuls ive dis order is warranted only when the obses sions or compulsions not res tricted to concerns about illnes s and meet other criteria for the dis order, including that the s ymptoms ego-dystonic. S pe cific phobias are generally not limited the body but s hould be cons idered in the person with hypochondriasis. P anic dis orde r and ge neralize d dis order are highly comorbid with hypochondrias is . Approximately 50 percent of patients diagnosed with panic dis orde r have significant hypochondriacal preoccupations. C onversely, one study demonstrated more than 50 percent of patients with hypochondriasis had panic disorder. G e ne ralize d anxie ty dis orde r is less common in hypochondriasis than in panic but studies about this comorbidity are scarce. T hese anxiety dis orders s hare common features with hypochondriasis, s uch as pathological fear and worry behaviors designed to diminish anxiety. However, in people with hypochondrias is , the fear and worry are limited to the idea of disease, and they do not have the autonomic s ymptoms ass ociated with panic or generalized anxiety disorder. Malinge ring and pe rs onality dis orde rs are in the 1609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 86 of 176

diagnosis of hypochondriasis and are cons idered more fully in other parts of this chapter.

C ours e and P rognos is T he cours e of hypochondrias is is us ually intermittent chronic. Approximately two-thirds of people diagnos ed with hypochondrias is continue to have the dis order 1 later, and thos e who are not diagnos able have hypochondriacal symptoms. P oor prognostic factors include s everity and duration of symptoms, comorbid ps ychiatric disorders, and neuroticis m, including instability and interpers onal vulnerability. Acute onset, medical comorbidity, the abs ence of a current or past or II ps ychiatric disorder, and the abs ence of gain are favorable prognos tic indicators . R is k factors developing trans ient hypochondriasis are a past ps ychiatric history, pers onality pathology, and an underlying s ens itivity to somatic s ens ations . Well-devis ed reas surance, cons is ting of the of a s hared explanatory model between doctor and patient, education, and the rational use of examination and laboratory tes ting can improve the prognosis in than one-half of people with hypochondrias is , those with trans ient or s hort duration of s ymptoms and with other positive prognos tic factors .

Treatment R eas s uranc e A thorough description of the definition and us e of reass urance in hypochondriasis has recently been well discuss ed. Discus sion with the hypochondriacal patient 1610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 87 of 176

about the fals e nature of his or her illnes s is not However, reass urance that is delivered confidently by a competent doctor us ing multiple modalities , including skillful examination, effective communication, and education, is the corners tone of treatment of the hypochondriacal patient. W ithout s ucces sful more s pecific treatments are not likely to be accepted adhered to by the patient. Important elements of reass urance are s hown in T able 15-4.

Table 15-4 E lements of E ffec tive R eas s uranc e in Hypoc hondrias is T horough examination of medical records and history Acceptance of the patient, his or her complaints , their legitimacy S cheduling regular visits with a clear goal Using clear and s imple language with terms P roviding relevant information and explanations F os tering the patient's respons ibility for his or her treatment

1611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 88 of 176

S hifting attention from physical symptoms to underlying ps ychological and s ocial problems and focus ing on patient as sets Adjusting a reass uring s tyle in a way that is for a given patient P roviding repeated reas surance P erforming appropriate examinations and tests adequate explanation

Adapted from S tarcevic V . R eas surance in the treatment of hypochondriasis . In: Lipsitt D, V , eds. Hypochondrias is : Modern P ers pective s Ancie nt Malady. Oxford, UK : Oxford University 2001:299-308. It is important that all therapies work to diminis h the preoccupation with the fear of having a dis ease. T hus , reass urance is effective when preoccupation and is harmful when it gets wors e. T his can happen, for example, when examinations and tes ts iatrogenically reinforce the notion that a dis eas e is present. Another example is when the patient believes that a doctor is competent to find the dis eas e that is believed to be present or that the doctor is dis miss ing the patient's concerns by shifting attention to emotional or social is sues. However, when there is a therapeutic 1612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 89 of 176

that is trusting due to the competence and s kill of the phys ician, then examinations, tes ts, and shifting to important ps ychosocial is sues in the patient's life encourage the patient to focus on relevant features of illness and not on the diseas e phobia. P.1814

C ognitive-B ehavioral Therapy (C B T) Uncontrolled case series have demons trated promis ing res ults of C B T in hypochondriasis . T wo controlled are als o s upportive for C B T being effective in hypochondriasis. P s ychoeducation and cognitive aimed at changing the thoughts that there is a disease present have been the standard of treatment for many years . P oor prognos tic factors for success ful C B T wors e hypochondriasis, more somatic s ymptoms , ps ychiatric comorbidity, more dysfunctional thoughts about body functions , and higher levels of health care and s ocial impairment.

Pharmac ologic al S elective serotonin reuptake inhibitors (S S R Is) and serotonin norepinephrine reuptake inhibitors (S NR Is ) been s hown to be us eful for hypochondriasis in a few small, open-label studies. Larger clinical trials were way at this writing. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > C ONV E R S ION DIS O R D

C ONVE R S ION DIS OR DE R 1613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 90 of 176

P art of "15 - S omatoform Dis orders"

Definition C onvers ion dis orde r is an illnes s of s ymptoms or that affect voluntary motor or sensory functions , which suggest another medical condition, but that is judged to be due to psychological factors because the illnes s is preceded by conflicts or other s tres sors. T he deficits of convers ion dis order are not intentionally produced, are not due to substances, are not limited to pain or sexual s ymptoms, and the gain is primarily ps ychological and not social, monetary, or legal.

His tory C onvers ion dis order is one of many dis orders that s tem from early concepts of hysteria, which was considered previous ly in this chapter.

C omparative Nos ology DS M-IV -T R convers ion dis order is considered a disorder in IC D-10. Approximately 30 percent of diagnosed with DS M-IV -T R convers ion dis order have a comorbid dis sociative disorder, all of whom report a history of childhood neglect and s exual abuse.

E pidemiology R eported rates of conversion disorder vary from 11 out 100,000 to 300 out of 100,000 in general population samples . F ive to 16 percent of all ps ychiatry patients in a general hos pital s etting have s ymptoms are consistent with conversion dis order. C onvers ion 1614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 91 of 176

disorder is the focus of treatment in 1 to 3 percent of outpatient referrals to mental health clinics. S ome suggest a lifetime risk of approximately 33 percent for transient or longer-term convers ion symptoms . B y contrast, convers ion disorder repres ents less than 1 percent of all admis sions to psychiatric hospitals and is infrequently diagnos ed in emergency departments. C onvers ion dis order appears to be more frequent in women than in men, with reported ratios varying from 2 1 to 10 to 1. S ymptoms are more common on the left on the right side of the body in women. W omen who present with conversion s ymptoms are more likely to subs equently develop somatization dis order than who have not had convers ion symptoms . T here is an as sociation between convers ion disorder and antis ocial personality dis order in men. T he ons et of convers ion disorder is generally from late childhood to early adulthood and is rare before 10 years of age or after 35 years of age, but ons et as late as the ninth decade of has been reported. W hen symptoms s uggest a disorder onset in middle or old age, the probability of occult neurological or other medical condition is high. C onvers ion symptoms in children younger than 10 age are us ually limited to gait problems or seizures. C onvers ion dis order s eems to be more common in populations, developing nations and regions , people in lower socioeconomic clas s, and people with less education and medical knowledge. T he form of symptoms may reflect cultural ideas about acceptable ways to expres s dis tres s. F alling or an alteration of cons ciousnes s is a feature of some culture-specific syndromes. On the other hand, behaviors resembling 1615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 92 of 176

conversion or diss ociative s ymptoms are aspects of culturally s anctioned religious and healing ceremonies. T hus, cultural norms are important to consider in the diagnosis. Limited data sugges t that convers ion symptoms are frequent in relatives of people with convers ion dis order. An increas ed risk of convers ion disorder in but not dizygotic, twin pairs has been reported.

E tiology T he term conve rs ion arose from the hypothes is that a symptom or deficit represents a symbolic playing out of unconscious psychological conflict aimed at reducing anxiety about the conflict and s erving to keep the out of awareness (primary gain). T he individual may derive secondary gain from the convers ion symptom, these external benefits are generally not the aim of the conversion s ymptom or deficit. T his hypothes is has support from s tudies that demons trate that aimed at helping the patient gain ins ight about the conflict can make the physical convers ion worse, and treatment aimed at rehabilitation, allowing the patient to further avoid the conflict, helps res olve the s ymptoms . Mr. J . is a 28-year-old s ingle man who is employed in a factory. He was brought to an emergency department his father, complaining that he had lost his vision while sitting in the back seat on the way home from a family gathering. He had been playing volleyball at the but had sustained no s ignificant injury except for the volleyball hitting him in the head a few times . As was for this man, he had been reluctant to play volleyball 1616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 93 of 176

because of the lack of his athletic s kills , and was a team at the las t moment. He recalls having s ome problems with s eeing during the game, but his vision not become ablated until he was in the car on the way home. B y the time he got to the emergency his vis ion was improving, although he s till complained blurriness and mild diplopia. T he double vis ion could attenuated by having him focus on items at different distances. On examination, Mr. J . was fully cooperative, uncertain about why this would have occurred, and nonchalant. P upillary, oculomotor, and general sens orimotor examinations were normal. After being cleared medically, the patient was sent to a mental center for further evaluation. At the mental health center, the patient recounts the story as he did in the emergency department, and he still accompanied by his father. He began to recount his vis ion started to return to normal when his father pulled over on the side of the road and began to talk to him about the events of the day. He spoke with his about how he had felt embarrass ed and s omewhat conflicted about playing volleyball and how he had felt that he really should play becaus e of external F urther his tory from the patient and his father revealed that this young man had been shy as an adolescent, particularly around athletic participation. He had never had another episode of visual loss . He did recount anxious and sometimes not feeling well in his body athletic activities . P.1815 1617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 94 of 176

Dis cus sion with the patient at the mental health center focus ed on the potential role of psychological and factors in acute vis ion loss . T he patient was somewhat perplexed by this but was als o amenable to dis cuss ion. stated that he clearly recognized that he began seeing feeling better when his father pulled off to the s ide of road and discuss ed things with him. Doctors admitted they did not know the caus e of the vision loss and that would likely not return. T he patient and his father were satis fied with the medical and ps ychiatric evaluation agreed to return for care if there were any further symptoms. T he patient was appointed a follow-up time the outpatient ps ychiatric clinic.

Diagnos is and C linic al F eatures T he es sential feature of convers ion dis order is that ps ychological factors are judged to be proximal to and res ponsible for the presence of s ymptoms or deficits affecting voluntary motor or s ens ory function that a neurological or other general medical condition, the initiation or exacerbation of the s ymptom or deficit preceded by conflicts or other s tres sors (C riteria A and T he symptoms are not intentionally produced or (C riterion C ), and the disorder is not diagnosed if the symptoms or deficits are fully explained by a or other medical condition, by the direct effects of a subs tance, or as a culturally sanctioned behavior or experience (C riterion D). It is not diagnos ed if are limited to pain or s exual dys function, occur only the cours e of somatization dis order, or are better accounted for by another mental dis order (C riterion F ). symptoms or deficits caus e marked dis tres s, 1618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 95 of 176

or the s eeking of medical care (C riterion E ). Motor s ymptoms or deficits include impaired or balance, paralys is or localized weaknes s, tremor or flaccidity, difficulty s wallowing or a sensation of a lump the throat, aphonia, and urinary retention. S ens ory symptoms or deficits include loss of touch or pain sens ation, hyperesthes ia and pares thesia, double blindnes s, deafnes s, and hallucinations . T hus, the can s pecify two types of conversion disorder: (1) with motor s ymptom or deficit and (2) with s ensory or deficit. Movements that mimic a form of seizures also occur, but there is a rich academic debate about whether thes e s ymptoms are best class ified as or as dis sociative, and this debate is highlighted by conversion proponents adding a third type: (3) with seizures or convulsions. T he clinician can als o specify fourth type: (4) with mixed presentation. It is perhaps obvious that a diagnosis of conversion disorder s hould be made only after a thorough medical inves tigation has been performed to rule out another medical condition as etiological for symptoms or However, it is only recently that research has demonstrated that mis diagnosis is uncommon, perhaps reflecting increased awarenes s of the dis order, as well improved knowledge and diagnos tic techniques . E arly studies found other medical etiologies to be for the purported illnes s in approximately one-fourth to one-half of pers ons initially diagnos ed with conversion symptoms. T hese studies were beset by different methodologies and the problem of attributing caus ality. Nonetheles s, there has been concern among years that attributing symptoms or deficits to the 1619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 96 of 176

diagnosis of conversion disorder is deprecatory and medically risky for the patient and less ens the s tature the physician owing to his or her inability to find something real. T his attitude can be helpful to a patient because of the insistence to find organic pathology it is eventually found but, at other times, can relegate a patient to becoming a s ubject of the obses sive and insecure physician's s earch for the Holy G rail. T he diagnosis of conversion disorder is not jus t one of exclusion and should be made firmly and tentatively at same time, with an ever-present eye to the overall biops ychos ocial context of patient and symptoms . the diagnosis is made with too much certainty, other medical illnes s is mis sed. When too tentative, multiple irrational medical evaluations are conducted, and iatrogenic reinforcement and harm are produced. His tory and physical examination must be us ed to diagnos e convers ion dis order. As this disorder is not diagnosis of exclusion, there must be pos itive data on history and examination that the s ymptoms or deficits , both, are functional and poss ibly trans ient and not from stable organic lesion or illnes s. T aking care to history in the context of a thorough examination and versa is critical to make or to exclude the diagnosis of conversion dis order. T here are no s ine qua non events to make the diagnos is , and there are us ually conflicting signs on examination. T able 15-5 that historical data generally thought to be helpful for diagnosis have not actually been found to be s pecific markers. T hus , as a working differential diagnosis is developed, each diagnos is is propos ed and worked through s equentially with history and examination, 1620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 97 of 176

sometimes in an iterative fas hion. Determining that a symptom or deficit is being experienced in the abs ence findings consistent with other organic diseas e and is being intentionally produced can be difficult. It must be inferred from a careful evaluation of the s ymptom contextualized by its development, its potential external rewards, or the as sumption of the s ick role. A his tory of other unexplained somatic or diss ociative symptoms increases the likelihood that the symptoms or deficits due to conversion disorder, especially if criteria for somatization disorder have been met in the pas t. A positive his tory for other medical dis orders does not the ris k for a convers ion disorder unles s the current symptoms are clearly of that medical disorder. In fact, a medical illnes s is a ris k factor for conversion disorder, is for other somatoform disorders .

Table 15-5 R elative Diagnos tic Validity of C riteria for S ymptoms

Diagnos tic

Validationa

R eference (s ) b

S omatization

3+

7, 8

Ass ociated 1621 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 98 of 176

ps ychopathology

3+

9

Model for the symptom

2+

8,10

E motional stress before the onset of symptoms

1+

—

Dis turbed s exuality

0–1+

11

S ibling position

0–1+

12, 13

S ymptom as symbolism (primary gain)

0

14

S econdary gain

0

8

Hys terical

0

—

L a be lle indiffé re nce

0

8, 15

aE xpres sed

on a s cale of 0 to 3+, according to es tablis hed validity. b

R eference number in original article.

Adapted from Lazare A: C urrent concepts in 1622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 99 of 176

ps ychiatry. C onversion symptoms . N E ngl J Me d. 1981;305:745.

A phenomenological problem with convers ion disorder that, although the diagnos is requires that ps ychological factors be judged proximal to and responsible for the symptoms or deficits , there are no good data that ps ychos ocial stress ors are s ensitive or s pecific a convers ion reaction. It may be that there are that are as sociated with convers ion disorder, but data about this are lacking. T he alternative is that there no natural P.1816 relations hip between s tres sors and convers ion An epis temological problem surrounds the concept of ps ychos ocial s tre s s . Although this concept has been discuss ed through medical history and across dis eas e states , meas uring it outside of experimental conditions remains as crude as it is difficult. T hus , in s pite of the experimental evidence, the notion that recent s tres sors caus al to conversion is a long-standing intellectual commitment for psychiatry, one that has been over centuries from a plethora of theoretical writings forceful thinkers , and one that is thus difficult to 1623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 100 of 176

DS M-IV -T R s its firmly on this fragile fence by not using words “caus e” or “res ponsible for” in C riterion B . the phrase “ps ychological factors are judged to be as sociated with the s ymptom or deficit” supports and s cience by indicating that there is believed to be a relations hip between s tres sors and convers ion even though s cience has not yet proven it. T his paradox is als o present with the concept of la indiffé rence, which, since the time of P ierre J anet, has us ed to characterize the lack of concern about symptoms or deficits s een in thes e patients . T his is a striking phenomenon to obs erve and goes by the synonym de nial in the patient with myocardial infarction and ne gle ct in the neurologically impaired patient. Although la be lle indiffére nce is also hard to measure, is no good evidence that it is more common in disorder than in other medical disorders .

P athology T he lack of tiss ue pathology and s ymptoms and signs do not correlate well is the pathology s een in disorder. C onversion s ymptoms typically do not to known anatomical pathways and physiological mechanisms but instead follow the individual's conceptualization of his or her illness . T able 15-6 examples of various convers ion s ymptoms and their phys ical examination findings that demons trate that conversion patterns do not conform to anatomically known patterns and may change on multiple and with sugges tion. E xpert skill with examination procedures is indis pensable for the proper diagnos is of conversion dis order, and there are multiple text 1624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 101 of 176

on how to conduct s uch examinations. However, knowledge of anatomical and physiological incomplete, and available methods of objective as sess ment have limitations. T his is highlighted in a of patients with ps ychogenic nonepileptic seizures (P NE S s), comparing them to s ubjects with other somatoform disorders and healthy controls . T he with P NE S s reported more minor head injuries in the than did the two comparison groups , and the P NE S had more nons pecific electroencephalogram (E E G ) dysrhythmias on E E G . T he mean number of comorbid ps ychiatric diagnoses was higher in the P NE S group 0.3 compared to 1.5 ± 0.5 in the somatoform group). 23 P NE S patients also had a s omatoform pain seven had an undifferentiated somatoform disorder.

Table 15-6 Dis tinc tive Phys ic al E xamination Findings in C onvers ion Dis order

C ondition

Anesthesia

Tes t

C onvers ion Findings

Map dermatomes.

S ensory loss does not conform to recognized

1625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 102 of 176

pattern of distribution. C heck midline.

S trict half-body split.

Astasia-abasia

Walking, dancing.

With suggestion, those who cannot walk may s till be to dance; alteration of sens ory and motor findings with suggestion.

P aralys is , paresis

Drop paralyzed hand onto face.

Hand falls next to face, not on it.

Hoover test.

P res sure noted in examiner's hand under paralyzed leg when attempting straight leg

Hemianesthes ia

 

1626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 103 of 176

raising.  

C oma

C heck motor strength.

G ive-away weaknes s.

E xaminer attempts to open eyes .

R es ists gaze is away from doctor.

Ocular cephalic maneuver.

E yes s tare straight ahead and do not move from to s ide.

R equest a cough.

E ss entially, normal coughing sound that cords are clos ing.

 

Aphonia

S hort nas al grunts with little or no sneezing on inspiratory phase; little or no

Intractable 1627

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 104 of 176

sneezing

Observe.

aerosolization of secretions ; minimal facial expres sion; open; s tops when as leep; abates when alone.

Head-up tilt tes t.

Magnitude of changes in signs and venous pooling does not explain continuing symptoms.

T unnel vision

V is ual fields .

C hanging pattern on multiple examinations.

P rofound monocular blindnes s

S winging flash light (Marcus G unn).

Abs ence of relative papillary

S yncope

S ufficient vision in “bad 1628 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 105 of 176

B inocular fields .

eye” precludes plotting normal phys iological blind spot in good eye.

S evere blindnes s

“Wiggle your fingers , I'm just testing coordination.”

P atient may begin to mimic new movements before the s lip.

 

S udden flas h of bright light.

P atient

“Look at your hand.”

P atient does not look there.

“T ouch your index

E ven blind patients can do this by proprioception.

 

 

Adapted from S adock B J , S adock V A. K aplan S adock's C ompre hens ive T e xtbook of P s ychiatry. ed. P hiladelphia: Lippincott W illiams & Wilkins; 1629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 106 of 176

2000:1512.

No s pecific laboratory abnormalities are as sociated conversion disorder. In fact, the abs ence of findings supports the diagnos is of convers ion disorder. laboratory findings cons is tent with another medical condition do not exclude the diagnos is of convers ion disorder, becaus e the diagnosis requires that the symptoms or deficits not be fully explained by the other medical condition. E xperimental psychophysiology has suggested two abnormalities in convers ion dis order. F irst, when given increasingly higher anxiogenic s timuli, convers ion have increas ing levels of sympathetic nervous s ys tem (S NS ) discharge, as meas ured by skin conductance, moderately high level, and then S NS discharge levels contrast, anxiety disorder s ubjects continue to have S NS discharge to higher levels of anxiogenic stimuli. S econd, convers ion subjects may have more rapid evoked potential spikes in contralateral sensory cortex than in ipsilateral cortex to P.1817 phys ical s timuli, s uggesting that the affected paralytic 1630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 107 of 176

is actually more s ens itized to s timuli, even though the subject states that he or she has no s ens ation. Other psychopathology that is commonly comorbid with conversion disorder includes mood and anxiety on Axis I in approximately 25 to 50 percent of patients C lus ter B pers onality disorders on Axis II in 10 to 40 percent of patients.

Differential Diagnos is T he most important conditions in the differential are ne urological or other me dical dis orders and induce d dis orde rs . Appropriate evaluation for thes e conditions includes a careful history of the current symptoms and context, a thorough medical history, complete neurological and general phys ical that focus on detection of s igns to include or to exclude medical illnes s, and appropriate laboratory s tudies, may include urine or serum toxicology. T horough documentation of the his tory, examination, context, laboratory tes ts, and clinician impres sion of the factors ruling in or out various medical conditions is important alleviate further unneces sary medical evaluations. 15-7 lists s ome of the more frequent neurological, other medical, and substance conditions that need to be cons idered in the differential diagnosis. P artial comple x s e izure dis orde rs and autoimmune dis orders may be misdiagnos ed for years , given the variability in symptomatology and the undulating nature of the illness es. Approximately 30 percent of systemic lupus erythematosus cas es pres ent with predominantly neurops ychiatric s ymptoms or deficits , or both, us ually mania or psychosis. 1631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 108 of 176

Table 15-7 Medic al Dis orders in Differential Diagnos is of C onvers ion Dis order Myas thenia gravis S ys temic lupus erythematosus P eriodic paralysis B rain tumor Multiple sclerosis Optic neuritis P artial vocal cord paralysis G uillain-B arré syndrome On-off syndrome of P arkinson's disease Degenerative neurological dis eas es Acquired myopathies Idiopathic and s arcoma-induced osteomalacia

1632 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 109 of 176

S ubdural hematoma Acquired, hereditary, and drug-induced dys tonias C reutzfeldt-J akob (prion) dis eas e E arly manifes tations of acquired immune syndrome Other somatoform and ps ychiatric dis orders are in the differential diagnos is of convers ion. If the or deficits are limited to pain or s exual function, then a pain dis orde r or a s e xual dis orde r is diagnosed instead conversion disorder. An additional diagnosis of disorder is not made if the s ymptoms or deficits occur during the course of s omatization dis order. T he must include body dys morphic dis order, for which the emphasis is on a preoccupation with an imagined or defect in appearance, rather than a change in voluntary motor or sens ory function. Hypochondrias is must be cons idered in the differential, although it distinguis hes its elf from convers ion by dis eas e phobia, not symptoms or loss of function. F actitious and dis orders need to be considered. B oth of these share the feature of intentionally produced s ymptoms , which distinguish them from convers ion disorder. However, determining whether s ymptoms are volitional us ually not an easy task. T he pres ence of catatonia or somatic delus ions mus t bring to cons ideration s chizophre nia or other ps ychotic dis orde rs , including a mood dis orde r with ps ychotic fe ature s . It is 1633 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 110 of 176

whether hallucinations s hould be cons idered as the presenting symptom of convers ion dis order. When they occur in convers ion disorder, they generally present without other ps ychotic s ymptoms , often involve more than one s ens ory modality, and often have a vague or fantas tic content. High anxiety states are as sociated multiple somatic s ymptoms or deficits that are sudden in onset. F or example, difficulty swallowing as sociated with a panic attack in the cours e of panic dis order or a phobic dis order. It is becoming unders tood that early advers e life experiences can lead a chronic and undulating course of P T S D, which may as sociated with s ymptoms or loss of function in body that were involved in the traumatic experience. T hus , a careful history of trauma type and res idual pos ttrauma symptoms is ess ential when thinking about the diagnosis of conversion disorder. C onvers ion dis order s hares features with dis s ociative dis orders . B oth involve symptoms that s ugges t neurological involvement, they may have antecedent stress ors , and the history may be difficult to obtain, because of the nature of the s ymptoms. At present, if a patient meets criteria for conversion and diss ociative symptoms, both diagnos es can be made.

C ours e and P rognos is T he onset of convers ion dis order is us ually acute, but a crescendo of symptomatology may also occur. or deficits are us ually of s hort duration, and 95 percent of acute cases remit spontaneously, us ually within 2 weeks in hospitalized patients . If s ymptoms been present for 6 months or greater, the prognos is for 1634 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 111 of 176

symptom res olution is less than 50 percent and further the longer that conversion is pres ent. occurs in one-fifth to one-fourth of people within 1 year the firs t epis ode. T hus, one episode is a predictor for episodes . A good prognos is is heralded by acute presence of clearly identifiable s tres sors at the time of onset, a s hort interval between ons et and the institution treatment, and above average intelligence. P aralysis , aphonia, and blindness are ass ociated with a good prognos is , whereas tremor and s eizures are poor prognos tic factors.

Treatment In acute cas es without a previous history of conversion, accurate reass urance coupled with reas onable rehabilitation to fit the s ymptoms is warranted. T he the symptoms remain, the more aggress ive the rehabilitation should be. C onfrontation of the patient about the s o-called false nature of the s ymptoms is contraindicated. P sychotherapy is a relative contraindication, but attention to the patient's ps ychos ocial needs is likely to be a valuable to symptom resolution. In acute cases with a his tory of conversion, reas surance and s uggestion of recovery coupled with early rehabilitation are the treatments of choice. If s ymptoms continue, more aggres sive rehabilitation is indicated. C hronic cases are more difficult to treat. As with acute cases, comorbid ps ychiatric illnes ses need to be aggres sively. T reatment then needs to begin with thorough and rational evaluation, open explanation to patient about the findings , and education aimed at 1635 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 112 of 176

helping the patient unders tand that, although the symptoms are real and are caus ing impairment, there hope for a full recovery. T his education focus es on the although not well-unders tood, ps ychophys iological P.1818 mechanisms that are likely contributing to the illness how rehabilitation can change these mechanis ms back normal, because the physiological pathways in are likely intact. T hree specific treatments must then be cons idered. F irst, psychomotor and s ens ory rehabilitation is us eful when aggres sively purs ued by an experienced multidis ciplinary team cons is ting of phys iatrists, ps ychiatris ts, and physical and occupational therapists . E arly rehabilitation aimed at the dys function coupled motivational interviewing, reass urance, and sugges tion may be followed by the ethical use of placing the in a double -bind if the initial treatment is not s ucces sful. T he double-bind works on the principle that the symptoms or deficits are being maintained to avoid ps ychological or s ocial conflict, or both, and that the unconscious will do anything, even get better, to avoid discuss ing the conflict. T hus, lack of progress is to the patient as being due to one of three poss ible reasons: (1) T he patient is not trying to get better, cons titutes a reason to end treatment; (2) the are caused by excess ive overstimulation and fatigue, which would necess itate periods of deep res t without stimulation of any kind; or (3) the continued s ymptoms due to deep-seated ps ychological conflicts , which neces sitate long-term ps ychotherapy and dis cus sion of 1636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 113 of 176

these conflicts . T he patient agrees that the second is the most likely caus e, because he or s he neither lose the therapeutic relationship nor wants to engage in interpersonal therapy. T reatment proceeds to have the patient work hard with intermittent periods of deep rest, which means no reading, no television watching, and social contact. T his encourages the patient to engage treatment s es sions to avoid deep rest periods and to rightful discharge. If the patient likes the deep rest then the alternative explanations for failure to improve need to be dis cuss ed again. T his technique has proven us eful to refractory cases when conducted on an rehabilitation unit. S econd, pharmacotherapy may be useful. Anxiolytic antidepres sant medications may decreas e s ome of the symptoms to allow the patient to engage in physical rehabilitation or psychotherapy. Medication-induced sedation therapy, such as an amobarbital (Amytal) interview, may be useful to gain information about early hidden conflicts and may facilitate integration of this information by the patient under s killed therapeutic supervis ion. Infusion of 50-mg doses of amobarbital is adminis tered in a dextrose 5 percent in water (D5W ) solution over 5 minutes every 30 to 40 minutes , until patient is sleepy, usually requiring between 100 and mg per interview. S tandard practice is that another in addition to the therapist is pres ent and that a cras h is available for us e by a capable clinician in the event severe res piratory depres sion. T he interview is meant relate symptoms to events , proximal or remote, and to elicit from the patient ways to ameliorate the symptoms conflicts. V ideotaping may be useful as feedback to the 1637 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 114 of 176

patient, when appropriate, to augment therapis t interpretation. F inally, psychotherapy may be us eful but also may be contraindicated in a patient who remains highly to it or who gets wors e when it is initiated. T herapy is directed at increasing function and having the patient demonstrate to hims elf or herself that the symptom or deficit is alterable and that it is als o related to ps ychological or s ocial phenomena, or both. T here is strong support for any given type of psychotherapy, further empirical work is needed to improve knowledge about how and when to apply ps ychological therapies. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > B ODY DY S MOR P HIC DIS OR

B ODY DYS MOR PHIC DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition B ody dys morphic dis orde r is characterized by a preoccupation with an imagined defect in appearance caus es clinically s ignificant dis tres s or impairment in important areas of functioning. If a s light phys ical is actually pres ent, the person's concern with the is excess ive and bothers ome.

His tory B ody dys morphic disorder was initially clas sified in the 1638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 115 of 176

United S tates as the atypical s omatoform dis order dys morphophobia in DS M-III in 1980. It has been in many parts of the world with various names over the past 150 years. Over this history, body dysmorphic has often been des cribed as a disorder with obsess ive neurotic features about one's body coupled with shame and s elf-loathing.

C omparative Nos ology B ody dys morphic disorder is included in the IC D-10 diagnosis of hypochondriacal dis orde r.

E pidemiology T he epidemiology of body dys morphic disorder is not unders tood. In a cross -sectional s ample of 318 and 658 nondepres sed women between 36 and 44 of age who were selected from seven B os ton area communities, the overall point prevalence was 0.7 percent and was significantly ass ociated with the of major depres sion and anxiety disorders . Other es timate community prevalence between 1.0 and 2.2 percent and prevalence in dermatology and cos metic surgery clinics between 6 and 15 percent.

E tiology T he neurobiology of body dysmorphic dis order is not known. G iven the high comorbidity of depress ion and obses sive features and the reputed benefits of S S R I medication in body dysmorphic dis order, it is ass umed that frontal, s erotonin pathways are involved in body dysmorphic dis order. S ociocultural bases for body dysmorphic dis order are more clear. T he epidemiology 1639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 116 of 176

varies between geographical region and gender, as do concepts of body normality, perhaps making body dysmorphic dis order the somatoform disorder with the strongest sociocultural basis . T here is an extensive literature describing how culture influences individual experience of ps ychopathology, and the clinical manifestations, course, diagnosis, treatment, and treatment outcomes of ps ychiatric illnes s. P redominant social contexts become internalized as ps ychobiology, pathogenes is is influenced by an ongoing s ociocultural fabric and a biogenetic s ubstrate. T his is why bodily preoccupation varies in type, clinical and cons equent behavior across the world. Ms. J ., a 30-year-old s ingle unemployed woman, to a ps ychiatris t with this chief complaint: “My biggest wis h is to be invisible so that no one can s ee how ugly I am. My biggest fear is that people are laughing at me thinking I'm ugly.” In reality, Ms . J . is an attractive who has been preoccupied with her s upposed ugliness since 12 years of age. At that time, s he became with her nos e, which she thought was too “big and B efore the onset of this concern, Ms. J . had been a good student, and s ocially active. However, as a her fixation on her nos e, s he became s ocially and was unable to concentrate in s chool; her grades plummeted from As to Ds and F s . At age 18 years , Ms. J . dropped out of school because her concern about her nos e. S hortly after this , she took job s he disliked and, at that time, als o became focus ed on her minimal acne. S he frequently picked at few “blemishes ”—sometimes all night long—with tweezers and needles, a behavior she 1640 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 117 of 176

P.1819 found difficult to res ist. Over the following years, Ms. J . developed additional excess ive preoccupations with appearance of her hair, which “was n't smooth and neat enough”; her breasts , which she thought were too her suppos edly thin lips; and her s upposedly large buttocks . Ms. J . thinks about her “defects ” nearly all long and s tates that “I always have two tapes playing— one s aying not to worry and the other s aying I'm ugly.” Ms. J . frequently checks her s uppos ed defects in and other reflecting s urfaces , such as windows , car bumpers, and spoons . B efore s he can leave her as ks her family members “at least 30 times ” whether looks OK , but she cannot be reass ured by their S he als o combs her hair excess ively and attempts to camouflage her s upposed defects with clothing, and elaborate makeup that takes several hours a day apply. Des pite her efforts to hide her “ugliness ,” Ms. J . thinks that others are probably taking s pecial notice of staring at her or laughing at her behind her back. S he sometimes drives through red lights, becaus e s he is “unable to tolerate people looking at me.” On one occasion, when s he was s tuck in a traffic jam, Ms . J . became s o anxious over her belief that other drivers staring at her nose, skin, and hair that she fled her car left it in the middle of the highway. Ms. J . thinks that her view of her appearance and her that others are ridiculing her are probably accurate. However, s he is able to acknowledge that she has “a amount of doubt” about her beliefs, noting that it is poss ible—although unlikely—that s he has a distorted 1641 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 118 of 176

view of her defects. Nonetheless , Ms. J . occasionally feels “100 percent” convinced that s he is hideous ly and is “completely certain” that others are taking notice of her, as happened when she abandoned her At thes e times , s he firmly believes that the neighbors staring at her through binoculars, and s he hides where thinks they cannot see her. As a res ult of her preoccupation with her appearance, J . has been able to work only briefly and intermittently. S he became increasingly s ocially isolated and avoided dating and other s ocial interactions . As her concern intens ified, Ms . J . began to go out only at night when could not be s een. F inally, after more than a decade of symptoms, Ms . J . stopped working altogether and went disability. S he als o became completely housebound, hiding when relatives came to visit. As she explains , “I didn't leave my hous e because I didn't want people to how ugly I was.” Although Ms. J . relies on her family members to buy her clothes , food, and other she is unable to tell them about her concerns about her appearance, because she is too embarrass ed. S he has become increas ingly depress ed, with poor s leep, and energy, and has s uicidal ideation. As a res ult of social isolation and her feelings of hopeless ness about appearance, Ms. J . has made two suicide attempts and been hospitalized on s everal occas ions. B efore s he became housebound, Ms. J . received from s everal dermatologists , but this did not alleviate concerns about her appearance. S he was refused a rhinoplas ty by a plastic s urgeon she consulted. Ms. J . sought outpatient psychiatric treatment but was never able to discus s her preoccupations with her therapist, 1642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 119 of 176

because she was too embarras sed to do so.

Diagnos is and C linic al F eatures T he critical feature to make the diagnos is of body dysmorphic disorder is preoccupation with an imagined defect in one's body or any of its parts or markedly excess ive concern about a s light phys ical defect A). T o meet diagnos tic criteria, as in other disorders , critical feature (dysmorphophobia) must cause distress or impairment in s ocial, occupational, or other important areas of functioning (C riterion B ) and must be better accounted for by another mental dis order (C riterion C ). Ass es sment instruments with acceptable ps ychometric properties have been developed to specifically ass es s body dysmorphic dis order (e.g., the B ody Dysmorphic Disorder E xamination and the Y aleB rown Obses sive-C ompulsive S cale modified for B ody Dys morphic Dis order). Determining C riterion C , that dysmorphophobia is not to another mental disorder, can be challenging. P eople with anorexia ne rvos a have the perception that they obese when they are not. It is common for people with s chizophre nia to think that a part or parts of their body distorted or defective when there is no objective of a defect. Highly anxious and depress ed people or with P T S D believe that something is wrong with their body, and this may take the form of dysmorphophobia. E ffective treatment of these other disorders does not always make the concern with body abate. F inally, dysmorphic dis order is highly comorbid with anxiety, affective, and eating disorders , although this is not well known. 1643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 120 of 176

Imagined or exaggerated flaws of the face and head the most common symptoms in body dys morphic disorder, s uch as wrinkles and s cars, vascular paleness or redness of the complexion, s welling, acne other lesions , facial as ymmetry or disproportion, hair thinning, or excess ive facial hair. Other imagined or exaggerated defects include the size or s hape of the eyes or their components , ears, mouth, lips , teeth, jaw, chin, cheeks, or head. Other body parts may be the dysmorphobic focus as well, and this may include specific parts, such as the s hape of a finger; larger areas, s uch as the shape of the hips ; or even the size shape of the whole body. P athological preoccupation focus on several body parts simultaneously. G etting an accurate his tory may be challenging owing to the high level of embarrass ment that s ome people have about imagined defects , the person's perception and of the defects , and the fear by the pers on that will not take them serious ly. T hus, they avoid their imagined or real, slight defects in detail and may instead refer only to the general s hame or uglines s of body. T he most common personality features as sociated with body dysmorphic dis order include obs ess ional and avoidant traits, although any clus ter of traits may be present, and no single personality trait or disorder dominates as comorbid with body dysmorphic dis order. T hese patients are shy, have a history of being highly sens itive to remarks about their body, and can often remember a single event in which negative comments about their body were as sociated with the ons et of bothers ome preoccupation with body image. If the 1644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 121 of 176

disorder begins in early adoles cence, it is likely a his tory of having fewer friends than others , dating than others , and being more is olated than their peers . Many individuals with this disorder describe their preoccupations as being intens ely painful. Ideas of reference related to the imagined defect are also in which people with this dis order think that others are taking s pecial notice of their reported flaw. S ome individuals are preoccupied with thoughts that their flawed body part will fail them. T hus , the are bothers ome and not des ired, but the belief about presence of the imagined defect is ego-syntonic. In body dys morphic disorder patients have difficulty controlling their bodily preoccupations, and they us ually make little or no attempt to res is t them becaus e they believe that they have P.1820 the imagined defect. As with hypochondriasis, a subs et people with body dys morphic disorder cannot easily be convinced or reass ured that the imagined defect is not present. T hus, there is a debate about whether there is subs et of body dys morphic disorder patients that more accurately be diagnos ed with a de lus ional As a res ult of this conflictual relationship between the dislike of the preoccupation and the belief that they are defective, people with body dysmorphic dis order often spend hours a day thinking about their defect, and thoughts and s ubsequent behaviors may dominate lives . C hecking the defect in any available reflecting surface may consume many hours of their day. S ome individuals us e magnifying glass es to s crutinize their 1645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 122 of 176

defect and conduct excess ive grooming behavior. mental and phys ical behaviors are intended to diminis h anxiety about the defect, but, as in all pathological states , the behaviors actually reinforce and intensify only the anxiety, distress , and isolation, but also the frequency and strength of the behaviors. this dis order becomes s o dis tres sing that s ome people with body dysmorphic dis order then s pend a lot of time and energy avoiding mirrors and other checking accoutrements and further is olate to prevent anxiety. may instead try to camouflage the defect by us ing excess ive makeup or padded clothing. In severe individuals may leave their homes only at night s o that they cannot be s een, or may become housebound. may quit their jobs, drop out of school, or work below capacity in an attempt to hide. F urther maladaptive behaviors ensue. T he dis tres s and dys function with body dysmorphic dis order, although variable, can lead to repeated hospitalization, s uicide attempts, and completed s uicide. S ome people with body dys morphic disorder try to the conflict and distress by getting help in medical, not ps ychiatric, s ettings . T hey may first go for frequent reques ts for diagnosis of or reas surance about the but such reas surance leads to only temporary, if any, After engaging in a pattern of comparing their body to those of others by observing others in the natural environment or in magazines or on televis ion, they decide to obtain medical or s urgical care, or both. In in which s elf-evaluation has been highly dis torted, and expectations for medical or surgical care are inappropriately high, such treatment may caus e the 1646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 123 of 176

disorder to worsen, leading to intens ified or new preoccupations. T his may lead to further unsuccess ful procedures , s o that these individuals eventually have a synthetic-looking body part. As with all the very elements of the dis order that are intended to us ed as a helpful defens e become maladaptive, and, in case of body dys morphic dis order, the literally worn on the patient's s leeve, or on the nos e, or breas ts , as it were. It is one of the disorders in in which the maladaptive ps ychological defens e may become vis ible. B ody dys morphic disorder is highly comorbid with affective, anxiety, substance us e, and eating disorders . S tudies about the epidemiological and pathogenesis of these dis orders are lacking. T here is s ome evidence high anxiety states more commonly predate body dysmorphic dis order, whereas depres sion and us e disorders are more a result of chronic body dysmorphic dis order, but more investigation of these relations hips is needed.

P athology T here is no known neurobiological pathology in body dysmorphic disorder. One preliminary s tudy s howed caudate asymmetry similar to that seen in OC D. T he ps ychopathology was described previous ly and als o demonstrates a s trong relations hip to anxiety

Differential Diagnos is T he primary condition in the differential diagnosis is somewhat excess ive, but nonpathological, concerns body features and appearance. Unlike normal 1647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 124 of 176

about appe arance , the preoccupation with appearance specific imagined defects in body dys morphic disorder and the changed behavior becaus e of the are exces sively time consuming and are as sociated significant dis tres s or impairment. T here is a significant and academic literature about the quest for certain types and body features in modern U.S . culture. T here also evidence that, for s ome individuals , exercise, body shaping, and cos metic surgery designed to change appearance can be helpful ps ychologically. there is also evidence that these behaviors can be maladaptive and harmful to an individual's and s ocial development. T he diagnosis of body dys morphic disorder s hould not made if the excess ive bodily preoccupation is better accounted for by another psychiatric disorder. bodily preoccupation is generally res tricted to concerns about being fat in anorexia nervos a, to discomfort with sens e of wrongness about his or her primary and secondary s ex characteristics occurring in ge nde r dis order, and to mood-congruent cognitions involving appearance that occur exclusively during a major de pres s ive e pis ode . Individuals with avoidant dis order or s ocial phobia may worry about being embarrass ed by imagined or real defects in but this concern is usually not prominent, persistent, distress ing, or impairing. T aijin kyofu-s ho, a diagnosis J apan, is similar to s ocial phobia but has s ome are more cons istent with body dysmorphic dis order, as the belief that the pers on has an offensive odor or parts that are offens ive to others. Although individuals with body dysmorphic dis order have obs ess ional 1648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 125 of 176

preoccupations about their appearance and may have as sociated compulsive behaviors (e.g., mirror separate or additional diagnos is of O C D is made only the obsess ions or compulsions are not restricted to concerns about appearance and are ego-dystonic. An additional diagnosis of de lus ional dis order, s omatic be made in people with body dys morphic disorder only their preoccupation with the imagined defect in appearance is held with a delusional intensity.

C ours e and P rognos is B ody dys morphic disorder us ually begins during adoles cence, although it may begin later after a diss atis faction with body. Age of onset is not well unders tood because there is variably long delay symptom onset and treatment s eeking. T he ons et may gradual or abrupt. T he disorder usually has a long and undulating cours e with few s ymptom-free intervals . T he part of the body on which concern is focused may the same or may change over time. T he prognos is with and without treatment is not well unders tood. R eass urance is not thought to be effective, but it may be that adoles cents with a gradual ons et are reass ured in their home or social context quite often never are detected by the medical profes sion. It is also clear whether an abrupt or gradual onset of the a higher ris k for s ymptom continuation.

Treatment It appears that many individuals with body dysmorphic disorder receive nonpsychiatric medical treatment and surgery. One study that ass es sed this iss ue in 289 1649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 126 of 176

individuals (250 adults and 39 children and with DS M-IV -T R body dysmorphic dis order found that percent of adults received nonps ychiatric treatment. Dermatological treatment was most often received (45 percent), followed by s urgery (23 percent). T hese treatments rarely improved body dys morphic dis order symptoms. R esults were s imilar in children and adoles cents . T hese findings s ugges t that a majority P.1821 of patients with body dys morphic disorder receive nonps ychiatric treatment and tend to have a poor outcome. R andomized, controlled s tudies support the efficacy of individual and group C B T for the treatment of body dysmorphic dis order. R es earch on the body dys morphic disorder is limited. T here is evidence from one open-label study and one placebo-controlled study that S S R Is may be effective for body dysmorphic disorder. In a published chart-review s tudy of 90 with DS M-IV -T R body dysmorphic dis order treated for long as 8 years by the authors in their clinical practice, subjects received an adequate dos e of an S S R I, and percent had improvement in body dysmorphic dis order symptoms. S imilar res ponse rates were obtained for type of S S R I. Dis continuation of an effective S S R I in relaps e in 84 percent of cases. Augmentation of the with clomipramine (Anafranil), buspirone (B uS par), (E skalith), methylphenidate (R italin), or antipsychotics improved the respons e rate between 15 and 44 E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > P AIN DIS O R DE

1650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 127 of 176

PAIN DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition A pain dis orde r is characterized by the presence of and focus on pain in one or more body s ites and is s evere enough to come to clinical attention. P s ychological are neces sary in the genesis, s everity, or maintenance the pain, which causes s ignificant distress or or both. T he physician does not have to judge the pain be “inappropriate” or “in exces s of what would be expected,” as these DS M-III criteria are not reliably R ather, the phenomenological and diagnos tic focus is the importance of psychological factors and the degree impairment caus ed by the pain.

C omparative Nos ology T he IC D-10 has a s imilar category called pe rs is te nt s omatoform pain dis orde r, which is not divided into subtypes by the pres umed role of ps ychological factors in the DS M-IV -T R . T he IC D-10 excludes back pain, and migraine headache, and general mus cle tension the diagnosis. T he IC D-10 retains an approach similar the DS M-III-R in which ps ychological factors are be the primary cause of the pain, whereas the DS M-IV now specifies genes is, severity, or maintenance of a combination of these, as different elements of the disorder on which the important ps ychological factors act. 1651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 128 of 176

T he S ubcommittee on T axonomy of the International Ass ociation for the S tudy of P ain propos ed a five-axis system for categorizing chronic pain according to (1) anatomical region, (2) organ s ys tem, (3) temporal characteristics of pain and pattern of occurrence, (4) patient's s tatement of intens ity and time s ince the onset pain, and (5) etiology. T his five-axis s ys tem focus es primarily on the physical manifestations of pain. It for ps ychological factors on the second axis , where a mental disorder can be coded, and on the fifth axis , poss ible etiologies include ps ychophys iological and ps ychological.

E pidemiology T he prevalence of pain disorder appears to be R ecent work indicates that the 6-month and lifetime prevalence is approximately 5 percent and 12 percent, res pectively. It has been estimated that 10 to 15 adults in the United S tates have s ome form of work disability due to back pain alone in any year. Approximately 3 percent of people in a general practice have persistent pain with at least one day per month of activity res triction due to the pain. P ain disorder may begin at any age. T he gender ratio unknown. P ain disorder is ass ociated with other ps ychiatric disorders, es pecially affective and anxiety disorders . C hronic pain appears to be mos t frequently as sociated with depress ive dis orders, and acute pain appears to be more commonly as sociated with anxiety disorders . T he as sociated psychiatric disorders may precede the pain dis order, may cooccur with it, or may res ult from it. Depress ive disorders , alcohol 1652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 129 of 176

and chronic pain may be more common in relatives of individuals with chronic pain dis order. Individuals pain is as sociated with severe depress ion and those pain is related to a terminal illness , s uch as cancer, are increased ris k for s uicide. T here may be differences in various ethnic and cultural groups respond to pain, but us efulnes s of cultural factors for the clinician remains obscure to the treatment of individuals with pain because of a lack of good data and because of high individual variability.

E tiology T he caus e of pain in general is complicated and is not pertinent to this chapter. W hat is important are the mechanisms thought to underlie how pain is phys iologically and perceptually enhanced by ps ychological factors , s uch as emotion and cognition. F igure 15-3 demonstrates a relations hip between nociception, cognition, and affect, in which all three interact to either enhance or diminis h pain perception. T here is phys iological evidence to support the between thes e three elements in the gating and theories of pain perception. F urthermore, treatment as mindfulness meditation and pain medication has shown to change these relations hips, as if the three are being pulled apart from each other, diminis hing the interaction that enhances pain perception.

1653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 130 of 176

FIGUR E 15-3 E lements of pain perception.

Diagnos is and C linic al F eatures T he critical diagnos tic feature of pain dis order is that is the predominant focus of the clinical pres entation of sufficient severity to warrant clinical attention A) and that psychological factors are cons idered in the ons et, severity, exacerbation, or maintenance of pain (C riterion C ). As in all ps ychiatric dis orders, the caus es s ignificant dis tres s or impairment in important areas of functioning (C riterion B ) and is not due to disorders considered in the dis cuss ion of differential diagnosis (C riteria D and E ). 1654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 131 of 176

T he diagnosis of pain disorder is divided into s ubtypes best characterize the factors involved in the etiology maintenance of the pain. P ain disorder ass ociated with ps ychological factors is the subtype diagnos ed when ps ychological factors are judged to have the P.1822 major role in the onset, s everity, exacerbation, or maintenance of the pain and when other medical conditions are thought to be unimportant to the onset maintenance of the pain. P ain dis order as sociated with ps ychological factors and a general medical condition the s ubtype diagnos ed when psychological factors and another medical condition are thought to be important the ons et, severity, exacerbation, or maintenance of pain. In this subtype, the other medical condition is an III diagnos is . P ain disorder ass ociated with another medical condition is the subtype that is not cons idered Axis I mental dis order, and the medical disorder res ponsible for the pain is diagnos ed on Axis III. P ain disorder as sociated with ps ychological factors and pain disorder as sociated with psychological factors and general medical condition may be acute ( T able of C ontents > V olume I > 15 - S omatoform Dis orders > UNDIF F E R E NT IAT E D DIS OR DE R

UNDIFFE R E NTIATE D S OMATOFOR M DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition Undiffe re ntiated s omatoform dis orde r is characterized one or more unexplained physical symptoms of at leas t months' duration, which are below the threshold for a diagnosis of somatization disorder. T hes e s ymptoms not due to or fully explained by another medical, ps ychiatric, or substance abuse dis order, and they clinically significant distress or impairment.

C omparative Nos ology T he category of undifferentiated s omatoform disorder also in the IC D-10, and it is virtually identical to the IV -T R category. Neurasthenia (T able 15-8) is an IC Ddiagnostic s yndrome characterized by at least 3 exhaustion, fatigue and weaknes s, and an inability to 1668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 145 of 176

recover from the fatigue with res t and is clas sified in DS M-IV -T R as an undifferentiated somatoform disorder symptoms have persis ted for longer than 6 months. However, neurasthenia is of dis order status in many parts of the world, and there are empirical data that support the validity of the construct.

Table 15-8 IC D-10 Diagnos tic C riteria for Neuras thenia F48.0 Neuras thenia    A. E ither of the following must be present: 



P ers is tent and dis tres sing complaints of of exhaustion after minor mental effort (such performing or attempting to perform everyday tas ks that do not require unus ual mental P ers is tent and dis tres sing complaints of of fatigue and bodily weakness after minor phys ical effort.

   B . At leas t one of the following s ymptoms mus t present:    

F eelings of mus cular aches and pains Dizzines s T ension headaches S leep disturbance 1669

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 146 of 176

 

Inability to relax Irritability

   C . T he patient is unable to recover from the symptoms in C riterion A (1) or (2) by means of relaxation, or entertainment.    D. T he duration of the disorder is at least 3    E . Mos t commonly us ed e xclus ion claus e . T he disorder does not occur in the presence of emotionally labile dis order (F 06.6), syndrome (F 07.1), pos tconcuss ional syndrome (F 07.2), mood (affective) disorders (F 30 through panic dis order (F 41.0), or generalized anxiety disorder (F 41.1).

Adapted from IC D-10 C las s ification of Me ntal and B ehavioural Dis orde rs . G eneva: World Health Organization; 1993:109–110.

E pidemiology As undifferentiated somatoform disorder is cons idered category that is residual to s omatization dis order, there little epidemiology about its prevalence. One s tudy of a representative community s ample in G ermany found a 19.7 percent prevalence using a G erman version of the DS M-IV –adapted C ompos ite International Diagnostic 1670 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 147 of 176

Interview. J avier E s cobar and his colleagues have demonstrated that somatization dis order may be described as a s pectrum on a s omatic symptom index, that four symptoms in men and six s ymptoms in predict s imilar levels of impairment and help s eeking as 13-item index or as full s omatization dis order. T he prevalence of this s ubs yndromal dis order is as much 100 times higher than that for somatization dis order. other investigators have argued for less res trictive for somatization disorder, which is why the DS M-IV -T R less res trictive than the DS M-III-R . F urther work on the most pars imonious class ification of s omatization is required and is being considered by many

E tiology No s pecific etiology for undifferentiated somatoform disorder is known.

Diagnos is and C linic al F eatures T he critical feature of undifferentiated somatoform disorder is the presence of one or more unexplained phys ical s ymptoms (C riterion A) that pers is t for 6 or longer (C riterion D) but do not meet full diagnostic criteria for somatization disorder and are not due to another defined illnes s (C riteria B and E ). T his is a category for persistent s ymptoms that do not meet the criteria for somatization or another s omatoform However, that does not imply a less severe illness . As ps ychiatric disorders, symptoms must cause clinically significant dis tres s or impairment in social, or other important areas of functioning (C riterion C ). F urthermore, as in other somatoform disorders, 1671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 148 of 176

are not intentionally produced or feigned (as in disorder or malingering) (C riterion F ). C ommon are chronic fatigue, loss of appetite, and G I or genitourinary s ymptoms, but an array of other may als o occur. One diagnos tic challenge is to between normal symptomatic dis tres s and a proces s. It is normal for people to experience some distress even while in good health, and s omatic are more common than ps ychological symptoms in random community s amples. Approximately 80 percent healthy individuals experience s omatic s ymptoms in given week. However, only a fraction of thes e go on to have pers istent symptoms that are dis tres sing and unexplained. It has been estimated that more than 4 percent of people in U.S . communities have chronic somatic complaints. A s econd diagnos tic challenge is in dis tinguishing between an unexplained symptom and a s ymptom that may be due to another medical or ps ychiatric disorder. S ymptoms comprising an undifferentiated disorder are directly due to or cannot be fully explained by any general medical or ps ychiatric condition or the direct effects of a s ubs tance. T hus , if the s ymptoms are another dis order, but the phys ical complaints or impairment is gross ly in exces s of what would be from the history, physical examination, or laboratory findings, an undifferentiated s omatoform dis order may exis t. T his highlights the fact that s omatoform disorders are not diagnos es of exclus ion nor are they mutually exclusive of other medical illness es. In fact, medical ps ychiatric illnes ses are risk factors for also having unexplained dis tres sing 1672 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 149 of 176

P.1824 somatic symptoms. T he challenge lies in proving that is no significant underlying medical disorder that is the symptoms without reinforcing the idea of illnes s to a patient by conducting multiple diagnostic evaluation E xcluding significant medical illness does not mean that there is no phys ical caus e for the symptoms. T he is replete with des criptions of altered he ighte ne d phys iological res pons es in people with s omatoform disorders . T rying to verbally convince a patient—just trying to convince him or her with medical technology— that there is nothing wrong with him or her may make somatoform disorder worse. B oth kinds of attempted reass urance may cause iatrogenic reinforcement of the illness becaus e there is no explanation for the felt symptoms. A third diagnos tic challenge is that unexplained physical symptoms and worry about illnes s may constitute shaped idioms of dis tre s s that are us ed to express about a broad range of pers onal and social problems , without necess arily indicating ps ychopathology. Unexplained phys ical complaints occur with high frequency in young women of low socioeconomic although thes e s ymptoms are not limited to any age, gender, or s ociocultural group.

P athology T here is no specific histopathology for undifferentiated somatoform disorder.

Differential Diagnos is 1673 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 150 of 176

B ecaus e phys ical complaints are so common in life, the differential diagnos is for undifferentiated somatoform disorder is large and broad. Other disorders are in the differential diagnos is. S omatization dis order requires more symptoms of several years ' and an ons et before 30 years of age. S omatoform NO S is diagnosed when the phys ical complaints have persis ted for les s than 6 months but are not due to medical, ps ychiatric, or s ubs tance use disorder. Hypochondrias is is often express ed with s omatic complaints , but preoccupation with the fear of having a disease or the belief that one has a disease coupled res is tance to reass urance is more prominent in hypochondriasis than in undifferentiated s omatoform disorder. C hronic pain and s omatoform pain dis orders diagnosed when the unexplained s omatic s ymptoms exclusively pain related. However, pain may be part of undifferentiated s omatoform dis order. T he medical literature has multiple accounts and s tudies of unexplained somatic s ymptoms in affe ctive dis orders , anxie ty dis orde rs , s ome ps ychotic dis orders , s ubs tance dis orders , adjus tme nt dis orders , and pe rs onality C hronic me dical illnes s e s make it more likely that a will develop a comorbid somatoform dis order. C hronic illness is reas onably perceived as a threat, which in caus es heightened vigilance and scanning of bodily functions , leading to amplification of somatic s ens ation and perception. Diagnos ing a s omatoform dis order in context of chronic medical illness s hould be a prudent thorough proces s, balancing the need to obtain data with the need to do no harm to the patient. T rans ie nt une xplaine d s omatic s ymptoms are normal. 1674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 151 of 176

Amplification of somatic s ens ations may occur in times personal s tres s or los s or even with positive events that caus e a pers on to become more aware of bodily sens ations, such as in the “medical student syndrome.” common theme of the pers onal context in each case is perception of some threat, res ulting in a hypervigilant survey of bodily s ys tems.

C ours e and P rognos is T he cours e of unexplained phys ical s ymptoms is unpredictable. G iven the time criteria for somatoform disorder, there is res olution or the eventual diagnosis of another medical or ps ychiatric dis order.

Treatment T here is no specific treatment for undifferentiated somatoform disorder. R eass urance by interpreting the threat and the phys iology of heightened arous al and perception is the treatment of choice in these cas es succes sful in more than 95 percent of the cas es . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S O MAT OF O R M DIS OR DE R NOT S P E C IF IE D

S OMATOFOR M DIS OR DE R NOT OTHE R WIS E P art of "15 - S omatoform Dis orders"

Definition S omatoform dis orde r NO S is diagnosed in people with 1675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 152 of 176

somatoform s ymptoms that do not meet the criteria for any of the s pecific s omatoform dis orders and that are due to another psychiatric, medical, or substance us e disorder. T he epidemiology and etiology of this are not studied.

C omparative Nos ology T he IC D-10 has a s imilar res idual category called other s omatoform dis orders , but it specifies that the are not mediated through the autonomic nervous and are not persistent as they are in s omatization

Diagnos is and C linic al F eatures T his diagnos tic category includes s omatoform that do not meet the criteria for any s pecific disorder. E xamples provided in the DS M-IV -T R include 1. P seudocyesis: a false belief of being pregnant that as sociated with objective s igns of pregnancy, such abdominal enlargement without umbilical eversion, reduced mens trual flow or amenorrhea, naus ea, engorgement and s ecretions, subjective s ens ation fetal movement, and labor pains at the expected of delivery. P s eudocyes is may be as sociated with endocrine changes that cannot be explained by another medical condition. 2. Nonpsychotic hypochondriacal symptoms of less 6 months ' duration. Hypochondriacal symptoms occur separate from other dis orders and also occur people with high s omatic sensitivity and with other specific ps ychiatric disorders . Although these hypochondriacal symptoms may be transient, even 1676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 153 of 176

they are s evere, they may progres s to a primary or secondary form of hypochondriasis or may remit reass urance or treatment of comorbid conditions . 3. Unexplained phys ical s ymptoms of les s than 6 duration that are not due to another illness or subs tance use dis order.

P athology T here are no known cellular or histopathological pathology features of unexplained phys ical symptoms . T here is ample evidence for physiological activity that accentuated by s tres s and emotions, which may cause unexplained s ymptoms.

S mooth and S triated Mus c le C ontrac tion Abnormalities of s mooth mus cle contraction, such as abnormal motility of the esophagus and intestinal tract, may cause symptoms in the chest and the right upper quadrant and middle or lower quadrants of the S triated muscle contracts and also returns to baseline more s lowly during various emotional states. Different emotional states affect various muscle groups Anxiety and depres sion are ass ociated with higher electromyographic (E MG ) activity in s ome mus cle C linical research has demonstrated a relations hip specific types of pain, s uch as headache and low-back increased avers ive emotional states , and increased activity. P.1825 1677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 154 of 176

B lood Flow and E ndoc rine P sychophys iology res earch has demons trated adrenergic and corticos teroid changes as sociated with various emotional s tates, particularly fear and anger. Increased sympathetic adrenergic tone in respons e to and anger may cause heightened blood pres sure, an increase in heart rate and s troke volume, increas ed res piration, and redis tribution of blood flow away from visceral organs and toward striated muscle. this increas ed tone in res ponse to fear and anger may res ponsible for vas cular s pas m, transient is chemic and instability of blood flow regulation in s ome people. T he cardiologist B ernard Lown demonstrated changes vascular tone, blood flow, and even atherogenesis and sudden death in respons e to severe emotional distress . Although death is not to be equated with unexplained phys ical s ymptoms, the point is that thes e phys iological changes in respons e to emotional distress are spectral, some people have s ymptoms due to thes e changes are not neces sarily measurable in the routine clinical setting. Other symptoms and s igns caus ed by stress emotional mechanis ms include cold s ens itivity of the R aynaud's type, acrocyanosis and erythromelalgia, perhaps , nutcracker esophagus.

Phys iologic al Arous al and T here is a demons trated ass ociation between arousal, perception of this arous al, and experiencing this various s omatic areas . Individuals have an and recurrent pattern of phys iological res ponse to which may explain the recurring unexplained s omatic symptoms in individuals during different stress 1678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 155 of 176

However, healthy subjects and anxious subjects with predominantly ps ychological symptoms may have sens ations that correlate poorly with physiological On the other hand, anxious patients with predominantly somatic symptoms have physiological arous al that correlates with their physical s ens ations .

Differential Diagnos is As with undiffe rentiate d s omatoform dis order, the differential diagnosis for s omatoform disorder NOS primarily includes other s omatoform, affective , and dis orders , undiagnos ed medical illne s s , and trans ie nt normal s omatic s ymptoms . When other psychiatric, medical and s ubs tance use disorders are excluded, the primary diagnos es to be cons idered are undiffe rentiate d s omatoform dis orde r trans ie nt amplification of normal s ymptoms . T here are empirical data about how to best distinguis h between these three categories . It is likely that there is a between trans ient amplification, the NOS category, the undifferentiated category, and full-blown s omatoform disorders in terms of s ymptom number, s everity, and as sociated dis tres s. T he NOS category is the only somatoform disorder that does not have explicit in the DS M-IV -T R diagnostic criteria about caus ing significant clinical dis tres s. T his does imply that the category is mos t like transient distress ing somatic symptoms. T hus , this diagnos is can be made when the patient has one or more distress ing somatic symptoms and when the clinician is not certain if this is transient the symptoms are beginning to form part of a disorder. If the symptoms persist for longer than 6 1679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 156 of 176

and are not due to another medical dis order, the of undifferentiated somatoform disorder becomes appropriate.

C ours e, P rognos is , and Treatment Approximately 95 percent of new-onset dis tres sing symptoms remit with competent reass urance. Once symptoms become chronic, the diagnos is should be changed to one of the more specific somatoform disorders . T he most appropriate first-line treatment is the presenting s omatoform s ymptoms become distress ing, then two treatments are indicated. F irst, cognitive and behavioral therapies can be us ed to help patient maintain functioning and not equate symptoms with being an illness or disease. E ducation about the nature of s ymptom amplification and its phys iological basis is important, so that the patient does not think the phys ician is lying or not competent. F amiliarizing patient with the concept of cognitive distortions is for the patient to learn that symptoms do not mean that there is an illness or disease pres ent and that can create catas trophizing cognitions that are P rudent examination and testing procedures s hould be us ed only when the physician truly believes that further clinical investigation is warranted. If the patient laboratory or radiological examinations that are unwarranted, the phys ician must review the s ymptoms, their meaning, and the need for tes ting rather than jus t send the patient for tes ting out of frustration. T he latter maneuver reinforces the patient's belief that his or her body may fail at any time and that the doctor is not 1680 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 157 of 176

competent. T he patient can be instructed to keep a behavioral log to enhance learning about how certain activities change symptoms . E xercise is als o a behavioral approach. S tretching and s trengthening specific muscle groups is the treatment of choice for myofascial pain s yndromes, which are a common in people with somatoform symptoms. T his may be prescribed through phys ical therapy programs or yoga or meditation clas ses, or both. F urthermore, exercise has demonstrated efficacy for depres sion and some anxiety disorders , which are highly comorbid with somatoform s ymptoms . T he second treatment is the prudent use of combined with patient education. Anxiolytics , antidepres sants, muscle relaxants, and hypnotics may warranted to ass ist with symptom relief if the patient unders tands the meaning and value of this treatment if there are no contraindications to their use. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S P E C IAL C ONS IDE R AT IO

S PE C IAL P art of "15 - S omatoform Dis orders"

P res entations in Different T he paradox that unexplained somatic symptoms cons idered ps ychological and entrenched in ps ychiatry has one remaining paradoxical twis t. T he patients did know about this nor have they accepted it. T hey 1681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 158 of 176

present to nonpsychiatric s ettings .

Primary C are S omatoform dis orders in primary care are common, ranging from 0.8 to 14.0 percent of all visits. T hes e have abnormal body sensations and authentically for help to understand and to manage them. T hey also have characteristics that are different from nonsomatoform patients. F or example, patients in primary care pres ent with more pain and levels of ps ychological distress , have les s cons is tent maintenance, and more often pres ent owing to anxiety fear than nonhypochondriacal patients. T hey worry their health and their emotional s tate, but they usually only s hare the somatic complaints with their doctor. often ass umed by doctors to be becaus e of the somatization and lack of psychological mindedness , high number of patients report that they wis h that their doctor would talk with them about emotional and is sues.

Other Tertiary S ettings S omatoform dis orders have a prevalence of 5 to 40 percent in some s ubs pecialty clinics, such as gastroenterology, neurology, cardiology, and endocrinology. Unexplained physical symptoms not meeting diagnos tic criteria are even more common in these settings. P atients with s omatoform dis orders who are P.1826 not satis fied with their primary care often seek an 1682 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 159 of 176

explanation from a s pecialis t physician. T hes e patients often disappointed that the specialist finds nothing with them.

Inpatient C ons ultation-L iais on Ps yc hiatry R eports about the prevalence of somatoform disorders patients referred to cons ultation psychiatry services widely. T he two largest s tudies found that 16 and 55 percent of all referred patients have a somatoform disorder, respectively. T hes e patients tend to be older have more active medical problems than patients in primary care with s omatoform dis orders . T his highlights the particular challenge in the cons ultation-liais on of making the diagnos is of a somatoform disorder in and more medically ill patients.

Ps yc hiatry Other psychiatric illnes ses are highly comorbid with somatoform disorders , which are rarely the focus of attention. R ather, unexplained phys ical s ymptoms are subs umed under diagnos es of major depres sion, panic disorder, s chizophrenia, and other illness es . Although there is little doubt that other psychiatric disorders have ris k of increased s omatic complaints, s omatoform disorders themselves are cons idered les s often than disorders , and patients are often encouraged to s ee primary care doctor for complaints about their stomach, head, heart, or back. P s ychiatris ts s ee their limits in the practice of general medicine, yet the primary care phys ician has referred the patient becaus e of the of a s omatoform process , and the ps ychiatris t's 1683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 160 of 176

places the patient firmly between doctors and s ys tems. T hus, somatoform patients are at high ris k of being los t care, which may reinforce narciss is tic and obses sional that are so common in these patients.

C ros s -C ultural Dis orders T his chapter is not about the authenticity of culturedisorders or the range of cultural effects on the process somatization. R ather, this section is here to s tress the importance of cultural variables to body sensation and expres sion. A few examples are given that highlight symptoms may occur and what the impetus for the symptoms might be.

P ibloqtoq (and Other Arc tic T his dis order, one of the arctic hys te rias (others amos , akek, kajat, matamuk, kalagik, s anraq, montak, s autak, te s ogat, and nirik), originated from made during a series of expeditions by R obert P eary expedition doctors to E llesmere Island and G reenland between 1891 and 1909. T he historian Lyle noted that this syndrome was described in 40 of 150 E skimo tribe members by expedition members . T he commonality between the numerous profes sional inves tigators who have s ince described this syndrome that none of them has witnes sed an epis ode of this intermittent disorder. P ibloqtoq has been des cribed as intermittent epis odes of withdrawal, followed by s inging or s creaming; rolling on the ground; making nois es like birds, dogs, or seals , with subs equent clonic and carpopedal s pas ms while “walking on the sky,” followed by up to an hour of trembling with resultant 1684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 161 of 176

weaknes s and dazedness . T he native treatment for an epis ode is generally for men not to intervene, the episode occurs in a wife, and for women to s oothe another woman who has an attack. E xpedition and doctors took a more interventional and approach, including prescriptions for sleep, brandy and whis key ingestion, emetics, and injections of mus tard water. More recent workers believe that this is multifactorial and not necess arily culture bound, with poss ible etiologies including partial complex s eizures , vitamin A exces s, infections , s omatoform phenomena, a s ocial protest res ulting from power differences in the contact between native and expedition people.

K oro K oro, a so-called culture-bound syndrome, occurs in S outheas t As ia and may be related to body disorder and hypochondriasis. However, koro has been diagnosed and s ucces sfully treated with S S R Is in the United S tates . It occurs primarily in men and is characterized by a belief that the penis or testicles will shrink and disappear into the abdomen, resulting in When koro occurs in women, the belief is usually that labia or nipples will involute and res ult in death. K oro differs from body dys morphic disorder by its usually duration, different as sociated features (primarily acute anxiety and fear of death), more of a positive res ponse reass urance, and occas ional occurrence as an

Other Medic al Dis orders L ikely to Mas querade as a S omatoform Dis order 1685 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 162 of 176

Any medical dis order that presents with vague or nonclass ic s ymptoms may be taken to be a disorder. One problem is that most medical illnes s presents nonclas sically a large minority of the time. debating whether symptoms are due to another illness or a somatoform disorder, the clinician should cons ider the diagnos es of thyroid dis eas es; parathyroid disease; uncommon infections, s uch as s yphilis; other infections, s uch as human immunodeficiency virus and diss eminated gonococcus; nervous s ys tem such as MS or tumor; and autoimmune disorders, such lupus erythematosus or myas thenia gravis.

C hildren and A doles c ents During childhood, people learn to integrate affect and body s ens ation with cognition to expres s thems elves . During infancy, body s ensation is the primary feeling to learn about the s elf in relation to other things. E arly childhood continues by pairing precognitive affect with somatic s ens ations . Late childhood brings thought and cognition to the pers on in his or her expres sion about self and its relation to the outs ide world. S omatic complaint or pleasure is thus the first, primary modality expres sing displeas ure or joy about the self and its to the world. Affect and then cognition are later, modalities that are learned parallel to s omatic E arly concepts of self and its relation to others are thus wrapped up in body-feeling, and the express ion of complaint in children is the expres sion of displeas ure the self or one's relations hip to other people or other things . T hat displeasure may be due to any number of noxious agents , including virus, phys ical injury, tumor, learned general sens ation that all is not right with the 1686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 163 of 176

in its world. It is the task of the phys ician to determine source of dis pleasure. S omatic s ymptoms in children are common, although prevalence in the community, schools , or primary care not known. S chool is a common place for expres sion of somatic dis tres s, which can influence the child's attendance and grades . T here may be gender in childhood somatization, with some evidence that have a higher prevalence of abdominal pain and that a higher prevalence of chest and back pain. B ecaus e somatic symptoms are common in children, the should be more concerned with the social and ps ychological context that may be respons ible for the symptoms than with diagnosis. S omatization disorder hypochondriasis diagnoses s hould be held in res erve, unles s the child has a prolonged course of unexplained symptoms in multiple body s ys tems or preoccupation having a serious illness . B ody dys morphic disorder is an underrecognized and underdiagnosed problem that is relatively common among adoles cents and may P.1827 be becoming more common with the increase in media depicting unattainable ideals of beauty and perfection. B ody dys morphic disorder has a high rate of with depress ion and s uicide, which argues for prompt diagnosis and treatment in adolescents. E ffective treatment options include C B T and pharmacotherapy S S R Is.

G eriatric P opulations 1687 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 164 of 176

R es earch about somatoform dis orders in the elderly is limited. T he late onset of a s omatoform disorder should cons idered another medical disorder until clearly otherwis e. However, the astute clinician realizes that somatoform disorders may be comorbid with other medical dis orders and that bodily preoccupations and fears of debility may be frequent in elderly persons. multiple los ses that occur with aging may caus e heightened distress , which may interact with the pains chronic illness . T he onset of preoccupation with health concerns in old age is more likely to be realis tic or to as sociated with an affective dis order or poor s ocial support, or both, than to be a s pecific s omatoform disorder.

R elations hip of P ers onality to S omatoform Dis orders T here are s ome data, given throughout this chapter, the relations hip of s omatoform dis orders to specific personality traits and disorders . T here are also and traits , such as defense and res olution of conflict, communication style, hos tility and anger, and certain cognitive s tyles, that have been studied and written in their relations hip to s omatoform dis orders . As is from the history of somatoform disorders , the between somatoform dis orders as pers onality cons tructs —stable characteristics of the pers on—and disorders that develop later in life is a lively academic debate. T he primary problem with this debate is the inability to distinguish between inherent traits of the person (i.e., temperament) and traits that develop into disorders . F or psychiatry, s eparating Axis I from Axis II disorders is problematic. T hey are both characterized 1688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 165 of 176

symptoms and enduring patterns of internal experience and behavior that develop over time, becoming chronic and pervas ive parts of the individual. T he trend of transforming chronic Axis I disorders into personality disorders becaus e of their duration is already evident other disorders , s uch that social phobia is thought of as avoidant personality dis order, and dysthymia is a depress ive personality disorder. T his is in light of the that personality dis orders have little empirical s upport discrete entities . T he state–trait problem is no more evident than in hypochondriasis. T here is s upport for cons idering this disorder a pers onality disorder. However, the s tate personality construct and the trait dis order are more than different. T hey are both defined by rigid preoccupation with amplified bodily s ymptoms, the that these symptoms equal illnes s, and behaviors to refute these frightening beliefs but that reinforce because of the rigidity of the conviction. F urthermore, both cons tructs can be viewed as the res ult of cognitive process ing that includes amplification and misinterpretation of bodily symptoms and the outcomes of help seeking coupled with resistance to reass urance. However, a view that is alternative to the state–trait dichotomy exists . T his view uses a developmental and life span approach to demonstrate that s omatoform disorders develop in the context of developmental tasks. E arly childhood experiences with temperament and culture to come together in adulthood as somatization—a process in which bodily distress is one way in which a person can express that something is not right with one's relations hip to s elf or 1689 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 166 of 176

things outside of the self. T his developmental view accurately describes how s omatoform disorders occur without forcing dis tinctions that have little or no support.

R elations hip of Trauma to S omatoform Dis orders T here is evidence that chronic stress and trauma are as sociated with increased physical s ymptoms. T he of the studies that examine this relations hip have been conducted in veterans of war. T he presence of unexplained phys ical s ymptoms is as sociated with ps ychological distress at the time of trauma; ongoing ps ychopathology; alcohol, tobacco, and medication and s ymptoms of P T S D. C ombat veterans with P T S D higher rates of cardiovas cular, neurological, G I, audiological, and pain symptoms compared to combat veterans without P T S D. T here is mounting evidence phys ical s ymptoms are a part of P T S D and also may nonspecific res ponse to trauma that is independent of P T S D. It has been documented that pain s ymptoms often localized to the s ite of previous trauma in people with P T S D. S omatization and hypochondrias is are ass ociated with presence of self-reported traumatic experiences. T here numerous reports about the increased history of people with somatization dis order. T here are two about this relationship in hypochondriasis. In one there was a three- to fourfold higher risk for having experienced traumatic s exual contact, phys ical major parental upheaval before 17 years of age in hypochondriacal people compared to normal control 1690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 167 of 176

subjects . T he other s tudy validated an interpersonal of hypochondrias is , which posits that early adverse experiences lead to ins ecure and fearful attachment high levels of physical symptoms and illnes s phobia, interpersonal problems in daily life and in medical care. T here is also mounting evidence that people with body dysmorphic dis order, diss ociative convers ion reactions , and pain dis orders experience a higher number of early advers e experiences than normal control s ubjects. T he mechanis ms for unexplained phys ical symptoms in people who have experienced trauma are unclear. Neuroimaging s tudies in trauma s urvivors with P T S D demonstrate dys function of the anterior cingulate with a failure to inhibit amygdala activation or an intrins ically lower threshold of amygdala res ponse to fearful stimuli, both. T here is als o s ome evidence that somatosens ory cortex and B rodmann's areas 1 through 4 and 6 have increased regional blood flow during traumatic recall that this activation is as sociated with s elf-reports of phys ical s ens ations . S ome investigators are propos ing subcortical memory s ys tems help determine this neurobiological respons e to trauma recall. It is well es tablis hed that memory function is changed in P T S D that cognitive and s omatos ens ory proces sing is Multiple physiological s ys tems are activated or with stress , and chronic stres s can produce lasting in autonomic nervous, immune, and hypothalamicpituitary-adrenal (HP A) axis systems . F urthermore, produces increas es of cortisol and epinephrine levels, of which have adverse effects on brain and body when unchecked. P erhaps the most parsimonious theory is that of Hans 1691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 168 of 176

S elye who observed in medical s chool that there was a nonspecific “syndrome of jus t being s ick” that was acros s various medical illness es . S elye went on to elegant laboratory work with animals to define the adaptation s yndrome (G AS ), which occurs with multiple stress ors , s uch as behavioral stress , heat, cold, trauma, hemorrhage, and other s timuli. T he G AS has stages: (1) the alarm reaction, (2) resistance and and (3) exhaus tion. If the s tres s is not resolved, then chronic changes begin to occur after days and weeks, including fatigue, s leep disorders , symptoms of and anxiety, and an increas ed risk for infection and res piratory and cardiovas cular compromis e. T he involvement of central memory and somatosensory proces sing, the HP A axis involving cortisol and epinephrine, and diminis hed immunity res ults in phys iological P.1828 changes in nearly every body system. T hus , phys ical sens ations are more prominent in those expos ed to stress ors that activate the G AS . W ithout rapid the stress res ponse, physiology can become so altered that it would be surprising if an individual did experience ongoing physical sensations. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "15 - S omatoform Dis orders" 1692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 169 of 176

P sychiatrists need improved training about recognition and treatment of individual somatoform dis orders, as as somatoform disorders that are comorbid with other ps ychiatric and medical illnes ses. P articularly when a patient is referred to ps ychiatry for care, it is bes t for ps ychiatris t to conduct relevant examinations and laboratory studies and to obtain the relevant history to make or to exclude a somatoform disorder. T his may include knowledge and s kill of a focused, thorough neurological examination to determine if conversion disorder is present or if there is pathology to s upport another medical dis order in the differential diagnos is . is where ps ychiatry can be at its bes t and where ps ychiatris ts bes t maintain their identities as doctors capable of diagnosing and treating the whole pers on. If this training is not improved, then patients with somatoform disorders will continue to receive care and to be dis miss ed as “crocks.” P rimary care phys icians require further education the known phys iology of somatoform dis orders; the distinction between s omatoform, factitious, and malingering dis orders ; and pharmacological and ps ychotherapeutic treatment principles and modalities. E xcluding other medical disorders is only one-half of equation in the care of the somatoform-disordered patient. T he other half is to make a pos itive diagnos is to use standard, helpful, nons pecific and s pecific treatment modalities that have been shown effective for this group of dis orders . P sychiatrists and primary care physicians need to forge further multidis ciplinary relations hips and care models 1693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 170 of 176

appropriate for the care of the s omatoform-disordered patient. T hese patients need a place to be s een and to taken serious ly rather than being s hunted back and between clinics. P s ychos omatic and medicalparadigms need to be introduced further into curricula and s ys tems of care, s o that the patient's illness is not being perpetuated by firs t being viewed through a biomedical paradigm and then a ps ychological one, mimicking the mind–body split in W estern culture that so elemental to their disorder. T he public will benefit from education about the high prevalence of unexplained physical s ymptoms and the that, although thes e are not necess arily life they can be dis abling. T he public should also know that there are treatments available for thes e disorders . F inally, research about s omatoform dis orders s hould be neglected. T hese disorders are impairing to patients and costly to s ociety, and medicine needs to better unders tand the pathogenes is , phenomenology, and treatment options for s omatoform dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "15 - S omatoform Dis orders" R elated dis orders are discus sed in C hapter 16 on disorders and C hapter 17 on diss ociative disorders . 1694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 171 of 176

24.11 on consultation-liais on ps ychiatry, S ection 30.12 noncompliance with treatment, and S ection 26.1 on malingering als o have information relevant to disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > R E F E R E NC

R E FE R E NC E S *B ars ky AJ : P atients who amplify bodily s ymptoms. Inte rn Med. 1979;91:63. B ars ky AJ , W ool C , B arnett MC , C leary P D: childhood trauma in adult hypochondriacal patients. Am J P s ychiatry. 1994;151:397. B as s C , ed. S omatization: P hys ical S ymptoms & P s ychological Illne s s . Oxford, UK : B lackwell 1990. B as s C , Murphy M: S omatoform and personality disorders : S yndromal comorbidity and overlapping developmental pathways. J P s ychos om R e s . B urton R : T he Anatomy of Me lancholy. London: Univers ity P res s; 1883. *E scobar J , C anino G : Unexplained physical P sychopathology and epidemiological correlates . B r P s ychiatry. 1989;154[S uppl 4]:24. F abrega H. C ultural and historical foundations of ps ychiatric diagnosis. In: Mezzich J E , K leinman A, 1695 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 172 of 176

F abrega H, P arron DL, eds . C ulture and P s ychiatric Diagnos is : A DS M-IV P e rs pe ctive . W ashington, DC : American P s ychiatric P res s; 1996. *F ord C V . T he S omatizing Dis orde rs : Illne s s as a L ife . New Y ork: E lsevier S cience; 1983. F ord C V : T he s omatizing dis orders. 1986;27:327. F oulks E . In: Maybury-Lewis D, ed. T he Arctic the North Alas kan E s kimo. Anthropological S tudie s , 10. W ashington, DC : T he American Anthropological Ass ociation; 1972. F rances A, R os s R . DS M-IV C as e S tudie s : A Diffe rential Diagnos is . W ashington, DC : American P sychiatric P ress ; 1996:208. F reud S . On narciss ism: An introduction. In: E dition of the C omple te P s ychological W orks of F re ud. London: Hogarth P res s; 1955. G rabe HJ , Meyer C , Hapke U, R umpf HJ , Dilling H, J ohn U: S pecific somatoform disorder in general population. P s ychos omatics . 2003;44:304. Hiller W , R ief W , F ichter MM: Dimensional and categorical approaches to hypochondrias is . P s ychol Me d. 2002;3:707. Hollifield M. Hypochondrias is and pers onality 1696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 173 of 176

disturbance. In: S tarcevic V , Lips itt DR , eds. Hypochondrias is : Modern P ers pective s on an Malady. Oxford, UK : Oxford University P ress ; 2001. Hollifield M, T uttle L, P aine S , K ellner R : and s omatization related to pers onality and attitudes toward s elf. P s ychos omatics . 1999;40:387. K aton W , K leinman A, R osen G : Depress ion and somatization: A review. P art I. Am J Med. *K ellner R . S omatization and Hypochondrias is . New P raeger; 1986. K ellner R . Abridge d Manual of the Illnes s Attitude Albuquerque, NM: Department of P sychiatry, of New Mexico S chool of Medicine; 1987. K ellner R . P s ychos omatic S yndrome s and S omatic S ymptoms . W ashington, DC : American P sychiatric 1991. K irmayer LJ , R obbins J M: T hree forms of primary care: P revalence, co-occurrence and sociodemographic characteris tics. J Ne rv Ment Dis . 1991;179: 647. K raus R . P ibloqtoq R e vis ite d. P aper presented at: annual meeting of T he S ociety for the S tudy of P sychiatry and C ulture; October 19, 2002; C harlottesville, V A.

1697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 174 of 176

Ladee G A. Hypochondriacal S yndrome s . North-Holland P ublis hing; 1966. Lipows ki ZJ : S omatization: T he concept and its application. Am J P s ychiatry. 1988;145:1358. Lipsitt DR . T he patient-phys ician relationship in the treatment of hypochondriasis . In: S tarcevic V , Lips itt eds. Hypochondrias is : Modern P e rs pe ctive s on an Malady. Oxford, UK : Oxford University P ress ; 2001. Looper K J , K irmayer LJ : B ehavioral medicine to somatoform disorders . J C ons ult C lin P s ychol. 2002;70:810. Morris on J : C hildhood sexual histories of women somatization disorder. Am J P s ychiatry. Noyes R J r, Holt C S , Happel R L, K athol R G , Y agla family s tudy of hypochondriasis. J Ne rv Ment Dis . 1997;185:223. Noyes R J r, K athol R G , F is her MM, P hillips B M, MT , Holt C S : T he validity of DS M-III-R Arch G e n P s ychiatry. 1993;51:961. Noyes R J r, S tuart S P , Langbehn DR , Happel R L, S L, Muller B A, Y agla S J : T est of an interpersonal of hypochondrias is . P s ychos om Me d. 2003;65:292. P hillips K A. S omatoform and F actitious Dis orde rs . Was hington, DC : American P sychiatric P ublis hing, 1698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 175 of 176

2001. P hillips K A, Albertini R S , R as muss en S A: A placebo-controlled trial of fluoxetine in body dysmorphic dis order. Arch G e n P s ychiatry. *P ilowsky I: Dimens ions of hypochondrias is . B r J P s ychiatry. 1967;113:89. P ilowsky I: P rimary and secondary hypochondriasis . Acta P s ychiatr S cand. 1970;46:273. S elye H. T he S tre s s of L ife . New Y ork: McG raw-Hill; S mith G R . S omatization Dis order in the Me dical Was hington, DC : American P sychiatric P ress ; 1991. S mith G R , R os t K , K ashner M: A trial of the effect of standardized ps ychiatric cons ultation on health outcomes and costs in somatizing patients . Arch P s ychiatry. 1995;52:238. S tarcevic V . R eass urance in the treatment of hypochondriasis. In: S tarcevic V , Lips itt DR , eds. Hypochondrias is : Modern P ers pective s on an Malady. Oxford, UK : Oxford University P ress ; 2001. S tekel W . T he Inte rpre tations of Dre ams : N ew Deve lopme nts and T e chnique . New Y ork: Liveright; S tolorow R D: Defens ive and arrested developmental as pects of death anxiety, hypochondriasis and 1699 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

15

Page 176 of 176

depers onalization. Int J P s ychoanal. 1979;60:201. T ezcan E , Atmaca M, K uloglu M, G ecici O, A, T utkun H: Dis sociative disorders in T urkis h with conversion disorder. C omp P s ychiatry. T orgers en S : G enetics of s omatoform dis orders. G e n P s ychiatry. 1986;43:502. T yrer P . T he R ole of B odily F e elings in Anxiety. Oxford Univers ity P res s; 1976. T yrer P : S omatoform and personality dis orders: personality and the s oma. J P s ychos om R e s . Weintraub MI. Hys terical C onvers ion R e actions : A G uide to Diagnos is and T re atme nt. New Y ork: S P and S cientific B ooks ; 1983.

1700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

01/01/2009

16

Page 1 of 79

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > 16 - F actitious Dis order

16 Fac titious Dis orders Dora Wang M.D. Deepa N. Nadiga M.D. J ames J . J ens on M.D. According to the American Heritage Dictionary, the factitious means “artificial; false,” derived from the Latin facticius , which means “made by art.” T hose with disorder s imulate, induce, or aggravate illnes s, often inflicting painful, deforming, or even life-threatening on thems elves or those under their care. Unlike malingerers who have material goals , such as gain or avoidance of duties , factitious dis order patients undertake thes e tribulations primarily to gain the emotional care and attention that comes with playing role of the patient. In doing s o, they practice artifice art, creating hospital drama that often causes and dismay. C linicians may exclaim, “He's not really He's doing it to himself!” and thus dis mis s, avoid, or to treat factitious disorder patients. S trong countertransference of clinicians can be major toward the proper care of these patients who arguably among the most psychiatrically dis turbed. S ignificant morbidity or even mortality often occurs. T herefore, even though pres enting complaints are falsified, the medical and psychiatric needs of thes e 1701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 2 of 79

patients mus t be taken serious ly. F actitious ly produced wounds can result in infection and os teomyelitis and even necess itate amputation. One woman factitious ly complained of an extens ive family his tory of breas t incurring a medically unneces sary bilateral C as es resulting in death are not uncommon. A 21operating room technician, the daughter of a phys ician, repetitively injected herself with ps eudomonas, caus ing multiple bouts of s epsis and bilateral renal failure her death. F or patients with factitious disorder, unmet emotional needs are so great that even imperilment of life or limb be merited. F actitious illness behavior often represents severe underlying ps ychiatric disturbance, such as a personality dis order. Ironically, even thos e pres enting factitious ps ychological complaints , such as or psychosis, usually have another ps ychiatric for which they are not s eeking help. T reatment involves harm reduction and efforts to steer patients toward the ps ychiatric care that they need, in face-saving, nonthreatening ways. Des pite potentially high stakes , relatively little empirical knowledge is available about the etiology, cours e and prognosis , and effective treatment of disorders . Most knowledge comes from cas e reports , information that is frequently s uspect, given the fals e, unreliable nature of the information thes e patients give. Methodological problems are inherent in the study of these deceptive patients, as they are difficult to identify, and, when found out, they often flee to avoid charges fraud from the hospital and ins urance companies. S ys tematic s tudies of factitious dis order are few, and 1702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 3 of 79

federally funded investigation is nonexistent, despite subs tantial human and financial cos t imposed by the disorder. However, the s ituation is not as grim as previous ly as sumed. Munchausen syndrome, the prototypical factitious disorder and the first to engender wide interes t, is now known to be a chronic, severe variant, comprising only a small portion of all factitious F actitious illness behavior represents a wide spectrum at one end, represents normal behavior, s uch as when children exaggerate dis tress from s crapes and bruises gain parental attention. It is important to remember that not all factitious illness behavior is as refractory or as chronic as that demons trated by Munchaus en patients. 

DE F INIT ION



HIS T OR Y



C OMP AR AT IV E NOS OLOG Y



E P IDE MIOLOG Y



E T IOLOG Y



DIAG NOS IS AND C LINIC AL F E AT UR E S



P AT HOLOG Y AND LAB OR AT OR Y R E P OR T S



DIF F E R E NT IAL DIAG NOS IS



C OUR S E AND P R OG NOS IS



T R E AT ME NT AND MANAG E ME NT



F UT UR E DIR E C T IONS



S UG G E S T E D C R OS S -R E F E R E NC E S 1703

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 4 of 79

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > DE F INIT ION

DE FINITION P art of "16 - F actitious Dis orders " T he main clinical feature is the intentional production or feigning of physical or psychological s igns or with the motivation of ass uming the s ick role. T he definition of factitious dis order, according to the revised fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ), is given in T able 16-1.

Table 16-1 DS M-IV-TR Diagnos tic C riteria for Fac titious Dis order A. Intentional production or feigning of physical or ps ychological signs or s ymptoms . B . T he motivation for the behavior is to as sume sick role. C . E xternal incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving phys ical well-being, as in malingering) absent.

1704 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 5 of 79

C ode based on type:    300.16 With predominantly ps ychologic al and s ymptoms : if ps ychological signs and symptoms predominate in the clinical    300.19 With predominantly phys ic al s igns s ymptoms : if physical s igns and s ymptoms predominate the clinical presentation.    300.19 With c ombined ps ychologic al and phys ic al s igns and s ymptoms : if ps ychological phys ical s igns and s ymptoms are pres ent, but neither predominates the clinical pres entation.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. Munchaus en s yndrome , a colorful name coined by Asher in his landmark 1951 publication, is also known chronic factitious dis orde r with predominantly phys ical and s ymptoms . T he two terms are us ed T hese cases are a s mall s ubs et of the most severe factitious disorder in which factitious illness behavior becomes a lifes tyle, usually precluding s table or employment. C ons tantly seeking medical care and hospitalization, these patients often ass ume grandiose, 1705 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 6 of 79

false identities , s ometimes claiming to be royalty, of celebrities , or figures in important historical events. T hey travel from hospital to hos pital s eeking medical and, when they become well-known in town, take their on the road to another locale, where they begin the behavior anew. T he nicknames hos pital hoboes , addicts , and profes s ional patients have been applied to them. T wo distinguishing features of Munchaus en syndrome are ps eudologica fantas tica, the telling of tall and fascinating but untrue tales , and pe re grination, as these patients tend to be well traveled. Munchaus en syndrome comprises only approximately percent of all cases of factitious disorder, and the two should be distinguished. Not all those with factitious disorder have the same poor prognosis as the s mall minority of Munchausen syndrome patients. In factitious dis order by proxy, a person intentionally simulates illness in another pers on who is under that individual's care. Most commonly, the perpetrator is a mother causing illness in her own child s o that that s he gains the emotional gratification of the sick role vicariously. In other cases, factitious disorder by proxy be committed by one adult against another adult, such an elder or spouse. Medical pers onnel have committed factitious disorder by proxy on patients, causing of hos pital deaths. P erpetrators usually gain the admiration of others, appearing like s elf-sacrificing caretakers . B ecause factitious dis order by proxy almos t always constitutes child abus e or a criminal act, the forens ic terms pe rpetrator P.1830 1706 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 7 of 79

and victim are us ed even in the medical literature. F actitious disorder by proxy currently falls under the category of factitious disorder not otherwise specified (NOS ), according to DS M-IV -T R . It is listed as a criteria deserving of further s tudy, and its research criteria are listed in T able 16-2. T he terms factitious dis order by and Munchaus en s yndrome by proxy are us ed interchangeably, and, at the current time, there is no distinction between the terms . Although, by DS M-IV -T R criteria, the term factitious dis order by proxy refers to perpetrator, not the victim, there is s ome variance of the literature.

Table 16-2 DS M-IV-TR R es earc h C riteria for Fac titious Dis order Proxy A. Intentional production or feigning of physical or ps ychological signs or s ymptoms in another who is under the individual's care. B . T he motivation for the perpetrator's behavior is as sume the s ick role by proxy. C . E xternal incentives for the behavior (such as economic gain) are absent. D. T he behavior is not better accounted for by another mental dis order. 1707 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 8 of 79

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > HIS T O R Y

HIS TOR Y P art of "16 - F actitious Dis orders " S elf-inflicted illnes s occurs throughout his torical In the s econd century AD, the G reek-born phys ician wrote of patients inducing or simulating s ymptoms such as vomiting or rectal bleeding. T he B ible relates of people self-inflicting injury. In the E uropean middle ages, hys te rics reportedly put leeches in their mouths simulate hemoptysis and abraded their s kin to skin conditions. However, judging historical accounts through contemporary mindsets is often problematical, and it is difficult to say if thes e accounts actually factitious disorder. In 1838, the S cottis h military phys ician Hector G avin published his es say, “On the F eigned and F actitious Dis eas es of S oldiers and S eamen, on the Means Us ed 1708 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 9 of 79

S imulate or P roduce T hem, and on the B es t Modes of Dis covering Impos tors .” Although most of G avin's were malingering, aiming to es cape duty in the high casualty Napoleonic Wars , G avin als o noted that the motive of s ome was simply “to excite compass ion or interes t” and that “some soldiers, indeed, without any ulterior object, s eem to experience an unaccountable gratification in deceiving their officers, comrades, and surgeon.” J ean-Martin C harcot, in approximately 1890, us ed the mania ope rativa activa to des cribe a young girl who continually sought surgery for pain in a knee joint, until she found a s urgeon who amputated the leg. S ubsequently, no pathology was found in the leg. In the S wis s phys ician Henri F . S ecretan described a syndrome, to which he lent his name, of nonhealing traumatically induced edema of the dorsum of the G eorge R eading, in 1980, confirmed that S ecretan's syndrome is factitiously produced. In 1934, K arl described polys urgical addiction. Interes t in factitious disorder increased markedly when term Munchaus en s yndrome was coined in a 1951 publication by B ritish physician R ichard As her. As her Here is des cribed a common syndrome which mos t doctors have seen, but about which little has been written. Like the B aron von Munchausen, the persons affected have always traveled widely; and their like thos e attributed to him, are 1709 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 10 of 79

both dramatic and untruthful. Accordingly, the syndrome is res pectfully dedicated to the baron, and named after him. Asher's provocative paper described three patients with false abdominal complaints , all of whom us ed multiple identities and s ought care at a number of hos pitals . paper inspired much correspondence and subs equent reports . T he B aron K arl F riedrich Hieronymus von (1720 to 1797) was an honorable nobleman who the R us sian army in war agains t the T urks (F ig. 16-1). retirement, he entertained friends with embellished of his war adventures. T he peregrinating, figure was in fact the B aron's friend, R udolph E ric who was forced to flee G ermany for E ngland after he caught embezzling from a mus eum. S eeking to pay off debts , R aspe published an account of the baron's tales 1785.

1710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 11 of 79

FIGUR E 16-1 T he B aron K arl F riedrich Hieronymus von Munchhausen (1720 to 1797). Left: T he B aron wears military armor in this 1750 portrait by G . B ruckner. An honorable nobleman who served in the R uss ian army in war against the T urks, the B aron entertained friends in retirement with embellished s tories of his war His tales gained fame when published by R udolph E . R ight: T he B aron appears as a caricature in this 19th-century artis t G ustave Dore. Like the B aron, with factitious disorders are pers ons deserving of even though they often pres ent themselves as (P ortrait courtes y of B ernhard W iebel, http://www.muenchhaus en.ch/. T he actual portrait was in W orld W ar II. C aricature from T he Adve ntures of Munchaus en: O ne Hundred and S ixty Illus trations by Dore . New Y ork: P antheon B ooks, Inc.; 1944, with 1711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 12 of 79

permis sion.) In 1968, Herzl R . S piro noted that, of the 38 cas es of Munchaus en s yndrome then published, none involved detailed psychiatric workup and les s than one-half evaluated by a psychiatrist. He advocated greater unders tanding of thes e patients and pres ented the first detailed psychiatric case study, confirming information with collateral sources. He called the Munchausen syndrome label “facetious ” and recommended the les s pejorative term chronic factitious s ymptomatology. F actitious disorder with ps ychological s ymptoms was described by Alan J . G elenberg in 1977, who mused although other factitious dis order patients avoided ps ychiatris ts, his patient, a war veteran, gained to more than 30 psychiatric hospitals within a few us ually feigning depres sion and s uicidal tendency various pseudonyms. T he term Munchaus en s yndrome by proxy was first 1976 by J ohn Money and J une W erlwas , who reported cases of child abuse and deprivation that resulted in ps ychos ocial dwarfism. T he motive of as suming the role was not a feature of thes e cas es. T he term Munchaus en s yndrome by proxy as it is us ed today applied in 1977 by B ritis h pediatrician R oy Meadow published the widely read article, “Munchaus en's by T he Hinterland of C hild Abuse,” which detailed the accounts of a mother P.1831

1712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 13 of 79

who caused salt pois oning in her child and another fabricated urinary tract infections in her daughter. T he latter cas e was of a 6-year-old girl who had undergone hospitalizations, more than 150 urine cultures , s ix examinations under anes thesia, five cystoscopies, and seven major X-ray procedures . W hen the girl was for obs ervation, the diagnosis of Munchausen by proxy was made based on urine s amples that were bloody when they were collected by the mother but normal when they were collected by the nurse. Of note, the mother had als o s ought medical treatment for factitiously induced urinary tract infections in hers elf. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > C O MP AR AT IV E NO S O LO

C OMPAR ATIVE P art of "16 - F actitious Dis orders " T he third edition of the Diagnos tic and S tatis tical Me ntal Dis orde rs (DS M-III) in 1980 was the first edition the DS M to recognize factitious disorder. Munchaus en syndrome was called the prototype of all factitious disorders , and, accordingly, emphasis was placed on chronic factitious dis order with physical s ymptoms. F actitious disorder with ps ychological s ymptoms was recognized, as was atypical factitious disorder, which included dis orders that would now fall into the DS M-IV category of factitious disorder with predominantly phys ical s igns and s ymptoms. S ubsequent editions of the DS M increas ingly 1713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 14 of 79

the rarity of Munchaus en s yndrome and accordingly placed more emphas is on a greater s pectrum of disorders . T he revised third edition of the DS M (DS Mrecognized factitious dis order with physical symptoms factitious disorder with ps ychological s ymptoms. T he emphasis on Munchaus en syndrome was less ened. F actitious disorder with combined phys ical and ps ychological symptoms made its appearance under category of factitious disorder NOS . In contras t, the fourth edition of the DS M (DS M-IV ) to es pouse a s ingle category, factitious disorder, with types : (1) with predominantly psychological s igns and symptoms, (2) with predominantly phys ical s igns and symptoms, and (3) with combined ps ychological and phys ical s igns and s ymptoms. F actitious disorder NOS exemplified by factitious disorder by proxy, a dis order named as a category des erving of more research, with res earch criteria listed. T he DS M-IV -T R criteria for disorders are unchanged in comparis on with DS M-IV criteria. When the diagnosis of factitious disorder by proxy is it s hould be coded as factitious disorder NOS . T he diagnosis applies to the perpetrator, not the victim. P hysical abuse of child for the caregiver and phys ical of child for the child should also be coded. E mphas izing the pers onality disorder aspect of disorders , the tenth revis ion of the Inte rnational C las s ification of Dis e as e s and R e late d He alth 10) lis ts factitious disorder under the category other dis orders of adult pe rs onality and be havior. T wo corres ponding with common notions of factitious are identified: (1) elaboration of phys ical s ymptoms for 1714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 15 of 79

ps ychological reasons and (2) intentional production or feigning of s ymptoms or disabilities , phys ical or ps ychological (factitious disorder). Under the s econd subtype, hos pital hopper syndrome, Munchaus en syndrome, and peregrinating patient are listed. T he excludes “person feigning illnes s (with obvious motivation),” just as DS M-IV -T R excludes malingering. IC D-10 makes no mention of factitious disorder by Limitations exist in the DS M-IV -T R and IC D-10 B oth clas sification s ys tems s pecify that s ymptoms of factitious disorder are intentionally or consciously produced. However, in reality, intent can be difficult to discern, and consciousness may repres ent a s pectrum awarenes s. Likewise, the DS M-IV -T R and the IC D-10 exclude cas es in which there are obvious or external motivations . Motive, however, can als o be difficult to determine. C riteria of intent and motivation are completely subject to the clinician's opinion. E ven the DS M-IV -T R and the IC D-10 exclude malingering, reality is that factitious disorder and malingering can coexist, as when patients who habitually gratify thems elves in the sick role dis cover that they can als o receive dis ability payments or pleasurable pain medications at the s ame time. Neither the current DS M-IV -T R nor the IC D-10 accommodates the growing literature about disorder by proxy diagnoses in which parents impose ps ychiatric disorders or emotional needs on their F or example, hypochondrias is by proxy can result in repetitive pediatric vis its and unnecess ary tes ts and procedures for a child, but without fabrication of of illnes s. Anore xia ne rvos a by proxy and malinge ring 1715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 16 of 79

proxy are other examples. Interes tingly, although the psychiatric nosology equivocal about the existence of factitious dis order by proxy as a disease entity, the legal system has 50 states require reporting of Munchausen syndrome proxy to child protective s ervices as a form of child Munchaus en s yndrome by proxy is well established in legal literature, with an abundance of representation in case law. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > E P IDE MIOLO G

E PIDE MIOL OGY P art of "16 - F actitious Dis orders " No comprehens ive epidemiological data on factitious disorder exis t, as traditional epidemiological methods would be problematical with this deceptive population. B ecaus e factitious dis order may be difficult to detect, prevalence may be underestimated. On the other hand, prevalence might be overestimated, as many of thes e patients s eek care at multiple venues . F urthermore, with factitious disorders may not present to a health setting but may play the s ick role with family, friends, or coworkers. F or example, a fan of the B roadway R ent feigned terminal illnes s and s uicidal tendency, the sympathies of fellow fans and even the cas t, who dedicated songs to her during performances. Internet bulletin boards P.1832 1716 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 17 of 79

and chat groups provide new opportunities to fabricate illness and to play the sick role in cybers pace. Limited s tudies indicate that factitious dis order patients may compris e approximately 0.8 to 1.0 percent of ps ychiatry consultation patients . Of 1,288 medical inpatients referred for psychiatric cons ultation at a T oronto teaching hospital, 0.8 percent were diagnos ed with factitious disorder. At a New Y ork C ity hospital, 1 percent of psychiatry cons ultation patients were diagnosed with factitious disorders . F ever is one of the most commonly detected factitious symptoms, and s tudies indicate that 2.2 to 9.3 percent fevers of unknown origins may be factitious. A S tanford Univers ity study showed that, of 506 cas es, 2.2 percent were factitious . On the other hand, more than four that percentage, a remarkable 9.3 percent of 343 the National Ins titute for Allergy and Infectious were found factitious. Other es timates include 3.5 in a s tudy of 199 cases in the 1980s and 6.5 percent of cases at the National Institutes of Health. In a s tudy of urinary calculi, 3.5 percent of s tones brought in by were factitious , cons isting of materials s uch as quartz felds par. F actitious dis orders may play a larger role expected in health care us e and may be an underrecognized confounding factor in medical V arious authors agree that approximately two-thirds of patients with Munchaus en syndrome are male. T hey to be middle-aged, unemployed, unmarried, and significant social or family attachments. F or thos e with non–Munchaus en syndrome factitious dis orders with predominantly phys ical s igns and s ymptoms, women 1717 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 18 of 79

outnumber men, with a ratio of 3 to 1. T hey are us ually to 40 years of age with a history of employment or education in nurs ing or a health care occupation. In a year retros pective s tudy, 28 of 41, or 68 percent, of hospitalized patients with factitious dis orders had in medically related fields, 15 as nurs es. F actitious disorders usually begin for patients in their 20s or 30s , although the literature contains cas es ranging from 4 to years of age. R eported cases are almost exclus ively whites, although two African-American men with Munchaus en syndrome have been reported. reports have come from E urope and Africa. F ar les s information is available about the factitious disorders with predominantly ps ychological signs and s ymptoms. Dines h B hugra estimated Munchaus en syndrome at 0.5 percent of adult admis sions who were younger than 65 years of age, on four diagnoses of Munchaus en syndrome out of 775 admis sions . In a s tudy of 4,500 visits to a ps ychiatric emergency room (E R ), seven vis its , or 0.15 percent, represented factitious disorder. S imilarly, a 1994 s tudy es timated the prevalence at 0.14 percent in a sample. F actitious disorder by proxy is most commonly perpetrated by mothers against infants or young R are or underrecognized, it accounts for les s than 0.04 percent, or 1,000 of three million cas es of child abus e reported in the United S tates each year. G ood epidemiological data are lacking. Of infants brought to Aus tralian clinic for apparently life-threatening an es timated 1.5 percent represented factitious by proxy. A clinical practice at G reat Ormond S treet in 1718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 19 of 79

E ngland reported that, in 20 years, 43 children from 37 families were diagnos ed as having induced illness es. Donna A. R osenberg's review of 117 cases revealed valuable information. Male and female children were equally victimized. T he mean age of a child at was 3.3 years of age, with the onset of s ymptoms mean of 1.24 years earlier. All perpetrators were with 98 percent being biological mothers and 2 percent being adoptive mothers. P aternal collus ion was in only 1.5 percent of the cases . In one-half of the illness was actively produced and inflicted on the child, whereas , in 25 percent, illness was simulated without direct infliction on the child. In 25 percent, illness was simulated and produced. Interes tingly, in 25 percent of cases, morbidity on the child was iatrogenic only, procedures and investigations . S urprisingly, 70 percent produced illnes s occurred in the hospital, making inves tigation during hos pitalization a valuable option. In R osenberg's review, 10 percent of perpetrators were thought to have Munchaus en s yndrome themselves , whereas another 14 percent s howed features of the syndrome. On the other hand, data collected from the G reat Ormond S treet clinic over a 20-year period that approximately one-third of perpetrating mothers a his tory of factitious dis order themselves. Nearly oneof them described s erious marital problems. Approximately one-half of the perpetrating caregivers a his tory of psychiatric s ymptoms ; approximately onegave his tories of emotional neglect or physical abuse. F athers were generally absent or peripheral. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di

1719 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 20 of 79

C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > E T IOL OG

E TIOL OGY P art of "16 - F actitious Dis orders " T he etiology of factitious dis order is not known, and a variety of caus es likely explain the wide s pectrum of factitious illness behavior. Although factitious illness behavior is, by definition, consciously produced, the underlying motivations for the behaviors are largely cons idered to be unconscious. T wo factors underlie cases of factitious disorder: (1) an affinity to the system and (2) poor, maladaptive coping s kills . A majority of factitious dis order patients have training in medicine, and many work as nurs es . In a review of s ix series compris ing a total of 165 patients , P eter R eich Lili A. G ottfried found that 60 percent worked in the medical profess ion. Motives behind medical career appeared to be lifelong preoccupations with health than access to information to deceive. Indeed, many factitious disorder s ee health care providers as allies, advers aries. In this case s eries, many patients had ties with their phys icians, having worked in their offices having baby-sat for them. C oping deficits are widely noted. P atients often have immature coping s kills , not falling into any current category of personality dis order. T his is consistent with observations that many factitious disorder patients from large families or have been neglected as children, therefore lacking the nurturing conducive to the 1720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 21 of 79

development of mature coping. T his is als o consis tent the fact that children often demonstrate factitious behavior that is not cons idered pathological, for feigning a stomachache to gain parental attention. On other end of the spectrum, poor coping may be part of personality dis order, such as borderline personality or antis ocial pers onality disorder. Dependent and personality traits may als o be evident. An underlying psychiatric diagnos is may predis pos e to factitious illness behavior. Many cas e reports indicate less ening or alleviation of factitious illness behavior major depress ion is treated. Other cas e reports point to hypochondriasis as an underlying factor. F or example, 27-year-old phys ician simulated ins ulinoma by ins ulin injections. W hen insulin and a syringe were found in toilet tank, he confess ed a preoccupation that he had pancreatic cancer and that he was trying to provoke further investigation. A 15-year-old boy, convinced that had a les ion in his urogenital system, s imulated to encourage investigation. S ubs tance abus e, disorders , and mental retardation have also been implicated. No genetic or familial inheritance pattern has been No s ubs tantial evidence of a biological etiology has found, des pite scattered P.1833 reports of abnormal brain s cans and deficits in neurops ychological testing in a few patients. Indeed, a great percentage of factitious dis order patients achieve advanced degrees , maintain high-functioning jobs as medical profess ionals , and demonstrate great cognitive 1721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 22 of 79

as tutenes s in their manipulations of medical s igns and symptoms. P sychodynamic theories have focus ed on the concepts mastery, masochism, and mothering. Achieving may be especially true for factitious disorder patients predominantly ps ychological signs and s ymptoms. F or example, as those who present with factitious often progres s to develop a genuine psychotic the feigning of ps ychos is may actually be a way of in control of initial psychotic s ymptoms . As for phys ical factitious disorder, many of these patients experienced traumatic illness es as children, and their adult factitious illness behavior may allow them to mas ter s ituations to feel control that they never did as children. T hey demand or refus e procedures and leave the hospital agains t medical advice when they feel that they are control. Mas ochism may be involved when patients repetitively endure painful or deforming surgeries and procedures , s uch as amputations of limbs and fingers, exploratory abdominal s urgeries that res ult in scars even the gridiron s tomach that As her des cribed as a symptom of Munchaus en s yndrome. T he theory here is that the patient relives childhood phys ical or emotional abuse in a repetition compulsion. T he physician and medical system at large become symbolic parents whom the patient reenacts dependency, idealization, anger. T he s ys tem res ponds with caring but also with phys ical and emotional abus e and, too often, ultimately with deris ion and abandonment. Indeed, for those with chronic factitious dis order, the medical system the main object relation in the patient's life, a s ubs titute mother. T he medical system may be a place to 1722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 23 of 79

caring, while avoiding emotional intimacy. F actitious illness behavior often occurs in the setting of loss , s uch as the death of a relative or an occupational S ecuring the attention of medical clinicians, family, and friends may be a way of obtaining emotional s olace without directly confronting the loss . Dependency and narcis sistic needs are fulfilled. F actitious illness behavior may organize s ome patients, giving them a role and identity. T hey acquire the role of patient and masterful orches trator of medical drama. T hrough ps eudologica fantas tica, they might even cons truct desirable and interes ting identities. B ehavioral theories postulate that, early in life, these patients received pos itive reinforcement while in the role. Many experienced childhood illness es and gained nurturing from the medical community that they did not receive at home. P erhaps, they learned to see the system as a s ource of caring and emotional support. Alternatively, many of these patients came from large families and became the center of focus when were ill. In factitious dis order by proxy, ps ychodynamic explanations predominate. A common view is that caretakers often have a profound s ense of loss , a his tory of early abandonment particularly by the or loss of contact with another child. C ontrovers y exists regarding the likelihood of a history of abuse for the mothers, as many have reported his tories of abuse that were later dis qualified by collateral sources. T he objectification of the child to serve the parent's ps ychological needs characterizes all variations of the 1723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 24 of 79

disorder. A dis order of empathy among perpetrating mothers was recognized by R os enberg, along with pervas ive themes of lonelines s and isolation, often circums tances of uninvolved or abs ent hus bands. the ill child, the mother seeks a relationship with the phys ician, the idealized parent, who substitutes for the uninvolved hus band. T he relations hip with the a highly ambivalent one in which the caregiver seeks clos enes s, although often belittling the physician in contexts . T he more s evere the child's illness , the more mother is needed, and the more s he fulfills her own for caretaking, vicarious ly through the child and more directly in her relations hip with the physician. F athers to be uninvolved or dis tant. D. Mary E minson and P os tlethwaite argue that two axes play a role in disorder by proxy: the desire to consult and the inability the parent to distinguish parental needs from the child's needs . Herbert A. S chreier and J udith A. Libow call Munchaus en syndrome by proxy a pe rve rs ion of in which the child is dehumanized and instead is seen the mother as a fetishis tic object through which her dependency needs are met. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > DIAG NO S IS AND C LINIC AL

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "16 - F actitious Dis orders "

1724 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 25 of 79

Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms E arly diagnos is and intervention can minimize physical harm to the patient and iatrogenic complications . T herefore, the diagnosis of factitious disorder s hould actively pursued. Dis eas es of every organ s ys tem have been simulated, including rare illness es , such as G oodpasture's and panhypopituitaris m. Dis eas e s imulation is limited by the patient's creativity and knowledge and the technological means available. As they tend to have medical training, the factitious patient's knowledge of disease may exceed that of his or her phys icians . T his es pecially true, as they often pres ent to hospital E R s or clinics during evenings or weekends when less experienced staff or resident phys icians are on duty. F actitious s ymptoms can be (1) fabricate d, for giving a fals e his tory of cancer, acquired immune deficiency syndrome (AIDS ), or another illness ; (2) for example, by faking s ymptoms such as pain or (3) induce d, by actively producing s ymptoms through infliction of injury or through injection or ingestion; or aggravate d, s uch as manipulating a wound so that it not heal. T able 16-3 lists various reported presentations of disorders along with the means us ed to produce the symptoms and pos sible means of detection. V iewing list, one can appreciate the creativity and of thes e patients , as well as their willingness to pain, injury, and inconvenience for the sake of 1725 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 26 of 79

emotional needs .

Table 16-3 Pres entations of Fac t Dis order with Predominantly Phys ic and S ymptoms with Means of S im and Pos s ible Methods of Detec S ymptom

Means of S imulation That Have B een R eported

Pos s ible Me Detec tion

Autoimmune

 

 

G oodpas ture's syndrome

F alse his tory, adding blood to urine

B ronchoalveo lavage negat hemos iderincells

S ys temic lupus erythematosus

Malar rash simulated cosmetics , feigning joint pain

Negative anti antibody tes t, removability o

Dermatologic al

 

 

B urns

C hemical agents,

Unnatural sha

1726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 27 of 79

such as oven cleaner

lesions , strea chemicals , m injury to finge

E xcoriations

S elf-infliction

F ound on acc parts of the b for example, preponderanc sided les ions right-handed

Lesions

Injection of exogenous material, such as talc, milk, or gasoline

P uncture ma needles, dis c syringes

E ndoc rine

 

 

C us hing's

S teroid ingestion

E vidence of exogenous s t

Hyperthyroidis m

T hyroxine or Liodothyronine inges tion

24-hr iodineuptake is sup in factitious d and increase G raves' disea

Hypoglycemia or insulinoma

Ins ulin injection

Ins ulin to C -p ratio is greate

1727 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 28 of 79

one, detectio serum ins ulin antibodies Inges tion of oral hypoglycemics

S erum levels of hypoglycemic medication

P heochromocytoma E pinephrine or metaraminol injection

Analys is of u catecholamin reveal epinep only or other suspicious fin

Gas trointes tinal

 

 

Diarrhea

P henolphthalein or cas tor oil inges tion

T es ting of sto laxatives, inc stool weight

Hemoptysis

C ontamination of sputum s ample, self-induced trauma, s uch as cuts to tongue

C ollect speci under observ examine mou

Ulcerative colitis

Laceration of colon with knitting needle

—

1728 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 29 of 79

Hematologic al

 

 

Aplastic anemia

S elfadminis tration of chemotherapeutic agents to suppress bone marrow

Hematologycons ultation

Anemia

S elf-induced phlebotomy

B lood s tudies

C oagulopathy

Inges tion of warfarin or other anticoagulants

—

Infec tious

 

 

Abdominal

Injection of feces into abdominal wall

Unus ual path microbiology

Acquired immune deficiency syndrome

F alse his tory

C ollateral info

Neoplas tic

 

 

C ancer

F alse medical family history,

C ollateral examination

1729 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 30 of 79

shaving head to simulate chemotherapy Neurologic al

 

 

P araplegia or quadriplegia

F eigning, history

Imaging s tud electromyogr

S eizures

F eigning, history

V ideo electroencep

 

 

Antepartum hemorrhage

V aginal puncture wounds, us e of fake blood

E xamination, blood

E ctopic pregnancy

F eigning abdominal pain while s elfinjecting hC G

Ultrasound

Menorrhagia

Using s tolen blood

T ype blood

P lacenta previa

Intravaginal use hat pin

E xamination

Obs tetric and gynecologic al

1730 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 31 of 79

P remature labor

F eigned uterine contractions , manipulation of tocodynamometer

E xamination

P remature rupture of membranes

V oiding urine into vagina

E xamine fluid

T rophoblas tic disease

Addition of hC G urine

—

V aginal bleeding

S elf-mutilation with fingernails , nail files, bleach, knives, tweezers , nut picks, glas s, and pencils

E xamination

V aginal discharge

Applying as h to underwear

E xamination

S ys temic

 

 

F ever

Warming thermometer agains t a light bulb or other source, drinking hot fluids , friction from mouth or

S imultaneous of temperatur two different (orally and re recording temperature o voided urine,

1731 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 32 of 79

anal s phincter, false recordings , injection of pyrogens such feces , vaccines, thyroid hormone, or tetanus toxoid

despite high thermometer readings, nor white blood c count, unusu or incons is ten temperatures

Urinary

 

 

B acteriuria

C ontamination of urethra or specimen

Unus ual path

Hematuria

C ontamination of specimen with blood or meat, warfarin foreign bodies in bladder (pins)

C ollect speci under observ

P roteinuria

Ins erting egg protein into urethra

—

S tones

F eigning of renal colic pain, bringing in made of exogenous

P athology rep

1732 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 33 of 79

materials or inserting them into urethra

hC G , human chorionic gonadotropin.

T able 16-4 lists clues that s hould trigger s uspicion of factitious disorder. F actitious dis order should be whenever medical signs or s ymptoms defy medical understanding or when they do not res pond to us ual medical treatment, for example, when a wound refuses to heal or when test res ults s how a pattern that inconsistent with us ual disease pres entation. F actitious disorder patients may also demons trate an exceptional eagerness to undergo invasive or extensive testing. may deny access to collateral sources of information, refusing to sign releases of information and refus ing to give contact information for family or friends. An medical his tory, evidence of multiple s urgeries , and reports of multiple drug allergies may also provide for the astute clinician. T hese patients often have jobs medical profess ion, have few visitors , and often have known to forecast the progres sion of their s ymptoms .

Table 16-4 C lues That S hould Trigger S us pic ion of Fac titious Dis order 1733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 34 of 79

Unus ual, dramatic pres entation of symptoms that defy conventional medical or psychiatric unders tanding S ymptoms do not respond appropriately to us ual treatment or medications E mergence of new, unusual s ymptoms when symptoms resolve E agernes s to undergo procedures or tes ting or to recount s ymptoms R eluctance to give access to collateral sources of information, that is, refus ing to s ign releas es of information or to give contact information for and friends E xtens ive medical his tory or evidence of multiple surgeries Multiple drug allergies Medical profess ion F ew vis itors Ability to forecas t unusual progress ion of or unus ual res ponse to treatment 1734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 35 of 79

S imply raising the s us picion of factitious dis order is the first important step toward diagnosis. After this , information s upporting the diagnosis s hould be A review of past medical records may reveal inconsistencies. G athering collateral information from family, friends, or other health care providers may show inconsistencies. Ward clerks may be the first to notice waxing and waning levels of distress , depending when the patient thinks clinicians P.1834 P.1835 are obs erving. C ollection of laboratory s pecimens clos e observation can minimize contamination or manipulation of s amples . S ometimes, laboratory values can provide important diagnostic clues, s uch as in the of high insulin and low C -peptide levels in patients simulating ins ulinoma through self-adminis tration of insulin or when microbiology reports reveal unusual pathogens . C onclusive confirmation of factitious dis order can be difficult. S urveillance techniques, s uch as covert observation, covert video, or s earching the patient's belongings for syringes or illness -inducing substances, have been us ed. When these techniques are is es sential to involve legal counsel as the patient's privacy, as well as constitutional protections against searches and seizures , is at stake. In s ome cases, orders should be obtained. C onsultation from a team can help weigh the benefits and risks of these violations of privacy versus morbidity from factitious 1735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 36 of 79

disorder. T his phase of acquiring information to confirm diagnosis is often a time of conflict for staff who may split opinions about the patient and about the means being used to confirm diagnosis. R egular meetings are helpful.

C hronic Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms (Munc haus en B ecaus e of more dramatic, exaggerated presentations , chronic factitious disorders with predominantly physical signs and s ymptoms are often more eas ily diagnosed those with les s chronic factitious dis order, even if treatment and management can be far more As thes e patients are prone to peregrination, they often arrive new in town. T hey demonstrate ps eudologia fantas tica, with grandiose and far-fetched tales . T hey appear eerily comfortable in hospital settings, talking to nurses , phys icians , and medical s taff as Many show up for hospital admis sion wearing surgical scrubs. One patient, who claims to be the s on of a golfer, arrives at the University of New Mexico Hospital each spring s eeking medical or psychiatric admiss ion, having made his rounds at other hos pitals acros s states , using various pseudonyms. T he cos t of this can be tremendous , as illus trated by the B ritish report “million-dollar man” who, over a 13-year period, s pent 1,300 days in ps ychiatric units, 556 days in prison, and days in medical care for 261 hospital admis sions . All diagnostic cons iderations that apply to factitious disorder also apply here. As the risk of morbidity and mortality may be higher in thes e patients, it may be 1736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 37 of 79

prudent to involve bioethics cons ultations and hos pital legal couns el early. Mr. S . was a 25-year-old, right-handed, married white who was admitted for s quare-shaped burns on his left forearm. B ecaus e of the odd shape of the burns, disorder was suspected, and psychiatry cons ultation promptly obtained. T wo weeks earlier, the patient was admitted for necrotizing fasciitis of the left forearm. that hospitalization, his wife gave birth to an infant s on. F actitious disorder was not s uspected at that time. Mr. reported a past medical his tory of juvenile-onset from 1 year of age, as thma, and accidental hot water to his left forearm and left lateral thigh at 10 years of He reported allergies to 13 medications. Mr. S . presented in a dramatic manner to the cons ultants s aying, “I'm safe nowhere! T hey happen while I'm here in the hos pital!” He pulled open his gown to reveal a square-shaped burn on his upper He reported being the 15th of 16 children born to a Mormon family. He des cribed his childhood as “good,” he denied a history of phys ical or sexual abuse. He that his father died of a fall P.1836 when he was 10 years of age. Mr. S . proudly s tated even though he was diabetic, he was admitted to the F orce at 16 years of age in which he worked as a and an emergency medical technician. S ubs equently, worked at commercial airlines, which took him to live in four different s tates over 4 years. He s tated that his marriage was his s econd and that he had los t a s on, a 1737 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 38 of 79

daughter, and his firs t wife all on the same day. As his year-old daughter was dying in the hos pital of a brain tumor, his 7-year-old s on was killed in a motor vehicle accident while cros sing the s treet to vis it her. Under the stress of los ing both children, his wife left him that day. His s econd wife had s chizoaffective disorder and heroin dependence in remiss ion. S he was known to the ps ychiatry cons ult team who evaluated her after the of her s on. T he diagnosis of factitious disorder was made, and the patient was informed in a nonconfrontational manner emphasized that he mus t have been under great emotional distress to have inflicted such physical pain hims elf. T he birth of his s on, childhood neglect, and traumatic experiences that he may not have dis closed were cited as poss ible s ources of s tres s. He was ps ychiatric services . T he week after discharge, the patient returned to seek the cons ulting psychiatrist who had confronted him. He voiced concern that his wife was having auditory hallucinations telling her that she was the next bride of C hris t. His eagernes s to seek treatment for his wife noted in the context of his reports of the deaths of his two children. T he vague pos sibility of Munchausen syndrome by proxy was first entertained at this time. Mr. S . s ought ps ychiatric s ervices , as directed by the ps ychiatry cons ultation team. At the ps ychiatric clinic, was pres cribed nefazodone (S erzone) and later was switched to sertraline (Zoloft) to target depres sive NOS , with the primary symptom being irritability toward his wife, with occasional urges to s trike her. presented to the ps ychiatric emergency s ervices 1738 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 39 of 79

complaining of urges to be violent with his wife. He s pent most of the next 4 months admitted to various hospitals in town. Of note, the records of one of the hospitals s tated that Mr. S . told them that he had been F -15 fighter pilot. T wo days after dis charge from that hospital, he was readmitted to the univers ity hospital necros is of a skin graft that he had received. T he burn surgery team initially refus ed to treat him, stating that was doing it to himself and that they suspected that he was s eeking narcotics . T hey agreed to accept care after conversation with the ps ychiatry consultation During this admis sion, his arm was placed in a cast, began to heal. T he next month, he was readmitted with wors ening of necrotizing fasciitis with poss ible osteomyelitis . He for amputation of the arm, citing his long treatment and s tating that he wanted to be rid of the pain. therapists noted that his arm healed whenever placed cast that precluded tampering of the wounds but that it wors ened when placed in loos er casts that allowed to the wounds. At this time, becaus e of the of los ing his arm, he was admitted to the ps ychiatric hospital involuntarily for clos e observation. He was informed of a new treatment plan that, whenever he admitted for a factitious illnes s, involuntary admiss ion the ps ychiatric hos pital would follow. On the psychiatric ward, the patient accepted ps ychotherapy and with sertraline. He continued to deny that his wounds were self-inflicted but inquired about treatment for Munchaus en s yndrome. At one point, when the ps ychiatris t as ked him, “Why do you do this? ” he don't know why I do it either.” Of note, during the 1739 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 40 of 79

ps ychiatric hos pitalizations, he required no slidinginsulin, and he rarely required it while in the medical hospital. One other admis sion to the univers ity hospital occurred wors ening of his wounds . He was transferred to the ps ychiatric hos pital according to plan. After this, he seeking admis sion to the univers ity hospital. Within 1 month, outpatient physical therapy notes indicated that the wound was 90-percent healed, and, within another month, it was near closure. Approximately 6 months later, he pres ented to the ps ychiatric emergency s ervices complaining of difficulty containing his anger toward his wife. S hortly after that, wife relaps ed on heroin and left Mr. S . alone to care for their 1-year-old s on. S ince his birth, pediatricians had recognized the precarious s ituation of this child and been s eeing him for s cheduled biweekly visits. C hild P rotective S ervices were already involved. During a with family in another state, the patient brought his s on an E R seeking admiss ion. His son was not admitted died the next day. Munchausen syndrome by proxy suspected. An autops y was performed, but no charges were ever filed against the patient. One year later, near the annivers ary of the s on's death, S .'s then ex-wife pres ented to the ps ychiatric services for relapse on heroin and wors ening auditory hallucinations telling her that she would be the next of C hris t. S he stated that she too found it s uspicious three of Mr. S .'s children had died. S he had recently him at a bus stop. His arm was healed, and he healthy. He ins is ted to her that the university had confirmed that his wounds had indeed been 1740 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 41 of 79

by spider bites.

DIS C US S ION Mr. S . s howed the class ic features of Munchaus en syndrome: peregrination, pseudologica fantas tica, and presentation of unusual s ymptoms that were selfHis case als o illus trates the overlap of different types of factitious disorder, as he s ought psychological and demonstrated activity consistent with factitious disorder by proxy. Lastly, his case demonstrates that Munchaus en syndrome, which generally has a grim prognos is , is not completely refractory to intervention. S elf-infliction was suspected, becaus e the squareburns defied us ual medical understanding, and they did not heal with usual treatment. T hat the nonhealing wounds healed when in a cast and was virtually diagnostic of s elf-infliction. Mr. S . sought from various hospitals locally, demonstrating peregrination. He had als o recently lived in s everal states in which he may have s ought medical care. he s ought hospitalization in the same month that he moved to town. P seudologica fantas tica was demonstrated in his bragging about admiss ion to the F orce, even though he was diabetic (the Air F orce accept diabetics). His tale of los ing two children and his first wife on the same day seemed exaggerated and had the hint of ps eudologica fantas tica. Although the patient sought narcotic pain medication, he had acces s narcotics without needing to endanger his arm or to pain, as his wife was a heroin user. His primary motive appeared to be to gain care and attention by ass uming patient role. Like many others with factitious disorder, Mr. S . 1741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 42 of 79

being from a large family in which he was poss ibly neglected. Other characteris tics present that are in factitious disorder patients included an affinity to a medical profess ion (he claimed he was an emergency medical technician), a history of childhood illness 10 years of age that injured his left arm), and multiple medication allergies. Like others with factitious he sought medical care at a time of interpersonal los s. the birth of his s on, he faced loss of his wife's attention, addition to facing other s tres ses of fatherhood. C omorbidity with other ps ychiatric disorders is more rule than the exception. Mr. S . was treated for disorder NOS . Opiate abus e was also diagnosed. Malingering for opiates may also have been part of his motivation. His eagerness to procure psychiatric treatment for his may have demons trated genuine concern, but, in the context of the death of his s on and the poss ible deaths two other children, it is quite likely that Mr. S . also had factitious disorder by proxy. T he comorbidity of disorder and factitious dis order by proxy is estimated to from 10 to 30 percent, and there is an extremely high likelihood of s iblings being victimized, us ually s erially. P.1837 Mr. S . s ought ps ychiatric treatment after referral from ps ychiatry consultation team. Often, he went to the ps ychiatric emergency s ervices complaining of anger potential violence toward his wife. Although there is no clear evidence that he feigned or fabricated ps ychiatric symptoms, he clearly enjoyed the attention of receiving ps ychiatry services. 1742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 43 of 79

Intervention from the psychiatry consultation team cons isted of gentle, nonaccusatory confrontation and ps ychiatric referral, which the patient accepted. Later, when he was in danger of los ing his arm, the intervention of involuntary psychiatric hospitalization deterred the course of s elf-injury, and the wounds to heal cons istently. Although morbid cons equences ensued with the death of the patient's son, at least intervention was able to prevent amputation of his arm.

Fac titious Dis order with P redominantly P s yc hologic al and S ymptoms F actitious psychological s ymptoms are more to diagnos e because of the lack of clear objective for psychiatric dis orders. Methods of confirmation applicable with factitious phys ical dis orders, s uch as contradictory laboratory tests or findings on room searches , do not apply here. Nevertheles s, certain of the patient's pres entation can alert the ps ychiatris t the patient may be s imulating illnes s. As with phys ical factitious disorders , the patient may pres ent with symptoms that fail to corres pond to any recognizable diagnosis. F or example, one patient reported no other ps ychotic symptoms except s eeing the entire cast of a television s how emerge from her clos et. Other features include worsening of s ymptoms when the patient is of being observed, inconsistencies in the patient's s tory over time, and the patient's overeagerness to recount symptoms of the illness . T he patient is often and readily admits to additional s ymptoms on questioning. T he patient may refuse to cooperate with 1743 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 44 of 79

obtaining collateral information, and untraceable prior health care providers are not unus ual. On admiss ion to ward, patients may reveal familiarity with hos pital although denying previous hos pitalizations . T hey may exhibit dramatic and unus ual reactions to medications . T hey may demonstrate attention-getting tactics by breaking ward rules . V is itors are us ually few or abs ent. In contras t to patients with physical factitious disorders who tend to avoid psychiatric care, these patients seek contact with the ps ychiatric s ys tem and readily acknowledge the presence of a ps ychiatric disorder, it may not be the one that the patient actually has . F eigned bereavement and then ps ychos is appear to be most common presenting s ymptoms. Ironically, one patient sought ps ychiatric admis sion for his syndrome, claiming that he feigned phys ical illness in fact, there was no evidence of this. In a s eries of 20 patients who pres ented with factitious bereavement, 15 also exhibited a history of factitious phys ical s ymptoms. A majority of them met criteria for other psychiatric disorders . T hey typically reported dramatic, violent, and, often, multiple deaths of loved ones, whereas collateral information s howed that, in no deaths had occurred. Another series of 12 cases of factitious bereavement yielded s imilar findings of complaints of violent, dramatic deaths and referral from medical wards for s upposed phys ical illness . Although complaints of bereavement were factitious, thes e exhibited prominent symptoms of depress ion. A theory about factitious bereavement is that patients are expres sing the underlying truth of their emotional s tate, not the factual truth. In contras t to the s tigma 1744 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 45 of 79

with ps ychiatric illnes s, sympathy and care are us ually offered to thos e in mourning. T his may be why bereavement is the mos t commonly seen factitious ps ychological disorder. One patient stated that she had fabricated the complaint of bereavement to rationalize depres sion. In a s eries of 219 consecutive cases of ps ychos is, nine percent) met criteria for factitious disorder. All nine patients demons trated s evere personality dis order. patients were doing poorly when followed up 4 to 7 later, with multiple hospitalizations and poor quality of T heir outcome was no better than for s chizophrenics were concurrently followed. In another study of s ix patients who presented with feigned psychosis to the Univers ity Hos pital of S outh Manches ter, five of the s ix developed s chizophrenia when followed up 3 months 10 years later. C ons is tent with ps ychodynamic theories about factitious dis orders being an attempt to feel mastery, feigning ps ychos is may have been a way for patients to feel in control over early ps ychotic T hese studies s how that factitious ps ychosis may bode poor a prognosis as genuine psychos is. P os ttraumatic stress dis order (P T S D) can be fabricated through the reporting of subjective symptoms , without requiring the patient to feign or to act. F actitious P T S D be elucidated through collateral sources of information about alleged trauma, for example, by checking military records for actual tours of duty. Ms. M. A. was 24 years of age when s he firs t 1973 after an overdose. S he gave a his tory of recurrent overdoses and wris t-slas hing attempts since 1969, 1745 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 46 of 79

admis sion, she stated that she was controlled by her sister who kept telling her to take her own life. Her history was negative. S he was found to be carrying a list of s chneiderian rank s ymptoms in her handbag; she behaved bizarrely, picking imaginary objects out of the was tepaper bas ket and opening imaginary doors in the waiting room. S he admitted to visual hallucinations and offered four of the first-rank s ymptoms on her list, but her mental s tate reverted to normal after 2 days . When s he was at a case conference, the cons ens us view was that she been s imulating schizophrenia but had a gros s disorder; however, the cons ultant in charge diss ented that general view, feeling that she was genuinely ps ychotic. On follow-up, this turned out to be the case. S he was readmitted in 1975 and was mute, catatonic, gross ly thought disordered, and the diagnosis was changed to that of a s chizophrenic illnes s. S he has been followed regularly s ince and now pres ents the picture of a mild schizophrenic defect s tate; s he takes regular depot medication but s till complains of auditory hearing her dead s ister's voice. S he is a day patient.

DIS C US S ION Ms. M. A.'s diagnos is was factitious disorder with predominantly ps ychological s igns and s ymptoms, with a personality dis order. Although her initial symptoms were elaborate and feigned, 2 years after initial presentation, she developed ps ychotic symptoms believed to be genuine by clinicians , even after observation as a day patient. T his cas e illustrates that, even if ps ychotic symptoms 1746 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 47 of 79

factitious, they are often a s ign of serious ps ychopathology, s uch as a severe personality a prodrome to a genuine ps ychotic dis order.

Fac titious Dis order with P s yc hologic al and P hys ic al F actitious disorder with combined ps ychological and phys ical s ymptoms is the appropriate diagnos is P.1838 for patients who pres ent with ps ychological and signs and s ymptoms of factitious disorder, with neither dominating the clinical picture. Mr. M. T . was a man who appeared to be middle-aged who arrived at a children's ps ychiatric hos pital claiming be 17 years of age and s uicidal. As he held a gun to head, s taff called s ecurity officers who promptly recognized him as the Munchausen s yndrome patient arrived in early May each year. He was denied Late that evening, he pres ented to the E R of the main hospital claiming that he was diabetic, dizzy, and weak. Intern phys icians found his blood glucose to be low and immediately admitted him. Hos pital s taff on the wards recognized him as “that Munchausen syndrome and a psychiatric cons ultation was reques ted. T he continued to ins ist that he was 17 years of age and that was the son of famous golfer Lee T revino. Hospital couns el revealed that he us ed at least two other ps eudonyms and social s ecurity numbers and was for health ins urance fraud in at least two other s tates. When the ps ychiatry consultants greeted him with 1747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 48 of 79

familiarity, the patient immediately claimed suicidal tendency, but, when denied ps ychiatric admiss ion, he the hos pital agains t medical advice. An inquis itive student called local pharmacies , which informed him if a customer claimed to be diabetic, traveling, and insulin, they would give the customer insulin even a pres cription to avoid liability. In this manner, Mr. M. T . could have procured ins ulin to induce hypoglycemia. At a care conference, a psychiatry cons ultant that, in the past, common practice was to call E R s in to alert them to Munchaus en s yndrome patients, giving poss ibly helpful descriptions and information. However, because of heightened attention to confidentiality she now instead advocated calling E R s and simply them about the pos sible appearance of a patient with factitious hypoglycemia. An E R phys ician, however, that he would go ahead and give a detailed des cription the patient to friends in each E R in town. T he May of following year, the patient failed to appear for the first time in s everal years.

DIS C US S ION T his cas e demonstrates an almos t exaggerated peregrination and pseudological fantas tica, typical Munchaus en syndrome patients. T he debilitating cons equences of the disorder are also demons trated, his life, by all indications, consisting of s hort hos pital acros s many states , precluding s table relations hips or employment. T he case als o illus trates the complexity of legal and ethical is sues involved in the management of factitious disorder in regard to privacy. As he s ought hospitalization for ps ychological and phys ical disorders equally in this ins tance, Mr. M. T .'s 1748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 49 of 79

diagnosis was factitious disorder with combined ps ychological and phys ical s igns and s ymptoms .

Fac titious Dis order by P roxy Als o called Munchaus en s yndrome by proxy, the feature of factitious dis order by proxy is the intentional feigning or production of physical or ps ychological symptoms in another person who is under an care. T he perpetrator's motive is to ass ume the s ick proxy. Mothers of young, preverbal children are the common perpetrators , however, fathers , grandmothers, fos ter mothers , stepmothers, and even baby-sitters also been implicated. V ictims can also be spouses, parents , or anyone under the care of the perpetrator. In unusual cas e of adult factitious dis order by proxy, a 34year-old man drugged his wife with s leeping pills in her coffee, then injected gas oline into her skin to caus e from which she eventually died. S ubs equently, he repeated his actions with a female baby-sitter whom he hired to care for his children. In each case, he role of the concerned caretaker in the center of hospital drama. F actitious dis order by proxy has als o been cited the etiology for death epidemics at hospitals and homes . P erpetrators have largely been nurs es and aides who produced illnes s through various means , as injection of ins ulin, lidocaine, digoxin, or other subs tances . B y and large, however, reported cases have involved mothers and their children. Difficulties in recognizing deception and diagnosing this condition are illus trated two unfortunate examples. F irs t Lady Nancy R eagan presented an award to an apparently valorous foster 1749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 50 of 79

mother of extremely ill children. T he woman was later suspected of having killed her children through disorder by proxy. S udden infant death syndrome was initially thought to have a strong genetic as it often occurred in s iblings . T oday, when siblings S IDS , infanticide is suspected. A s tudy of 81 children died at the hands of parents but who were initially to have died of S IDS or natural causes s howed that half of the perpetrating parents had factitious dis order another somatizing dis order. In both of these in other cases, perpetrators were initially regarded with sympathy and respect. T he variety of medical pres entations of factitious by proxy is impres sive. In the first comprehens ive the disorder published in 1987, R osenberg des cribed different induced or fabricated signs or s ymptoms. T he most common presentations were bleeding (44 seizures (42 percent), central nervous system (C NS ) depres sion (19 percent), apnea (15 percent), diarrhea percent), vomiting (10 percent), fever (10 percent), and ras h (9 percent). Many children had more than one presentation. T wenty-five percent of cases involved simulation of illness , 50 percent involved illnes s production, and, in the remaining 25 percent, and production of illness were concurrent. P erpetrating caregivers us ually appear concerned and interes ted in every as pect of their children's care. T hey exemplary in their interactions with medical staff, support and s ympathies , often cros sing profes sional boundaries by helping nurses with duties or eating with s taff. T hey may demons trate unusual willingness even excitement at the prospect of invasive procedures 1750 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 51 of 79

their children. F actitious disorder by proxy s hould not be cons idered a diagnosis of exclusion. C onfirmatory evidence s hould actively pursued, s o as to less en risk to the child. the child should be ens ured at the s ame time. T he gold standard for confirming factitious disorder by proxy is covert video s urveillance that may record evidence of a parent causing harm to a child. C overt video has als o shown cas es in which mothers , who appear concerned the presence of s taff, behave indifferently toward their children when they are not aware of being watched. C overt video s hould only be undertaken after with legal counsel. A court order may need to be and a bioethics cons ultation may be helpful to weigh potential benefits to the child versus compromis es of privacy for the parent. Other means of confirming factitious dis order by proxy include s earching the mother's belongings for illness inducing agents , reviewing collateral information and medical records for incons istencies , gathering on siblings , recording temporal as sociations between parental visits and the child's s igns and s ymptoms , observing the child's well-being when removed from parent's care for extended periods, and analyzing specimens taken in the pres ence of the parent to thos e taken in the parent's absence. T he international literature on Munchaus en s yndrome proxy indicates that the s igns and s ymptoms appear cons istent across the world. P erpetrators are usually mothers, and s erial abus e of children P.1839 1751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 52 of 79

is common. T his does not appear to be a phenomenon that is exclusive to medicalized societies . B . C . was a 1-month-old girl admitted for evaluation of temperature elevation. P s ychiatric consultation was reques ted owing to incons istencies in the mother's reporting of medical information, des pite her initial presentation as a knowledgeable and caring mother worked as an emergency medical technician. B . C .'s said that she was diagnos ed with ovarian cancer at 3 months' ges tation with B . C ., that s he had had a hysterectomy during the cesarean section, and that had been getting radiation therapy at a local hospital B . C .'s birth. T he pediatrician called the local hos pital the mother's permis sion and found that she had a luteum cys t removed at 3 months' gestation and mild hydronephrosis, but no cancer and no hysterectomy. B . mother, when confronted with this , stated only that s he might need a kidney transplant for the hydronephros is . On further exploration, it was dis covered that the had pursued care for her children in multiple E R s and reported inaccurate histories that res ulted in excess ive tes ting. F or example, she told clinicians that her 2son had lupus and hypergammaglobulinemia and, at another time, that he had asthma and seizures . S he pursued a minor cosmetic s urgical procedure for her agains t the recommendation of his pediatrician. No clinicians suspected that B . C .'s mother had produced symptoms in any of her children, but rather that s he intentionally fabricated symptoms by raising the temperature on B . C .'s thermometer. S he had been in keeping medical appointments . Her children 1752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 53 of 79

healthy and well cared for, des pite her descriptions of illness . T he mother denied a ps ychiatric his tory but permis sion for clinicians to call the local ps ychiatric hospital to inquire. Her record there showed a history depres sion, anorexia, and panic disorder and included ps ychiatric hos pitalization after a s uicide attempt. S ubsequently, s he received ps ychotherapy and ps ychopharmacotherapy, which s he stopped a few months before this presentation. During B . C .'s for temperature elevation, her mother agreed to treatment with her previous psychiatric clinicians . A services referral was als o made, and the children's pediatrician agreed to coordinate regularly s cheduled follow-up visits and monitoring of the children.

DIS C US S ION B . C .'s cas e illustrates several common features of disorder by proxy. T his mother, who had medical simulated fever in her child in the hos pital as a means maintaining contact with the hos pital s ys tem and obtaining the sympathy of clinicians. S he had a history that, in this cas e, included depres sion, and panic disorder. S hortly before this pres entation, had lost the s upport of her ps ychiatric clinicians, which may have exacerbated her need for contact with the medical system. S everal of her children had been the victims of her s imulations of illness , as is common in factitious disorder by proxy. A less common aspect of this case was the mother's willingnes s to engage in treatment. T he medical team's supportive, nonaccusatory approach most likely helped enable her to cooperate as much as she did. toward clinicians , including overt praise and 1753 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 54 of 79

alternating with covert rage and belittling, is more common. Acceptance of psychiatric treatment recommendations is not often s o s mooth. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > P AT HO LOG Y AND LAB OR AT O R Y

PATHOL OGY AND LAB OR ATOR Y R E POR TS P art of "16 - F actitious Dis orders " No laboratory or pathology tests are diagnostic of factitious disorders , although they may be us eful in demonstrating deception and helping to confirm diagnosis. In the firs t Munchaus en syndrome by proxy article published in 1977, Meadow reported the case of a 6old girl with unexplained hematuria. T able 16-5 urine s amples collected during one evening that helped es tablis h the diagnosis.

Table 16-5 Urine S amples C onfirming Munc haus en by Proxy from a 6-Year-Old G irl with Unexplained Hematuria

1754 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 55 of 79

Time

Appearanc e

C ollec tion

5:00 P M

Normal

B y nurs e

6:45 P M

B loody

B y mother

7:15 P M

Normal

B y nurs e

8:15 P M

B loody

B y mother

8:30 P M

Normal

B y nurs e

Adapted from Meadow R : Munchaus en s yndrome proxy: T he hinterland of child abus e. L ance t. 1977;2:343. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "16 - F actitious Dis orders " A true phys ical or ps ychiatric dis order is the main cons ideration in the differential diagnosis of a factitious disorder. T his is particularly true of factitious disorders , as they are most often a 1755 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 56 of 79

of, or a prodrome to, an actual psychiatric illness . C omorbid phys ical or ps ychiatric dis orders are more rule than the exception in factitious disorder. F or most patients who feign ps eudos eizures have true underlying s eizure dis orders. T hos e who manipulate sugars to produce symptoms are us ually diabetics . Munchaus en syndrome patients who compuls ively the sick role for emotional reas ons may als o become addicted to narcotics or learn to seek dis ability thereby also demonstrating s ubs tance abus e and malingering. A woman who consciously produced by smearing feces on a leg wound was sometimes also seen in a diss ociative state, uncons ciously picking at wounds. Often, factitious disorder patients aggravate actual phys ical illness . F urthermore, even factitiously produced phys ical symptoms , s uch as infections or poisonings, must be treated s eriously, as, once the symptoms are induced, they are all too real. In all factitious disorder, underlying psychopathology should suspected. Other special cons iderations in the differential are detailed in the following sections.

Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms F igure 16-2 provides an algorithm for the differential between factitious dis order, malingering, and disorders .

1756 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 57 of 79

FIGUR E 16-2 Differential diagnosis of factitious with predominantly physical s igns and s ymptoms. NOS , otherwis e s pecified. If the primary goal is not to play the patient role but is material, such as procuring dis ability payments, or an excuse from work, the diagnosis is malingering. If symptoms are manifes t unconscious ly, then the somatoform disorders should be considered. In dis order, neurological s ymptoms, such as paralysis or ps eudoseizures , are uncons cious ly manifested, usually res ponse to stress es . In s omatization dis order, the has a pattern of multiple unexplained medical in four categories : at leas t four pain s ymptoms, four gastrointestinal (G I) symptoms, one s exual s ymptom, one neurological symptom. F or thos e with unexplained phys ical complaints that last 6 months or longer but do not meet the threshold for the diagnosis of somatization disorder, undiffe rentiate d s omatoform 1757 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 58 of 79

dis order s hould be P.1840 diagnosed. In pain dis order, psychological factors contribute to the exacerbation or ons et of pain. T hos e hypochondrias is are preoccupied with the fear of and are vigilant about bodily s ymptoms, falsely that they are ill. T hos e with body dys morphic dis order preoccupied with an imagined or exaggerated defect in bodily appearance. S omatoform dis orde r NO S s hould diagnosed for patients who uncons cious ly manifest phys ical s ymptoms but who do not meet criteria for the previous ly mentioned dis orders . In actuality, whether a symptom has conscious or unconscious origins can be difficult to dis cern. F urthermore, whether the patient's primary motive is to as sume the s ick role or to avoid a court date of which clinician is unaware can also be difficult to dis cern. judgments are completely dependent on the s ubjective opinion of the clinician. F or these reasons, Marc D. F eldman, J ames C . Hamilton, and Holly N. Deemer that these dis orders fall along a continuum: “T here is to be gained, and much to be los t, by the us e of the current practice of viewing the somatoform disorders , factitious disorder, and malingering as discreet and distinct clinical entities .”

Fac titious Dis order with P redominantly P s yc hologic al and S ymptoms With ps ychological factitious s ymptoms , it can be es pecially difficult to separate conscious from 1758 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 59 of 79

production of symptoms . F or this reas on, R ichard questions the legitimacy of this diagnostic category. F urthermore, many authors propose that and unconsciousness cons titute a continuum and are distinct entities. G ans er s yndrome, first des cribed in 1897, consists of twilight s tates, memory dis turbances, and vorbe irede n, G erman term loos ely translated as “talking at cross purpos es.” An example would be answering “65” to the question of “How much is eight times eight? ” G ans er syndrome is thought to be diss ociative in nature or due organic caus es . Again, comorbidity s hould be s trongly considered, as these patients often have coexisting pers onality F actitious psychological s ymptoms can often be a prodrome to true ps ychiatric illnes s, as in the case of factitious psychosis evolving into s chizophrenia.

Fac titious Dis order by P roxy F actitious disorder and malingering at the initiation of child s hould also be considered, es pecially in older children and teenagers . Other by-proxy disorders be considered. C hildren can be made to manifest the ps ychopathologies of their parents . F or example, in hypochondriasis by proxy, a hypochondriac mother is preoccupied with the health of her child and repetitively seeks pediatric care, putting her child at risk for unnecess ary procedures and iatrogenic illnes s. In nervos a by proxy, an anorexic mother restricts her food owing to unfounded fears of excess ive weight in child. One mother with malingering by proxy put her through multiple evaluations to maintain dis ability 1759 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 60 of 79

payments . A paranoid father with a his tory of psychos is feared that his son was being pois oned by breas t milk insis ted that the E R check his s on's hair for mercury. by-proxy syndromes described in the literature include mas querade s yndrome (in which illness fabrication in the child's increasing dependency on the mother), mothe ring to de ath (confining a child to a sick role as if child were ill, while avoiding phys icians and agencies ), extreme illne s s e xaggeration (when a parent the child's symptoms in an effort to increase a pediatrician's attention to the child), and achie ve me nt proxy (as in youth sports). C linicians s hould also keep in mind the wide range of normal behavior in parents who seek medical care for children. According to Meadow, “exaggeration and mild deception are part of everyday behavior.” T o aid in differential diagnos is , it is helpful to keep in that, in factitious disorder by proxy, illness es tend to exotic, dramatic presentations , and parents often remarkable lack of relief as the child's condition E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > C O UR S E AND P R OG NO

C OUR S E AND PR OGNOS IS P art of "16 - F actitious Dis orders "

Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms 1760 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 61 of 79

T he wide spectrum of factitious dis order with predominantly phys ical s igns and s ymptoms should be remembered when considering course and prognosis . the more benign end of the spectrum, factitious illnes s behavior can be cons idered normal, as when a child exaggerates distress from a knee s crape to gain or when a mother magnifies her child's symptoms to reass urance. F urther along the spectrum, factitious behavior can be a maladaptive way of coping with and does not necess arily imply an ongoing factitious disorder. An underlying mood, anxiety, or s ubs tance abuse that is treatable bodes for a better prognos is , whereas underlying personality disorder, especially antis ocial personality dis order, bodes for a poorer prognosis . patients with factitious dis order experience remis sion at approximately 40 years of age, corresponding to the remis sion for many with borderline pers onality disorder. Munchaus en syndrome or chronic factitious dis order predominantly phys ical s igns and s ymptoms , on the hand, has an unremitting, refractory cours e. and treatment are directed toward harm reduction, than remis sion or cure.

Fac titious Dis order with P redominantly P s yc hologic al and S ymptoms P sychological factitious dis order is also thought to forebode a poor prognosis. A 1982 study of patients factitious ps ychosis s howed that at follow-up 4 to 7 later, the functioning of thes e patients was comparable the functioning of schizophrenic patients in the same 1761 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 62 of 79

study. Other s tudies found that feigned psychosis is commonly a precurs or to actual ps ychosis , leading one inves tigator, Hays , to comment: “Acting crazy may more ill than being crazy.” In general, factitious with predominantly ps ychological s igns and s ymptoms thought to have a poor prognos is comparable to that of Munchaus en syndrome.

Fac titious Dis order by P roxy F or victims of factitious dis order by proxy, the mortality rate is from 6 to 22 percent, P.1841 us ually through s uffocation or pois oning. In 1987 review, 10 of the 117 children in the review died, mortality rate of 9 percent, and the youngest were the most vulnerable to death. A s obering statis tic is that, in percent of the deaths, caretakers were confronted with diagnosis of Munchaus en syndrome by proxy, but the children were sent back to them, s ubs equently to die. the survivors , 8 percent had long-term morbidity, including impairment of G I functioning, des tructive joint changes, limp, cerebral palsy, cortical blindness , and serious psychiatric problems . In 75 percent of the morbidity was caused by the medical staff and the perpetrator. In 25 percent of the cas es, however, was solely iatrogenic, caus ed by procedures and inves tigations . S iblings of victims of factitious disorder by proxy are at great risk. S tudies indicate that 9 to 29 percent of die, unders coring the vital importance of inves tigating siblings of sus pected factitious disorder by proxy 1762 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 63 of 79

T he involvement of different children tends to occur serially rather than simultaneous ly, so one must always on the alert for additional victims. In 1990, Meadow studied 27 young children s uffocated by their mothers . Over 13 years , nine died, and one had s evere brain damage. T hes e 27 children had 18 siblings who had “suddenly and unexpectedly in early life.” In another of 32 children pres enting with factitious epilepsy, 21 percent of siblings (7 of 33) had died of S IDS . S imilarly, separate s tudy of suffocation cas es, 21 percent of (3 of 14) had died unexpectedly. In another study of 56 victims of Munchaus en s yndrome by proxy, 39 percent siblings were subjected to illnes s fabrication. Among R os enberg's review of 117 cas es , ten siblings had died under “unusual circumstances.” E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > T R E AT ME NT AND MANAG E M

TR E ATME NT AND MANAGE ME NT P art of "16 - F actitious Dis orders " G uidelines for the treatment and management of factitious disorder are given in T able 16-6. T here are major goals in the treatment and management of factitious disorders : (1) to reduce the ris k of morbidity mortality, (2) to addres s the underlying emotional ps ychiatric diagnosis underlying factitious illnes s and (3) to be mindful of legal and ethical iss ues . 1763 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 64 of 79

Table 16-6 G uidelines for Management and Treatment of Fac titious Dis order Active pursuit of a prompt diagnosis can minimize the risk of morbidity and mortality. Minimize harm. Avoid unneces sary tests and procedures , es pecially if invas ive. T reat clinical judgment, keeping in mind that subjective complaints may be deceptive. R egular interdis ciplinary meetings to reduce and s plitting among staff. Manage s taff countertransference. C ons ider facilitating healing by us ing the doublebind technique or face-saving behavioral such as s elf-hypnosis or biofeedback. S teer the patient toward ps ychiatric treatment in empathic, nonconfrontational, face-saving Avoid aggress ive direct confrontation. T reat underlying ps ychiatric disturbances , s uch Axis I dis orders and Axis II dis orders. In ps ychotherapy, address coping s trategies and emotional conflicts. 1764 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 65 of 79

Appoint a primary care provider as a gatekeeper all medical and ps ychiatric treatment. C ons ider involving risk management and bioethicists from an early point. C ons ider appointing a guardian for medical and ps ychiatric decis ions. C ons ider prosecution for fraud, as a behavioral disincentive.

Management of countertransference is also a major as strong negative feelings on the part of clinicians can interfere with appropriate patient care. Allowing the patient to save face is es sential to establishing a therapeutic alliance and preventing the patient from simply taking the factitious illness behavior els ewhere. is es pecially true, as factitious disorder patients us ually have immature personalities or pers onality disorders make them es pecially s ens itive to narcis sistic injury. disincentives might be purs ued. In Arizona, a woman factitious disorder was prosecuted for fraudulent procurement of medical, psychiatric, and dental and s he pled guilty.

Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms 1765 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 66 of 79

T he hippocratic doctrine of “first do no harm” should be kept firmly in mind. P rompt recognition of factitious disorder can reduce the risk of morbidity or mortality. T herefore, active purs uit of the diagnosis and timely management are es sential. F or example, in the cas e of woman who sought prophylactic mastectomy for an extensive family his tory of breas t cancer, early of the factitious dis order may have prevented the mastectomies that were performed. R ecognition of factitious as thma or arthritis prevents the pres cribing of potentially harmful steroid medications. Likewis e, and potentially harmful tests, procedures, and can be minimized. Once symptoms are confirmed or agreed on as factitious, clinicians s hould adminis ter medical treatment according to their own clinical judgment, weighing objective evidence and keeping in mind that subjective complaints and reques ts from the patient can be deceptive. Of cours e, in many patient has induced illnes s, so that invas ive treatments must be adminis tered. In a medical setting, ps ychiatric cons ultation should be promptly obtained. Involvement of ris k management bioethicists is us ually prudent. As these patients are to cause confus ion and splitting of caretakers, good communication between all involved is ess ential. interdisciplinary meetings are helpful. S everal strategies have been success fully used to the healing of factitiously produced symptoms in facesaving ways. S tuart J . E is endrath has advocated a bind technique, whereby patients are told that, if the phys ical or psychological symptoms are genuine, then they s hould improve with the treatment being 1766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 67 of 79

adminis tered. If the s ymptoms do not improve, then are factitious . T his technique can be used with wounds, factitious paralysis, or ps ychological factitious symptoms that should improve with medications . F or example, factitious patients who chronically induce or wors en wounds can be informed, “this treatment heal your wound. If it doesn't, we have no choice but to conclude that this is due to a factitious dis order.” S elf-hypnosis and biofeedback can also allow the to relinquis h factitious behavior while s aving face. F or example, a patient can be told that, under selfblood flow to a wound can be increas ed and therefore promote healing. In this manner, the patient can take control of healing the wound, rather than s eek control wors ening s ymptoms . P os itive feedback should be to patients when their efforts res ult in healing. B iofeedback can be used in a s imilar way. On an outpatient bas is, all medical care should be through a single primary care phys ician through whom care is coordinated. T his can minimize unneces sary repetition of tests and treatments . However, it s hould remembered that the patient may s eek care from in another system, in another city, or even in another or country. Appointments with the gatekeeping primary care phys ician should be regular and frequent and not dependent on medical crises. P.1842 T his fosters object constancy while minimizing the patient's need to induce illness to seek medical Once the factitious disorder is confirmed, or sus picions 1767 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 68 of 79

deemed s ufficient, the patient s hould be gently and artfully s teered toward ongoing ps ychiatric treatment in face-saving, sympathetic manner that the patient can accept. T he patient can be told that the factitious behavior is an express ion of great emotional need or distress . T he clinician can make empathic s tatements about the neglect, abuse, or trauma that the patient undergone. T his allows the patient to save face, while promoting ins ight about probable origins of the patient's factitious behavior. T he patient should then be steered toward s eeking care in a ps ychiatric s etting in which underlying ps ychiatric is sues can be address ed and in which the risk of morbidity and mortality is s ubs tantially less . P ers onality-disordered patients usually crave to unders tood and to have their emotional needs T his type of unders tanding confrontation that focuses the patient's genuine, rather than factitious, needs can well accepted by patients . Direct or aggress ive confrontation is generally not effective. T he patient us ually res ponds with anger and denial and may leave against medical advice only to perpetuate the factitious illnes s behavior els ewhere, need for mastery through deception now amplified. C linicians s hould remember that confess ion is not a neces sary aspect of management or treatment. P sychiatric treatment should first focus on the underlying Axis I disorders. Although rare, the a comorbid Axis I disorder, such as a mood disorder, anxiety dis order, or s ubs tance abuse disorder, bodes a better prognosis. P harmacological and treatments should be us ed according to the diagnosis . Other than targeting comorbid ps ychiatric dis orders, 1768 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 69 of 79

is no standard pharmacological treatment for factitious disorder. C omorbid Axis II disorders are more common than Axis I disorders . B orderline personality dis order is most common comorbid diagnosis. Antis ocial traits are als o common, es pecially in thos e exhibiting ps eudologica fantas tica and Munchausen s yndrome. P sychiatric treatment should be directed at thes e underlying disorders . P sychiatrists s hould be aware of their own countertransference and then s hould help medical clinicians cope with their countertrans ference, so that do not let negative feelings interfere with treating thes e patients who may falsify symptoms but who als o have genuine needs . Negative countertransference can lead therapeutic nihilis m, nonemergent breaches of confidentiality, or denial of care. C ountertrans ference feelings of frustration and anger s hould be us ed cons tructively, as a way of understanding the patient's long-standing feelings . Once in psychiatric treatment, relaps es should be expected in a s imilar manner as for s ubs tance abus ers . C linicians s hould not be disappointed at relaps es but should s ee them as opportunities for further unders tanding about the patient. F or example, if a has a pattern of relaps ing under conditions of new romantic involvements or arguments with authority figures , then this provides valuable insight into the patient's vulnerabilities , and these is sues can be in ps ychotherapy. Legal and ethical is sues play prominently in the management of factitious disorder patients , and, for reason, ris k management profes sionals and 1769 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 70 of 79

should be involved from an early point. C onfidentiality, right to privacy, and the constitutional protection unwarranted s earches and s eizures are major iss ues . once-common practice of alerting all E R s about disorder patients is now not routinely practiced heightened sens itivity about confidentiality rights . Nevertheles s, this kind of wides pread alerting can be with the consent of the patient. F or example, once a patient acknowledges having factitious disorder, the patient can be as ked, “I'd like to minimize harm to you. I have your permis sion to alert E R s and some doctors community? ” Likewise, the patient's right to should be res pected when gathering collateral information in nonemergent s ituations. V erbal or, preferably, signed releas es of information should be obtained before contacting collateral s ources , except in emergency s ituations. C linicians should be careful revealing information to the patient's employers , or family. T he diagnosis of factitious disorder mus t be revealed, even to spouses or s ignificant others, the explicit permis sion of the patient. S earching a hospital room or pers onal belongings for illnes smeans may facilitate the diagnosis of factitious disorder and may les sen morbidity, but this should only be done after cons ulting with risk management or other legal couns el, as it may violate a patient's constitutional protections. Likewis e, covert s urveillance, s uch as video, s hould only be undertaken after careful legal cons ultation. It should als o be remembered that, s imply because an action is legal, it is not necess arily ethical. T herefore, the involvement of bioethicists can be

Fac titious Dis order with 1770 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 71 of 79

P redominantly P s yc hologic al and S ymptoms T he most widely used strategy is empathic that the feigned illness represents intraps ychic distress that can be alleviated through proper psychiatric treatment. B rief but regular contacts on a timerather than a distres s-contingent, basis are the therapy. C onsis tent long-term ps ychotherapy is aimed enabling patients to expres s their feelings , to gain and coping s kills , and to provide a reliable and outlet for communication. T he double-bind approach can be applied. P atients are told that their conditions should improve with certain medications and ps ychotherapy and that, if they do not improve, factitious dis order will be suspected. A critical as pect of treatment in an inpatient s etting is management of s taff reaction, which can include and negative countertransference. It is es sential to preserve good staff communication and to formulate a clear management plan involving the whole team, to minimize s plitting. T he ps ychiatris t or psychotherapist also be prone to negative countertransference, aris ing from feelings of being duped or manipulated. T he must take care to manage poss ible feelings of nihilism and other feelings that may interfere with the ability to form a therapeutic alliance. C omorbid mental illness es mus t be recognized and treated appropriately. F or example, mos t cases of bereavement are comorbid with major depress ion. One patient claimed to have feigned bereavement to justify depres sion. Another claimed to have recently been 1771 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 72 of 79

and s ought help for P T S D. Although she was not raped, she had experienced long-standing childhood sexual abus e. F eigned mental illnes ses may express emotional truth for the patient, if not a factual truth.

Fac titious Dis order by P roxy P rotection of the child is the firs t priority in factitious disorder by proxy. Active pursuit of the diagnos is and prompt intervention are es sential toward minimizing the ris k of morbidity and mortality to the vulnerable child. In the proces s of gathering clinical information and clinicians should keep in mind that, if the mother feels suspicions are raised or that she is los ing control of the situation, she is likely to take the child out of the setting and to seek care els ewhere. W hen the factitious disorder by proxy is confirmed, or as sufficient s o that clinicians are convinced, parents be confronted together. In this way, the father's involvement in the perpetration, as well as his pos sible as an ally, can be ass es sed. In advance of P.1843 C hild P rotective S ervices should be involved, and a hold s hould be instituted to prevent parents from with the child. In all 50 s tates, reporting of factitious disorder by proxy to child abuse protection authorities mandatory. In R osenberg's review of cases, 20 percent of children died of factitious disorder by proxy were sent home their parents, after parents were confronted with the diagnosis. G iven the high rate of mortality and in these cas es , the child should be removed from the 1772 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 73 of 79

parents until treatment and further as ses sment indicate that it is safe for the family to be reunited. C hild S ervices usually take respons ibility for this action. this is done, there is a high likelihood that the mother need intervention for s uicidal ideation. Inves tigation poss ible abuse of s iblings s hould also be initiated. After separation, the child mus t be treated for ongoing medical problems , as well as for psychological F or many children, long-standing refractory medical illness es resolve, once they are separated from perpetrators . P sychologically, many children P T S D and s hould be treated. As is typical of those with P T S D, many victims avoid medical care as adults. On other hand, others develop factitious disorder B y adolescence, many victims of factitious disorder by proxy collude with parents in perpetrating deception. T he perpetrator, usually the mother, should also treatment. Underlying ps ychiatric dis orders s hould be addres sed. T he mother should be evaluated to whether it is likely that she will ever achieve good parental s tatus and whether reunification with the child a realistic goal. T hos e who actively induce illness in children are less likely to ever be adequate parents. If reunification is unrealistic, then psychotherapy s hould focus on the mother's underlying psychopathology, as as her los s of the child. If reunification is the goal, then treatment s hould address emotional maturation of the mother, the ability to put the child's needs before her relinquis hing the defens e of denial, and learning to help and to expres s herself in appropriate ways . T he mother should also work on boundary iss ues and learn to distinguish her own needs from the needs of 1773 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 74 of 79

child. If reunification occurs, careful monitoring should follow. C hild P rotective S ervices s hould be involved. A primary pediatrician should act as a gatekeeper who monitors approves all medical care. Although the literature on factitious disorder by proxy is cast in the s hadow of the mos t severe cases, mild occur. Meadow advocates that, in these mild cas es, mothers s hould be s upported and prevented from their children through needles s investigations and treatments . P sychotherapy s hould be undertaken. T he prognos is in thes e cas es may not be so grim. T here is little literature on the treatment of factitious disorder by proxy between adults. In thes e cases, of the victim through legal means is usually not an as the victim is an adult. T he victim mus t us ually be res ponsible for initiating s eparation. In cases in which health care providers are sus pected of perpetrating among their patients, removal of the health care is es sential, and legal prosecution s hould be E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "16 - F actitious Dis orders " C learly, the entire area of factitious disorder would from more research, as little empirical evidence is available, and virtually no controlled s tudies have been done. T he deceptive nature of the illnes s makes 1774 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 75 of 79

study difficult. At the current time, factitious dis order by proxy is not official DS M diagnosis but is cons idered a diagnosis deserving of further study. Acceptance as an official and IC D-10 diagnosis s hould increase its recognition in clinical s etting and s hould lead to decreas ed morbidity and mortality. W ithin the realm of factitious disorder by proxy, perifactitious disorders , s uch as hypochondrias is proxy and other by-proxy dis orders that res ult in medical care for children, s hould als o be further cons idered. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "16 - F actitious Dis orders " S omatoform dis orders are discus sed in C hapter 15. Malingering is the s ubject of S ection 26.1. P ers onality disorders are address ed in C hapter 23. P s ychotherapy discuss ed in C hapter 30. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > R E F E R E NC

R E FE R E NC E S Ads head G , B rooke B , eds. Munchaus en's P roxy: C urrent Is s ue s in As s es s ment, T re atme nt R es e arch. London: Imperial C ollege P ress ; 2001. 1775 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 76 of 79

Aduan R P , F auci AS , Dale DD: F actitious fever and induced infection: A report of 32 cases and review of the literature. Ann Inte rn Me d. 1979;90:230. Allison DB , R oberts MS . Dis orde r Mothe r of Diagnos is ? Munchaus e n by P roxy S yndrome . T he Analytic P ress ; 1998. *Asher R : Munchausen's s yndrome. L ance t. Ayoub C C , Alexander R : Definitional iss ues in Munchaus en by proxy. AP S AC Advis or. 1998;11:7. B hugra D: P s ychiatric Munchausen's syndrome: Literature review with case reports. Acta P s ychiatr S cand. 1988;77:497. E di-Osagie E C , Hopkins R E , E di-Osagie NE : Munchaus en's syndrome in obstetrics and A review. O bs te t G yne col S urv. 1998;53:45. E is endrath S J : F actitious physical dis orders: without confrontation. P s ychos omatics . E is endrath S J , McNeil DE : F actitious dis orders in litigation: T wenty cas es illus trating the s pectrum of abnormal illnes s -affirming behavior. J Am Acad P s ychiatry L aw. 2002;30:391. E mins on DM, P os tlethwaite R J : F actitious illness : R ecognition and management. Arch Dis C hild. 1776 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 77 of 79

1992;67:1510. F eldman MD, E is endrath S J , eds . T he S pe ctrum of F actitious Dis orde rs . W ashington, DC : American P sychiatric P ress ; 1997. *F eldman MD, Hamilton J C , Deemer HN. F actitious disorder. In: P hillips K A, ed. S omatoform and Dis orde rs . W ashington, DC : American P sychiatric P ublis hing; 2001. F olks DG : Munchaus en's syndrome and other disorders . Neurol C lin. 1995;13:2. F ord C F . T he S omatizing Dis orde rs : Illne s s as a New Y ork: E lsevier S cience; 1983. G avin H. O n the F e igne d and F actitious Dis e as e s of S oldie rs and S e ame n, on the Me ans Us e d to P roduce T he m, and on the B e s t Mode s of Impos tors . E dinburgh: University P ress ; 1838. G elenberg AJ : Munchaus en's syndrome with a ps ychiatric pres entation. Dis Ne rv S ys t. Hay G G : F eigned psychosis: A review of the of mental illness . B r J P s ychiatry. 1983;143:8. K rahn LE , Li H, O'C onnor MK : P atients who strive to ill: F actitious disorder with phys ical s ymptoms . Am J P s ychiatry. 2003;160:1163.

1777 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 78 of 79

*Meadow R : Munchaus en s yndrome by proxy: T he hinterland of child abus e. L ance t. 1977;2:343. Meadow R : Management of Munchaus en syndrome proxy. Arch Dis C hild. 1985;60:385. Meadow R : Unnatural sudden infant death Arch Dis C hild. 1999;80:7. P hillips MR , W ard NG , R ies R K : F actitious P ainless patienthood. Am J P s ychiatry. P ope HG , J onas J M, J ones B : F actitious ps ychos is: P henomenology, family his tory, and long-term outcome of nine patients . Am J P s ychiatry. 1982;139:1480. *R eich P , G ottfried LA: F actitious dis orders in a hospital. Ann Inte rn Me d. 1983;99:240. R ogers R , B agby R M, R ector N: Diagnos tic factitious disorder with ps ychological s ymptoms. Am P s ychiatry. 1989;146:1312. *R osenberg DA: W eb of deceit: A literature review of Munchaus en s yndrome by proxy. C hild Abus e 1987;11:547. S chrier H: Munchaus en by proxy defined. P ediatrics . 2003;110:958. S chreier HA, Libow J A. Hurting for L ove : 1778 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

16

Page 79 of 79

P roxy S yndrome . New Y ork: G uilford P res s; 1993. S nowdon J , S olomons R , Druce H: F eigned bereavement: T welve cases. B r J P s ychiatry. S piro HR : C hronic factitious illness : Munchaus en's syndrome. Arch G e n P s ychiatry. 1968;18:569. S utherland AJ , R odin G M: F actitious disorders in a general hospital s etting: C linical features and a of the literature. P s ychos omatics . 1990;31:392. Wallach J : Laboratory diagnosis of factitious Arch Inte rn Med. 1994;154:1690. Wise MG , F ord C V : F actitious disorders . P rimary 1999;26:2.

1779 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

01/01/2009

17

Page 1 of 302

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > 17 - Dis s ociative Dis orde

17 Dis s oc iative Dis orders R ichard J . L oewens tein M.D. Frank W. Putnam M.D. 

DIS S OC IAT ION AND DIS S OC IAT IV E



DIS S OC IAT IV E AMNE S IA



DE P E R S ONALIZAT ION DIS OR DE R



DIS S OC IAT IV E F UG UE



DIS S OC IAT IV E IDE NT IT Y DIS OR DE R



DIS S OC IAT IV E DIS OR DE R NOT OT HE R W IS E



F OR E NS IC IS S UE S AND DIS S OC IAT IV E



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IO N AND P HE NO ME NA

DIS S OC IATION AND DIS S OC IATIVE P art of "17 - Dis sociative Dis orders "

1780 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 2 of 302

Introduc tion According to the text revision of the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV -T R ), “the es sential feature of the diss ociative a disruption in the us ually integrated functions of cons ciousnes s, memory, identity, or perception of the environment. T he dis turbance may be s udden or transient or chronic.” T he DS M-IV diss ociative diss ociative identity disorder, depersonalization diss ociative amnesia, diss ociative fugue, and disorder not otherwis e s pecified (NOS ). In the following section, many iss ues that are common to all the diss ociative dis orders are discuss ed together, with separate s ections on the different disorders to follow.

Diagnos tic C riteria: DS M and IC D T he study of the diss ociative dis orders began at the the 18th century. However, the modern notion that conditions are a dis tinct group of disorders , with systematic res earch about them, did not really begin the advent of the third edition of the DS M (DS M-III) in 1980. Although the first edition of the DS M (DS M-I) distinguished dis s ociative re actions from other the second edition of the DS M (DS M-II) subsumed diss ociative conditions under the s uperordinate of hys terical neuros is . T he latter was conceptualized as conversion or diss ociative s ubtype. In DS M-III, conditions that developed from the 19th century cons truct of hys te ria were dis tributed among different diagnostic categories : diss ociative dis orders , somatoform disorders (es pecially convers ion dis order 1781 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 3 of 302

somatization disorder), pos ttraumatic s tres s dis order (P T S D) (in the anxiety dis order section), and his trionic borderline personality dis orders. T he DS M-III took the stance that the label hys te ria had become so imprecise variously defined that it had become meaningles s. T he DS M-III took the approach that thes e conditions would defined and organized separately, s o that s ys tematic, empirical res earch could better clarify their reliability validity. T he tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d He alth 10) class ifies the dis sociative disorders among the s tre s s -re late d, and s omatoform dis orders . T he IC D-10 explicitly states that the term hys te ria s hould be because of its lack of precis ion. T he IC D-10 [convers ion] dis orders include diss ociative amnesia, diss ociative fugue, diss ociative stupor, trance and poss ess ion disorder, and diss ociative dis orders of movement and s ens ation (roughly equivalent to the IV -T R convers ion dis order diagnosis ). T he latter diss ociative motor disorders , diss ociative convulsions , diss ociative anes thesia and sensory loss . G ans er and multiple pers onality disorder are clas sified under diss ociative dis orders. Depers onalization disorder is clas sified separately. T he IC D-10 diagnostic criteria for these disorders are found in T able 17-1.

Table 17-1 IC D-10 Diagnos tic C riteria for Dis s oc iative (C onvers ion) Dis orders 1782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 4 of 302

   G 1. T here must be no evidence of a phys ical disorder that can explain the characteristic symptoms of this dis order (although phys ical disorders may be present that give rise to other symptoms).    G 2. T here are convincing as sociations in time between the ons et of symptoms of the dis order stress ful events , problems , or needs. Dis s ociative amnes ia    A. T he general criteria for diss ociative dis order must be met.    B . T here must be amnesia, partial or complete, recent events or problems that were or s till are traumatic or s tres sful.    C . T he amnesia is too extensive and persistent be explained by ordinary forgetfulness (although depth and extent may vary from one ass es sment the next) or by intentional s imulation. Dis s ociative fugue    A. T he general criteria for diss ociative dis order must be met.

1783 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 5 of 302

   B . T he individual undertakes an unexpected yet organized journey away from home or from the ordinary places of work and social activities , which s elf-care is largely maintained.    C . T here is amnes ia, partial or complete, for the journey, which als o meets C riterion C for amnes ia. Dis s ociative s tupor    A. T he general criteria for diss ociative dis order must be met.    B . T here is profound diminution or absence of voluntary movements and s peech and of normal res ponsiveness to light, nois e, and touch.    C . Normal muscle tone, s tatic posture, and breathing (and often limited coordinated eye movements) are maintained. Tranc e and pos s es s ion dis orders    A. T he general criteria for diss ociative dis order must be met.    B . E ither of the following must be present:    (1) T rance . T here is temporary alteration of the 1784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 6 of 302

state of cons cious nes s, shown by any two of the following:    (a) Loss of the usual s ens e of personal identity    (b) Narrowing of awarenes s of immediate surroundings or unusually narrow and s elective focus ing on environmental s timuli    (c) Limitation of movements, postures , and to repetition of a s mall repertoire    (2) P os s e s s ion dis orde r. T he individual is that he or s he has been taken over by a s pirit, deity, or other pers on.    C . (1) and (2) of C riterion B must be unwanted troublesome, occurring outs ide, or being a prolongation of, s imilar states in religious or other culturally accepted situations.    D. Mos t commonly us ed e xclus ion claus e . T he disorder does not occur at the same time as schizophrenia or related dis orders, or mood (affective) disorders with hallucinations or Dis s ociative motor dis orders    A. T he general criteria for diss ociative dis order must be met. 1785 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 7 of 302

   B . E ither of the following must be present:    (1) C omplete or partial los s of the ability to movements that are normally under voluntary control (including s peech)    (2) V arious or variable degrees of ataxia, or inability to s tand unaided Dis s ociative c onvuls ions    A. T he general criteria for diss ociative dis order must be met.    B . T he individual exhibits s udden and spas modic movements, clos ely resembling any of the varieties of epileptic seizure but not followed loss of cons cious nes s.    C . T he symptoms in C riterion B are not accompanied by tongue biting, serious bruis ing or laceration due to falling, or urinary incontinence. Dis s ociative anes thes ia and s ens ory los s    A. T he general criteria for diss ociative dis order must be met.    B . E ither of the following must be present:

1786 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 8 of 302

   (1) P artial or complete loss of any or all of the normal cutaneous sens ations over part or all of body (specify: touch, pin prick, vibration, heat,    (2) P artial or complete loss of vision, hearing, or smell (s pecify) Mixed dis s ociative (c onvers ion) dis orders Other dis s oc iative (convers ion) dis orders T his residual code may be us ed to indicate other diss ociative and convers ion states that meet G 1 and G 2 for diss ociative (conversion) disorders do not meet the criteria for the diss ociative listed previous ly. G ans er s yndrome (approximate ans wers) Multiple pers onality disorder    A. T wo or more distinct personalities exis t the individual, only one being evident at a time.    B . E ach personality has its own memories , preferences , and behavior patterns and, at some time (and recurrently), takes full control of the individual's behavior.    C . T here is inability to recall important pers onal 1787 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 9 of 302

information, which is too extens ive to be by ordinary forgetfulness .    D. T he symptoms are not due to organic mental disorders (e.g., in epileptic dis orders) or subs tance-related dis orders (e.g., intoxication or withdrawal). T ransient dis sociative (conversion) dis orders occurring in childhood and adoles cence Other specified dis sociative (convers ion) S pecific research criteria are not given for all disorders mentioned previously, because these other diss ociative s tates are rare and not well described. R es earch workers studying these conditions in detail s hould s pecify their own according to the purpose of their s tudies . Dis s ociative (c onvers ion) dis order,

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permiss ion.

C ontrovers ies about Dis s oc iative 1788 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 10 of 302

Dis orders T he DS M-IV -T R and the IC D-10 take divergent to the relations hip of convers ion dis orders to disorders . T he former treats them as s eparate and the latter treats them as conditions with similar underlying mechanisms. T his difference symbolizes one of the many pass ionate disagreements that the disorders that have evolved from clas sic hys teria. Indeed, it is unlikely that any other group of disorders in ps ychiatry can evoke so much heated controversy, and fervent debate than the conditions derived from the hysteria concept, particularly the diss ociative dis orders. T his is especially ironic, becaus e, s ince the 1980s , finally an increasingly rigorous body of research data many of the DS M-IV -T R diss ociative dis orders, as well the phenomenon of dis sociation, itself. Why s hould there be s uch a pas sionate debate? Why should appeals to the res ults of scientific research not res olve it? More so than other ps ychiatric conditions, disorders touch on many complex and contentious as pects of personal, political, philosophical, and even religious beliefs. T hes e include the nature of memory, volition, and consciousness and the res ponsibility of individuals for their own behavior. Indeed, the debate touches on fundamental ques tions about the nature of mind, the self, and the mos t intimate human behaviors . When viewed within a larger s ociopolitical perspective, diss ociation theory inters ects with many of the mos t controvers ial social iss ues of modern times. R ecent systematic res earch cons is tently has found a robust relations hip between diss ociation and traumatic experiences . T he role of trauma in Wes tern culture, 1789 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 11 of 302

particularly intergenerational violence and sexual cross es into historically taboo subjects, such as rape, inces t, child abus e, and domestic violence, and their prevalence in W estern society. In addition, the s tudy of trauma leads into larger legal, s ocial, and cultural questions related to peace and war, the meaning of violence in W es tern society, and even varying religious views about the relations hip between men, women, children and the nature of the family. In psychiatry and ps ychology, thes e disorders are the of controversies that include the long-standing debates between mentalists and behaviorists , between ps ychodynamically orie nte d and biologically oriente d clinicians , between various res earchers in cognitive ps ychology, between cognitive res earchers and clinical res earchers and practitioners , and between different theoretical s chools at odds over the nature of hypnos is. S ome fundamentalist C hris tian clinicians even have viewed demonic poss es sion as part of the differential diagnosis of diss ociative disorders . P.1845 P.1846 Is sues here include the significance of early trauma for human ps ychopathology; the existence of uncons cious mental life and intraps ychic de fens es , s uch as nature of memory; and the nature of hypnos is and whether it involves altered s tates of consciousness . F urthermore, the exis tence of diss ociative amnesias delayed recall of traumatic events raise difficult-to1790 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 12 of 302

questions about the reliability of traumatic memory. latter iss ue has been a significant controversy in the ps ychiatric community that has s pilled over into the and the popular media, arenas in which dispass ionate scientific inquiry is unlikely to be the central concern of participants. A particularly contentious debate has evolved over the relations hip of dis sociative disorders to psychological trauma. T his idea has been the s ubject of s ys tematic res earch, generally s howing a repeated, robust relations hip between trauma and diss ociative and disorders . In fact, this research led the American P sychiatric Ass ociation (AP A) DS M-IV Advis ory on P T S D to include diss ociative amnesia, diss ociative fugue, and diss ociative identity disorder/multiple personality dis order among the dis orders most strongly related to an antecedent history of traumatic or experiences , or both. Alternatively, another group of psychiatric clinicians res earchers has decried the emphas is on trauma in the conceptualization of diss ociative dis orders. T hes e doubt the relations hip between traumatic and the development of diss ociative dis orders, in regard to diss ociative amnes ia and diss ociative disorder. T hey dis pute the notion that there is a strong as sociation between the development of diss ociative identity dis order and early childhood maltreatment. S imilarly, they insist that amnesia for trauma does not occur, particularly for childhood s exual abus e. S ome of these critics have argued that diss ociative disorder and diss ociative amnes ia are not valid all and s hould be dropped from the DS M-IV -T R . Others 1791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 13 of 302

have proposed a resurrection of the term hys te ria to account for these conditions. Others have them as factitious conditions , related to patient suggestibility and clinician naïveté. S ome relate the development of thes e disorders to underlying disorders , particularly borderline personality dis order. this view, the pers onality disorder is s een as the disorder, with the diss ociative dis order developing secondary to s ociocognitive factors. T he clas h of views about thes e iss ues has been notable in the debate over re pre s s ed or re cove red that has divided the mental health community since the 1990s . High-profile legal cas es have been the center of debate. In one incarnation, so-called victims alleging delayed recall for childhood maltreatment have been given standing to s ue or to bring criminal actions bas ed the de laye d dis covery rule, overcoming the statute of limitations . In the alternative form, accused parents or recanting former victims, or both, have sued mental health alleging malpractice or alienation of affections , or both, based on the notion that there is no s uch thing as diss ociation, amnesia, repres sion of memory, and diss ociative disorders . T hese cases have been the of considerable media attention.

Dis s oc iation and the Media F rom the middle of the 19th century to the pres ent, the popular media has nurtured public fascination with various forms of dis sociation, es pecially multiple personality. Accounts of 19th century cas es were popular magazines s uch as Harpe rs , and famous 1792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 14 of 302

such as Morton P rince's Mis s B eauchamps (1905), the subjects of books and plays. R obert Lewis T he S trange C as e of Dr. J e kyll and Mr. Hyde (1886) is most well-known of these works . Other popular 19th century novels and plays focused on fugue, amnesia, crimes committed under the influence of hypnosis or in somnambulistic s tates. F rom at leas t the 1930s sens ational reports of patients with generalized diss ociative amnesia or fugue, or both, were featured the daily news papers. S imilar cases are s till featured in the news when amnestic patients are found who cannot be identified. In the late 20th century, popular accounts of multiple personality, s uch as T he T hre e F ace s of E ve , S ybil, recent s pate of s imilar first-person accounts , continued this vein. T he widespread us e of multiple pers onality as fictional plot device—generally to give a bizarre twis t to the story—has contributed to the public and confusion that s urrounds this disorder. S imilarly, for life circums tances and for trauma is als o a recurrent story mechanis m in contemporary novels, films , and television—almos t never portrayed accurately. Media stereotyping occurs for many forms of mental illnes s, the distortions typical in mos t fictional depictions of diss ociative dis orders are particularly mis leading. Highly publicized criminal and civil cas es, such as the Hillside S trangler, the F ranklin murder case, the case, and many others, have brought additional media attention to claims of multiple personality, amnes ia, recovered memory. T hese contentious cas es, with their warring academic experts and s ens ationalized media depictions, have also fueled popular s tereotyping of 1793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 15 of 302

diss ociative dis orders. Media s pin about thes e cases often been inaccurate and mis leading. B ecaus e of all this, one commentator ruefully obs erved that most clinicians get the bulk of their training about diss ociation and diss ociative disorders from television. the foreseeable future, becaus e of the complexity of social, cultural, philosophical, and political is sues that these conditions evoke, it is unlikely that debates about them will remain purely in the academic arena.

His tory T he study of hys teria and diss ociation begins at the the 18th century with s hift of interest in thes e from the religious to the medical realm. P aracels us , in 1646, is credited with the first medical report of an individual with alternating s elves . In 1791, E berhardt G melin described a G erman woman who alternately exchanged her peasant personality for that of an aristocratic F rench lady, each amnesic for the other's exis tence. B y the early 19th century, such cas es , with diagnos es dual, double, or duplex consciousness , were being regularly reported on both s ides of the Atlantic. In B enjamin R ush, considered the father of American ps ychiatry, included a clas sic example in his medical school lectures . R us h propos ed that dual personality reflected a functional disconnection between the two cerebral hemispheres . In the same year, the case of R eynolds, who became the American archetype of diss ociative identity disorder for the remainder of the century, was first publis hed. 1794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 16 of 302

In E urope, disciples of F ranz Anton Mesmer developed first s ys tematic descriptions of what is now called T hese thinkers developed an interes t in magne tic (from Mesmer's theories of animal magnetis m): fugue, somnambulis tic states , and alternating or personality that could be treated with artificial s omnambulis m, that is, hypnos is . T hese magne tize rs mostly outs ide the mains tream of E uropean academic medicine, and their works are not widely known. them, Antoine Des pine, a F rench family doctor, wrote systematic case studies and reports about s everal multiple pers onality patients , including child and adoles cent cases. Mos t of these 19th century patients had extensive convers ion and s omatoform s ymptoms part of the clinical pres entation. P sychiatric his torians have charted the s hift in interest from s omnambulism to multiple personality to hys teria and back over the cours e of the 19th century, with finally s een as a unifying concept for all these Many contemporary debates about diss ociation were prefigured by those in the 19th century. F or example, B riquet, who wrote a famous study of hysteria in the 19th century, dis puted the prevailing notion that P.1847 the disorder was caused by s exual frustration. He that traumatic, overwhelming, and grief-engendering experiences led to the development of hys teria. T he famous 19th century F rench psychiatrist, J eanC harcot, s ynthes ized the teachings of the magnetizers with those of the more accepted medical and es tablis hment, including B riquet's etiological theories. 1795 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 17 of 302

C harcot influenced major figures in psychiatry and neurology, such as S igmund F reud, P ierre J anet, G illes de la T ourette, and J oseph B abinski. As is well known, he gave public demonstrations of hysterical patients and hypnos is at his hos pital, La S alpetriere. Unknown to the careless C harcot, however, many were readily prompted in various ways to perform spectacularly for him. S ome were magnetized (i.e., hypnotized) on the wards or encouraged by followers of C harcot to act as dramatically as poss ible the great man. In addition, C harcot's methods of demonstrating his patients abundantly cued them to expected res pons es . After his death, two of C harcot's mos t important succes sors , B abins ki and J anet, took divergent views hysteria. B abinski took the radically nihilis tic view that hysteria was caus ed by s ugge s tion and could be by persuasion or counters uggestion. He coined the pithiatis m as a s ubs titute for hysteria. In addition, the Nancy school of hypnos is , led by Hippolyte B ernheim, believed that hypnos is was not neces sarily a s ign of pathology, as C harcot believed, but an effect of suggestion. B abinski and B ernheim believed that the symptoms of C harcot's patients were artifacts of suggestion and contagion, not of bone fide dis orders. view continues today, most prominently in the thinking P aul McHugh, a vehement critic of the current traumabased theories of dis sociation. At the end of the 19th century, P ierre J anet in F rance, P rince and W illiam J ames in the United S tates, and acros s E urope were engaged in a lively trans atlantic discuss ion about pos sible psychological and 1796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 18 of 302

mechanisms underlying cas es of multiple pers onality, amnes ia, and fugue. Medical models of the time phenomena such as sleep and dreams, hypnos is and somnambulism, epilepsy, and disconnections between cerebral hemispheres to explain multiplicity. P ierre res earch and clinical theory, in particular, his emphasis the role of traumatic antecedents of dis sociation, are widely regarded as the foundation for modern views of diss ociation. As the 20th century began, however, interest in diss ociation waned, and alternative theories, like ps ychoanalys is, began their ascendance. However, interes t in diss ociative phenomena has reoccurred in war s ince the turn of the century with the observation of amnes ia, fugues , and conversion s ymptoms in soldiers . S ubs equently, thes e observations tended to forgotten by the ps ychiatric community, as the wars thems elves fade from memory. F or example, B abinks i's ideas had cons iderable on E uropean ps ychiatris ts until the onset of W orld W ar that time, with the development of the concept of s hell s hock, ps ychiatris ts systematically reported that of the symptoms of diss ociation, amnesia, automatism, and hysteria could be found among battle traumatized soldiers , plainly contradicting B abinski's ideas and supporting those of J anet.

J anet and Freud J anet is generally regarded as the founder of modern approaches to diss ociation and dis sociative disorders . was als o the first psychiatrist to provide s ys tematic, modern des criptions of obs ess ive-compuls ive disorder 1797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 19 of 302

(OC D), phobias, and anorexia nervosa. He was deeply knowledgeable of the works of the magnetizers and early papers on diss ociation, hys teria, and multiple personality. He developed theories of hysteria and diss ociation, s ugges ting that many cases of hysteria based on covert, dis sociated aspects of the personality that were engendered by traumatic experiences in susceptible individuals . He believed that the lesion in hysteria was the narrowing of cons cious ne s s which the hys terical pers on is unable to perceive of subjective or objective phenomena. T hese then diss ociated, independent-agent aspects of the mind. also pos ited a kind of s tre s s -diathe s is model in which cons titutional and environmental factors coincided to produce the ps ychopathological diss ociative outcome. J anet developed a s ort of cognitive behavioral ps ychotherapy for his patients , involving hypnos is and search for a hierarchy of hidden traumatic memories related fixed ide as going back in the patient's history. also used hypnotic suggestion, imagery, and creative engagement with his patients to modify their bizarre hallucinations , disturbed perceptions, and hys terical alterations of consciousness . J anet worked intensely the hysterical cris es of the patients and, des pite symptomatic s torms and s uicidal cris es , found that the patients improved after this work. In addition, tas ks and work were pres cribed for the patient. J anet described many is sues in the proces s of therapy that been redis covered by contemporary students of the diss ociative dis orders. T hes e include a kind of altered states of consciousness and intens e with the therapis t, leading to therapeutic s talemate. 1798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 20 of 302

J anet was attacked by followers of B abinksi and a credulous disciple of the dis credited ideas of C harcot. critics notwithstanding, J anet hims elf was dis tress ed by the contamination of patients under C harcot's hospital adminis tration; C harcot's failure to fully understand the work of prior scholars, such as the magnetizers ; and factitious nature of many of the patients' s ymptoms . F or the most part, he refus ed to work with former patients C harcot and took careful histories of patients ' prior treatments to uncover potential therapeutic s haping of symptoms. F reud and J os eph B reuer's revered S tudie s in H ys te ria (1893) referenced J anet's work, and us ed s imilar fixed ideas and traumatic etiology, and introduced the cathartic method of cure for hysteria. Anna O., the archetypal F reudian hys teric, is clearly des cribed as a dual pers onality and a plethora of dis sociative symptoms, such as complex amnes ias for current and historical experience; spontaneous age regres sions trances; depersonalization; fluctuations in handwriting, handednes s, and language; and alternating s tates of cons ciousnes s. However, as time went on, many psychoanalys ts excoriated J anet, as serting that he dis hones tly claimed priority for these ideas related to hysteria, even though J anet's work clearly antedated F reud's . J anet, for his was uncharacteris tically publicly angry at this failure to acknowledge his work. T hroughout his career, he remained critical of F reud and ps ychoanalytic ideas . Des pite the janetian ideas found in early freudian hysteria, freudian theories of hysterical and diss ociative phenomena differ in important ways from those of 1799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 21 of 302

F reud posited the ideas of the dynamic unconscious, intraps ychic conflict, and intraps ychic defense related unacceptable thoughts, wishes, ideas, and memories. Later, he developed theories of transference and countertransference. After F reud repudiated the theory and developed a new and different theory of mental life, he and his followers increas ingly focused the somatoform as pects of hys terical phenomena, to neglect of the dis sociative ones . David R appaport, G ill, Margaret B renman, C harles F is cher, and E lisabeth G eleerd, among others , wrote important psychoanalytic papers on fugue, amnesia, and diss ociation in the and 1950s . However, psychoanalytic thinkers have ignored this work. It is unfortunate that disputes over primacy of ideas led a s chism between J anet and the freudians . Modern conceptualization of diss ociative disorders often synthes is of janetian ideas and freudian ones . F or current theories of treatment include the janetian of s ys tematic work with traumatic memories using adjunctive hypnotic and imagery techniques, work with posttraumatic cognitive distortions, using cognitive P.1848 and behavioral ps ychotherapy, ps ychoeducation, and building of life skills. T he psychoanalytic concepts of transference, countertrans ference, object relations, intraps ychic defens e, and conflict, among others, are es sential to understanding modern therapy of patients. J anet continued to be active in ps ychology and until his death in 1947, writing on many different 1800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 22 of 302

theoretical, and philosophical subjects . J anet never developed a formal s chool of psychology nor a group disciples committed to his theories . He was deeply concerned with the protection of patient confidentiality, perhaps in part as a reaction to the excess es of the era. Accordingly, he had his library of detailed cas e histories , including those of the mos t famous clas sic hysterics, des troyed at his death. B ecaus e of this, and because of the primacy of the psychoanalytic theories the latter part of the 20th century, his work was largely neglected until the recent resurgence of interes t in diss ociation. J anet's contributions to modern diss ociation theory include (1) recognition of the caus al role of trauma in diss ociation in a stres s-diathesis model; (2) the taxonometric approach—J anet believed that was not on a continuum from normal ps ychological experience; (3) recognition that the underlying mental mechanisms of somatoform and diss ociative dis orders were s imilar; (4) the role of fixed ide as in diss ociative disorders and attempts to find the most fundamental that influence the patient's behavior; (5) treatment multimodal approach with hypnotic and trauma-focus ed methods combined with cognitive therapy, behavioral therapy, and life-skills building.

World Wars I and II and after C linicians treating battlefield cas ualties in W orld W ars I II readily noted dis sociative s ymptoms , such as fugue, automatisms , and s omatoform s ymptoms , in traumatized s oldiers as part of traumatic war ne uros is , came to be known in W orld W ar II. T he extent of 1801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 23 of 302

described in ps ychiatric battlefield casualties in W orld II ranged from relatively brief periods of time to amnes ia for life history (generalized amnes ia), as well fugue epis odes. T reatment of these W orld War II amnesia cases hypnosis , narcosynthesis with sodium amobarbital (Amytal), or individual and group ps ychotherapy, or a combination of thes e. Attempts were made to treat soldiers on the front lines and to return them rapidly to combat. Detailed cas e descriptions of dis sociative and fugue can be found in clinical studies from that S oldiers from the K orean conflict also were noted to amnes ia as part of the posttraumatic s yndromes combat experiences and were treated with s imilar modalities. T he observations of thes e military ps ychiatris ts were mostly los t until the resurgence of interest in trauma diss ociation in the 1970s and 1980s . Authorities cite several s ocial and cultural factors leading to this T hese include the return of the V ietnam veterans and systematic academic s tudy of their ps ychiatric the recognition of the prevalence of childhood physical and s exual abus e with its as sociated mandated development of clinical attention to, mandated of, and res earch on child abuse and family violence; ris e of feminism with its critique of ps ychological that as cribed sexual abuse reports to fantas y; academic rigor in theories about hypnosis , s uch as Hilgard's ne odis s ociation theory, and greater academic hypnosis research; popular interes t in personality owing to works, such as S ybil; and the with its promulgation of diagnostic criteria for the 1802 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 24 of 302

diss ociative dis orders and P T S D.

L ater His tory S ince the publication of the DS M-III in 1980, a large of s ys tematic res earch has developed about disorders , particularly diss ociative identity disorder, diss ociative amnesia, and depersonalization disorder. Many academic studies have also investigated as a quantifiable trait in clinical and nonclinical S tudies have als o looked at the prevalence and phenomenology of amnes ia, particularly as it relates to question of delayed recall for traumatic experiences . As noted previous ly, the study of the diss ociative appears to be ins eparable from the social and cultural ambiance in which it occurs. Academic interest in and its clinical outcomes has been paralleled by s ocial religious movements focusing on self-identification as a victim of childhood abus e, and the s eeking of recovery through a variety of therapeutic and s elf-help F urthermore, some feminis t theorists opined that from childhood s exual abus e mandated confrontation with alleged perpetrators in personal meetings or in the courts , or both. Legal theoris ts, concerned that victims of childhood maltreatment did not have standing to sue for damages to bring criminal actions under us ual s tatutes of limitations , lobbied s tate legislatures to expand the of time that victims could s eek legal redres s. T his was based on the idea that many survivors had amnes ia for abuse or did not recognize the harm that had been to them until many years after the abus e had occurred, 1803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 25 of 302

both. Many states did alter the s tatute of limitations for childhood s exual abus e, allowing the statute to begin to toll after the person recovered memory of the abuse or, alternatively, after recognizing the harm that had been done whether amnes ia was present or not. A number succes sful legal actions were brought under these theories, with courts accepting expert tes timony concerning the validity of “repress ed memory” for childhood maltreatment. In the 1980s, clinicians working with diss ociative began to report patient accounts of multiperpetrator, multivictim abus e in the context of suppos ed underground cult groups . T hes e frightening and chilling accounts were amplified by highly publicized day care abuse cases that alleged multiple perpetrators , in some cases with elements of occultism and ritualized abuse. S everal state governments developed commis sions to inves tigate allegations of ritual abuse and claimed to found evidence of these activities. Needless to s ay, the media also developed an intense interest in thes e with publication of popular autobiographical accounts patients with reported histories of “ritual abus e,” as well frequent news s tories and televis ion s pecials on this related topics . Unfortunately, s ome clinicians working with thes e diss ociative patients chose to respond to their patients ' reports in a highly publicized and s ens ationalized rather than s ubjecting them to dispass ionate and scrutiny. S ome of these clinicians painted themselves crusaders against a vast criminal cons piracy that threatened the nation, pres enting thems elves and their 1804 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 26 of 302

patients on televis ion and in the newspapers. P atients some specialized diss ociative disorders units shared detailed recollections of trauma in group therapy and in the hos pital milieu, with relatively little concern for poss ible cross -contamination or confus ion about the origin of accounts of trauma. C autionary or critical among dis sociative disorders res earchers and were ignored or rebuked. F orens ic and clinical was dis regarded that cast doubts on the veracity of patients' accounts and s uggested alternative for many of these ritual abus e narratives . Ultimately, an extens ive backlas h occurred that broadly on a large number of claims related to maltreatment. T his included a wholes ale debunking of day care criminal cas es, even those that had res ulted convictions and for which there was s olid proof. T here increased s kepticis m about the reliability of children's reports of childhood maltreatment, particularly for childhood s exual abus e. P opular works that readers to work on recovery from abuse were suggesting abus e to millions when none had occurred. Allegations of delayed recall for childhood trauma in clinical and forens ic cas es were dis paraged as P.1849 based on erroneous views of human memory and cognition. T he diss ociative dis orders cons truct was dismiss ed completely as engendered by suggestion sociocognitive factors . T herapy based on working with traumatic memories was dis counted as ris ky. T he of an extensive prevalence of childhood abuse in the general population and its actual impact on 1805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 27 of 302

ps ychopathology were questioned. S ome critics raised doubts about the validity of the diagnos tic cons truct of P T S D. As always, the print and television media, looking for a new angle on an old story with which to increase or viewer and reader interest, devoted extensive space these critiques. W here they once had devoted hours to crying child abuse victims , they now showed hours of crying wrongfully accus ed parents, day care providers, recanting former victims . A s ignificant impact on this debate was produced by F alse Memory S yndrome F oundation, founded in 1992 parents whos e psychologist daughter had privately accused her father of sexual abuse, reportedly recalled only in adulthood. T hese parents sought out other with similar histories , s ome of whom had had criminal or civil judgments brought against them of their children's allegations of abuse. T he sought to publicize the claims of its founders and members that their adult children's accounts of trauma were confabulations caus ed by psychotherapy. T his organization, accompanied by several attorneys , developed a legal theory that was a direct counterpoint that developed by the feminist clinicians and attorneys who had sought legal confrontation with alleged In this theory, there was no such thing as delayed trauma. Ins tead, clinicians who were ignorant of the complexities of human memory engaged in risky strategies , s uch as hypnosis or guide d image ry. T hey convinced credulous patients that their difficulties were based on a history of repress ed childhood abus e and engaged in therapeutic techniques that led patients to 1806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 28 of 302

believe that thes e confabulations were accurate. T he patients then made these abuse accounts the center of their lives , as cribing all problems to their early maltreatment. T he patients were urged to or to s top all contact with family members accused of sexual abus e, ritual abuse, and other forms of maltreatment. A group of attorneys and a coterie of academic expert witness es s ought out patients and ex-patients to bring cases throughout the country in which therapis ts were sued for malpractice or were subject to licensing board complaints , or both, bas ed on diagnos es of diss ociative identity dis order and diss ociative amnes ia and engagement in therapy involving work with apparent traumatic memories . Many of these cases were settled without ever ending up in court. S everal resulted in jury findings for the plaintiffs with s ignificant damage Others concluded with juries finding for the defendant doctors. A federal mail fraud case agains t several ended in a mistrial before the prosecution's cas e had concluded, with the prosecution declining to retry the case. Only one published s tudy has looked s ys tematically at retractors of abus e allegations, amnes ia, and identity dis order. It found that virtually all of these individuals had long psychiatric histories , with P T S D diss ociative s ymptoms predating contact with clinicians . V irtually all of these patient-plaintiffs had significant pers onality disorders in which they readily the victim role and looked to forces outside themselves explanation of their problems . F actitious elements were prominent in many patients' presentations. W ith 1807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 29 of 302

treatment, mos t had actually improved with res pect to their diss ociative ps ychopathology, but the other Axis I and Axis II difficulties remained s ubs tantial. Later, after termination of treatment by their clinicians, the patients s hifted their perception of victimization from parents to their prior therapists , now putting their attorneys in the role of res cuer, usually with the large s ums of money if they prevailed in their laws uits. Des pite its popularity in the media, fals e me mory as a clinical construct has never been operationalized studied using methods to validate it as a cons truct. V irtually no res earch has been done on this entity as a clinical disorder. However, a number of experiments on memory have been performed by cognitive psychology res earchers, s ubs equent to the naming of the false memory s yndrome, that s upport or cast doubts on whether memory is permanently altered by various of mis information and sugges tion. S tudies are regarding whether memory is easy to modify for a of types of experiences . S tudies vary with the studied, the type of information (or misinformation) provided, and the res earch paradigm to test memory fallibility. Often pres ented as a s imple problem in that has been definitively solved, the oppos ite is more accurate: T his is a complex area of res earch on a set highly complex phenomena in which a number of competing paradigms exis t. Nonetheles s, the experience of many experts however, that s ome therapies that resulted in false memory lawsuits could have been s ubject to litigation without this factor. Although many such treatments were exemplary, others resulted in a 1808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 30 of 302

outcome, des pite clinicians ' difficulties in managing transference and countertransference, therapeutic and boundaries , and overinvolvement with the patient. case example s uggests the complexity of many of cases. Ms. C ., a s ingle woman in her mid-20s, brought a malpractice suit against her former primary therapist, several clinicians who had seen her as a hospital and a hos pital s ys tem that has a specialty trauma and women's program. Ms . C .'s psychiatric history adoles cence. S he ran away from home repeatedly, res ulting in a social s ervice inves tigation. S he was from her parental home bas ed on her reports of sexual, and emotional abuse primarily perpetrated by father. S he s ubs equently recanted these accus ations , her father was not pros ecuted. Attempts to return her home were unsuccess ful, however, and she lived in a succes sion of fos ter placements . S poradic contact with family continued, usually as sociated with clinical deterioration. S he was treated with multiple trials of outpatient, inpatient, and day hospital care throughout her adoles cence and early adulthood. S he received different diagnoses and was treated uns uccess fully several different psychopharmacological regimens. reported amnes ia, fugue, automatic writing, and a shifting internal states to s everal treating clinicians who documented a dis sociative disorder diagnos is in the T he patient was terrified of this diagnosis and was reluctant to cooperate with as sess ing it. E ventually, s he was hospitalized in the women's unit and became the patient of Dr. Z., a clinical ps ychologist. Ms . C . developed an intense therapeutic 1809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 31 of 302

relations hip with Dr. Z., who made the diagnos is of diss ociative identity disorder based on switching to defined alter identities and the presence of diss ociative amnes ia. Dr. Z. rapidly became overinvolved with Ms . telling her that s he loved her and cons idered her to be one of her daughters. In addition to treatment ses sions , which Ms. C . was not billed for ins urance copayments, Z. saw Ms. C . outside of sess ions in s everal social T hey als o engaged in a voluminous e-mail on a daily basis. Ms. C . began to report a bizarre multiperpetrator occultist abus e, based in her family rural hometown. S ome of thes e accounts appeared to fanciful and unlikely to be poss ible in physical reality. Des pite this, Dr. Z. repeatedly reass ured Ms. C . that believed her accounts. Dr. Z. would s creen Ms. C .'s mail mes sages , lest evil “cult programming” calls her. Dr. Z. als o helped Ms. C . financially. P.1850 T he treatment lasted s everal years. Despite the problems , Dr. Z. ins is ted that the patient work on maintaining hers elf free from self-harm and out of the hospital. Ms . C . was gradually more able to do this. Her social function improved, with a more cons istent performance at school and work. S he did require hospitalization, but these became less frequent. Her identities worked on becoming less s eparate and many them fused, with decreased diss ociative symptoms and better functioning. As the therapy wore on, however, found hers elf increas ingly enervated by the extensive demands that Ms. C . continued to place on her for outsess ion contacts , e-mail, cris is management, and 1810 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 32 of 302

support. Dr. Z. consulted with more s enior clinicians suggested more rigorous boundaries and attention to transference and countertransference iss ues . W hen attempted to change the therapy framework according these sugges tions, Ms . C . reacted catastrophically to a profound rejection. F inally, Ms . C . physically attacked Z. in her office, resulting in summary termination of the therapy. Ms. C . eventually began treatment with a clinician who debunked the diss ociative identity disorder and memory ideas and encouraged Ms. C . to sue Dr. Z. other clinicians to right the so-called wrongs that had done to her. E ventually, the case was settled out of for a relatively s mall s um from Dr. Z. As the previous discus sion indicates, thes e academic social debates of the me mory wars parallel many of that polarized the field in the days of B abinski and Like J anet, modern authorities on the diss ociative disorders generally accept the trauma-based etiology diss ociative conditions and the validity of the traumadiss ociation cons truct. T his model mos t completely and rigorously accounts for the current data about these patients. Like J anet, s ophisticated modern s tudents of diss ociative dis orders have a healthy respect for the of phenomenological and ps ychotherapeutic that many dis sociative patients embody and the multilayering of pathologies that may appear in their treatment. F or example, there is a broad spectrum of dis sociative individuals . At one extreme are high-functioning with significant adaptive res ources and relatively circums cribed and treatment-res ponsive pers onality 1811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 33 of 302

disorder s ymptoms. At the other extreme are patients major multiaxial difficulties , factitious and antis ocial clinical features, s ignificant s ubs tance abus e, in criminal subgroups, and major life problems in most spheres of function. T he current polarization of the ps ychiatric community about diss ociative dis orders it more difficult to develop res earch that evaluates these subgroups . A comprehensive model evaluating this complexity could include genetic factors relative vulnerability or res ilience, or both, ps ychobiological developmental factors, the differential effects of trauma and neglect, res titutive environmental factors , and the impact of differing forms of family and dysfunction on the individual.

S c ientific Inves tigation of Dis s oc iation T he scientific investigation of diss ociation dates to the experiments of P rince in 1908 us ing a crude polygraph meas ure galvanic s kin res is tance (G S R ) acros s the personality s tates of a dis sociative identity disorder patient—a physiological meas ure that remains of today. P rince reported seeing differential G S R words that were emotionally laden for one alter personality s tate but not for another. Over the next century, s everal dozen psychophysiological and performance s tudies were added to the literature. Many these reported findings s uggesting differential acros s diss ociative identity disorder alter pers onality states . T he s mall s ample sizes —often only a s ingle and the frequent lack of controls limit their credibility, however. T he few s tudies with larger samples and controls generally s upport the earlier findings of 1812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 34 of 302

differences acros s alter personality states . T he experimental methodologies and the often idios yncratic differential res ponses elicited in dis sociative identity disorder s ubjects have limited opportunities for replication. Nonetheless , inves tigation of differential ps ychophys iological res ponses and cognitive acros s alter pers onality states of dis sociative identity disorder patients continues to be an important s ource information about the nature of dis sociation. T he advent of reliable and valid measures of opened up a new avenue of experimental inves tigation. T he correlation of scale scores with a variety of phys iological, neuroendocrine, cognitive, and brain imaging data facilitates examination of the biological underpinnings of dis sociation and the impact of diss ociation on phys ical and mental functioning. B y dividing subjects into high and low dis sociative subgroups , inves tigators have identified s ignificant differences in the way in which highly diss ociative individuals perform on physiological and cognitive meas ures . Meas ures such as the C linicianDis sociative S tates S cale (C ADS S ) document pharmacologically induced diss ociative-like normal controls and in clinical populations, such as patients. T hes e s tudies primarily focus on traumatized individuals , most of whom do not have a diagnosable diss ociative disorder but often have P T S D or traumaas sociated psychopathology. Much of what has been learned since the 1990s is a result of the large studies including meas ures of dis sociation in their as sess ment.

1813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 35 of 302

Dis s oc iation S c ales and Diagnos tic Interviews F ollowing the example set by affective and anxiety disorder res earchers, dis sociation screening measures DS M–based structured diagnos tic interviews were developed in parallel. After approximately a decade of clinical and research application, the best of these instruments equal the levels of reliability and validity es tablis hed for meas ures of depres sion, anxiety, and R eliable and valid meas urement of diss ociation has particularly important in neurobiological s tudies, as well for understanding the clinical contribution of to trauma-as sociated dis orders. Many of these are now available on the Internet or are reproduced in articles and books. A number have been modified by others and then circulated under names s imilar to the original, so provenance should be established to that a properly validated vers ion is being used.

S Y MP TOM S C R E E NING ME A S UR E S S everal general dis sociation s creening s cales exist. best known of these is the Diss ociative E xperiences (DE S ), developed by E ve B ernstein C arlson and F rank P utnam in the mid-1980s and now included in studies. T here are 28 items, which primarily tap identity alteration, depers onalization, derealization, and absorption. T he overall DE S s core can range from 0 to S everal studies using receiver operating characteristic (R OC ) methodology converge on DE S scores of 30 or greater as the cut-point for identifying pathological of dis sociation. S tudies comparing high- and lowsubjects typically use an overall DE S score of 30 or a 1814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 36 of 302

of 30 on the eight-item, DE S taxon (DE S -T ) s ubs cale dividing line. T he DE S has high coefficients of internal tes t-retest reliability acros s multiple s tudies , and DE S scores are highly correlated with other diss ociation meas ures and diss ociative dis order structured scores. F actor analyses with clinical s amples generally produce trifactorial s olutions with s ubs cales for depers onalization, and abs orption. G ender, status , and, within reas on, intelligence quotient (IQ), do not appear to have significant confounding effects on scores. T he DE S has been translated into more than languages , and s tudies across cultures reveal s trong similarities P.1851 for W es tern and non-Wes tern samples , attes ting to the universality of the dis sociation. T he P eritraumatic Dis sociative E xperiences (P DE Q) developed by C harles R . Marmar and as sess es dis sociative experiences at the time of the traumatic event. S everal vers ions exis t, with the P DE Q item s elf-report vers ion (P DE Q-10-S R V ) now widely for research and clinical s creening. A metaanalytical es tablis hed that peritraumatic diss ociation is the s ingle best predictive factor for the subsequent development P T S D. T he 20-item S omatoform Dis sociation (S DQ-20) developed by E llert R . S . Nijenhuis taps the somatosens ory and convers ion s ymptoms common diss ociative patients . T hese include motor inhibitions, of function, anesthesias and analgesias, pain, and problems with vis ion, hearing, and s mell. T he S DQ-20 good reliability and validity for discriminating 1815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 37 of 302

disorder patients . T he five-item S DQ (S DQ-5) provides quick s creening meas ure. T he C ADS S by J . Douglas B remner is administered by a clinician, usually in the context of an experimental s tudy, to as sess symptoms amnes ia, depers onalization, and derealization. T he has proven particularly useful in pharmacological and in military s tres s studies . It has good convergent validity with other meas ures of dis sociation and high interrater and test-retest reliability. T wo other self-report inventories , the Multis cale Dis sociation Inventory (MDI) and the Multiaxial of Diss ociation (MID), have been developed to as ses s pathological dis sociative s ymptoms and to ass is t in differential diagnosis of diss ociative dis orders. T hree primary dis sociation measures exist for children adoles cents . T he C hild Dis sociative C hecklis t (C DC ) is parent-caretaker-teacher 20-item report measure that a three-point scale. T he C DC is a reliable and valid for dis sociation in children who are 5 to 12 years of S cores can range from 0 to 40, with s cores of 12 or indicative of pathological levels of diss ociation. A diss ociative s ubscale has also been extracted by inves tigators from the popular C hild B ehavior C hecklis t (C B C L) and has proven useful in res earch s tudies , its clinical usefulness has not, as yet, been tes ted with diss ociative patients . T he Adoles cent Dis sociative E xperiences S cale (A-DE S ) is an adoles cent-oriented version of the DE S with differences in item content but similar constructs of amnesia, identity alteration, depers onalization, and derealization. T his 30-item instrument us es a 0-to-10 ans wer format and has good reliability and validity as a research tool and a clinical 1816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 38 of 302

screening instrument.

DIA G NOS TIC INTE R VIE WS T wo DS M-based structured interviews have been developed for the formal diagnosis of dis sociative disorders , the S tructured C linical Interview for DS M-IV Dis sociative Dis orders, R evis ed (S C ID-D-R ) and the Dis sociative Dis orders Interview S chedule (DDIS ). T he S C ID-D-R by Marlene S teinberg is widely regarded as gold s tandard for research studies requiring a is a semi-structured clinician-adminis tered interview as sess es the pres ence and s everity of amnesias , confusion and alteration, depers onalization, and derealization and renders a DS M-IV diagnos is for all diss ociative disorders and for acute s tres s disorder. It includes 276 questions and rates the s everity of each symptom on a four-point scale. F or dis sociative patients, administration time typically ranges from 1 to hours but is much briefer for nondiss ociative patients. T he S C ID-D-R has good to excellent tes t-retest reliability and well-es tablis hed validity in numerous studies. It has been trans lated into at least a dozen languages with s imilar results in different T he DDIS by C olin R os s is primarily a clinical instrument and is s ometimes used as a screen for pathological dis sociation. It inquires about a wide range phenomena in addition to dis sociative s ymptoms , including child abuse his tory, major depres sion, complaints , substance abus e, and paranormal It requires approximately 30 to 60 minutes to diss ociative identity disorder patients . E xcept for depers onalization disorder, interrater reliability is 1817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 39 of 302

acceptable, and convergent validity includes s trong correlations with the DE S and clinical diagnos es of diss ociative dis orders.

Memory and C ognitive Dys func tions Dys functions of memory are a central feature of the diss ociative disorders . Dis sociative identity dis order, its apparent web of directional amnesias among alter personality s tates, was the focus of early attempts at experimental inves tigation. Many of the cas e s tudies followed also sought to document thes e amnesias. A National Ins titute of Mental Health (NIMH) s tudy us ed diss ociative identity disorder patients and ten matched controls, who were tes ted as themselves and in a simulated alter pers onality s tate. T hey tested the separateness of memory between pairs of reportedly mutually amnes ic alter personality states by measuring intrus ions from categorically s imilar word lis ts learned the other alter personality states . T he diss ociative disorder patients were more likely to compartmentalize the stimuli learned, whereas thos e mimicking showed far less evidence of information partitioning. S ubsequent studies s ugges ted that diss ociation had differential impacts on the domains of implicit and memory. C onvers ely, in some recent s tudies of memory and amnes ia in diss ociative identity disorder, cognitive res earchers have not been able to document claimed amnes ia between s ubjectively mutually amnes tic alters us ing a variety of implicit and explicit memory In one study, feigning control s ubjects familiar with diss ociative identity disorder s howed lack of priming in 1818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 40 of 302

implicit memory task because they “knew” they were supposed to be amnestic, although actual dis sociative identity dis order subjects did s how normal priming. On other hand, in another s tudy, researchers could not document suppos ed trans fer of information between alters claiming to be “co-cons cious” us ing implicit and explicit memory tasks. Accordingly, some researchers have questioned the actuality of diss ociative identity disorder amnesias. However, the failure of transfer of information in supposedly co-cons cious alters s ugges ts other implications of these studies. T hes e include that diss ociative identity disorder patients may not always reliable reporters of either amnesia or coawareness between alter self-states . F or example, in a single case study, a dis sociative identity dis order subject was randomly signaled by a beeper and filled out mood and activity rating scales , as well as information pertaining the personality s tate who was “out.” R ating s cales filled in real time were discrepant with the alters ' selfmood and activity reports during clinical interviews . F inally, it may be more us eful to devise studies using autobiographical memory paradigms and to more and naturalis tically s tudy diss ociative identity disorder patients' memory problems and s witching behaviors without necess arily devoting s pecific attention to which alter does or does not have recall at a given time. However, the exis tence of differential and directional amnes ias acros s dis sociative identity dis order alter personality s tates has been found in most studies to T he more rigorous s tudies , however, also document cons iderable leakage or transfer of information across 1819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 41 of 302

personality s tates, which report being completely for one another. T he mos t parsimonious neurops ychological explanation put forward, that these amnes ias are examples of s tate-dependent learning retrieval, was first articulated by T heodule R ibot at the of the 19th century. T he degree of amnesia in diss ociative identity disorder patients , however, that typically s een in experimental studies of s tate dependent memory. S tudies s how that memory tasks can be constructed that highly diss ociative individuals perform better or than control s ubjects. Memory tasks that involve of attention or compartmentalization of highly P.1852 similar information seem to favor highly diss ociative individuals . Memory tasks that demand focused place them at a s ignificant disadvantage. T hese and memory differences, perhaps together with other unrecognized cognitive differences, operating during critical periods of development and over the life span of the individual, could lead to cons iderable deviation normal developmental trajectories, as described in the section on the developmental model.

Ps yc hophys iology of Dis s oc iation C linical obs ervations of differences in handednes s; acuity; s ens itivity to various vis ual, tactile, olfactory, auditory s timuli; and energy level date to some of the earliest cas e descriptions and became a staple of 19th century cas e reports . In a study measuring a battery of autonomic nervous system indices , including G S R , 1820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 42 of 302

nine diss ociative identity disorder patients consistently manifested phys iologically dis tinct pers onality s tates a s everal week period. T hree of the five simulating could, by us ing hypnosis or deep relaxation, also distinct pe rs onality s tate s , although thes e differed phys iologically from thos e produced by the patients . C as e reports continue to report electroencephalogram (E E G ) differences across dis sociative identity dis order personality s tates, but, increasingly, investigators are turning to the newer brain imaging technologies in their efforts to document these. A functional magnetic res onance imaging (fMR I) s tudy of 12 s witches among three alter pers onality states found changes in brain activity bilaterally in the hippocampus and in the right parahippocampal and medial temporal regions. In a comparing 15 diss ociative identity disorder patients to eight controls , the patients showed s ignificant hypoactivity bilaterally in the orbitofrontal region and increased left lateral temporal activity. No differences found between alter personality states , however. An study of alpha wave coherence us ing five s imulator controls and five diss ociative identity disorder s ubjects found s ignificant differences between pers onality s tates for alpha wave coherence in s ix brain regions, whereas there were no differences for the controls . Another compared event-related potentials elicited by words learned in the same or a different alter personality state four diss ociative identity disorder patients. Here, little support was found for the existence of amnes ia personality s tates, when compared to controls from another study who had deliberately concealed of previously learned words. 1821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 43 of 302

Using s cript-driven traumatic imagery to evoke diss ociative s tates in P T S D patients, one fMR I study significantly increas ed activation in the s uperior and middle temporal gyri (B rodmann's area [B A] 38), the inferior frontal gyrus (B A47), the occipital lobe (B A19), parietal lobe (B A7), medial frontal gyrus (B A10), the cortex (B A9), and the anterior cingulate (B A24 and A recent study us ed positron emiss ion tomography to investigate the functional anatomical repres entation autobiographical s elf-awarenes s in 11 diss ociative disorder patients . S ubjects were tested with pers onally relevant s cript-driven imagery of traumatic vers us narratives . Dis sociative identity dis order subjects were tes ted in s elf-states that reported subjective owners hip a traumatic event with accompanying emotional (T raumatic P ers onality S tate [T P S ]) and, in alternation, self-states that denied emotional reactivity to the event and denied that the event had happened to them P ers onality S tate [NP S ]). C omparison of s ubjects in various conditions , s uch as neutral s cript, NP S -neutral script, T P S -traumatic script, NP S -traumatic script, in various trials s howed that T P S subjects res ponded to trauma s cripts with changes in perfus ion of right hemisphere frontal, visual and parietal integration areas similar to thos e of normal subjects res ponding to autobiographical episodic retrieval. T P S subjects showed activation of areas to regulation of emotion and pain. NP S subjects did not show changes in perfusion between neutral and scripts, consistent with their failure to recognize the trauma scripts as autobiographical. T he authors that the res ults are cons istent with a single human 1822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 44 of 302

brain/mind generating at leas t two dis tinct s tates of awarenes s with differing acces s to autobiographical memory primarily related to differential activation of medial prefrontal cortex (MP F C ) areas and pos terior as sociation areas. S imilarly, another group us ed fMR I to s tudy s criptimagery in traumatized s ubjects with and without F unctional connectivity analys is s howed significantly different patterns of activation between the P T S D and non-P T S D groups with script-driven imagery. P T S D subjects experienced the trauma s cripts as producing flashbacks with strong emotional, s omatic, and s ens ory res ponses . Non-P T S D s ubjects experienced recall as personal narratives without intense emotion. Nonsubjects s howed a more left-hemis phere activation pattern including verbal ass ociation areas. P T S D showed a right-hemis phere dominance pattern with increased blood flow to right brain frontal, posterior as sociation, s ubcortical, and paralimbic areas similar to findings in the P E T study of diss ociative identity subjects and prior P E T and fMR I s tudies of P T S D fMR I has also recently been used to study a laboratory paradigm of memory s uppres sion/repres sion using subjects instructed to either think or not think of the second member of a pair of words previous ly seen. S ubsequent cued recall of suppres sion items was to recall of baseline items and actually generalized to novel tes t cues . Neural networks implicated in this suppress ion res pons e involved bilateral prefrontal paralimbic, s ubcortical, and parietal integration areas . addition, suppres sion reduced activation bilaterally in hippocampal areas. Hippocampal activation patterns 1823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 45 of 302

differed from trials involving ordinary forgetting with those involving s uppress ion-induced forgetting. Hippocampal activation was increas ed in s uppress ioninduced forgetting compared to that found in items that were recalled. T he authors concluded that activation of a broad neural network was involved in memory s uppress ion, including interrelation of the dorsolateral prefrontal cortex, hippocampus, anterior cingulate cortex, medial-temporal lobe, dorsal premotor cortex, presupplementary motor area, and intraparietal areas. In addition, the authors stated that thes e strongly sugges t a neurobiological model for memory control in res ponse to trauma, including the poss ibility that these networks are involved in producing lasting amnes ia in res ponse to traumatic events. A few individual case studies of patients with global diss ociative amnesia and with dis sociative fugue with of pers onal identity have s hown unus ual metabolic and activation patterns using P E T scanning and single emis sion computed tomography (S P E C T ). T hes e revers al of the us ual patterns of right and left activation during autobiographical and s emantic recall, res pectively, with s imilarities to some individuals with traumatic brain damage and related memory deficits. A recent review of these s tudies sugges ted that or functional dis connections between major neural networks may be etiological in dis sociative amnesia syndromes. T he strategy of dividing traumatized s ubjects into high and low diss ociative subgroups has als o yielded interes ting res ults for ps ychophysiological meas ures . S everal studies of rape victims , s ubjects with P T S D 1824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 46 of 302

script driven imagery, and s exually abused girls to controls on a meas ure of mos t traumatic life have found a unique pattern of psychophysiological res ponding in high diss ociatives. Using indicators of subjective dis tres s, P.1853 heart rate, and G S R , high dis sociatives s howed heart rate and G S R with highes t reported subjective distress . T his combination of increas ed dis tres s and decreased heart rate predicted more P T S D s ymptoms, blunted emotion, and poorer outcome. T wo s tudies have found an invers e relations hip diss ociation s cores and urinary catecholamines. Delahanty and colleagues collected 15-hour urine from motor vehicle accident victims on hos pital admiss ion. men, peritraumatic diss ociation was correlated with epinephrine but not norepinephrine, whereas women showed a revers ed pattern of significance. Us ing DS Mdepers onalization disorder s ubjects, Daphne S imeon colleagues found s trong negative correlations between urinary norepinephrine and depers onalization s cores . T hese res ults are congruent with the phys iological suggesting that high levels of dis sociation act to arousal in the face of s tres sors but do little or nothing dampen s ubjective dis tres s.

Neurobiology of Dis s oc iation Understanding of the neurobiology of diss ociation is based on two primary s ources of information. T he firs t body of case reports des cribing diss ociative reactions the context of illicit drug use or as a side effect of 1825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 47 of 302

medications . Drugs that can precipitate dis sociativereactions include alcohol, barbiturates and related hypnotics, benzodiazepines , scopolamine (T ransdermS cop), β-adrenergic blockers , marijuana, other ps ychedelics , and anes thetics , s uch as ketamine and its relatives . T he array of implicated drugs and range of activities would sugges t that many neurotransmitter s ys tems might be involved in diss ociative reactions. T he second s ource is data from placebo-controlled, challenge s tudies using a range of diss ociative drugs . C hallenge s tudies that have elicited depers onalization other diss ociative phenomena include marijuana, of lactate, yohimbine (Actibine), metachlorophenylpiperazine (mC P P ), and ketamine. studies appear to narrow down the number of neurotransmitter s ys tems that are likely to make significant contributions to diss ociative s tates. evidence suggests that the N-methyl-D-as partate glutamate receptor plays a central role in diss ociative symptoms. A s eries of studies, using ketamine, an NMDA that increases glutamate releas e, found that the drug produced dose-dependent increases in diss ociation High dos es of ketamine produced slowed perception of time, tunnel vis ion, derealization, and similar to that des cribed by trauma victims. with a benzodiazepine or lamotrigine (Lamictal), an anticonvuls ant that decreas es glutamate release, but did not entirely eliminate the diss ociative effects of ketamine. T hese studies s ugges t that diss ociation, heretofore widely regarded as virtually impervious to 1826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 48 of 302

medication, may be res ponsive to certain clas ses of Neurobiological theories of diss ociation draw on preclinical data indicating that stres s increas es the of glutamate and the s imilarity of the effects of NMDA antagonis ts with stres s- and traumainduced dis sociative symptoms. In s ummary, it that NMDA blockade decreases inhibitory tone, leading increased glutamate release and s ubs equent symptoms. T his theory als o accounts for the structural brain changes in the hippocampus found in magnetic res onance imaging (MR I) s tudies of P T S D s ubjects controls. In two studies, dis sociation measures s trongly correlated with volume los s in key brain regions in P T S D. G lutamate has a well-documented role in and increased glutamate releas e can lead to cellular events . It s hould be noted, however, that studies with marijuana and mC P P implicate s erotonin, studies with yohimbine sugges t that noradrenergic systems may play roles in diss ociation and P T S D symptoms. Also, in two s tudies of military s ubjects undergoing high s tres s training, a s trong negative relations hip was found between neuropeptide Y (NP Y ) levels and dis sociative symptoms.

C omparative Nos ology T his s ection discuss es nos ological is sues for all of the diss ociative dis orders, although is sues related to the specific disorders are described briefly in the individual sections . T he disorders are dis cus sed together, most of the major nos ological is sues bear on the group disorders and their relations hip to other DS M-IV -T R 1827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 49 of 302

disorders . T he early DS M definitions and IC D-10 have been reviewed in the introduction. S cales and meas ures for the ass ess ment of diss ociation and diss ociative dis orders are also dis cuss ed.

His tory T he DS M-III criteria for dis sociative disorders were es tablis hed by expert consens us. B y the time the was publis hed, there was a body of s ys tematic the diss ociative dis orders . Little changed in the criteria for depersonalization disorder, psychogenic amnes ia, and ps ychogenic fugue. However, the criteria multiple pers onality disorder changed considerably to make them more flexible, less reified, and more compatible with research findings about the phenomenology of alter identities. In the DS M-IV revis ion, the names of most of the were changed; for example, ps ychoge nic amne s ia and ps ychoge nic fugue became, respectively, dis s ociative amne s ia and dis s ociative fugue , and multiple dis order became dis s ociative ide ntity dis order. T he for diss ociative amnes ia now specified that the us ually occurred for traumatic or s tres sful Dis sociative fugue now could be diagnos ed even if were no ass umption of another identity. Amnes ia was added back as a criterion s ymptom for dis sociative disorder. T he disorders were s tructured to reflect pathologies of memory, identity, and perception, res pectively.

Dis s oc iation and Trauma T he current diagnos tic categories for diss ociative 1828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 50 of 302

developed from nosological s ys tems based on the concept, not on modern res earch showing a robust relations hip between diss ociation and trauma. F urthermore, the complexity and overlapping nature of the phenomenology of diss ociative amnes ia, fugue, and dis sociative identity dis order were not appreciated. In particular, the complexity of the phenomenology of diss ociative identity disorder was unders tood with its multifaceted amnesias, fugues, and depers onalization and derealization s ymptoms. In addition, the DS M-IV work group for P T S D unsuccess fully proposed adding to DS M-IV the of dis orders of extreme s tres s NOS . T his cons truct was developed to des cribe a group of multiply traumatized individuals with problems of affect regulation, somatization, and relations hip, identity, and safety problems . Despite its lack of inclus ion in the DS M-IV , res earchers have begun to systematically s tudy this complex form of P T S D to help differentiate patients single acute traumas from thos e with multiple types of trauma and life advers ity. F or example, recent s tudies shown that the complex P T S D paradigm more conceptualizes traumatized borderline patients than the borderline pers onality disorder cons truct. Mos t patients with dis sociative identity dis order, diss ociative disorder NOS , and dis sociative amnesia fit readily into the of extreme s tres s NOS or complex P T S D paradigms, both. Many trauma res earchers cons ider these to be s lightly diss imilar ways of conceptualizing the spectrum of patients . R ecent neurobiological s tudies of diss ociative identity disorder patients show similarities neurobiological variables to P T S D patients without 1829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 51 of 302

diss ociation. Accordingly, some members of the DS M-IV work for P T S D and the diss ociative dis orders propos ed that DS M-IV create a s ection of posttraumatic P.1854 or s tres s-related dis orders (trauma s pectrum disorders) that would include P T S D, acute stress disorder, the diss ociative dis orders, and, pos sibly, other disorders , as conversion disorder, somatization dis order, and borderline pers onality disorder. A trauma spectrum dis orders category would help logically integrate multiple lines of res earch s howing different ps ychopathological outcomes to trauma and would help better organize future res earch efforts . F urthermore, such a category would help with confusion; for example, amnesia is a criterion symptom the avoidance clus ter of DS M-IV P T S D and for disorder, not just for diss ociative amnes ia and identity dis order. F inally, s uch a class ification would be more helpful for the clinician confronted with typical patients with mixtures of pos ttraumatic, diss ociative, somatoform s ymptoms who now frequently wind up in NOS categories. It would be more logical to combine the DS M-IV -T R diss ociative disorders and P T S D work groups as of a s ingle trauma and s tres s disorders work group for fifth edition of the DS M (DS M-V ). T his group could nosological categories that better define the broad spectrum of posttraumatic conditions, from acute to chronic, from simple to complex, and from thos e with 1830 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 52 of 302

marked diss ociation to those with minimal diss ociation. Many of thes e s uggested changes would involve res tructuring of several DS M diagnos tic categories. might involve negotiations among s everal different groups of clinicians and researchers who otherwis e relatively s eparately from one another. However, the strongly sugges t that, at the least, a unifying trauma spectrum dis orders s ection, including P T S D and the diss ociative dis orders, would be the mos t logical clas sification of apparently disparate dis orders related trauma.

R evis ions to Dis s oc iative Dis order C ategories E ven if this radical pers pective is not adopted, major critiques have been launched at the current disorders class ification. In general, thes e involve the relatively greater complexity and pleomorphism of diss ociative, P T S D, and somatoform s ymptoms in diss ociative patients . F or example, patients with diss ociative amnesia, diss ociative fugue, and identity dis order may exhibit or describe a number of significant s ymptoms that are not included in the diagnostic criteria. Dis sociative identity dis order patients commonly of s pontaneous autohypnotic phenomena, depers onalization, derealization, P T S D s ymptoms, somatoform s ymptoms , and ps eudops ychotic in addition to complex amnes ias and s witching to alter self-states . In clinical evaluation of diss ociative identity disorder, thes e as sociated symptoms are frequently 1831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 53 of 302

es sential in arriving at a correct diagnosis. Many patients with diss ociative amnesia or dis sociative fugue describe depers onalization, derealization, alterations of consciousness , s omatoform and symptoms, and autohypnotic s ymptoms along with the DS M-IV -T R criterion symptoms . Accordingly, many of patients may be placed in the dis sociative disorder category, becaus e they have a number of diss ociative symptoms that go beyond the current diagnostic for diss ociative amnes ia and diss ociative fugue, some of thes e are described in the text as as sociated features. T his creates the awkward s ituation in which clinician mus t wres tle with the problem that a large number of typical patients potentially will be class ified NOS . Many patients with acute dis sociative amnesia and diss ociative fugue may actually be in an epis ode of diss ociative identity disorder amnesia. Modern clinical as sess ment of such patients frequently finds a much chronic history of multiple types of diss ociative including partial or full alter identities or personality Accordingly, several critics have s uggested developing new diagnostic criteria bas ed on the data s ets already acquired using the S C ID-D-R , the DDIS , the MID, the and s imilar ins truments , along with data sets from case series . S ome have proposed radical restructuring the diss ociative dis orders category to reflect the phenomenological data. Others have proposed more a cons ervative position maintaining the current structure but moving to a polythetic clas sification with additional s ymptom categories as part of the 1832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 54 of 302

diagnostic criteria for mos t dis orders.

E pidemiology T here is only one systematic general population study the prevalence of diss ociative dis orders. R oss and colleagues studied a random s ample of 1,055 adults in Winnipeg, C anada. T hey were given the DE S , and a representative subsample of 502 res pondents was subs equently reevaluated with the DDIS . T able 17-2 the findings for the various diss ociative dis orders.

Table 17-2 Prevalenc e of Dis s oc iative Dis orders in the General Population of Winnipeg, C anada (N = 502) Diagnos is

S ubjects (%)

Dis sociative amnes ia

6.0

Dis sociative fugue

0

Dis sociative identity dis order

1.3

Depersonalization dis order

2.8

Dis sociative disorder not otherwis e

0.2

1833 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 55 of 302

specified All dis sociative disorders

12.2

F rom R os s C A. Dis s ociative Ide ntity Dis orde r: Diagnos is , C linical T re atme nt of Multiple P e rs onality. Y ork: J ohn W iley & S ons ; 1997:109, permis sion. T his s tudy has significant limitations and needs to be replicated. T hese include the lack of validating clinical interviews , the unknown validity of the DDIS in samples , the relatively s mall s ample size from only one city, and the lack of other diagnos tic ins truments given the participants . T he DE S findings, however, have been replicated in studies. T hese include the finding that dis sociation is found in a left-skewed distribution, indicating that most individuals in the general population experience few diss ociative s ymptoms . A s mall s ubs et of the to 5 percent, endorses many forms of pathological diss ociative experience. A taxonometric reanalysis of data of R oss and colleagues found that 3.3 percent of population s howed pathological dis s ociation and could completely dis criminated from nondiss ociative controls and normal s ubjects.

E tiologic al Theories 1834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 56 of 302

T his s ection discuss es etiological theories about diss ociation and diss ociative dis orders. A etiological model involves integration of data from of thes e models and theories .

Taxon Model of Pathologic al Dis s oc iation R ecent interest in the taxon model res urrects a debate about whether dis sociation occurs along a continuum proceeding from normal to pathological or whether pathological diss ociation, such as diss ociative identity dis order, represents a different type (a taxon) ps ychological organization. J anet favored the latter, believing that cons titutional factors , sugges tibility, and powerful emotional events contributed to creation of a group of individuals who were fundamentally different from normal individuals . J ames and P rince argued for a continuum model, ranging from s o-called normal diss ociative P.1855 phenomena, s uch as abs orption, to pathology, s uch as amnes ias, fugues, and multiple personalities. T he continuum theory carried the day, although s ome hypnosis res earchers continued to caution about discontinuities between normal consciousness and deep trance phenomena. As data with dis sociation measures accrued acros s and normal populations, it became apparent that there exis ted a distinct group of high-scoring individuals. Different diagnos tic groups contained different percentages of these high s corers, yielding different 1835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 57 of 302

diagnostic group mean s cores. T he greater the of high scorers, the greater the elevation of the group's mean score relative to the group's modal score. On the DE S , for example, high s corers cluster around a mean of 45, with the rest of the s ample clustering around 8. T hese obs ervations led to a statis tical study directly inves tigating the poss ibility that there exists a type of individual who differs s ignificantly on meas ures from other individuals , irrespective of their ps ychiatric status . Using newly developed taxonometric approaches, researchers examined item-res ponse data manifestations of a latent clas s variable. T hey identified eight DE S items, compos ing the DE S -T s ubs cale, that robustly differentiate dis sociative disorder patients from other psychiatric patients and normal controls , who never endorsed these items. T hese items are listed in 17-3.

Table 17-3 Dis s oc iative S c ale Items That Make Up the Dis s oc iative E xperienc es S c ale Taxon S c ore S ubjects are asked to rate the percentage of from 0 to 100 percent, that they have the experience. 3. S ome people have the experience of finding 1836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 58 of 302

thems elves in a place and having no idea how got there. 5. S ome people have the experience of finding things among their belongings that they do not remember buying. 7. S ome people sometimes have the experience feeling as though they are s tanding next to thems elves or watching thems elves do and they actually s ee themselves as if they were looking at another pers on. 8. S ome people are told that they s ometimes do recognize friends or family members. 12. S ome people have the experience of feeling other people, objects , and the world around them are not real. 13. S ome people have the experience of feeling their body does not s eem to belong to them. 22. S ome people s ometimes find that, in one situation, they may act so differently compared to another situation that they feel almos t as if they were two different people. 27. S ome people s ometimes find that they hear voices inside their head that tell them to do things 1837 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 59 of 302

comment on things that they are doing.

F rom W aller NG , P utnam F W , C arlson E B : T ypes diss ociation and diss ociative types : A analysis of diss ociative experiences. P s ychol 1996;1:300–321, with permis sion. S tudies have subsequently affirmed that a taxonic approach is a clinically us eful way to cull out a dis tinct subgroup of diss ociative patients within any given diagnosis who differ on s ymptoms and features from res t of the group. In ps ychophysiological investigations diss ociation, s imply dividing samples into high and low scorers has proven fruitful in identifying distinctly phys iological and cognitive res ponses to stimuli that as traumatic reminders. T he taxon model implies a significantly different developmental s cenario than the continuum model, as well as a different approach to treatment. T he differences between high diss ociators and virtually everyone else would have to lie in a s trong genetic predis pos ition or a fundamentally different early developmental trajectory, or both, that es sentially wires their brains differently. A convincing genetic difference remains to be demons trated, but res earch linking diss ociation with type D attachment dis turbances offers potential mechanis m for the latter. In a continuum model of dis sociation, a pos itive 1838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 60 of 302

res ponse would be conceptualized as moving a diss ociative individual more toward the normal diss ociation s egment of the continuum. B y contrast, a positive treatment outcome in a taxon model implies changing an individual's type from the diss ociative to nondis sociative category. T he clinical lore on fus ion or integration of dis sociative identity dis order alter personalities into a unified personality hints at this poss ibility. However, beyond thes e clinical accounts, empirical data exis t to confirm that integration produces taxonic clinical change. T he few studies of diss ociative identity dis order that include pretreatment and posttreatment dis sociation measures show moderate significant) decreas es in scale scores rather than a significant taxonic s hift from the diss ociative to nondis sociative categories. T he taxonic model has valuable in spurring res earchers to compare high and diss ociators on a variety of measures, but its clinical us efulnes s as a index of treatment s ucces s remains to demonstrated.

Dis s oc iation As a R es pons e to S ince the 1980s, research has elucidated multiple lines evidence linking dis sociative disorders with antecedent trauma. In aggregate, these s eparate lines of evidence cons titute a strong cas e for significant trauma as a neces sary antecedent to the development of diss ociation. T he most bas ic set of thes e lines of evidence involves quantification of J anet's early clinical observations. F or each of the DS M-IV -T R diss ociative dis orders, there exis t multiple independent case series , including non1839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 61 of 302

Wes tern samples , documenting unusually high rates of trauma in diss ociative dis order patients (although this linkage is notably weaker for depers onalization Although critics often point out that thes e s tudies are retrospective, and, thus, the accuracy of the reports of trauma cannot be es tablis hed, s everal cas e s eries which the majority of subjects had one or more verified. S everal hundred peer-reviewed s tudies have found significantly higher levels of dis sociation, as meas ured well-validated instruments, such as the DE S , in groups compared to nontraumatized clinical and population s amples . T he frequency of this finding for many different forms of traumatic experience (e.g., combat, rape, natural dis asters, child abus e, and C ambodian holocaust, among others) and across cultures indicates the universality of the ass ociation between trauma and diss ociation. Measures of trauma severity, for example, combat intensity or rape s everity scales, are approximately equally correlated with P T S D diss ociation meas ures (r ≈ .025 to .40), indicating a to moderate dose effect–like relationship. T he lack of a stronger correlational relationship between trauma and P T S D and diss ociation may reflect the difficulties in quantifying the s ubjective elements of traumatic experience. Although thes e findings significantly link diss ociation with antecedent trauma, they are not sufficient to demons trate that the trauma actually the diss ociation. More s ophisticated statis tical approaches are new lines of evidence indicating that increased diss ociation is instrumental in shaping outcomes 1840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 62 of 302

traumatic experience and ps ychophys iological to future stress and trauma. P eritraumatic diss ociation, meas ured proximal to the trauma in some s tudies and retrospectively in others , has been found to predict the subs equent development of P T S D. T his predictive important for identifying individuals at risk for P T S D after an P.1856 acute trauma. A smaller number of studies has demonstrated that dis sociation qualifies as a mediator the relationship between antecedent trauma and subs equent psychopathology, including P T S D. T his that, if the level of diss ociation is statis tically controlled, the s trength of the relationship between trauma and ps ychopathology is s ignificantly decreased or High levels of diss ociation also alter the ps ychophys iological res ponses of traumatized to traumatic reminders . Not every s tudy meas uring peritraumatic dis sociation that it predicts subsequent P T S D, nor have there, as been a sufficient number of replications for the phys iological and statis tical mediation s tudies to be unques tionably accepted. T hes e findings do sugges t, however, that trauma-as sociated dis sociation may an important mechanism mediating the transformation traumatic experiences into subsequent T he remarkable studies of C harles A. Morgan and colleagues conducted on military special operations under extremely s tres sful conditions are as clos e as can ethically come to an experimental model of induced dis sociation. Working with units undergoing 1841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 63 of 302

forms of s imulated combat, such as s urvival s chool, Morgan examined the neurobiological and effects of intens e s tres s uniformly applied to drug-free, healthy, nonclinical s ubjects . S tress ors included semistarvation, exhaustion, sleep deprivation, lack of over hygiene and bodily functions , and control over movement, s ocial contact, and communication. T he neuroendocrine stress effects meas ured in thes e was equal to or exceeded thos e reported for individuals subjected to life-threatening experiences. T here were significant differences between pretes t and posttest on the C ADS S overall and for virtually all s cale items, the greates t effects for depers onalization items , s uch looking at the world through a fog, feeling time slow down, and s pacing out. Life threat from a prior trauma significantly correlated with prestress and posts tres s diss ociative s ymptoms . Dis sociation scores also for 41 percent of the variance in health complaints after the stress experience. Morgan's s ys tematic studies are congruent with observational reports of the high frequency of es pecially depers onalization s ymptoms, in normal individuals expos ed to life-threatening stress . T he of increas ed acute levels of diss ociation during stress indicates that other factors, perhaps the of prior life-threatening trauma, are operative in the peritraumatic dis sociation–P T S D linkage dis cuss ed previous ly. T he highest dis sociation scores were with intens e s ubjective appraisal of life threat from past trauma. One highly traumatized subgroup, S pecial soldiers , had low life-threat appraisals of their pas t and, cons equently, the lowes t prestress and pos ts tress 1842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 64 of 302

change in diss ociation s cores. T his s tres s -hardy group unders cores the importance of ps ychological to prior trauma on responses to current stress ors. T he significant relations hip (r = .67) between the pres tres s posts tres s change in diss ociation s core and somatic symptoms is congruent with many clinical studies reporting linkages between somatization and In summary, a number of independent lines of point to a caus al relationship between trauma and diss ociation. T his relationship is apparent for many of trauma and has been found across all cultures in it has been investigated. S ignificant levels of in the immediate aftermath of a trauma appear to predis pos e an individual to developing P T S D and ps ychopathology, although additional factors related to ps ychological apprais al of prior trauma also appear to involved. Dis sociation appears to serve as a major mediating proces s between traumatic experiences and subs equent psychopathology and thus is an important target for prevention and early intervention efforts . res is tant individuals can be characterized, in part, by lack of dis sociative res ponses to significant s tres sors.

Dis c rete B ehavioral S tates Model T he discrete behavioral states (DB S ) model pos tulates diss ociative dis orders belong to a group of ps ychiatric conditions characterized by rapid—often triggered—discrete shifts in s tate of cons cious nes s. E xamples include rapid-cycling bipolar disorder, panic disorder, periodic catatonia, and P T S D. Although these disorders differ in many respects, a central feature of pathology is abrupt s witches between two or more 1843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 65 of 302

states of consciousness , at least one of which is pathological in some fashion. P anic attacks and the abreactions and flas hbacks of P T S D are examples of dysfunctional behavioral s tates, often triggered by stimuli or interactions , that rapidly reorganize an individual's emotions, thinking, and behavior. B ipolar patients often cycle through a s pectrum of dis tinct affective s tates extending from deep depress ion to ps ychotic mania. T he concept of a s tate of consciousness —as a dis tinct of behavioral organization—has been part of the ps ychological vocabulary for s everal centuries. R ibot's speculations that s tate-dependent learning and explained the phenomena seen in diss ociative identity disorder arose in the context of widespread interes t clinical experimentation with hypnos is, s omnambulism, and trance-like states . In his 1896 Lowel lectures on exceptional mental s tates, J ames often referred to states of consciousness as underlying multiple fugues , convers ion symptoms , and other hysterical symptoms. Modern s tate theory owes much to ps ychologist C harles T art, who advocated for a science discrete states of cons cious nes s. Hilgard's theory, which he traces in part to J anet, conceptualizes hypnosis as a set of altered s tates of consciousness characterized by increased s uggestibility, enhanced imagery, decreas ed planning capacity, and a reduction reality testing. R esearch with drug-induced altered and meditation has also contributed to current theory unders tanding. It remained, however, for a group of child ps ychologists and ps ychiatris ts to formally operationalize the s tudy of 1844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 66 of 302

DB S of consciousness . Heinz P rechtl, R obert E mde, Harmon, and P eter W olff empirically validated a multidimens ional class ification system us ed in the normal infants . B y us ing as few as four or five variables , s uch as heart rate, res piratory rate, extremity muscle tone, skin perfusion, vocalization, or facial expres sion, researchers were able to delineate a bas ic of DB S shared by mos t full-term, newborn infants . As child matures , additional behavioral s tates are added, the pathways of connections among the dis tinct s tates grow more complex—corres ponding to an increased behavioral repertoire on the part of the child. T he ability self-modulate the express ion of thes e DB S and to the many additional states created with growth and development is regarded as fundamental to healthy emotional regulation. T he DB S model conceptualizes dis sociative the manifes tations of alternations among dis tinct s tates cons ciousnes s that differ in terms of the individual's of identity, access to explicit, implicit, and autobiographical memory, and psychophysiological reactivity. Identity dis turbances are the nucleus around which other features of the diss ociative state organize much the same fashion as dis tinct affects serve to the DB S of a bipolar patient. Dis sociative disturbances memory are viewed as extreme examples of statedependent learning, s torage, and retrieval. Alterations ps ychophys iological s ens itivity in diss ociative disorders reflect state-dependent changes in autonomic nervous system and neuroendocrine function. C hanges of equal magnitude have been measured in laboratory studies panic attacks and P T S D flas hbacks. 1845 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 67 of 302

P.1857 T he DB S model of dis sociation pos tulates that early childhood trauma or dis turbances in attachment, or disrupt the proces ses ess ential to self-modulation and developmental integration of new behavioral states. T he DB S model pos tulates three levels of psychopathology inherent in such s tate disorders . T he firs t is intrinsic to nature of the pathological s tates per se, for example, anxiety, depress ion, mania, catatonia, or T he second level res ults from the individual's inability to self-modulate the express ion of thes e dys functional or to better integrate them into their lives. T he third level res ults from the cons equences of maladaptive attempts block the often painful experiences of these pathological states , for example, attempts to self-medicate social withdrawal to avoid triggering flashbacks . T he increased ps ychiatric comorbidity commonly noted in these patients is a consequence of the s econd and third levels of ps ychopathology. T he DB S model predicts that effective treatment s hould facilitate better selfof intense or dys phoric states and should addres s the dependency of dysfunctional perceptions , cognitions, as sumptions .

Developmental Model of Dis s oc iation Modern interes t in a developmental model of disorders , es pecially diss ociative identity disorder, can traced to pioneers with child cases, such as C ornelia and R ichard K luft. S ubsequently, long-forgotten case reports were discovered in which 19th century clinicians us ed Latin phrases to hint at inces t and uns peakable 1846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 68 of 302

familial trauma. S mall cas e s eries and reviews of diss ociative dis orders appeared in the mid- to late with more s ys tematic s tudies coming in the last with the adult cas e s eries, his tories of severe trauma commonly noted. T he core phenomenology of child cases is, for the most part, s imilar to adult cases with the corresponding diss ociative dis order diagnos is . As is the cas e for most childhood manifestations of lifelong ps ychiatric the day-to-day manifes tation of core s ymptoms varies the child's age. In general, older children and are more overtly s ymptomatic than younger children. In part, this may reflect the ability of older children to report s ubjective distres s, as well as their greater opportunity to manifes t ps ychopathology in a variety of settings . In a pooled s ample of 177 child and adoles cent diss ociative disorder cas es, amnes ias , identity disturbances , and auditory hallucinations increased age, whereas trance-like and spacey behavior was ubiquitous acros s all age groups. R elated ps ychopathology, s uch as s uicidal ideation, s elfand s omatization, increas ed with age in parallel with diss ociative s ymptoms . B oys and girls did not differ on diss ociative s ymptoms , but girls were s ignificantly more symptomatic for anxiety and phobic symptoms , P T S D, sleep dis turbances , sexual acting out, and T hese findings clos ely parallel the gender differences adult clinical profiles . C hildren and adolescents with dis sociative identity dis order were the mos t symptomatic acros s all age groups, which is cons onant with the clinical belief that diss ociative identity disorder 1847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 69 of 302

the most severe of the diss ociative disorders . V alidated child and adolescent dis sociation meas ures been adminis tered to a variety of clinical and samples . S cores were s ignificantly higher for (typically child abus e) vers us nontraumatized s ubjects acros s all age groups. Higher levels of dis sociation also significantly as sociated with more general ps ychopathology. Among maltreated preschoolers , were robus t correlations with externalizing and internalizing behavior problems for boys and girls . A comparis on of these maltreated preschoolers with demographically and family cons tellation-matched, nontraumatized preschoolers found that the group had s ignificantly increased levels of diss ociation year later, with the phys ically abus ed children for the greatest increas e in s cores. T he controls subs tantial decreas es in their dis sociation s cores over same period, in line with the often reported decrease in diss ociation s cores with age in normal children. S tudies have explored the pos sible mediating role of diss ociation in the development of ps ychopathology in sexually abus ed children and adolescents . Meas uring ps ychopathology with a variety of s tandard measures, main effect of sexual abus e on behavioral problems disappeared when levels of diss ociation were for, as measured by a self-report meas ure (A-DE S ) or observer report (C DC ). T he poss ibility that dis sociation critical mediating variable for s ubs equent ps ychopathology has s ignificant implications for early intervention with maltreated and traumatized children. Ass es sment of diss ociation s hould be a standard part the evaluation of traumatized children and adolescents , 1848 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 70 of 302

and s ignificant elevations s hould be addres sed as part the treatment plan.

S E A R C H F OR DE VE L OP ME NTA L P R E C UR S OR S A ND S UB S TR A TE S DIS S OC IA TION Imaginary C ompanions hip T he focus on child dis sociative identity dis order led inves tigators to initially focus on childhood fantasy phenomena, s uch as imaginary companions hip, as poss ible developmental precursors for dis sociative disorders . Imaginary companions are reported in 20 to percent of normal children, depending on the age of child and the definition us ed. Normal imaginary companions hip is widely regarded as benign and is commonly cons idered to be a sign of creativity in children, but it becomes increasingly s uspect in older children and adoles cents and is thought to be always pathological in adults . In dis sociative children, the rates imaginary companions hip range from 42 to 84 percent, with the highes t rates reported for children diagnos ed with dis sociative identity dis order. S tudies comparing normal children's imaginary companions with thos e of maltreated boys s how differences. T he maltreated boys averaged 6.4 entities compared to 2.5 entities for the normal boys . T he latter first appeared between 2 and 4 years of age and had disappeared by 8 years of age. T he imaginary reported by the boys in residential treatment, however, served other functions, including (1) helpers and comforters , (2) powerful protectors , and (3) family 1849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 71 of 302

members. In s ome cases, the boys reported feeling as they had los t control, and their imaginary companions took over their behavior. T he maltreated boys reported that their imaginary companions were s till present at a mean age of 10.6 years , well after they had the normal boys. T he imaginary companions of the maltreated boys often had names s uch as G od, the and guardian ange l. A number of authorities theorize some of the imaginary companions found in maltreated children eventually evolve into the alter personality that personify diss ociative identity disorder. As yet, no has documented this transformation, but diss ociative identity disorder patients sometimes report that this happened with them.

Type D Attac hment T ype D attachment is characterized by the child disorganized and conflicting movement patterns when primary caregiver returns to the room after a period of enforced s eparation during the s trange s ituation, a standardized procedure for as ses sing attachment in preverbal children. T he child may exhibit contradictions intention, lack of orientation to the environment, and sudden immobility as sociated with a dazed expres sion trance-like state, termed s tilling in the attachment literature. T ype D attachment disturbances are maltreated infants and toddlers and are thought to when the child periodically experiences the primary caretaker as frightening. S tudies s how that the best predictor of type D attachment is a high DE S s core in P.1858

1850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 72 of 302

mother. It is hypothes ized that an infant with multiple incompatible models of s elf and other res ulting from intermittent frightening experiences with the caretaker would rapidly s witch back and forth between models when confronted with a s tres sful interaction involving the primary caretaker, such as the s trange situation. In a prospective longitudinal s tudy, 168 high-ris k were followed over a 19-year period, examining trauma, sense of self, quality of early mother–child relations hip, temperament, intelligence, and meas ured at four time points were related to diss ociative s ymptomatology with a clinical measure (C DC ). Age of onset, chronicity, and s everity of trauma were highly correlated and were predictive of T wo forms of attachment dis orders, avoidant and type attachment, were strong predictors of subsequent diss ociation. A subsequent structural equation model analysis found that type D attachment acted as a mediating variable, accounting for 15 percent of the variance in dis sociation scores (DE S ) at 19 years of

Developmental Mediation of Ps yc hopathology by Dis s oc iation T he negative effects of high levels of dis sociation on development are pos tulated to operate through impacts on the development of s ens e of self, emotional impulse control, and impairments in information proces sing and coping with s tres sors. C hildren and s eek to integrate a complex, multidimens ional of self over the cours e of development. Dis sociative components, such as autobiographical amnesias, 1851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 73 of 302

depers onalization, and pas sive influence experiences , interfere with the integration of self and the of a unified s ens e of self-agency. Dis sociative amnes ias also dis rupt the child's unders tanding of caus e-and-effect sequences , s o that negative or ris ky behaviors may not appear to be connected to their subs equent cons equences , which be experienced as coming from out of the blue. C onvers ely, cons equences may not be well related to behaviors that caus ed them, so that diss ociative have a great deal of difficulty learning from experience. T he impact of dis sociation on the metacognitive of self-monitoring one's behavior is thought to disrupt integration of experience across contexts , further complicating the child's ability to learn and to practice control, particularly in the context of s tres sors . diss ociation is well correlated with increas ed impulsivity, and poorer social s kills in a number of child and adolescent s tudies . P ros pectively comparing s exually abus ed girls with carefully matched controls, s tudies have found that diss ociation is negatively as sociated with competent learning and overall class room performance and is strongly predictive of school avoidance. T he of cognitive dysfunctions and negative school puts the diss ociative child at an academic which has profound implications for adult attainment. C hronic depersonalization, clos ely as sociated with emotional numbing in P T S D patients , is thought to promote a s ense of detachment from self that fosters and s elf-destructive behavior, s uch as self-mutilation. mutilation has been strongly ass ociated with increas ed 1852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 74 of 302

diss ociation in numerous studies. Diss ociative patients often describe s elf-inflicting pain in attempts to break through profound states of depersonalization. At other times , they report feeling nothing as they cut or burn thems elves . Alienation from self is also thought to play role in the high rate of suicide attempts in diss ociative patients. In addition, dis sociation has been implicated predis pos ing an individual to revictimization. In these experiences expose dis sociative individuals to further traumatization, which takes a cumulative toll the individual's life. Identification of environmental protective factors may help s timulate intervention models that prevent the development of s ignificant diss ociation in acutely traumatized children.

Hypnotic Model In its bas ic form, the hypnotic model hypotheses that a traumatized individual uses his or her innate hypnotic capacity to induce autohypnos is as a defens e against overwhelming or repetitive traumatic experiences. W ith continued us e, the autohypnotic s tate is transformed an independent alter personality s tate. S everal lines of evidence are said to support the autohypnotic T he firs t is that diss ociative, es pecially dis sociative disorder, patients are highly hypnotizable. S econd, of the clinical phenomena as sociated with pathological diss ociation, s uch as trance states , age regres sion, hallucinations , and amnes ias , can be produced in individuals us ing hypnos is . F inally, a pair of studies suggested that childhood trauma might increas e hypnotizability. 1853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 75 of 302

More s ys tematic research has dis pelled the notion that childhood trauma generally increas es hypnotizability. least six s tudies found no differences between and nontraumatized adult or child s amples , nor are discernible dos e effects between meas ures of trauma severity and hypnotizability in clinical and general population s amples . However, a small group of termed double dis s ociators , s core high on meas ures of diss ociation and hypnotizability. T hes e individuals generally have histories of earlier and more severe T his obs ervation is most compatible with the taxonic model of pathological diss ociation and may explain the greater hypnotizability of diss ociative identity disorder patients. Hypnotizability studies have shown that there may be different types of hypnotizability, with high diss ociators making up a dis tinct type. T hey are in to other subgroups of highly hypnotizable people, like fantas y-prone pe rs onality, a specific construct in people elucidated in hypnotizability res earch s tudies . Autohypnos is is not the only pathway to dis sociative symptoms, but it remains a pos sible contributing mechanism in s ome individuals.

Neurologic al Models T wo bas ic neurological explanations of diss ociation been repeatedly propos ed over the las t century and a the epileptic model and the hemispheric laterality V ariants of thes e two models continue to be offered as explanations for dis sociation, although recent empirical tes ts have not provided substantial s upport for either. T he epileptic model originates from the clinical observation that diss ociative symptoms s uch as 1854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 76 of 302

depers onalization; amnesias for complex behavior, fugue epis odes; and phenomena such as autos copy sometimes ass ociated with ictal and preictal s tates in seizure patients . S everal cases s eries of s eizure with dis sociative identity dis order–like or diss ociative disorder NOS –like clinical profiles have been and abnormal E E G s , particularly temporal s low waves , be more common in dis sociative disorder patients than ps ychiatric patients in general. Y et, the vast majority of seizure patients score in the normal range on scales. T he strongest finding to emerge from thes e thus far is that high levels of child abus e and as meas ured by high DE S s cores, are common in diagnosed with ps eudoseizures. More than 12 s tudies documented this relationship in well-diagnosed patient samples in which genuine seizure patients had low scores and low clinical levels of diss ociative symptoms . However, recent s tudies have identified abnormal E E G activity, particularly left-hemis phere s lowing, as significantly more common in abus ed children than in nonabused ps ychiatric inpatients or normal controls . there may be an effect of child abus e on the brain that accounts for the high rates of E E G seen in diss ociative identity disorder patients . T he hemis pheric laterality model was s timulated by clinical observations of differences in the dominant handednes s of alter personality P.1859 states . S uch handedness changes are s till frequently reported today. S everal modern s ingle-case studies 1855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 77 of 302

document apparent s hifts in laterality us ing indirect meas ures , s uch as the G S R . One study of two identity dis order patients with seizures involved anesthetizing each cerebral hemis phere individually an intracarotid injection of amobarbital (the W ada tes t). T hey reported emergence of different alter personality states s eemingly related to inactivation of one or the cerebral hemispheres . E E G monitoring during thes e procedures revealed no epileptiform activity ass ociated with the alter personality s tates. T he largest s ample only controlled study to examine the laterality however, did not find evidence of shifts in laterality alter personality. S tudies of split-brain patients who had commis surotomies for intractable epilepsy do not find evidence of alter pers onality–like phenomena. In s hort, intriguing as the s hifts in dominant handednes s are, in laterality or differences in hemispheric laterality do readily account for many of the clinical features of diss ociative identity disorder patients .

Iatrogenic and S oc ioc ognitive of Dis s oc iative Dis orders S ome authorities believe that diss ociative identity and diss ociative amnes ia are not authentic ps ychiatric disorders but rather the product of sugges tion on susceptible individuals that leads them to believe that have a diss ociative dis order and to enact the role of a person with multiple selves or amnes ia for childhood maltreatment. T his has been called the iatroge nic or s ociocognitive mode l (S C M). C aution should be used concerning the term iatroge nic, however. T his term is rarely defined rigorous ly and frequently is us ed pejoratively. T he term is almos t never operationalized, 1856 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 78 of 302

its boundaries are unclear with res pect to other as pects of clinical encounters, s uch as s ide effects , complications , misdiagnos is, or acceptance by factitious or malingered pres entations, or a these. T he S C M pos its several interrelated factors that the phenomenon. T he firs t, a s us ceptible patient, is commonly described as being highly s ugges tible, hypnotizable, or having a fantas y-prone personality, or combination of thes e. In the clinical literature, thes e patients usually are described as having personality disorders characterized by dependent, borderline, or histrionic traits , or a combination of thes e, and who are conceptualized as des perate to find acceptance or a of identity, or both. T he second factor is a therapist who unwittingly, or through an ideological belief in the existence of diss ociative identity disorder or amnes ia for traumatic experiences , engages in a therapy that implicitly or explicitly encourages the patient to undertake the role the diss ociative identity disorder patient or the patient with so-called recovered memories for abus e. the condition is worsened by paying attention to the apparent diss ociative dis order and engaging therapeutically with the alter identities. T he patient develops a real, albeit iatrogenic dis order, now truly believing in the roles that he or she enacts. A third factor has to do with broader cultural and s ocial influence, often promulgated by the mas s media, selfbooks , or victim s upport groups in which people, in North America, come to accept the poss ibility of multiple identity enactments or a his tory of forgotten 1857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 79 of 302

childhood victimization, or both, as part of an social role. In this view, therapy may not be a factor in the development of a diss ociative disorder; a susceptible person could do s o s imply through social influence. R ecent comprehens ive reviews of the S C M for disorders have made s everal points. V irtually no scientific studies have been performed in clinical populations to attempt to examine the S C M or related ideas . T he original database supporting this cons truct comes from a small, heterogeneous group of studies in the 1940s and 1950s, mos tly uncontrolled, quas iexperimental, anecdotal case reports. T hes e that s ome degree of role enactment of an alternative identity occurred with hypnos is , automatic writing, and strong repeated sugges tions . S ome of the subjects the students of the researchers and were of the goals of the studies. T he role enactments were limited to the experimental situation. In fact, one of the res earchers, s tudying a traumatized soldier, concluded that hypnosis allowed access to authentic, previous ly diss ociated self-as pects , not to artifacts of the S tudies of thousands of s ubjects undergoing hypnosis res earch over s everal decades have shown that a of highly hypnotizable individuals can exhibit limited, temporary alter self-states with hypnotic sugges tions. T hese were diss imilar phenomenologically to clinical of dis sociative identity dis order and were limited to the experimental situation. T he res earchers noted that they could not determine whether these procedures previous ly existing dis sociated aspects of the mind or created them de novo. 1858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 80 of 302

A s mall s eries of s tudies on college student volunteers variety of hypnotized and nonhypnotized conditions found that highly hypnotizable, fantasy-prone s tudents would enact the role of a diss ociative identity dis order murderer with amnes ia when given a series of robus tly explicit s uggestions to do s o. Hypnosis was not a or s ufficient condition for this finding. T hese latter have been critiqued on a variety of grounds , including lack of controls (e.g., enacting another psychiatric such as a murderer with schizophrenia); lack of equivalence of the research design with the clinical situation; conflation of dis sociative identity dis order with role enactments, rather than the complex polys ymptomatic picture des cribed in the clinical and res earch literature; failure to produce alter behavior reactivity typical of dis sociative identity dis order; lack of control for strong expectancies and demand characteristics of the research des ign; role enactments limited to the experimental situation; and failure to for preexis ting diss ociated s elf-states and traumatic experiences . F inally, it is generally agreed among dis sociative authorities , beginning with J anet, that the shaping of fide diss ociative identity dis order us ually does occur in clinical s ituation, although this phenomenon itself has never been subject to s ys tematic res earch. In this the core s ymptoms of diss ociative identity disorder are created in the therapeutic encounter. A variety of developmental, s ocial, cultural, intrapsychic, and cognitive factors, which can include are hypothesized to account for the secondary structuralization of the dis sociative process into the 1859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 81 of 302

individualized dis sociative identity disorder alter characteristic of a given person. Little res earch has been conducted on clinical disorders patients to as ses s factors such as fantasypersonality and other forms of s ugges tibility. A recent report s tudied 17 diss ociative identity disorder patients with the G udjonss on S uggestibility S cale (G S S ), an inventory developed to as ses s sus ceptibility to making false confes sions to crimes . It tests memory for an and liability to interpers onal press ure to change one's story about the event. In this study, diss ociative identity disorder patients scored lowe r in overall s uggestibility control groups with P T S D, borderline pers onality and trauma victims without P T S D. Dis sociative identity disorder s ubjects were more res is tant than the other clinical groups to interpersonal pers uas ion. In another study of patients with so-called recovered memories of childhood s exual abus e, thes e patients als o had lower scores when compared to nonabus ed control patients. F urthermore, ps ychological ass es sment of large of diss ociative identity disorder patients us ing the R ors chach tes t and other as sess ment instruments did show a pers onality profile typical of borderline or personality types. R ather, dis sociative identity dis order individuals show P.1860 a unique personality structure characterized by obses sional features, traumatic reactivity, complexity of res ponse, introversion, unus ual thinking at times , and 1860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 82 of 302

insightfulness . It remains a researchable question whether fully autonomous clinical diss ociative identity disorder can produced in s usceptible individuals by s ociocognitive factors alone. T hese studies would be difficult to design from an ethical s tandpoint. However, to be definitive, would have to rigorously demonstrate a lack of diss ociative psychopathology or history of trauma, or similarity of the experimental to the clinical s ituation res pect to the interactions of res earchers and s ubjects; production of the extensive clinical phenomenology of diss ociative identity disorder reported in the literature, just role enactments ; automatization of the s ymptoms outside the experimental situation; us e of control populations enacting other ps ychiatric dis orders; for researcher bias ; and extensive longitudinal followE ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E AMNE

DIS S OC IATIVE AMNE S IA P art of "17 - Dis sociative Dis orders " According to DS M-IV -T R (T able 17-4), the es sential of dis sociative amnes ia is an inability to recall personal information, us ually of a traumatic or stress ful nature, that is too extensive to be explained by normal forgetfulness .

Table 17-4 DS M-IV-TR Diagnos tic 1861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 83 of 302

C riteria for Dis s oc iative Amnes ia A. T he predominant dis turbance is one or more episodes of inability to recall important pers onal information, us ually of a traumatic or s tres sful nature, that is too extens ive to be explained by ordinary forgetfulness . B . T he disturbance does not occur exclusively the cours e of dis sociative identity dis order, diss ociative fugue, posttraumatic s tres s disorder, acute stress dis order, or s omatization disorder not due to the direct phys iological effects of a subs tance (e.g., a drug of abuse, a medication) neurological or other general medical condition (e.g., amnestic disorder due to head trauma). C . T he s ymptoms cause clinically s ignificant or impairment in s ocial, occupational, or other important areas of functioning.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he disturbance does not occur exclus ively during the cours e of diss ociative identity disorder, dis sociative 1862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 84 of 302

P T S D, acute stress disorder, or somatization dis order not due to the direct phys iological effects of a or a neurological or other general medical condition. Dis s ociative amne s ia can be more broadly defined as a revers ible memory impairment in which groups of memories for pers onal experience that would ordinarily available for recall to the cons cious mind cannot be retrieved or retained in a verbal form (or, if temporarily retrieved, cannot be wholly retained in consciousness ). T his dis turbance may be based on neurobiological changes in the brain caused by traumatic stress . the disorder manifes ts its elf as a potentially reversible of psychological inhibition. T he diagnosis of dis sociative amnesia generally four factors. F irst, relatively large groups of memories as sociated affects have become unavailable, not just memories , feelings , or thoughts . S econd, the memories us ually relate to day-to-day information that would ordinarily be a more or less routine part of cons cious awareness : who a person is , what he or s he where he or s he went, what happened, with whom he she s poke, what was said, what he or she thought and at the time, and s o forth. T hird, the ability to remember new factual information, general cognitive functioning, and language capacity are usually intact, although, in extreme cases, the dis sociative proces s can interfere retrieval of procedural memory information and registration of new memories. F inally, the diss ociated memories often indirectly reveal their pres ence in more less dis guised form, s uch as intrusive visual images, flashbacks , somatoform s ymptoms, nightmares , conversion s ymptoms , and behavioral reenactments . 1863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 85 of 302

is , in most cas es , diss ociative amnes ia mus t be as a part of the spectrum of memory dysfunction traumatic stress , often alternating with forms of hyperamnesia or a derealized awarenes s in which the person experiences detachment or es trangement from elements of autobiographical memory, or both. T here are two bas ic pres entations of diss ociative T he first is a dramatic, sudden dis turbance in which extensive aspects of memory for personal information not available to conscious verbal recall. T hes e patients often s een in emergency departments or general or neurological services , because the sudden of memory loss requires medical as ses sment. In during an acute amnes tic epis ode, some of these individuals may demons trate dis orientation, perplexity, alterations in cons cious nes s, somatoform symptoms, purpos eless wandering, or a combination of these. A 45-year-old, divorced, left-handed, male bus was seen in ps ychiatric consultation on a medical unit. had been admitted with an epis ode of ches t discomfort, light headedness , and left-arm weaknes s. He had a of hypertension and had a medical admiss ion in the year for is chemic chest pain, although he had not a myocardial infarction. P s ychiatric consultation was called, as the patient complained of memory los s for previous 12 years, behaving and res ponding to the environment as if it were 12 years previous ly (e.g., he didn't recognize his 8-year-old s on, ins isted that he was unmarried, and denied recollection of current events , as the current president). P hys ical and laboratory were unchanged from the patient's usual baseline. 1864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 86 of 302

computed tomography (C T ) s can was normal. On mental s tatus examination, the patient displayed intellectual function but insisted that the date was 12 earlier, denying recall of his entire subsequent personal history and of current events for the last 12 years . He denied awarenes s of his current addres s, life circums tances , job, recent political events, and so was perplexed by the contradiction between his and current circumstances. T he patient described a history of brutal beatings and phys ical discipline. He decorated combat veteran, although he described amnes tic episodes for some of his combat the military, he had been a champion golden glove noted for his powerful left hand. He was educated about his dis order and given the suggestion that his memory could return as he could tolerate it, perhaps overnight during s leep or perhaps a longer time. If this strategy was uns uccess ful, an amobarbital interview was proposed. On the s ubs equent examination, the patient reported his memory had returned. B efore the amnestic described an escalating s eries of conflicts at work, in marriage, and with his s on. His wife was discus sing a separation and had as ked him to discuss this with his He felt completely res ponsible for his coworkers and the care of his relatives . He had felt panicked, overwhelmed, and enraged. He had felt violently angry his wife but had vowed in the past that he would “beat death anybody who tried to hurt her.” He s tated that he would have attempted s uicide, but he “couldn't,” he had too many people relying on him. T he amnes ia developed after he felt a kind of “paralysis ” in his left 1865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 87 of 302

His wife had rushed him to the hospital and had been extremely concerned about his well-being. P.1861 He was aware that none of these problems exis ted 12 years before and that he had unconsciously returned to less stress ful time by losing his memory. T he patient treated with s upportive psychotherapy in the hos pital, coordination of care was arranged with his cardiologis t. T he patient was referred for marital and individual ps ychotherapy and for ps ychopharmacological intervention. Des pite its relative rarity, this type of dis sociative is featured in the media and in mos t textbooks as representative of the condition. However, a far more prevalent form of dis sociative amnes ia is a deletion cons cious memory of significant aspects of the history. Ordinarily, patients do not complain of this, and is us ually only discovered in taking a careful life his tory. Dis sociative amnes ia typically has a clear-cut onset offset, so that the pers on is subjectively aware of a gap continuous memory. F or example, a patient may report that s he does not remember being in third grade, although having clear memory for other s chool years. Usually s uch s ymptoms are ass ociated with traumatic circums tances , for example, the patient reports that has been told that, during third grade, s he was by her es tranged father in a custody dis pute, held by for a number of months , and was sexually abus ed by during that time. In extreme cas es, the patient may recall for his or her entire childhood or other major life 1866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 88 of 302

epochs. Dr. G . is a 33-year-old clinical ps ychologist who was admitted to the hospital becaus e of repeated acts of severe s elf-mutilation. S he reported chronic depress ed mood, anxiety, and interpers onal problems with to form intimate relations. S he had periods of bulimia anorexia requiring hospital treatment during her early and ongoing s truggles with eating. S he described a of OC D s ymptoms, including recurrent checking “to sure” that the doors were locked to her home, things to “prevent harm from befalling me,” and rituals of counting and s inging in her mind. Medications and intens ive outpatient ps ychotherapy had helped moderate s ome of her symptoms, but s he had become increasingly demoralized by her overall failure to in treatment. Mental s tatus revealed an oddly cheerful, cerebral woman who could not explain the profound impulses that s he felt to harm hers elf or to commit S he was articulate and s poke in intellectualized ps ychodynamic formulations . When asked about her childhood his tory, s he virtually no recall for her life between 5 and 13 years of age. Her siblings would joke with her about inability to recall family holidays , s chool events, and vacation trips. S he described her relationship with her family as “great,” reporting a warm, supportive with her parents. On further ques tioning, however, she revealed that her father had been an alcoholic her childhood, only achieving sobriety in her early adoles cence. S he had reported s everal epis odes of sexual” touching by him to her s eventh grade teacher, res ulting in a social s ervice inves tigation. Her father 1867 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 89 of 302

acknowledged thes e epis odes at the time and received treatment for alcoholism and “sex addiction.” He denied any other epis odes of s exual abus e toward his T he children were not removed from the home. Dr. G . denied any feelings about thes e episodes , s tating that took care of the problem. Now, he's a great support. I no reas on to be mad at him.” S he explained her by saying that “maybe nothing important happened and that's why I don't remember.” T reatment focused on establishing safety from selfC ognitive therapy focused on the patient's self-blame, of affect, minimization of s elf-harm, and a profoundly negative view of herself. T he patient was provided with education about her disorders and was taught management s kills . T he patient increasingly became of affects of s hame, anger, hurt, and betrayal related to having been abus ed. T hese s eemed to precede of self-harm. T he latter als o occurred after phone conversations with her parents . As therapy progress ed, patient began to s pontaneous ly remember other of abus e that her father had not acknowledged, s uch episodes of oral and vaginal s ex. As this occurred, she more intrus ive P T S D s ymptoms , including nightmares, flashbacks , and intrus ive images and bodily S he remembered that, as a child, s he would arrange obses sively in the belief that, by doing so, she could prevent her father's nocturnal visits. During the abus e, recalled that she sang and counted in her head to herself from the experience. S he also began to recall more s erious conflict and chaos in the family related to father's alcoholis m during the years for which she had been amnestic. Dr. G . reported intense dis tres s at the 1868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 90 of 302

conflict between the attachment to her parents and and the implications of these emerging memories. S he became increas ingly aware of the extent to which she avoided thinking about the abus e, her response to it, its impact on her life. F ollowing J anet, s everal different patterns of amnes ia have been identified. T hese are lis ted in T able 5.

Table 17-5 Types of Dis s oc iative Amnes ia Localized amnesia    Inability to recall events related to a period of time S elective amnes ia    Ability to remember some, but not all, of the occurring during a circums cribed period of time G eneralized amnes ia    F ailure to recall one's entire life C ontinuous amnes ia

1869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 91 of 302

   F ailure to recall succes sive events as they S ys tematized amnes ia    Amnesia for certain categories of memory, such all memories relating to one's family or to a particular pers on

E pidemiology As noted in the overview, dis s ociative amne s ia, as by DS M-IV -T R , has been reported in approximately 6 percent of a general population s ample in W innipeg C anada, studied with the DE S and the DDIS . T here is known difference in incidence between men and C as es generally begin to be reported in late and adulthood. Dis sociative amnesia may be es pecially difficult to ass ess in preadolescent children becaus e of their more limited ability to describe subjective experience. It may be confused with daydreaming, inattention, anxiety, oppos itional behavior, learning disorders , and ps ychotic dis turbances. Adoles cents are better able to verbalize the experience of amnesia. F or example, one teenager s aid, “I s kip time” to des cribe amnes ia experience. P atients may des cribe more than amnes ia episode. A variety of s tudies have looked at the prevalence of amnes ia for s pecific types of traumatic experiences: combat, s exual abuse, physical abuse, and emotional 1870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 92 of 302

abuse. Other studies have reported amnesia along with other s ymptoms of P T S D in various traumatized P.1862 Across several s tudies , the prevalence of amnes ia combat reported among several thous and active duty soldiers in W orld War II ranged from 5 to 14.4 percent. a s mall percentage of these soldiers were reported to suffered s ignificant head injuries . In one study of 1,000 soldiers , 35 percent of the group expos ed to the most intens e combat had amnesia. P ast or family his tory of diss ociation or hysterical s ymptoms was ass ociated amnes ia in s oldiers with minimal battlefield expos ure. S tructured interview data using the S C ID-D-R have significantly higher amnesia scores in V ietnam era with P T S D compared to combat veteran controls P T S D. S tudies of Nazi Holocaust survivors , K orean veterans, and V ietnam era combat veterans with P T S D adult s urvivors of childhood sexual abus e have documented deficits in explicit memory on memory tests as compared to matched controls. F orty percent of a s ample of 50 randomly selected survivors of the C ambodian Holocaust endorsed on P T S D diagnostic inventories . T he average DE S this group of s everely traumatized individuals was 37.1. Amnes ia was reported in 3 to 10 percent of Holocaust survivors as sess ed with a P T S D inventory. T he highest prevalence was found in tattooed s urvivors of S tudies of natural dis asters, such as the S an F rancisco earthquake in 1989, have found that 3 to 5 percent of survivors report amnesia for at leas t s ome as pects of 1871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 93 of 302

events. With res pect to delayed recall of sexual or physical or both, more than 70 studies have confirmed this in clinical, community, and forens ic populations, retrospective, prospective, and longitudinal s tudy In various s tudies of clinical populations and individuals who identified thems elves as survivors of abuse, 16 to almos t 100 percent reported amnesia for the abus e at some time in their lives, averaging approximately 30 percent acros s s tudies . Lower prevalence was found in outpatients. In studies of college undergraduates and women in the community, prevalence of amnes ia for abuse ranged from 13 to more than 50 percent. A random s ample of 505 men and women in the population found that approximately 21 percent a his tory of childhood s exual abus e. Of these, 20 described full amnesia, and 22 percent reported partial amnes ia for the abus e at some time in their lives . S omewhat lower rates of amnes ia for phys ical and emotional abuse have been reported in clinical and nonclinical samples : Approximately 20 percent of endors e this finding across studies. Longitudinal and pros pective s tudies , primarily up large s amples of individuals with documented prior childhood s exual trauma from court or medical reports , have found that almost 40 percent of res pondents recall a forens ically or medically documented episode childhood s exual abus e when interviewed 20 years or more later, even though, in some cases , other trauma or maltreatment were recalled. S ome denied any history of maltreatment at all. 1872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 94 of 302

In a recent 10-year follow-up study of children of ages involved in criminal pros ecution against their abuse perpetrators, 19 percent of this highly s elected sample appeared unable or unwilling to describe the abuse at a later time. F actors thought to predispose to amnes ia for trauma are listed in T able 17-6. However, of thes e factors has been shown to exclusively those with amnesia for trauma from those without amnes ia.

Table 17-6 Fac tors L eading to Dis s oc iative Amnes ia after Traumatic E xperienc es T rauma caused by human as sault rather than disas ter R epeated traumatization as oppos ed to single traumatic events Longer duration of trauma F ear of death or significant harm during trauma T rauma caused by multiple perpetrators C los e relations hip between perpetrator and victim

1873 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 95 of 302

B etrayal by a caretaker as part of abus e T hreats of death or s ignificant harm by the victim dis closes his or her identity or regarding the traumatic experience V iolence of trauma (i.e., phys ical injury caus ed by trauma) E arlier age at onset of trauma

Note: No factor has exclusively been as sociated diss ociative amnesia. Adapted from Loewens tein R J . Diss ociative and diss ociative fugue. In: G abbard G O, ed. T re atme nt of P s ychiatric Dis orde rs , 3rd ed. V ol 2. Was hington, DC : American P s ychiatric P res s; 2001:1625.

E tiology S everal different theories have been developed to diss ociative amnesia. A unified theory combines these.

B ehavioral S tate and Information Proc es s ing Model In the behavioral state and information process ing diss ociation is conceptualized as a bas ic part of the 1874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 96 of 302

ps ychobiology of the human res ponse to lifedanger: a protective activation of altered s tates of cons ciousnes s that change perception, pain sensation, time s ense, and sense of self. Memories and affects to the trauma are encoded during these altered s tates . When the person returns to the baseline s tate, there is relatively less access to the diss ociated information, leading, in many cases, to dis sociative amnesia for at some part of the traumatic events . However, the diss ociated memories and affects can manifes t in nonverbal forms: posttraumatic nightmares, reenactments , intrus ive imagery, and s omatoform symptoms. Not only is there amnes ia for the trauma, the person als o frequently has diss ociated that certain basic as sumptions about the self, relations hips, other people, and the nature of the world have been altered the trauma. T his model does not pos it that trauma is forgotten. F urthermore, the model does not necess itate that pain is the controlling variable in the onset of amnesia, although the latter may be a factor in inhibiting retrieval diss ociated information. R ather, it s uggests that trauma encoded and remembered but remains relatively inacces sible owing to difficulty in retrieving information acros s different DB S . S ome authorities have made the analogy between posttraumatic diss ociative amnesia experimentally produced hypnotic amnes ia. In both implicit memory for the material can usually be demonstrated. F ollowing J anet, some have that amnes ia occurs when there is a relative decrease executive control or synthesis among groups of ps ychic memory elements and the inhibition of control elements 1875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 97 of 302

that can give access to information that is stored in memory. T he res ults of recent neuroimaging s tudies of s mall of trauma survivors s upport this model by indicating poss ible neurobiological s ubs trates of diss ociative amnes ia. F or example, P E T and fMR I studies of P T S D subjects have shown that stimulation of trauma recall script driven imagery is as sociated with activation of nondominant hemisphere areas, limbic areas, and the occipital lobe with relative suppres sion of left-brain language areas , s uch as B roca's area, and inhibition of prefrontal cortex. S ome researchers have focus ed on the finding of significant reduction of hippocampal volume in various traumatized populations as a marker for pathological proces ses involving memory in pos ttraumatic Als o, s tudies using ketamine, a noncompetitive of the NMDA receptor, res ult in increases in symptoms as measured by the C ADS S , including

Amnes ia and E xtreme Intraps yc hic C onflic t Acute, florid amnestic epis odes and the chronic covert amnes ias generally occur after severe, overwhelming, threatening traumas , s uch as combat, childhood sexual as sault, adult rape, threats of death or physical and P.1863 other s imilarly overwhelming events. However, in many cases of acute dis sociative amnes ia, the ps ychos ocial environment out of which the amnesia develops is not 1876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 98 of 302

traumatic per se, but, rather, mas sively conflictual, with patient experiencing intolerable emotions of shame, despair, rage, and des peration. T hese are usually to result from conflicts over unacceptable urges or impulses, s uch as intense s exual, s uicidal, or violent compuls ions. T hus , these patients are conceptualized experiencing mass ive ps ychological conflict from which fight or flight s eems impos sible or ps ychologically unacceptable. However, mos t of the latter cas es have histories of severe trauma predating the episode of amnes ia. T he los s of memory in s ome of thes e has been conceptualized as an alternative to suicide. Indeed, premature therapeutic efforts to overcome amnes ia have been reported to res ult in success ful in some cas es .

B etrayal Trauma A related explanatory model is derived from social ps ychological principles and from developmental attachment theory. B etrayal trauma attempts to explain amnes ia by the intensity of trauma and by the extent a negative event represents a betrayal by a trus ted, needed other. T his betrayal is thought to influence the in which the event is proces sed and remembered. F or example, in this model, a child is more likely to develop amnes ia when subjected to abus e by a family member another pers on whom the child trusts or on whom the child is dependent. T he amnes ia is protective of the developmentally mediated need for attachment, for pres ervation of overall emotional and cognitive growth, despite the abus e. In this model, information about the abus e is not linked to mental mechanis ms 1877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 99 of 302

control attachment and attachment behavior. Lack of s hareability of trauma experiences is also to contribute to amnesia for trauma. T hat is , in addition the neurobiological factors that inhibit verbal access to such events , they are less likely to be s hared with because of threats , s hame, lack of developmental have words for the experience, and intense confus ion emotional arousal engendered by the abuse. T hus, it is theorized that traumas involving betrayal are differently cognitively from other autobiographical experiences , leading to s ubjective memory deficits . B etrayal trauma theory als o helps to explain the lower prevalence of amnes ia for wartime trauma, natural disas ters , and the Nazi Holocaus t, among others, as compared to that for childhood s exual or physical V arious studies have supported the betrayal trauma model. In one s tudy of college undergraduates , abuse caretaker was a better predictor of memory impairment related to the abus e than age at the time of the abuse duration of the abuse. S troop tes t data have als o that high DE S s ubjects who report more trauma and betrayal trauma, compared to low DE S s ubjects , may actively inhibit threatening information, but not neutral information, from being acces sed cons cious ly. A unified information process ing and betrayal model predicts the relative likelihood of amnes ia under circums tances , s uch as high threat and low betrayal, threat and high betrayal, and s o forth.

Validity of Dis s oc iative Amnes ia S tudies that addres s the validity of dis sociative 1878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 100 of 302

have primarily centered on the exis tence of the phenomenon, not on the study of the clinical disorder. noted previous ly, all of the studies that have attempted inves tigate the pres ence of amnes ia for trauma have reported that it occurs . Alternative hypotheses about trauma and memory that trauma virtually always caus es an indelible of memory in the brain and that diss ociative amnes ia is myth. T he debate about the exis tence of dis sociative amnes ia has also focused in part on hypothesized ps ychological mechanis ms for the reported amnes ia, as repress ion or dis sociation. C ritics have s uggested more mundane proces ses , s uch as failure to report, cognitive avoidance, or ordinary forgetting, might for the apparent delayed recall, although it is difficult to unders tand how thes e alternative mechanisms could account for the findings of amnesia during acute such as combat. Data from a variety of research studies s how that individuals who report problems with recall of trauma describe several s ubjective proces ses . S ome inability to recall some or all of traumatic life events or epochs in which the trauma occurred. Others report deliberate attempts to avoid thinking about the traumas because of the s ubjective dis tres s or s hame that they experience when they try to do so. Another group describes lack of ability to appreciate the abusive trauma until they were older or more emancipated from abusive social milieus , or both. In clinical practice, all of these mechanis ms may help account for as pects or apparent diss ociative amnesia in an individual patient. Many studies have found corroboration for the abuse 1879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 101 of 302

trauma recalled by individuals with diss ociative T ypes of corroboration have included medical records , social s ervice records , church dioces an records, verbal written admiss ion by perpetrators, criminal convictions civil judgments against perpetrators, reports of family members, and information from witnes ses or other of the same perpetrator. Als o, s tudies have s hown no significant differences in the accuracy of delayed recall trauma compared to accounts of individuals who report continuous memory for trauma. Like continuous memories , delayed memories may be shown by corroboration to be generally accurate, accurate, or completely confabulated. R eliable corroboration, which may be very difficult to obtain, particularly in cas es of reported childhood or intimate-partner violence, is the only way to resolve extent to which a memory is generally accurate.

Diagnos is and C linic al F eatures As des cribed in prior sections, there are two major presentations of dis sociative amnes ia.

C las s ic Pres entation C las sically presenting patients are the textbook cas es form the image of dis sociative disorders for mos t health profess ionals . T he clas sic disorder is an overt, dramatic clinical dis turbance that frequently res ults in patient being brought quickly to medical attention specifically for s ymptoms related to the diss ociative disorder. T he paradigmatic case is that of the individual who is found without memory for identity or life history, sometimes leading to media reporting of the case. Less 1880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 102 of 302

extreme forms of amnesia, s uch as acute amnesia for recent traumatic circumstances, s uch as combat or also fall into this category. T his pres entation of amnesia is frequently found in who have experienced extreme acute trauma. also commonly develops in the context of profound intraps ychic conflict or emotional s tres s. F or example, terrified s oldier in combat experiences excruciating conflict over his or her urge to flee and his or her belief that “all cowards s hould be shot.” T here are little systematic modern data about patients with this form of diss ociative amnesia. P atients may present with intercurrent somatoform or conversion symptoms, or both, alterations in cons cious nes s, depers onalization, derealization, trance s tates, spontaneous age regress ion, and even ongoing anterograde dis sociative amnesia. Depress ion and ideation are reported in many, but not all, cas es . No personality profile or antecedent history is consis tently reported in thes e patients , although a prior personal or family history of s omatoform or diss ociative s ymptoms been s hown to predis pos e individuals to develop acute amnes ia during traumatic circums tances . C as e reports suggest that many of these patients have his tories of adult or childhood abuse or trauma. However, in the wartime cas es , as in other forms of combat-related P.1864 posttraumatic disorders , the most important variable in the development of diss ociative symptoms appears to the intensity of combat. 1881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 103 of 302

F actors relating to avoidance of res pons ibility may be prominent in s ome of thes e cas es, with s exual indis cretions, legal difficulties , financial problems , or of anticipated combat being part of the clinical matrix surrounds the amnesia. T here is a poss ible as sociation some cases with an antecedent history of head trauma with or without los s of cons cious nes s, although this finding has never been s tudied rigorous ly using controls. T here are no data on the prevalence of P T S D symptoms in these patients. If carefully ques tioned, some of these patients give a history of recurrent epis odes of amnes ia or fugue. actually meet criteria for diss ociative identity disorder diss ociative dis order NOS . In the diss ociative identity disorder cases, the amnesia occurs when the person creates a new alter s elf state that experiences its elf as unaware of s ome or all of the past history of the pers on cope with overwhelming or traumatic circums tances . In mos t of the acute dis sociative amnes ia cas es , the amnes ia res olves within hours to months , or through psychotherapy, hypnotherapy, pharmacologically facilitated interviews , or of thes e modalities . However, in rare cases , a chronic cours e develops , with the patient s eemingly unable to tolerate recall of the events that surrounded the onset the amnes ia. Ms. M. is a 55-year-old woman who was seen in cons ultation because of the s udden, complete loss of memory for her entire life history. F or the s everal years preceding this event, the patient had been s eeking “meaning” in her life subsequent to the las t of her 1882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 104 of 302

leaving home. S he had been involved in a number of community activities in her home city but began to s eek inner understanding through ps ychotherapy. S he a reported history of neglect, emotional abus e, and phys ical abus e in her family of origin and a history of childhood s exual abus e involving several women her family. S he became friends with a female ps ychotherapis t who encouraged the patient to seek training as a counselor, hers elf. T he friend declared a sexual attraction to the patient, although the patient apparently did not reciprocate this attraction. T he two became involved in therapy training and activities, culminating in their attendance at a new age– oriented therapy workshop in a distant city. T hey room, and the friend began to press ure the patient sexually. T he patient remains uncertain whether she rebuffed these advances . On one hand, she was that her friend would be “mad” about her refus al. On other hand, she was panicked les t her family find out about the s exual press ures from her friend. T he cons isted of a number of group s ess ions involving movement, imagery, “inner child work,” artwork, and similar experiences . During an intens e s es sion picturing oneself going back in time and being reborn, patient appeared to enter a deep trance s tate. At the conclus ion of the s es sion, s he remained in a fetal When ques tioned, s he could not identify who s he was, where she was , or anything else about herself or her situation. Ins tead of seeking psychiatric help, the works hop organizers took the patient back to her hotel room, lit candles, and provided aromatherapy. At the end of 1883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 105 of 302

days , there was no change in the patient's condition, the members of the workshop and the patient's companion left. T he patient's family found her in a confused, and disoriented s tate, unable to recognize or to provide any his tory of recent events. S he had difficulty learning new information, s eemingly forgetting as it was provided. S he was panicked and complained not “feeling in my body.” In addition to los s of autobiographical memory, she appeared to have dress ing hers elf until s hown how, did not know how to in her contact lenses, and was confused about a activities of daily living. B rought to neuropsychiatric attention, the patient was given an extensive neurological and workup, all of which showed that the cognitive deficits were consistent with a psychologically based amnes ia, a neurological process . On mental s tatus examination, patient presented as a s cared, confused, neatly woman who frequently entered trance s tates, s taring and losing track of the convers ation. S he had relearned variety of information, including the identities of her children and spouse but had no s ens e that s he had any of this before being recently taught it. S he “knew” about a variety of family events but had no sens e of hand memory for them. S he complained of ongoing amnes ia, spontaneous trances , and periods of intens e depers onalization and derealization. S he was unable to perform daily functions, s uch as driving and cooking, having no recall of thes e s kills . Mood was depres sed, periods of intens e s uicidal preoccupation. In reviewing history with family members , the patient's former ps ychotherapis ts, and the patient herself, s ignificant 1884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 106 of 302

marital conflicts and family conflicts between the her siblings , and her elderly mother were described. As treatment progres sed, the patient began to describe the s ubjective experience of different self-states , it was quite difficult to determine if they met DS M-IV criteria for a diss ociative identity disorder alter identity. S he des cribed the belief that “the old M.” had been to cope with the family, marital, and personal conflicts preceding the amnes ia “and just crumbled into pieces .” T he workshop exercis es that preceded the memory uncannily recreated features of s ome of the patient's reported childhood trauma, about which s he had extensively before the ons et of the amnes ia. At times , experienced hers elf as “the little girl” who recalled horrifying epis odes of sadis tic childhood maltreatment and was terrified lest they recur. At other times, she experienced hers elf as the “new M.” who had to relearn entire life his tory. S he was rediagnosed as diss ociative disorder NOS . After several years , despite individual ps ychotherapy supportive, psychodynamic and cognitive-behavioral modalities, hypnotherapy, couples therapy, family and antidepres sant medication, the patient continues to experience amnesia, although s he has “relearned” to manage her day-to-day life. Mood has improved, the patient has made some adjustment to her difficult family s ituation. S ettlement of a laws uit agains t the workshop organizers did not res ult in any clinical S he has repeatedly refused an amobarbital interview.

Nonc las s ic Pres entation T he nonclass ic diss ociative amnesia patients can be 1885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 107 of 302

have a cove rt diss ociative syndrome, becaus e their complaints infrequently relate directly to amnes ia. recurrent, or persistent diss ociative amnes ia, or a combination of thes e, is the most common s ymptom in these cas es , although s ome may als o describe a fugue-like s tates. C ommonly, patients with the presentations of amnesia do not reveal the presence of diss ociative s ymptoms unles s directly as ked about T hese patients are often uncomfortable when amnes ia inquired about and may minimize the presence or rationalize the importance of the symptom. In thes e patients , the amnes ia manifes ts its elf as a circums cribed memory gap or series of memory gaps the life history, primarily for times when traumatic occurred, such as childhood or wartime. T hese patients frequently come to treatment for a of s ymptoms, such as depress ion or mood swings , subs tance abus e, s leep disturbances , s omatoform symptoms, anxiety and panic, s uicidal or s elf-mutilating impulses and acts , violent outbursts , eating problems , interpersonal problems. S elf-mutilation and violent behavior in these patients may als o be accompanied amnes ia. Amnesia may als o occur for flas hbacks or behavioral reexperiencing epis odes related to trauma. P.1865 Only one systematic study exists that has examined characteristics of thes e patients. In a small, highly sample referred for consultation at a specialty clinic for diss ociative dis orders, mos t diss ociative amnes ia were women. Almos t all had a prior his tory of childhood 1886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 108 of 302

adult physical, sexual, or emotional abuse and neglect, combination of thes e. T he trauma history was less than has been reported in patients with diss ociative identity dis order. Duration of reported amnes ia ranged from minutes to years . S lightly les s than one-half of the sample had recurrent epis odes . T raumatic precipitants the amnes ia were most common, although, in 30 of cas es , amnes ia was pres ent for problematic such as sexual indis cretions and s elf-mutilation. T he common comorbid conditions were mood dis orders, P T S D, and a mixed pers onality disorder. P atients from diss ociative identity disorder patients in that they had lower rates of s ubs tance abus e, s elf-mutilation, hallucinations , fugues , sexual dysfunction, and somatoform s ymptoms . DE S scores averaged lower those of diss ociative identity disorder patients . F amily history was characterized by alcoholism and mood disorders .

P athology and L aboratory E xamination Dis sociative amnes ia can be diagnos ed with the DDIS the S C ID-D-R , or both. Dis sociative amnes ia patients been reported to have high hypnotizability, as with standardized hypnos is scales.

Differential Diagnos is Ordinary Forgetfulnes s and Nonpathologic al Amnes ia T he DS M-IV -T R diagnostic criteria for dis sociative specify that the disturbance mus t be “too extens ive to explained by normal forgetfulness .” F urthermore, 1887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 109 of 302

nonpathological forms of amnes ia have been such as infantile and childhood amnesia, amnesia for and dreaming, and hypnotic amnes ia. Most forms of diss ociative amnesia are thought to primarily involve difficulties with episodic and autobiographical memory, not implicit or semantic memory. S everal s tudies have confirmed the clinical observation that s ubjects with pathological dis sociative amnes ia for their life his tory can demons trate implicit autobiographical memory while amnesic. W hen asked free as sociate, to imagine, or to make up a story or expos ed to projective tests, patients with diss ociative amnes ia include in their productions elements that contain autobiographical information without being consciously aware of this. Amnes ic patients may als o have intens e reactions to stimuli that are emotionally significant, without knowing cons ciously the reason for the reaction or the of the stimulus, such as when a patient with P T S D has flashback without consciously knowing what triggered it and often without clear recall later of the memory being evoked. S tudies of autobiographical memory in s everal populations support the notion that infantile and childhood amnes ia can be experimentally documented. However, there is now a substantial body of data being accumulated on preverbal learning and memory in children. Amnesia may result in later years owing to the difficulty in translating this preverbal memory into form. However, experiments designed to overcome this factor in young children have shown that children can report preverbal memories accurately in verbal form 1888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 110 of 302

suitable experimental conditions . S tudies demonstrate that normal adult autobiographical memory has a retention gradient for memory for the recent 20 to 30 years of the s ubject's life, often with a subjective sense of wearing away of memories for the in contras t to the subjective gaps in memory typical of diss ociative amnesia. E lderly patients in memory s tudies have been shown to have a relative decrease in recent autobiographical memories and a re minis cence compone nt for the subject's youth. S ubtle cumulative memory difficulties may be a feature of aging, often with decreased ability to retain new information, increas ed time to recall already learned information, or both, res ulting in age -re late d cognitive de cline , also known as be nign forge tfulne s s of the Memories for repeated routine events , such as going to work or s chool every day, may not be encoded as memories for each day, but rather as broad memory categories for the events that repeatedly reoccur. T his also thought to occur with some traumatic experiences , such as repeated epis odes of childhood sexual abus e happen recurrently over many years. C linically, patients with dis sociative amnesia may exaggerated or extended forms of childhood amnesia. finding has been documented in an experimental study a cognitively normal diss ociative identity dis order who, unlike normal controls, showed a virtual abs ence memories for the firs t 10 years of her life. In another a patient with a global dis sociative amnes ia after a was evaluated with cognitive tes ting while amnesic and after memory recovery. As compared to an organically impaired control, the diss ociative amnes ia patient was 1889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 111 of 302

able to recall memories from various parts of the life history without the temporal gradient that characterized the retrograde amnes ia of the organic patient. R ecall of autobiographical information during dis sociative seemed related to life events with positive affects that were unconnected with the traumatic events the amnes ia. Implicit autobiographical memory phenomena were documented as well in this patient. S imilar phenomena have been des cribed in amnes ia, with implicit demons tration that the memories for which amnesia has been s ugges ted have been encoded and s tored, but without their being access ible directly for retrieval.

Dementia, Delirium, and Organic Amnes tic Dis orders T here is no single test or examination that can absolutely whether a memory dis order is dis sociative, organic, malingered, or of mixed etiology. T he clinician evaluating the amnesic patient must have a reasonable index of s us picion about any of thes e. In ambiguous there s hould be careful reass ess ment of the clinical situation on an ongoing bas is. However, mos t cases of diss ociative amnesia present differently from other disorders with memory impairment (T able 17-7).

Table 17-7 Differential Diagnos is Dis s oc iative Amnes ia

1890 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 112 of 302

Ordinary forgetfulnes s    Age-related cognitive decline Nonpathological forms of amnesia    Infantile and childhood amnesia    Amnesia for s leep and dreaming    Hypnotic amnes ia Dementia Delirium Amnes tic dis orders Neurological disorders with dis crete memory los s episodes    P osttraumatic amnesia    T rans ient global amnes ia    Amnesia related to s eizure disorders S ubstance-related amnes ia    Alcohol 1891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 113 of 302

   S edative-hypnotics    Anticholinergic agents    S teroids    Marijuana    Narcotic analges ics    P s ychedelics    P hencyclidine    Methyldopa (Aldomet)    P entazocine (T alwin)    Hypoglycemic agents    β-B lockers    Lithium carbonate    Many others Other dis sociative disorders    Diss ociative fugue

1892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 114 of 302

   Diss ociative identity disorder    Diss ociative dis order not otherwise s pecified Acute s tres s dis order P os ttraumatic stress dis order S omatization dis order P sychotic epis ode    Lack of memory for ps ychotic epis ode when returns to nonpsychotic state Mood dis order episode    Lack of memory for as pects of epis ode of when depres sed and vice vers a or when F actitious disorder Malingering

T he evaluation of acute dis sociative amnes ias is in T able 17-8.

Table 17-8 E valuation of Ac ute 1893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 115 of 302

Amnes ia C omplete history (to the extent that this can be gathered)    Medical history    P s ychiatric history    T rauma history (combat, violence, childhood maltreatment, etc.)    Developmental history    C ollateral informants (if available)    F amily and concerned others    Medical, military, police, and s ocial service    S equential clinical observation P hysical and neurological examination    B aseline phys ical and laboratory examination    F ull mental status examination    Mini-Mental S tate E xamination 1894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 116 of 302

   Dementia workup    E lectrocardiogram    E lectroencephalogram    T elemetry in unusual cas es    B rain imaging    Neuropsychological as sess ment

In patients with dementia, organic amnes tic disorders, delirium, the memory loss for personal information is embedded in a far more extensive s et of cognitive, language, attentional, behavioral, and memory Loss of memory for personal identity is usually not without evidence of a marked disturbance in many domains of cognitive function. C onfabulation may be present to various degrees and is us ually implausible bizarre. C aus es of organic amnes tic dis orders include K ors akoff's psychosis, cerebral vas cular accident postoperative amnes ia, pos tinfectious amnesia, anoxic amnes ia, and transient global amnesia. therapy (E C T ) may als o caus e a marked temporary amnes ia, as well as pers is tent memory problems in cases. Here, however, memory loss for experience is unrelated to traumatic or overwhelming experiences and seems to involve many different types 1895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 117 of 302

personal experience, most commonly that occurring before or during the E C T treatments.

Pos ttraumatic Amnes ia In pos ttraumatic amnesia due to brain injury, there is us ually a history of a clear-cut phys ical trauma, a unconsciousness or amnesia, or both, and P.1866 objective clinical evidence of brain injury. In general, length of the posttraumatic amnesia is a reas onable predictor of cognitive outcome. R etrograde amnes ia also occur. An extens ive retrograde amnesia out of proportion to the extent of the head injury sugges ts that an inves tigation for dis sociative factors may be

S eizure Dis orders In mos t s eizure cas es , the clinical presentation is quite different from that of diss ociative amnesia, with clearictal events and s equelae. P atients with seizures may also have dis sociative symptoms, such amnes ia and an antecedent his tory of psychological trauma. R arely, patients with recurrent complex partial seizures may present with ongoing bizarre behavior, memory problems , irritability, or violence, leading to a differential diagnostic puzzle. In some of these cases , diagnosis can only be clarified by telemetry or E E G monitoring.

S ubs tanc e-R elated Amnes ia A variety of s ubs tances and intoxicants have been implicated in the production of amnes ia. C ommon 1896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 118 of 302

offending agents are listed in T able 17-7. In mos t cas es, a careful history from the patient and ancillary s ources , sequential clinical observation, and objective testing clarify the s ubs tance-related nature of the amnes ia. In s ome instances of pathological intoxication, in which a small amount of alcohol or subs tance produces a major behavioral disinhibition, alcohol may be producing its effect by facilitating the onset of a dis sociative epis ode in a susceptible T his may be analogous to the disinhibition that occurs clinical amobarbital interview. S ubjects may report amnes ia for violent or other out-of-character behavior during such an epis ode. T he most difficult differential diagnos tic problem us ually involves patients with a history of substance-induced diss ociative memory problems. S ome of these patients may minimize dis sociative amnesia and vice versa. C linically, the relative contribution of the substance and the diss ociation may only be fully clarified by sequential clinical observation once the patient has achieved sobriety.

Trans ient G lobal Amnes ia T ransient global amnesia may be mis taken for a diss ociative amnesia, es pecially becaus e s tres sful life events may precede either disorder. However, in global amnes ia, there is the sudden onset of complete anterograde amnes ia and learning abilities ; retrograde amnesia; preservation of memory for identity; anxious awareness of memory los s with often perseverative, ques tioning; overall normal lack of gros s neurological abnormalities in most cases ; 1897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 119 of 302

rapid return of baseline cognitive function, with a persis tent s hort retrograde amnesia. T he patient older than 50 years of age and shows risk factors for cerebrovas cular disease, although epileps y and have been etiologically implicated in s ome cases. P.1867

Dis s oc iative Dis orders As noted previous ly, dis sociative identity dis order can present with acute forms of amnes ia and fugue episodes . However, dis sociative identity dis order are characterized by a plethora of symptoms, only which are us ually found in patients with dis sociative amnes ia. With res pect to amnes ia, most dis sociative identity dis order patients and patients with diss ociative disorder NOS with dis sociative identity dis order report multiple forms of complex amnesia, including recurrent blackouts, fugues, unexplained pos sess ions, fluctuations in skills, habits, and knowledge.

Ac ute S tres s Dis order, S tres s Dis order, and S omatoform Dis orders As dis cuss ed in the introductory nosology s ection, forms of diss ociative amnes ia are best conceptualized part of a group of trauma s pectrum disorders that acute stress dis order, P T S D, and somatization Many dis sociative amnesia patients meet full or partial diagnostic criteria for acute stress dis order, P T S D, or somatization disorder, or a combination of thes e. is a criterion symptom of each of the latter disorders . 1898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 120 of 302

IV -T R s tipulates that, to be diagnosed, the diss ociative amnes ia must be dis tinct from the cours e of acute disorder, P T S D, or s omatization disorder. In practice, clinical judgment us ually determines whether the extent of the amnesia warrants a s eparate dis sociative

Malingering and Fac titious Amnes ia F eigned amnesia is more common in patients with the acute, clas sic forms of dis sociative amnes ia. However, in one recent forensic case, an adult attempting to sue an admitted abuser us ing the discovery rule was s hown to have falsified delayed for trauma in an attempt to overcome the statute of limitations . Inves tigations s howed that the patient had discuss ed the abus e with others on many occasions the purported delayed recall. On the other hand, some patients may have s econdary amnesia for having remembered and discuss ed traumatic experiences in past. T here is no absolute way to differentiate diss ociative amnes ia from factitious or malingered amnes ia. Malingerers have been noted to continue their even during hypnotically or barbiturate-facilitated interviews . As noted previously, many of the class ical were des cribed as occurring in a clinical context of financial, s exual, and legal problems or in s oldiers who wis hed to escape from combat. On the other hand, in the clinical cas e reports , many malingerers quickly confess ed their deceptions spontaneously or when confronted by the examiner. In these nonforensic reports , the malingered amnes iacs frequently pathetic individuals whos e deception was 1899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 121 of 302

transparent. It was often unclear where the cons cious deception began and the uncons cious defenses ended. In the current clinical environment, a patient who to ps ychiatric attention asking to recover repres sed memories as a chief complaint is most likely to have a factitious disorder or to have been s ubject to influences. Mos t of these individuals actually do not describe bona fide amnesia when carefully questioned are often insistent that they mus t have been abused in childhood to explain their unhappines s or life

C linic al C ours e and P rognos is Little is known about the clinical course of diss ociative amnes ia. Acute dis sociative amnes ia frequently spontaneously resolves once the pers on is removed to safety from traumatic or overwhelming circums tances . the other extreme, there are patients who develop forms of generalized, continuous, or s evere localized amnes ia who are profoundly disabled and require high levels of s ocial s upport, such as nursing home or intensive family caretaking. T hose with nonclas sic dis sociative amnes ia may have persis tent form of the dis order that does not cause overt dis tres s, and, thus , they do not s eek clinical S ome of these individuals may be understood as being an episode of P T S D characterized primarily by symptoms. In s ome cases, a later traumatic event or even a relatively minor one, precipitates a florid P T S D with alternations of reexperiencing and avoidant amnes ia symptoms . S tudies have shown that recall of previously 1900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 122 of 302

memory frequently occurs outside of therapeutic triggered by a variety of s timuli, including one's own children reaching an age at which one was abus ed, child being abus ed, media accounts of trauma or death of an abusive parent, a variety of s ens ory cues, feeling s afe in one's life situation, among others .

Treatment T he treatment of diss ociative amnesia became controvers ial in the 1990s . C ontroversy exis ts not only the exis tence of dis sociative amnesia, but also for how treat it. C ritics of the diss ociative amnes ia construct invented the term re cove red me mory the rapy (R MT ) to characterize treatment in which clinicians are thought make aggress ive efforts to have patients recall s oforgotten traumas as the central focus of treatment. does not repres ent a known school of therapy or of scholarly res earch. It may more accurately describe individual fringe practitioners or media or laypers on of trauma treatment. In fact, reviews of the literature on trauma treatment report that the predominant model for work on traumatic memories involves a focus on integration of pos ttraumatic memories, beliefs , affects, s omatic repres entations, and object relations, on memory recall per s e.

Phas e-Oriented Treatment P hase-oriented treatment is the current s tandard of for the treatment of trauma dis orders, including diss ociative amnesia. T reatment of the acute class ical diss ociative amnesia patient follows a similar phasic model. However, here, memory recall is a central 1901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 123 of 302

because los s of memory for personal identity and large gaps in current autobiographical memory are acutely disabling s ymptoms that require relatively rapid intervention. In general, three basic phases are recognized. T his structure is heuris tic to some extent, becaus e as pects each phas e may be worked on during another. F irst, is a s tabilization phase, with a focus on safety, control, containment of affects and impuls es , and education about trauma treatment. Once adequate personal s afety and clinical stability are established, if indicated, the individual may engage in a s econd the focus of which is the integration of traumatic in greater depth. T his process ing may involve attempts overcome pers is tent amnes ia symptoms and to resolve material that is not diss ociated or les s completely diss ociated. F inally, there is a third phas e of re s olution re inte gration, in which the traumatized pers on is reconnected to ordinary life. In this phase, the focus is on the trauma per s e and more on the development of renewed, reinvigorated life apart from the lack of impos ed by symptoms of the trauma disorder and the domination of the person's ps ychology by is sues traumatization.

S afety in Ac ute Dis s oc iative In the cas e of the patient with an acute stress disorder primarily characterized or accompanied by dis sociative amnes ia, the es tablishment of the person's phys ical is the firs t concern. T his involves removing the P.1868 1902 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 124 of 302

from the traumatizing environment (e.g., acute evaluating and treating medical problems , and shelter, food, and sleep. S edative medications , such as benzodiazepines, may be indicated to as sis t the patient with sleep. P atients with acute amnesia for personal identity or life circums tances , or both, frequently have a relatively rapid spontaneous remis sion of s ymptoms brought to the s afety of the hospital or other protected environment. If immediate spontaneous remis sion does not occur in patients with acute amnes ia after removal from environments , s ymptoms may abate later s imply in the cours e of the clinician's taking a psychiatric his tory or merely with suggestions and reas surance.

S afety in Nonc las s ic Dis s oc iative Amnes ia P atients with nonclass ic, covert amnes ia pres entations generally s hould be managed within the framework of a longer-term ps ychotherapy directed at res olution of the complex ps ychological sequelae of the events the amnesia, us ually severe traumatization due to childhood abuse, combat, rape, domestic violence, or other forms of adult victimization, or a combination of these. Here, too, the firs t tasks of treatment are res toration of patient's phys ical well-being and safety and of a working alliance. T he clinician mus t be prepared to intervene actively if the patient is acutely dangerous to or others or is abusing s ubs tances in an uncontrollable way, or both. T ypically, thes e patients' difficulties suicide attempts, s elf-mutilation, eating disorders , 1903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 125 of 302

or s ubstance abuse, involvement in abusive or relations hips , epis odes of rage or violence, abus e of individual's own children or family members , and lack adequate food, clothing, or shelter. Hos pitalization may neces sary to s tabilize s uch patients, as may referral to specialty resources, s uch as treatment for s ubs tance or eating disorders . In individuals with s evere intrusive P T S D s ymptoms alternating with amnesia, containment and of intrusive recollections rather than detailed the traumatic material are us ually the goal in the stabilization phas e of treatment. T his may be accomplis hed with s upportive ps ychotherapy, pharmacotherapy, imagery or hypnotic techniques for containment and s ymptom control, or cognitive therapy techniques, or a combination of these. T here is no pharmacological agent that specifically targets amnes ia. However, s pecific psychopharmacological treatment of the patient's P T S D, affective, dys control, ps ychotic, obs es sive-compuls ive, or anxiety s ymptoms with medications may help stabilize severe symptoms prevent the patient's meaningful participation in ps ychotherapy. Long-term treatment for these patients is focused on manifold dimensions of dys function that chronic trauma engenders . T hese include problems with mood, and impulse regulation, dis ordered attachment engendering troubled relations hips and problems with interpersonal boundaries, s pontaneous altered states diss ociation, memory problems, cognitive distortions disordered meaning s ys tems, perceptual abnormalities, problems with the sense of s elf and body image, 1904 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 126 of 302

somatoform s ymptoms , and s elf-destructiveness .

Treatment of Amnes ia T reatment of patients with nonclas sic forms of amnes ia necess itates that the clinician familiarize or hers elf with the current controversies about trauma memory to provide adequate informed consent to the patient. In general, studies of treatment outcome in survivors of rape and childhood s exual abus e have shown better outcome when patients directly dis cus s trauma the context of a carefully designed, phasically individual or group psychotherapy. Nonetheless , it is a matter of clinical judgment and the patient's individual decis ion whether the patient has achieved s ufficient stability and has s ufficient ego strength to move from stabilization phas e of treatment to the phas e of integration. F actors that usually contraindicate memory integration work are lis ted in T able 17-9.

Table 17-9 C ontraindic ations to Integration Phas e of Amnes ia Treatment Has not achieved safety from high-ris k behaviors C urrent s ubs tance abus e or dependence

1905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 127 of 302

Has not achieved symptom stabilization    S evere, uncontrolled, intrusive posttraumatic disorder s ymptoms    S evere, uncontrolled dis sociative epis odes    Dysregulated mood s ymptoms    Dysregulated anxiety s ymptoms Inadequate therapeutic alliance C urrent or ongoing abusive relations hip Acute life crisis or times of life trans ition (divorce, change, etc.) S evere physical illnes s or infirmity S evere pers onality disorder s ymptoms, ps ychos is C urrent involvement in litigation Impending abs ence of therapist

Adapted from Loewens tein R J . Diss ociative

1906 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 128 of 302

and diss ociative fugue. In: G abbard G O, ed. T re atme nt of P s ychiatric Dis orde rs , 3rd ed. V ol 2. Was hington, DC : American P sychiatric P res s; 2001:1633.

Free R ec all P atients with the acute and chronic forms of amnes ia may respond well to free recall s trategies in they allow memory material to enter into T he clinician is s upportive and nondirective but focus es reluctance or resistance to allowing free recall to take place. C lass ic free-as sociation suggestions are often most helpful in understanding factors that interfere with recall and for allowing recall to occur at a pace that the patient can tolerate. In general, it is believed that accuracy is improved if the clinician as ks nonleading questions of the patient, whether in a free-recall or with methods that facilitate memory recall.

Trans ferenc e Interpretations S tudies of trans ference in patients with combat-related P T S D and s evere diss ociative dis orders indicate that a traumatic transference is us ually the predominant initial transference theme in these individuals. T his is a set of unconscious perceptions of the clinician, bas ed on relations hips formed in traumatic circums tances : T he 1907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 129 of 302

therapist becomes the buddy who was killed next to the patient in battle, the pers ecutory abusive parent, the incompetent officer who sent the patient into battlefield disas ter, the neglectful relative unconcerned about the patient's abus e, or the patient himself or hers elf who is subject to the s adis tic, abus ive behaviors of an other. Identification of the overt patterns of traumatic transference observed by the therapist may be another route to undoing amnes ia. A recent study of trauma memory found that trans ference-based recall more accurate than other forms of facilitated recall.

C ognitive Therapy C ognitive therapy may have s pecific benefits for individuals with trauma disorders. Identifying the cognitive distortions that are based in the trauma may provide an entrée into autobiographical memory for the patient P.1869 experiences amnes ia. As the patient is more able to cognitive distortions, particularly about the meaning of prior trauma, more detailed recall of traumatic events occur.

Fac ilitated R ec all of Trauma Material A hierarchy of techniques for facilitation of recall has described for dis sociative amnes ia. R es earch s uggests each of these may s ucces sively introduce the potential greater error rates for what is recalled. T hese include context-reinstatement, that is , attempts to focus the patient on time periods for which there is amnes ia; (2) 1908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 130 of 302

state-dependent recall, that is, intensification and focus affects or somatic s ensations that appear to be related trauma, such as terror, horror, confusion, rage, or suddenly nauseated or dizzy; and (3) s pecialized adjunctive techniques , s uch as hypnosis , relaxation, imagery, or pharmacologically as sisted interviews . these may facilitate recall of dis sociated memory information in clas sic and nonclas sic forms of amnes ia. In each of thes e, the clinician s hould use nonleading, nons uggestive questions to minimize about inaccurate or confabulated recall.

Hypnos is for Amnes ia Hypnos is has frequently played an important adjunctive role in the treatment of individuals with dis sociative amnes ia and dis sociative fugue. Hypnos is is not a treatment in itself; rather, it is a set of adjunctive techniques that facilitate certain psychotherapeutic T he cons truct of hypnosis encompass es a wide and complex domain of phenomena and res pons es that been applied to a divers e array of therapies offered to variety of individuals . C oncern about inaccuracies in hypnotically facilitated recall cite res earch studies of memory for nontraumatic information recalled with hypnosis that have shown that hypnosis increas es the subject's confidence in what is recalled, even if it is erroneous. However, critical reviews have noted the complexity of this res earch problem, the incons is tency findings among s tudies , and the many variables related hypnosis and nonhypnotic factors that appear to this and related phenomena. T he critical reviews have emphasized that memory confabulation is related to techniques of s ocial influence on sugges tible subjects, 1909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 131 of 302

to hypnos is per se. T he us e of hypnos is for memory recall in no way the veracity, or lack of veracity, of the information produced. T he clinician should be well aware of the recons tructive nature of memory and should avoid suggestions to the contrary. T hus, in addition to the patient's informed consent for the use of hypnos is, currently considered prudent to also obtain informed cons ent concerning the reliability or pos sible lack for autobiographical information revealed during hypnosis . S tudies also suggest that educating patients about the controversies regarding hypnos is and and informing them of the need to critically evaluate memory material that they recall during hypnosis or at other time in treatment reduce the likelihood of acceptance of potentially inaccurate information. Als o, clinicians s hould be aware that, in s ome states , individuals who have been exposed to therapeutic hypnosis may be enjoined from giving testimony as a witness in court. T his may be s o even if the hypnosis little relations hip to the events at legal is sue. T he should attempt to discus s fully these is sues with the patient and his or her legal counsel. F inally, the use of hypnos is as part of a fore ns ic examination should proceed only after obtaining from the patient after he or s he has consulted with relevant legal authorities and attorneys involved in criminal or civil litigation. T raining in forens ic hypnos is mandatory in this context. S hould hypnosis be us ed in way, electronic recording of all hypnos is ses sions , preferably on videotape, s hould be us ed. 1910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 132 of 302

Hypnos is can be used in a number of different ways in treatment of dis sociative amnesia. In particular, interventions can be us ed to contain, modulate, and the intens ity of symptoms ; to facilitate controlled recall diss ociated memories ; to provide support and ego strengthening for the patient; and, finally, to promote working through and integration of dis sociated material. In addition, the patient can be taught self-hypnosis to apply containment and calming techniques in his or her everyday life. S uccess ful us e of containment whether hypnotically facilitated or not, als o increases patient's s ens e that he or s he can more effectively be control of alternations between intrusive symptoms and amnes ia. In the acutely amnes tic patient, a few s ess ions to help patient experience trance s ucces sfully and to explore containment and dis tancing techniques may be to allow focus ed hypnotic work on the material for the patient is amnes tic. However, in nonclas sic cas es severe, long-standing, pos ttraumatic dis orders, the amnes ia its elf should be address ed only gradually, in context of a longer-term ps ychotherapy in which life stability and function are the basic foci. C linicians s ince W orld W ar I have recognized the importance of the patient's repeatedly process ing diss ociated material in a number of different s ess ions, often at different levels of affective intens ity, to the process of integrating the material. In cas es of acute amnesia, the firs t s es sion for memory proces sing may neces sarily be explorative. Here, initial goal is to gain an overview of the information for 1911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 133 of 302

which the patient is amnestic. As in cases of chronic amnes ia, subsequent s ess ions then focus on material in greater detail. It is useful to try to account s ys tematically for different dimensions of the traumatic experience: s ensory, cognitive, and behavioral, s o as to ensure that all key components have been identified and reconstructed. It likewise useful to attempt to account s ys tematically for variety of dysphoric affects that are commonly experienced during traumatic experiences : despair, sorrow, grief, horror, shame, helples sness , rage, guilt, confusion, anguish, and the like. Not all of these may present in a given patient; however, it is us eful for the clinician to keep track of which affects s eem most described by the patient and which s eem less Inquiry about thes e other affects may be quite helpful res olving the amnes ia. In particular, shame, horror, helpless nes s, and overwhelming confusion are that patients may have the mos t trouble identifying without ass is tance from the therapist. T he treatment process is similar when the acute res ults not from traumatic experiences , but rather from as pects of their current behavior that are in conflict with deeply held moral values or behavioral s tandards . T reatment in s uch instances s eeks to help the patient tolerate these affects and conflicts without res orting to diss ociative defenses. F requently, thes e patients developmental history characterized by a rigid family moral code enforced with harsh physical discipline. experiences often appear to be the traumatic underpinning of the diss ociative diathes is. and hypnotherapy in thes e patients are directed in part 1912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 134 of 302

reducing the patient's brutally unreasonable, and often conflicting, expectations of himself or hers elf and the and s hame that s o often accompany acute F urthermore, these patients may have tremendous difficulty tolerating anger or violent impulses, becaus e such affects tend to trigger recall of earlier experiences with physical abuse or s imilar traumas , often as a experience. T hus , ps ychotherapy may s erve not only to focus on the conflicts that led to the acute amnesia, but also to explicate and to work through the patient's thoughts, feelings , and s elf-perceptions related to the antecedent traumatic events . P.1870

S omatic Therapies T here is no known pharmacotherapy for dis sociative amnes ia other than pharmacologically facilitated interviews . A variety of agents have been us ed for this purpos e, including s odium amobarbital, thiopental (P entothal), oral benzodiazepines, and amphetamines . present, no adequately controlled s tudies have been conducted that as sess the efficacy of any of these comparis on with one another or with other treatment methods. A single placebo-controlled study of the barbiturate-facilitated interview did not find s uperiority sodium amobarbital over placebo in producing more clinically us eful information. In more s ys tematic W orld II s tudies of barbiturate-facilitated interviews for and conversion reactions, this treatment was described leading to more rapid recovery, especially for amnesia, although little overall difference was found in recovery 1913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 135 of 302

comparis on to subjects treated with psychotherapy or with hypnotherapy. Amobarbital narcos ynthe s is is a term devised to the need for material uncovered in a pharmacologically facilitated interview to be proces sed by the patient in or her usual cons cious state. P harmacologically interviews are used primarily in working with acute amnes ias and convers ion reactions, among other indications , in general hos pital medical and psychiatric services . T his procedure is also occasionally us eful in refractory cas es of chronic dis sociative amnesia when patients are unres pons ive to other interventions . T he current standard of care is that this procedure performed in s ettings in which res us citation equipment available in case of res piratory arrest, a poss ible, albeit complication. T he interview usually is audiotaped or videotaped to replay for the patient, becaus e amnes ia generally is present for material produced. Although in some cases repeated procedures may be helpful, in cases, repeated procedures may lead to the patient's developing a dependence on pharmacologically interviews . T he current controvers ies over delayed recall for experiences have also focus ed on the us e of pharmacologically facilitated interviews for patients with reported amnes ia for childhood maltreatment. No systematic data exis t on memory fallibility or accuracy those undergoing pharmacologically facilitated As dis cuss ed previous ly, pharmacologically facilitated interviews were used extens ively in World W ar II for treatment of combat-related dis sociation. Although wartime memories recovered with pharmacologically 1914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 136 of 302

facilitated interviews were generally cons idered to be accurate, some s ubjects were reported to dis semble completely or withhold crucial information, or both, despite barbiturate treatment. G iven the current controvers ies , the clinician s hould similar informed consent regarding the nature of to the patient contemplating a pharmacologically facilitated interview for amnesia symptoms as that to the patient considering hypnosis. T he clinician emphasize that these drugs are not a truth serum; whatever apparently new information emerges under drug condition should be regarded no differently with res pect to accuracy than any other material that in the course of treatment.

Group Ps yc hotherapy for Amnes ia During W orld W ar II, group psychotherapy and group hypnotherapy were among the treatments given to promote recovery in traumatic war-related amnesia. supportive, s tructured, reass uring, and reeducative approaches were often us ed by therapis ts in s uch an attempt to accomplis h return of the patient to functional s tatus and to prevent chronic disability. T ime-limited and longer-term group psychotherapies been reported to be helpful for combat veterans with P T S D and for survivors of childhood abus e. During sess ions, some authors report that patients may memories for which they have had amnes ia. interventions by the group members or the group therapist, or both, may facilitate integration and the diss ociated material. 1915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 137 of 302

On the other hand, concern has been rais ed about memory contamination in s uch group therapy s ettings , it has for patients ' involvement in 12-step or self-help groups for trauma s urvivors.

E MDR E ye movement desensitization and reprocess ing a s et of s tructured procedures for working on specific traumatic memories in P T S D. Originally, therapistfacilitated eye movements were thought to be an part of the technique for E MDR . However, subsequent res earch has shown this to be a nons pecific factor compared to the s tructured approach for work on reported traumas . S tudies have shown greater efficacy of E MDR compared to waiting lis t and other control conditions, especially for individuals reporting single traumas. However, comparis on of E MDR to forms of s tructured, multistaged trauma treatment has been performed, es pecially for individuals with multiple traumas and complex comorbidities. Longitudinal of such cas es have not s hown a pers is tent with E MDR . B ecaus e E MDR is defined as a procedure for helping res olution of consciously recalled traumatic memories, data have been presented on its efficacy for reducing diss ociative amnesia. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DE P E R S ONALIZAT ION

DE PE R S ONAL IZATION 1916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 138 of 302

DIS OR DE R P art of "17 - Dis sociative Dis orders " F or many years, the ubiquity of depersonalization as a ps ychiatric s ymptom obscured its broader recognition disorder. R ecent res earch has identified clinical cours e and prognosis , and neurobiological correlates distinguish it from other ps ychiatric dis orders with symptoms of depers onalization. V alid and reliable instruments exist for s creening and diagnosis. with these measures is advancing understanding of often unrecognized condition.

Definition T he DS M-IV -T R identifies the ess ential feature of depers onalization as the persis tent or recurrent feeling detachment or es trangement from one's s elf. T he individual may report feeling like an automaton or as if dream or watching hims elf or herself in a movie. to DS M-IV -T R , “there may be a s ens ation of being an outside observer of one's mental process es , one's parts of one's body.” T here is often a s ens e of an of control over one's actions .

His tory F irst described by Maurice K ris hnaber in 1872, depers onalization was formally named in 1898 by Dugas, who s ought to convey “the feeling of los s of F reud, J anet, E ugen B leuler, and other 19th century authorities reported patients with s ymptoms of 1917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 139 of 302

depers onalization and derealization. A monograph by S childer in 1914 is regarded as a turning point in ps ychiatric interest. C las sic s tudies followed by Mayer-G ross in 1939, Harold S horvonn in 1946, and J erome S aperstein in 1949 furthered the delineation of syndrome of chronic depers onalization. B rian Ackner enumerated the es sential features of current diagnos tic definitions in 1954. T hes e include “(1) the feeling of unreality or s trangeness apropos the self; (2) the of insight and lack of delus ional elaboration; (3) the affective res ponse (‘numbness ') except for the regarding depers onalization; and (4) the unpleasant property that may vary in intens ity invers ely with the subject's familiarity with the phenomenon.” In the las t decade, research by E ric Hollander, S imeon, and colleagues has significantly P.1871 increased unders tanding of depers onalization dis order with systematic case s eries, medication trials , brain imaging, and improved measurement.

C omparative Nos ology T he DS M has class ified depersonalization as a diss ociative disorder s ince its firs t inclusion in 1980. current DS M-IV -T R definition of depers onalization is found in T able 17-10.

Table 17-10 DS M-IV-TR C riteria for Depers onalization Dis order 1918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 140 of 302

A. P ersis tent or recurrent experiences of feeling detached from, and as if one is an outs ide of, one's mental process es or body (e.g., feeling one is in a dream). B . During the depersonalization experience, tes ting remains intact. C . T he depers onalization caus es clinically distress or impairment in s ocial, occupational, or other important areas of functioning. D. T he depers onalization experience does not exclusively during the cours e of another mental disorder, s uch as s chizophrenia, panic dis order, acute stress dis order, or another diss ociative disorder, and is not due to the direct physiological effects of a s ubs tance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he IC D-10 (T able 17-11), however, lists 1919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 141 of 302

derealization syndrome under other neurotic dis orders. T he IC D-10 requires concurrent experiences of derealization in addition to symptoms of depers onalization. T he IC D-10 and the DS M require the affected individual mus t have intact reality tes ting must retain good ins ight into the ps ychological nature his or her symptoms .

Table 17-11 IC D-10 Diagnos tic C riteria for Depers onalizationDerealization S yndrome F or a definite diagnos is , there must be either or (a) and (b), plus (c) and (d):    (a) Depersonalization symptoms, that is, the individual feels that his or her own feelings or experiences , or both, are detached, distant, not her own, or lost    (b) Derealization s ymptoms , that is , objects , people, or surroundings , or a combination of seem unreal, dis tant, artificial, colorles s, or    (c) An acceptance that this is a s ubjective and spontaneous change, not impos ed by outs ide or other people (i.e., ins ight)

1920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 142 of 302

   (d) A clear sensorium and absence of toxic confusional state or epilepsy

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural C linical Des criptions and Diagnos tic G uide line s . G eneva: W orld Health Organization; 1992:172, permis sion. S ome authorities disagree with the class ification of depers onalization as a dis sociative disorder. T hey that the absence of amnesia and its occurrence acros s many different ps ychiatric and organic conditions make likely that depersonalization is a final common pathway proces s rather than a s pecific dis order. T he DS M focus instead on the diss ociative alteration in s ens e of that is inherent in the pers is tent or recurrent of feeling detached from one's own body or mind. It is profound, but not ps ychotic, divis ion in sense of s elf qualifies it as a dis sociative disorder. Depers onalization disorder does differ in some important ways from the other diss ociative dis orders, but it may prove an informative exception. Its ubiquity as a symptom and ability to experimentally induce it in laboratory s ettings provide unique opportunities for res earch that may light on diss ociation in general.

E pidemiology T ransient experiences of depers onalization and 1921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 143 of 302

derealization are extremely common in normal and populations. T hey are the third most commonly ps ychiatric symptoms, after depress ion and anxiety. A survey of a random s ample of 1,000 adults in the rural S outh found a 1-year prevalence of 19 percent for depers onalization and 14 percent for derealization. Not uncommon in seizure patients and migraine s ufferers , can also occur with us e of ps ychedelic drugs , marijuana, lysergic acid diethylamide (LS D), and and less frequently as a s ide effect of some such as anticholinergic agents. T hey have been after certain types of meditation, deep hypnos is , mirror or crystal gazing, and sensory deprivation experiences . T hey are common after mild to moderate head injury, where there is little or no loss of cons ciousnes s, but are s ignificantly les s likely if unconsciousness las ts for more than 30 minutes. One study es timated that at least 20 percent of minor head injury patients experience significant depers onalization and derealization. T hey are also common after lifethreatening experiences , with or without serious bodily injury. P sychiatric cas e s eries typically have two to four times more women than men. However, a recent, rigorous ly diagnosed s eries of 117 patients s howed a 1 to 1 ratio. Head injury and s eizure dis order samples are generally equally divided. S everal s tudies have age as a s ignificant factor for transient experiences of depers onalization and derealization, with adolescents young adults reporting the highes t rates in normal population s amples . Approximately one-half of college students (46 percent) in one s tudy reported at leas t 1922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 144 of 302

significant episode of depersonalization within the prior year.

E tiology Ps yc hodynamic T raditional ps ychodynamic formulations have the disintegration of the ego or have viewed depers onalization as an affective res ponse in defense the ego. T hese explanations stress the role of overwhelming painful experiences or conflictual as triggering events. T he high rates in normal and in patients conceptualized as having borderline or narcis sistic pers onality organizations are cited as that ego immaturity or ego deficits are predisposing factors . More recently, attention has been drawn to the similarities between depersonalization and obsess ivecompuls ive s ymptoms. Depers onalization dis order patients often dis play obsess ive-like behaviors with res pect to their s ymptoms. T he split between an and a participating s elf is likened to the divis ion of and emotional experience in obsess ive patients. B oth groups res pond to serotonin reuptake inhibitors, the therapeutic res ponse for depers onalization disorder patients is usually less robust.

Traumatic S tres s A s ubs tantial proportion, typically one-third to one-half, patients in clinical depersonalization cas e s eries report histories of s ignificant trauma. S everal studies of victims find as much as 60 percent of those with a lifethreatening experience report at least trans ient depers onalization during the event or immediately 1923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 145 of 302

thereafter. Military training s tudies find that symptoms depers onalization and derealization are commonly by stress and fatigue and are invers ely related to performance. One of P.1872 the few controlled, clinical studies found s ignificantly childhood trauma, es pecially emotional abuse, in welldiagnosed depers onalization disorder patients with normal s ubjects. In approximately 20 percent of a sample of chronic depers onalization patients , there was a first-degree relative with a severe ps ychotic illnes s, either schizophrenia or bipolar dis order. It was hypothesized the chronic fear engendered by the ps ychotic relative etiological in the s ubs equent development of the depers onalization disorder. F or example, one patient reported that, throughout her childhood, she was left alone by her father and older brother to handle her schizophrenic mother whenever the mother had episodes . T he patient recalled waiting in a s tate of and dread until the emergency workers came and hospitalized her mother. In general, the trauma reported by the patients was less severe than that typically reported by other diss ociative dis order patients. A large general population s tudy found that individuals with chronic were three times more likely to have episodes of depers onalization, but there was only a weakly as sociation with dangerous or ups etting experiences . A subs tantial number of individuals with disorder do not identify a traumatic antecedent and 1924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 146 of 302

that the onset of their disorder occurred without a clear precipitant. On the other hand, nontraumatic s tres sors , such as interpers onal, financial, or occupational loss es, have been as sociated with the ons et or exacerbation of depers onalization disorder. In addition, chemical such as marijuana, hallucinogens, and s timulants , have been known to precipitate chronic depersonalization in some people. T hese individuals can be conceptualized having a neurobiological or genetic vulnerability to chronic depersonalization after drug us e.

Temporal L obe and L imbic Theories In the epileps y literature, there is a long-standing as sociation between symptoms of depersonalization derealization and temporal lobe and limbic s ys tem dysfunction. Wilder P enfield reported depersonalization symptoms elicited during neuros urgery by s timulation the superior and middle temporal gyri. B rain imaging studies have likewise found differential activation of areas. T he only s tudy to date res tricted to depers onalization patients found decreas ed activity in right s uperior and middle temporal gyri and increased brain glucos e metabolism bilaterally in the parietal Dis sociation and depers onalization s cale s cores were strongly correlated with increased parietal metabolic activity. Imaging s tudies of dis sociative s tates in P T S D patients find activation in all of thes e areas , as well as medial frontal gyrus and anterior cingulate gyrus. S ierra and G erman B errios propos e that involves a corticolimbic disconnection, such that left medial prefrontal activation reciprocally inhibits the left amygdala, producing detachment and decreased whereas right dorsolateral prefrontal activation with 1925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 147 of 302

concomitant right amygdala inhibition leads to problems and feelings of emptines s.

Neurobiologic al Theories T he as sociation of depersonalization with migraines marijuana, its generally favorable res pons e to s elective serotonin reuptake inhibitor (S S R I) drugs , and the in depersonalization s ymptoms s een with the depletion L-tryptophan, a s erotonin precurs or, point to serotoninergic involvement. Depers onalization is the primary diss ociative symptom elicited by the drugchallenge s tudies des cribed in the s ection on neurobiological theories of dis sociation. T hese studies strongly implicate the NMDA s ubtype of the glutamate receptor as central to the genesis depers onalization symptoms. It s eems likely that serotoninergic and glutamate systems are involved in clinical depers onalization. T wo recent twin s tudies are for a genetic contribution to the development of depers onalization disorder.

Diagnos is and C linic al F eatures P atients experiencing depers onalization often have difficulty express ing what they are feeling. T rying to expres s their subjective s uffering with banal phras es , as “I feel dead,” “nothing s eems real,” or “I'm s tanding outside of myself,” depers onalized patients may not adequately convey to the examiner the distress they experience. W hile complaining bitterly about how this is ruining their life, they may nonetheles s appear undis tres sed. Accordingly, clinicians may not take the severity of this dis order as s eriously as they should. 1926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 148 of 302

this outward appearance of lack of distress , depers onalization disorder patients are enduring an intens ely unpleasant, and often disabling, s ubjective experience. Many s ay that they would gladly exchange depers onalization for physical pain, which would at reconnect them with their body. T here are a number of distinct components to the experience of depers onalization. T hes e include a bodily changes , a s ens e of duality of self as observer actor, a s ens e of being cut off from others , and a sense being cut off from one's own emotions. On the other de re alization, coined by W illiam Mapother, is the s ens e that the world appears s trange, foreign, or dream-like. conceptualized as a diss ociative alteration in the perception of the environment. Objects may appear as viewed from a great dis tance and as if they are two dimensional, without depth or s ubs tance. S ounds come from a dis tance, muffled and dis torted. Objects feel strange to the touch. C olors dim and lose their vitality. faces of others change, becoming unfamiliar and frightening. T he world and all action and behavior los e meaning and purpose. Ms. R . was a 27-year-old, unmarried, graduate student a Masters in B iology. S he complained about episodes of “standing back,” us ually ass ociated with anxiety-provoking social s ituations . When as ked about recent episode, s he des cribed pres enting in a seminar cours e. “All of a s udden, I was talking, but it didn't feel it was me talking. It was very disconcerting. I had this feeling, ‘who's doing the talking? ' I felt like I was just watching. W atching someone els e talk. Lis tening to 1927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 149 of 302

come out of my mouth, but I was n't s aying them. It me. It went on for a while. I was calm, even sort of It was as if I was very far away. In the back of the room somewhere—just watching myself. B ut the pers on didn't even seem like me really. It was like I was someone els e.” T he feeling lasted the res t of that day persis ted into the next, during which time it gradually diss ipated. S he thought that s he remembered having similar experiences during high school but was certain they occurred at leas t once a year during college and graduate s chool. Although she said that she us ually felt detached and s ometimes peaceful during the she was upset at the thought that s he would likely have more epis odes. S he complained that the sudden ons et, eeriness of s eemingly watching an almos t version of herself from a dis tance, and the sense of not “being in the world” were almos t unbearable in As a child, Ms. R . reported frequent intense anxiety overhearing or witnes sing the frequent violent and periodic physical fights between her parents. S he remembered lying awake in bed, listening to her imagining the terrible things that were occurring, or to occur, between them. In addition, the family was to many unpredictable dislocations and moves owing to the patient's father's intermittent difficulties with and employment. T he patient's anxieties did not abate when the parents divorced when she was a late adoles cent. Her father moved away and had little contact with her. Her relations hip with her mother increasingly angry, critical, and contentious. S he was unsure if she experienced depers onalization during childhood while listening to her parents ' fights. 1928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 150 of 302

P.1873

Differential Diagnos is T he variety of conditions ass ociated with complicate the differential diagnos is of disorder. Depersonalization may result from a medical condition or neurological condition, intoxication or withdrawal from illicit drugs , or as a s ide effect of medications or may be ass ociated with panic attacks, phobias, P T S D, or acute s tres s disorder, schizophrenia, another dis sociative disorder. A thorough medical and neurological evaluation is es sential, including s tandard laboratory s tudies , an E E G , and any indicated drug Drug-related depers onalization is typically trans ient, but persis tent depers onalization may follow an episode of intoxication with a variety of s ubs tances , including marijuana, cocaine, and other psychostimulants. A neurological conditions , including s eizure disorders , tumors , postconcus sive syndrome, metabolic abnormalities , migraine, vertigo, and Ménière's dis eas e, have been reported as causes . Depersonalization organic conditions tends to be primarily s ensory without the elaborated des criptions and pers onalized meanings common to ps ychiatric etiologies.

C ours e and P rognos is Depersonalization after traumatic experiences or intoxications commonly remits spontaneously after removal from the traumatic circums tances or ending of episode of intoxication. Depersonalization mood, ps ychotic, or other anxiety disorders commonly 1929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 151 of 302

remits with definitive treatment of these conditions . Depersonalization dis order its elf may have an episodic, relaps ing and remitting, or chronic course. T he latter is most common. Many patients with chronic depers onalization may have a course characterized by severe impairment in occupational, s ocial, and functioning. Mean age of ons et is thought to be in late adoles cence or early adulthood in mos t cases. Mos t depers onalization disorder patients are initially treated secondary anxiety and mood dis order symptoms. T he primary nature of the depers onalization dis order is only recognized later on. T raumatic or s tres sful events exacerbate depers onalization disorder symptoms . S ymptom exacerbations are commonly related to affects; high levels of sensory input; and threatening, stress ful, or unfamiliar situations .

Treatment C linicians working with depersonalization patients often find them to be a singularly clinically refractory group. T here is s ome s ys tematic evidence that S S R I antidepres sants, such as fluoxetine (P rozac), may be helpful to depersonalization patients. However, two recent, double-blind, placebo-controlled studies found efficacy for fluvoxetine (Luvox) and lamotrigine, res pectively, for depers onalization disorder. C linical experience s uggests that many depers onalization res pond at bes t s poradically and partially to the usual groups of psychiatric medications, s ingly or in combination: antidepres sants, mood s tabilizers , typical and atypical neuroleptics , anticonvuls ants, and s o Many different types of psychotherapy have been used 1930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 152 of 302

with depers onalization patients : ps ychodynamic, cognitive, cognitive-behavioral, hypnotherapeutic, and supportive. No systematic data exist that compare modalities. C linical experience s ugges ts that many depers onalization patients do not have a robust to thes e s pecific types of standard ps ychotherapy. A large cas e s eries of severely ill depers onalization found that s tres s management strategies , dis traction techniques, reduction of sensory s timulation, relaxation training, and phys ical exercise may be somewhat some patients. Nonetheles s, many s everely impaired patients may require long-term s upportive treatment, the clinician being acutely aware of the patient's interpersonal sensitivity, distress , and s ens e hopeless nes s about the condition. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E F UG

DIS S OC IATIVE FUGUE P art of "17 - Dis sociative Dis orders " Dis sociative fugue is the leas t s tudied and mos t poorly unders tood of the dis sociative disorders . T he the disorder are similar to those of dis sociative and diss ociative identity disorder.

Definition T he es sential feature of diss ociative fugue (T able 17described as sudden, unexpected, travel away from 1931 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 153 of 302

or one's customary place of daily activities, with recall some or all of one's past (C riterion A). T his is accompanied by confusion about pers onal identity or even the ass umption of a new identity (C riterion B ). disturbance does not occur exclus ively during the of dis sociative identity dis order and is not due to the phys iological effects of a s ubs tance or a general condition (C riterion C ). T he symptoms mus t cause significant distress or impairment in s ocial, or other important areas of functioning (C riterion D).

Table 17-12 DS M-IV-TR C riteria for Dis s oc iative Fugue A. T he predominant dis turbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall past. B . C onfus ion about personal identity or of a new identity (partial or complete). C . T he disturbance does not occur exclusively the cours e of dis sociative identity dis order and is due to the direct phys iological effects of a (e.g., a drug of abus e, a medication) or a general medical condition (e.g., temporal lobe epilepsy). D. T he s ymptoms cause clinically s ignificant 1932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 154 of 302

or impairment in s ocial, occupational, or other important areas of functioning.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

His tory In the 19th century, the magnetic dis orders included nocturnal s omnambulism and its waking counterpart, ambulatory automatis m or fugue. In these conditions, person performed activities that were complex and coordinated but apparently “cut off from the continuity cons ciousnes s ” with res ultant amnes ia. C harcot and contemporaries reported a number of these cases and studied them intens ively. C harcot divided the cases those with epileptic, traumatic, or hys terical etiology, although a modern reading of the cases s ugges ts that some of thos e diagnosed with epileptic or traumatic fugues would be more readily class ified as having a diss ociative dis order today. Outs ide E urope, during this time, there was interes t in similar phenomena as well. In the United S tates, described one of the paradigmatic cases of fugue with change of pers onal identity, that of Ansel B ourne. an itinerant preacher, dis appeared from his home in P rovidence, R hode Is land, in J anuary 1887, after 1933 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 155 of 302

withdrawing $500 from his bank account to pay some T wo months later, he “awoke,” finding hims elf in Norristown, P ennsylvania, where had been living under the name of A. J . B rown and working as a shopkeeper. S ubsequently, he had no memory for the between his disappearance and his return to the identity. Under hypnos is , he could communicate as and described his activities during the fugue but could unify his memory with that of B ourne. During the fugue, B ourne apparently behaved normally and did not unusual attention. J anet als o s tudied fugue s tates in his clas sic s tudies of diss ociation and hys teria. J anet hypothesized that was bas ed on diss ociation of more complex groups of mental functions than occurred in amnesia and was us ually organized around a powerful emotion or feeling state that linked many trains of ass ociations by a wish to run away. P.1874 Dis sociative fugue was also des cribed by World W ars I II military ps ychiatris ts. Important papers des cribing studies of diss ociative fugue in civilian and military populations were written in the 1940s by the ps ychoanalytic authors David R appaport, C harles E lisabeth G eleerd, Merton G ill, and Margaret B renman, among others. However, many of thes e cases would clas sified as dis sociative amnesia, diss ociative NOS , or, poss ibly, dis sociative identity dis order by contemporary diagnos tic criteria.

Nos ology 1934 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 156 of 302

T here are insufficient data to validate diss ociative a disorder distinct from diss ociative amnes ia, identity dis order, or other trauma s pectrum conditions. F urther research is needed to clarify whether fugue s hould be cons idered a s eparate disorder rather than a s ymptom of other disorders. Individuals with various culturally defined running syndromes may have s ymptoms that meet diagnos tic criteria for dis sociative fugue. T hese conditions are characterized by a s udden onset of a high level of trance-like states , potentially dangerous behavior in the form of running or fleeing, and ens uing exhaustion, and amnesia for the epis ode. T hey include pibloktoq among native peoples of the Arctic, gris i s iknis among Miskito of Honduras and Nicaragua, latah and amok in Wes tern P acific cultures , and Navajo frenzy witchcraft.

E tiology T raumatic circumstances, leading to an altered s tate of cons ciousnes s dominated by a wish to flee, are be the underlying caus e of most fugue episodes . have included combat, rape, recurrent childhood abuse, mass ive s ocial dis locations , and natural most other cases , there has been a s imilar antecedent history, although a ps ychological trauma was not at the ons et of the fugue epis ode. In thes e cases, of, or in addition to, external dangers or traumas, the patients were us ually s truggling with extreme emotions impulses, s uch as overwhelming fear, guilt, shame, or intens e incestuous , s exual, suicidal, or violent urges, or combination of thes e, that were in conflict with the patient's cons cience or ego ideals . T hus, the patients 1935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 157 of 302

also des cribed as experiencing mas sive ps ychological conflict from which fight or flight was experienced as impos sible or psychologically unacceptable, resulting in diss ociation in which the patient could flee without cons ciously acknowledging doing s o. S hortly after the end of the G ulf War, a s oldier was to a military ps ychiatric facility after emerging from a movie in a disoriented and disorganized s tate. the police were called and determined that he had no apparent awarenes s of his identity or life his tory and he was disoriented to current circumstances. At the hospital, a complete medical, toxicological, and neurological workup was within normal limits, and a ps ychiatric consultation was reques ted. T he patient presented as a perplexed, disoriented, healthy young who des cribed complete amnesia for pers onal identity life history, depers onalization, derealization, confus ion, and anxiety and fear at his predicament. Military were located that showed the patient to have been in combat in the G ulf W ar. He had been s ubject to a fire incident in which several of his buddies were killed he himself barely escaped severe injury or death. He treated at a military hospital and was airlifted back to United S tates , where he was treated at another military facility, was adjudged healthy, and, at his reques t, was discharged back to active duty. He was noted to have gone absent without leave at this point and only res urfaced in the movie theater, 3 months later, 2,000 miles from where he was suppos ed have reported back for duty. W hen family and friends visited, he experienced them as “familiar” but did not 1936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 158 of 302

who they were. T he patient's father was a decorated veteran of World II who had phys ical dis abilities and P T S D subsequent service. He enforced brutal phys ical discipline on his children but was a charis matic, complex man deeply loved by his children, who protected and him. He had died suddenly, shortly before the patient entered military s ervice. T he s on had vowed to follow his father's footsteps. T he patient did not res pond to attempts to help him regain his memory by free recall s trategies, and a hypnosis was begun. Over a s eries of hypnosis the patient was given age-regress ion suggestions , him back to the beginning of the fugue, the time during the fugue, the point of loss of awarenes s of pers onal identity, and the events during the war. T he events were recons tructed as follows: T he patient not shown it at the time but had been profoundly traumatized by the friendly fire incident. He felt guilt at surviving his friends, horror at the carnage that had place around him, terrified at what had happened, and furious at his own military and government for its in the occurrence of the friendly fire event. He was at his superiors, his branch of service, and his country, whom he felt had failed him and his friends by attacking them. At the s ame time, he was deeply loved his country, and identified with his father's wish him to be a “good s oldier.” After dis charge from the state-side hos pital, he that he needed to get back to his unit and put the past behind him. Unconsciously, however, he felt vengeful toward the military and had violent fantas ies of 1937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 159 of 302

agains t his superiors. During his travels acros s the he had the overriding conviction that he had to get to join his unit, although traveling thousands of miles in the oppos ite direction. He ass umed another name and apparently attracted no attention during his In the city in which he was found, he met several who sugges ted that he attend a movie with them. T he movie plot centered around a friendly fire episode the V ietnam W ar. T he patient became emotionally overwhelmed, entered an altered s tate, and eventually brought to clinical attention. Over the course of s everal months of hypnotherapy ps ychotherapy, the patient was able to regain his and to better integrate his respons e to the wartime traumas and began to work out and tolerate his mixed feelings about his father. At times, recall of the wartime and childhood traumas was as sociated with intense of sadnes s, anger, horror, and confusion. He well to addition of an S S R I antidepress ant to help modulate symptoms of P T S D, dysphoria, depres sion, anxiety. As therapy progress ed, the patient was more to tolerate thes e emotions and was less overwhelmed them. He also began to report a much more chronic history of diss ociative s ymptoms, with pers is tent imaginary companions until late adoles cence, fugue and amnesia episodes in childhood and adoles cence, and a sens e of inner division into multiple s elf-states . He received a medical dis charge from the military with diagnoses of P T S D, diss ociative dis order NOS , and disorder NOS .

1938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 160 of 302

E pidemiology As noted previous ly, no cas e of diss ociative fugue was diagnosed in a random general population s ample in Winnipeg, C anada. T he disorder is thought to be more common during natural disasters , wartime, or times of major social dislocation and violence, although no systematic data exis t on this point. Most of the pre– cases are difficult to ass ess , because the diagnostic conventions are so different. Most cas es in the describe men with diss ociative fugue, primarily in samples . However, no adequate data exis t to a gender bias to this dis order. Dis sociative fugue is described in adults . P.1875

Diagnos is and C linic al F eatures Dis sociative fugues have been des cribed to las t from minutes to months. S ome patients report multiple However, in most cases in which this was described, a more chronic dis sociative disorder, such as identity dis order, was not ruled out. In some extremely s evere cas es of P T S D, nightmares be terminated by a waking fugue in which the patient to another part of the hous e or runs outs ide, for C hildren or adolescents may be more limited than in their ability to travel. T hus, fugues in this population may be brief and involve only short distances. S ome of children or adoles cents who precipitously run away actually may be cases of diss ociative fugue, with the es caping from an abusive or violent home situation. No 1939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 161 of 302

systematic res earch exis ts on this point. A teenage girl was continually sexually abused by her alcoholic father and another family friend. S he was threatened with perpetration of sexual abus e on her younger s iblings if she told anyone about the abuse. girl became suicidal but felt that she had to stay alive to protect her siblings . S he precipitously ran away from after being raped by her father and s everal of his a “birthday present” for one of them. S he traveled to a of the city where she had lived previously with the idea that s he would find her grandmother with whom she lived before the abus e began. S he traveled by public transportation and walked the s treets, apparently attracting attention. After approximately 8 hours , she stopped by the police in a curfew check. When she could not recall recent events or give her current addres s, ins isting that she lived with her grandmother. initial ps ychiatric examination, she was aware of her identity, but she believed that it was 2 years earlier, her age as 2 years younger and insisting that none of events of recent years had occurred. C las sically, three types of fugue have been described: fugue with awarenes s of loss of pers onal identity; (2) with change of pers onal identity; and (3) fugue with retrograde amnesia. In stage I, there is thought to be generation of an altered state of cons cious nes s during which complex activities may be engaged in, over long periods of time. A s ingle idea that s ymbolizes condenses, or both, a number of important ideas and emotions frequently dominates the patient's thinking in this s tage. In stage II, the patient becomes aware of 1940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 162 of 302

amnes ia or loss of pers onal identity, at which point he she frequently is brought for treatment. In this s tage, amnes ia is us ually pres ent for the first stage. In s tage patient returns to his or her baseline state, usually with amnes ia for the first stage and s ometimes for the as well. An alternative view des cribes stage II as a the baseline state with amnesia for stage one or to a in which there is (1) awarenes s of loss of pers onal (2) change in personal identity, or (3) return to a chronologically earlier period of life, similar to a spontaneous hypnotic age regress ion. During a fugue, patients often appear without ps ychopathology and do not attract attention. On the other hand, some individuals may display overtly disorganized, or dangerous behavior, such as a soldier the mids t of battle who began a fugue epis ode by standing up and walking away from the front lines , expos ing hims elf to intense enemy fire. After the termination of a fugue, the patient may experience perplexity, confus ion, trance-like behaviors, depers onalization, derealization, and convers ion symptoms, in addition to amnesia. S ome patients may terminate a fugue with an epis ode of generalized diss ociative amnesia. T hey may be brought to media attention in an attempt to dis cover who they are and where they have come. As the dis sociative fugue patient begins to become diss ociated, he or s he may display mood disorder symptoms, intense suicidal ideation, and P T S D or anxiety dis order symptoms. In the class ic cases, an identity is created under whos e auspices the patient for a period of time. Many of these latter cas es are 1941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 163 of 302

clas sified as dis sociative identity disorder or disorder NOS with features of dis sociative identity disorder.

P athology and L aboratory E xamination P atients with diss ociative fugue tend to have high on s tandardized measures of hypnotizability and diss ociation. Diss ociative fugue can be diagnosed with DDIS or the S C ID-D-R . B ecause dis sociative fugue res ponse to s exual trauma, clinicians s hould have an of sus picion for s exually trans mitted dis eas es and or rectal trauma. P hysical and laboratory examinations should be directed at ruling out medical caus es of diss ociative fugue.

Differential Diagnos is Individuals with dis sociative amnes ia may engage in confused wandering during an amnes ia epis ode. in dis sociative fugue, there is purpos e ful travel away the individual's home or customary place of daily us ually with the individual preoccupied by a single idea that is accompanied by a wish to run away. P atients with diss ociative identity disorder may have symptoms of diss ociative fugue, usually recurrently throughout their lives . Dis sociative identity dis order patients have multiple forms of complex amnes ias and, us ually, multiple alter identities that develop starting in childhood. In complex partial s eizures, patients have been noted exhibit wandering or semi-purpos eful behavior, or both, during seizures or in pos tictal s tates, for which there is 1942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 164 of 302

subs equent amnesia. However, seizure patients in an epileptic fugue often exhibit abnormal behavior, confusion, perseveration, and abnormal or repetitive movements. Other features of s eizures are typically reported in the clinical his tory, s uch as an aura, motor abnormalities , s tereotyped behavior, perceptual alterations , incontinence, and a postictal s tate. events may be ass ociated with an increas e in s eizure frequency in some s us ceptible patients . T hus, this alone is not s ufficient as a differential diagnostic S erial or telemetric E E G s, or both, usually s how abnormalities as sociated with behavioral pathology. Wandering behavior during a variety of general medical conditions, toxic and s ubs tance-related dis orders, dementia, and organic amnes tic s yndromes could theoretically be confus ed with diss ociative fugue. However, in most cases , the s omatic, toxic, subs tance-related dis order can be ruled in by the phys ical examination, laboratory tes ts, or toxicological drug s creening. Us e of alcohol or substances may be involved in precipitating an epis ode of dis sociative Wandering and purposeful travel may occur during the manic phase of bipolar disorder or schizoaffective Manic patients may not recall behavior that occurred in the euthymic or depress ed s tate and vice versa. In purpos eful travel due to mania, however, the patient is us ually preoccupied with grandiose ideas and often attention to hims elf or herself owing to inappropriate behavior. Ass umption of an alternate identity does not occur. S imilarly, peripatetic behavior may occur in some with s chizophrenia. Memory for events during 1943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 165 of 302

episodes in such patients may be difficult to ascertain owing to the patient's thought P.1876 disorder. However, dis sociative fugue patients do not demonstrate a ps ychotic thought disorder or other symptoms of ps ychosis . Malingering of diss ociative fugue may occur in who are attempting to flee a s ituation involving legal, financial, or pers onal difficulties , as well as in soldiers are attempting to avoid combat or unpleasant military duties . T hese precipitating factors may be present as in bona fide diss ociative fugue, however. T here is no battery of tests, or s et of procedures that invariably distinguish true dis sociative s ymptoms from those that malingered. Malingering of diss ociative symptoms, reports of amnes ia for purpos eful travel during an of antisocial behavior, can be maintained even during hypnotic or pharmacologically facilitated interviews. malingerers confess s pontaneous ly or when the forensic context, the examiner s hould always give careful cons ideration to the diagnos is of malingering fugue is claimed.

C ours e and P rognos is Most fugues are relatively brief, lasting from hours to Most individuals appear to recover, although refractory diss ociative amnesia may persist in rare cases. S ome studies have described recurrent fugues in the majority individuals presenting with an epis ode of dis sociative fugue. However, no s ys tematic modern data exis t that attempt to differentiate diss ociative fugue from 1944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 166 of 302

diss ociative identity disorder with recurrent fugues .

Treatment Dis sociative fugue is usually treated with an eclectic, ps ychodynamically informed ps ychotherapy that on helping the patient recover memory for identity and recent experience. Hypnotherapy and facilitated interviews are frequently necess ary techniques to as sist with memory recovery. T herapy should be carefully paced, following the phas ic discuss ed in prior sections. T he initial phase is es tablis hing clinical s tabilization, safety, and a alliance us ing supportive and educative interventions . P atients may need medical treatment for injuries during the fugue, food, and sleep. Once stabilization is achieved, s ubs equent therapy is focus ed on helping the patient regain memory for life circums tances , and personal history. During this proces s, extreme emotions related to trauma or s evere ps ychological conflict, or both, may emerge that require working through. In general, the therapist should a s upportive and nonjudgmental stance, es pecially if fugue has been precipitated by intense guilt or shame an indis cretion. At the s ame time, it is important for the therapist to balance this with being a spokes pers on for patient, taking realis tic res ponsibility for misbehavior. C linicians s hould be prepared for the emergence of suicidal ideation or s elf-destructive ideas and impuls es the traumatic or s tres sful prefugue circums tances are revealed. P sychiatric hospitalization may be indicated if the patient is an outpatient. 1945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 167 of 302

In this phase of treatment, hypnotherapy may be containing intense affects and impulses , titrating the of returning memory, and process ing and integrating memory material. P atients may need specific ps ychopharmacological interventions for mood, and dyscontrol s ymptoms as the acute dis sociative symptoms are reduced and the patient becomes cons ciously aware of his or her actual life situation. S ome diss ociative fugue patients may res is t their actual identity even with hypnosis or pharmacologically as sis ted interviews. Appeals through the local (or even regional) media may not alert the patient's concerned others if the patient has wandered subs tantial dis tance from home. In one case, the was as ked to randomly s elect numbers on a phone key pad. T his res ulted in the patient's tapping out a phone number—apparently outside of cons cious awarenes s — that allowed the treating clinician to find the patient's family hundreds of miles away. F amily, s exual, occupational, or legal problems , or a combination of these, that were part of the original that generated the fugue episode may be s ubs tantially exacerbated by the time the patient's original identity life s ituation are detected. T hus , family treatment and social s ervice interventions may be necess ary to help res olve s uch complex difficulties . R arely, in the mos t extreme cases, the fugue patient es tablis hed a new identity, occupation, and s ocial relations hips in a different location. When the original identity is dis covered, often by accident, a variety of predicaments may ensue regarding the real-world complications of the s ituation. In res pons e to these, the 1946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 168 of 302

patient may become acutely s uicidal, overwhelmed, or confused, or a combination of these. Als o, the patient display other extreme or bizarre dis sociative such as the G anser s ymptom of approximate answers the question “What color is snow? ” is answered with “green”) or attempt to engage in another fugue to the s ituation. When diss ociative fugue involves ass umption of a new identity, it is us eful to conceptualize this entity as ps ychologically vital to protecting the person. experiences , memories , cognitions, identifications, emotions , s trivings , or self-perceptions, or a of thes e, have become s o conflicting and, yet, s o peremptory that the pers on can res olve them only by embodying them in an alter identity. T he therapeutic in such cas es is neither s uppress ion of the new identity fas cinated explication of all its attributes . As in identity dis order, the clinician s hould appreciate the importance of the psychodynamic information within the alter pers onality state and the intensity of the ps ychological forces that necess itated its creation. In cases, the mos t desirable therapeutic outcome is the identities , with the person working through and integrating the memories of the experiences that precipitated the fugue. Once the fugue had resolved, the problem of for illegal acts may become an is sue (e.g., having without divorcing a prior s pouse, financial T he treating ps ychiatris t may become involved with and legal agencies , military authorities, and others who may be brought into these complex cases . It is prudent for the treating clinician to try to balance in 1947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 169 of 302

commons ens e way the patient's real respons ibility for or her behavior, as well as the ps ychopathological that may be mitigating factors. Attempts to find a mediated agreement among the contending parties than punis hment alone may be best in s ituations in sexual, marital, or financial mis deeds, or a combination these, complicate the clinical situation. However, it is important that, whatever resolution is found, it should focus on real res ponsibility for mis conduct being by the patient. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E IDE NT IT Y

DIS S OC IATIVE IDE NTITY DIS OR DE R P art of "17 - Dis sociative Dis orders " Dis sociative identity dis order, previously called multiple pe rs onality dis orde r, has been res earched most of all the dis sociative disorders . It is the paradigmatic diss ociative psychopathology in that the symptoms of the other diss ociative disorders are commonly found in patients with diss ociative identity disorder: amnesias, fugues , depers onalization, derealization, and similar symptoms. According to DS M-IV -T R , diss ociative identity disorder characterized by the pres ence of two or more distinct identities or P.1877 1948 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 170 of 302

personality s tates that recurrently take control of the individual's behavior accompanied by an inability to important pers onal information that is too extensive to explained by ordinary forgetfulness .” T he identities or personality s tates, sometimes called alters , s e lf-s tate s , ide ntitie s , or parts , among other terms , differ from one another in that each pres ents as having “its own enduring pattern of perceiving, relating to, and thinking about the environment and self” (T able 17-13).

Table 17-13 DS M-IV-TR C riteria for Dis s oc iative Identity Dis order A. T he presence of two or more dis tinct identities personality s tates (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and s elf). B . At least two of thes e identities or pers onality states recurrently take control of the person's behavior. C . Inability to recall important personal that is too extens ive to be explained by ordinary forgetfulness . D. T he disturbance is not due to the direct 1949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 171 of 302

phys iological effects of a s ubs tance (e.g., or chaotic behavior during alcohol intoxication) or general medical condition (e.g., complex partial seizures ). Note: In children, the s ymptoms are attributable to imaginary playmates or other play.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

His tory After the extraordinary interest in multiple pers onality throughout the 19th century, the study of diss ociative identity dis order mostly waned after the beginning of 20th century. Authorities s ugges t that this was related variety of factors , including the rising dominance of freudian paradigms of hysteria; the dis repute into which hypnosis fell at this time; the ris e of the bleulerian cons truct of s chizophrenia, which may have s ubsumed diss ociative patients; and the los s of interest in the of J anet, P rince, and others who had been so crucial in development of models of diss ociation. A number of studies, such as the famous T hre e F ace s of E ve , to be published in the profes sional and popular In addition, periodic s ys tematic reviews of the literature continued to support the validity of the diagnos tic 1950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 172 of 302

cons truct. T he modern era in the s tudy of multiple pers onality disorder began with the work of Arnold Ludwig and colleagues at the Univers ity of K entucky during the T his included their extens ive work on the single cases of diss ociative identity disorder and personality disorder, studying the differential findings among the alter identities . C ornelia W ilbur, widely identified with the cas e of S ybil, was influential in describing the clinical features of the modern construct diss ociative identity disorder and identifying the role of childhood trauma as a major factor in the etiology of disorder. W ilbur, R ichard K luft, and others began the articulation of a systematic modern treatment B eginning in the 1980s , P utnam, E ve C arls on, J udith Armstrong, R os s, P hillip C oons , S teinberg, Onno van Hart, S uzette B oon, Nel Draijer, V edet S ar, and other res earchers in the United S tates , C anada, E urope, America, T urkey, and J apan began systematic studies on the phenomenology, epidemiology, ps ychobiology, and treatment of diss ociative identity disorder in children, adoles cents, and adults . Des pite controvers y continues over the validity of the disorder, with a vocal minority of clinicians subscribing to the of dis sociative identity dis order.

Validity of the Dis s oc iative Dis order C ons truc t Debate about the existence of dis sociative identity disorder has waxed and waned for more than a However, s ufficient data on pathological diss ociation, in general, and on diss ociative identity disorder, in 1951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 173 of 302

have accrued to judge this condition by the s ame standards that are applied to the validity of other ps ychiatric diagnoses . T he most widely accepted s tandards are bas ed on a criteria first articulated by E li R obins and S amuel G uze subs equently refined by others . In ess ence, a diagnosis is cons idered valid if it satis fies three basic requirements: content validity, criterion-related validity, and cons truct validity. C ontent validity requires a clinical description of the disorder that is repeatedly independently replicated. More than a dozen clinical phenomenological s tudies of dis sociative identity including those from North America, S outh America, E urope, T urkey, and Asia, document the presence of a diss ociative psychopathology in dis sociative identity disorder patients that fulfills this requirement. C riterionrelated validity requires that laboratory tests or reliable ps ychological tes ts are consis tent with the defined picture. T his stipulation is met by the reliable and valid diagnostic interviews and s cales that have increas ingly been used in diss ociation research, as well as tes ting protocols that discriminate diss ociative identity disorder patients from normals, s chizophrenics, and depres sed patients, among others . C ons truct or dis criminant validity requires that the disorder be differentiable from other disorders . T his been empirically demonstrated for diss ociative identity disorder with res pect to dis orders such as borderline and other pers onality disorders , and disorders . Als o, diss ociative identity disorder patients be dis criminated from normal individuals and other ps ychiatric patient groups , including those with 1952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 174 of 302

personality dis orders, P T S D, and dis sociative disorder by structured interviews such as the S C ID-D-R . P sychological tes t batteries and experimental cognitive and ps ychophys iological s tudies have discriminated diss ociative identity dis order patients from other including s imulators. In addition, recent reviews of the diss ociative identity disorder cons truct, using a number different ps ychiatric validity paradigms , found that diss ociative identity dis order met all current criteria for valid diagnosis in ps ychiatry. R ecent psychobiological s tudies have s hown that a of variables, s uch as s alivary cortis ol, urinary catecholamines , low-dose dexamethas onetes t (DS T ), and MR I meas urements of hippocampal amygdala volume, dis criminate dis sociative identity disorder from patients with borderline pers onality and trauma controls (T C s ). However, there were only subtle biological differences between dis sociative disorder and P T S D s ubjects, although the two groups differed s ignificantly in s everal meas ures of such as the C ADS S and the DE S . On the G S S , a meas ure of susceptibility to external press ure to confabulated narrative accounts , the diss ociative disorder s ubjects s cored as le s s s uggestible than with P T S D, borderline personality dis order, and traumatized controls . T hese findings s upport the notion that diss ociative identity disorder is best a posttraumatic ps ychopathology, not an iatrogenic condition or an epiphenomenon of borderline disorder or other disorders. Accordingly, dis sociative identity dis order satis fies accepted standards for ps ychiatric validity and s hould 1953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 175 of 302

regarded as a legitimate disorder requiring an informed diagnostic and treatment approach. P.1878

E pidemiology F ew s ys tematic epidemiological data exist for identity disorder. One study yielded a prevalence rate 3.1 percent for a stratified s ample (N = 1,055) of the general population of W innipeg, C anada, although a cons ervative analysis of these data sugges ts a of approximately 1.3 percent for dis sociative identity disorder. Independent analys is of the DE S data on the same s ample found a prevalence rate of 3.3 for pathological dis s ociation, a construct including DE S items for amnes ia, depersonalization, derealization, identity confus ion and alteration, and inner voices (ps eudohallucinations), a s ymptom profile typical of clinical diss ociative identity disorder patients . S everal studies have examined the prevalence rate of identity dis order in general ps ychiatric patient s amples . R es ults from the United S tates , C anada, T urkey, and Wes tern E uropean countries using structured interview data s uggest that between 1 and 20 percent of and adult psychiatric inpatients meet diagnostic criteria diss ociative identity disorder, with an average es timate 3 to 5 percent across studies. Higher rates were found subs tance abus e treatment populations and inpatient adoles cents . Available epidemiological data are insufficient, and a large-scale, population-based study neces sary to res olve controversies about the diss ociative identity disorder. 1954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 176 of 302

C linicians have long noted gender differences in the frequency of diss ociative identity disorder. C linical report female to male ratios between 5 to 1 and 9 to 1 diagnosed cases. R esearch with meas ures s uch as the however, finds no evidence of gender differences in the propens ity or capacity to dis sociate. Developmental studies indicate that the ratio of female to male diss ociative identity disorder cas es s teadily increas es 1 to 1 in early childhood to approximately 8 to 1 by late adoles cence. R easons proposed for the increas ed of female dis sociative identity dis order patients relative male patients include gender-related differences in the types , age of ons et, and duration of maltreatment experienced by men and women; differences in clinical presentations , s uch that male cas es are more likely to miss ed; and the poss ibility that more male diss ociative identity dis order cases end up in the criminal jus tice or alcohol and drug treatment systems , or both, rather the mental health system.

E tiology T heories of the etiology of diss ociative dis orders have been extensively discus sed in the introductory section diss ociative phenomena. T his section briefly the theories that are most relevant to diss ociative disorder and that are best s upported by empirical data. Dis sociative identity dis order is strongly linked to experiences of early childhood trauma, us ually maltreatment, in all studies —in W estern and noncultures—that have systematically examined this T he rates of reported severe childhood trauma for child and adult diss ociative identity disorder patients range 1955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 177 of 302

from 85 to 97 percent of cases acros s a wide variety of studies. P hys ical and sexual abuse, us ually in are the mos t frequently reported sources of childhood trauma in clinical research studies , although other trauma have been reported, s uch as multiple painful medical and surgical procedures during childhood and wartime trauma. C ritics have raised questions about validity of dis sociative identity dis order patients' s elfreports of childhood trauma. R ecent studies, including large s amples of maltreated children with diss ociative disorders and intensively validated case studies, have provided rigorous independent corroboration of the patients' reports of maltreatment. T hese studies to strongly s upport a developmental linkage between childhood trauma and diss ociative identity disorder. E arly life experiences resulting in dis turbances in attachment relations hip with the primary caregiver and other abnormal family proces ses have been implicated the genes is of pathological levels of diss ociation and development of diss ociative identity disorder. R ecent res earch indicates that a high level of diss ociation in mothers is ass ociated with dis turbed, often like, attachment behavior in their children. In another study, early pres ence of these attachment dis turbances prospectively predicted higher levels of diss ociation in adoles cence. T he contribution of genetic factors is only now being s ys tematically ass es sed, but preliminary have not found evidence of a significant genetic contribution. One small s tudy did find an elevated prevalence of dis sociative identity disorder and other diss ociative disorders in the firs t-degree relatives of diss ociative identity disorder patients. 1956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 178 of 302

Autohypnotic Model T he autohypnotic model is widely s ubs cribed to by clinicians working with dis sociative identity dis order patients. It postulates that pathological diss ociation is extreme form of s elf-hypnosis or autohypnos is . Autohypnos is is pos tulated to be adaptive in the immediate context of trauma or abus e but becomes maladaptively elaborated into dis sociative personality s tates. P roponents point to s imilarities between the phenomenology of deep trance states and some of the clinical phenomenology seen in identity dis order. Als o, adjunctive hypnotherapeutic interventions can be quite helpful in the treatment of many dis sociative identity dis order patients. In addition, studies of hypnotizability us ing s tandardized scales shown that dis sociative identity dis order patients have highes t hypnotizability compared to patients with other diagnoses, s uch as affective disorders , panic disorder, personality dis orders, and s chizophrenia, among well as normal controls. On the other hand, more than a dozen s tudies find only low correlations between meas ures of hypnotizability diss ociation in clinical and nonclinical s ubjects. A trauma is not ne ce s s arily as sociated with increas ed hypnotizability, although a s ubgroup of traumatized individuals shows high levels of hypnotizability clinically and on standardized measures. T hes e findings indicate that hypnotizability and clinical diss ociation, as defined standard meas ures , are different proces ses. Although hypnotizability may be a correlate of traumatization in some patients, the autohypnotic model of the etiology diss ociative identity disorder does not by its elf appear 1957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 179 of 302

account for the disorder. However, autohypnotic and phenomena may be involved in s haping the clinical presentation of diss ociative identity disorder.

Dis c rete B ehavioral S tate Model T he DB S model conceptualizes dis sociative identity disorder as a developmental failure by a traumatized to consolidate a core s ens e of identity. Drawing on res earch demons trating the key role of DB S in the patterning and organization of normal early childhood behavior and affect regulation, the behavioral s tate postulates that trauma disrupts unification of identity in least two key ways . T he first is through the creation of as sociated with the mitigation of and res titution from repetitive traumatic experiences, s uch as incest. T hes e diss ociative behavioral s tates psychologically intolerable memories and affects through cognitive mechanisms, s uch as s tate-dependent learning and memory retrieval, described previous ly. S econd, traumatic experiences, together with disturbed child attachment and parenting, dis rupt the of normal metacognitive process es involved in the elaboration and cons olidation of a unified sense of s elf. T hese metacognitive process es, which flower between 6 years of age, enable the child to integrate the experiences of s elf that normally occur acros s different contexts , for example, with parents, peers , and others. corollary of this notion is the idea that the failure of integration of self may pres erve as pects of parent–child attachment neces sary for development, becaus e the may continue to perceive the caretaker as good, mistreatment 1958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 180 of 302

P.1879 or neglect (as in betrayal trauma therapy). traumatic experiences may also permit more normal maturation in other developmental dimensions , s uch as educational and intellectual tas ks , interpersonal and artistic endeavors. Overall, however, the long-term outcome of thes e developmental deficits and deformations operating over childhood and adolescence is an individual with relatively concretized, quasi-independent s ens es of s elf, which are often in psychological conflict with each other. T he secondary s tructuring of these s elf-states , due to a variety of developmental press ures and intrapsychic res ults in the concrete elaboration of the alter identities with names , personal des criptors , and variable ways of presenting thems elves to others. T hes e s econdary elaborations are not the core aspect of the disorder. However, they may be highly invested in by some diss ociative identity disorder individuals and thus may quite resistant to change. At the other extreme, some diss ociative identity dis order patients may show liability to influence and s uggestion in outward presentational features of the alters. V irtually no empirical data in any clinical or res earch population exis t to support the sociocognitive or iatrogenes is theory of the etiology of diss ociative disorder.

Diagnos is and C linic al F eatures T able 17-13 lists the DS M-IV -T R criteria for diss ociative identity dis order. T he comparable IC D-10 dis order, 1959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 181 of 302

personality dis order, falls under the other diss ociative (conversion) dis order category. T he DS M-IV -T R and criteria are virtually identical. B oth require that organic disorders (e.g., general medical conditions , s ubs tance abuse) be ruled out. DS M-IV -T R adds that, in children, symptoms cannot be attributable to imaginary or other fantasy play.

Dimens ions of Trauma T raditional characterizations of dis sociative s ymptoms largely derive from 19th century formulations and do incorporate recent unders tanding of the psychiatric of trauma. C omparative study of ps ychiatric s ymptoms as sociated with different types of trauma sugges ts that number of common dimensions underlie traumatic sequelae. Affect modulation is frequently disturbed, ris e to mood s wings, depress ion, suicidal tendency, generalized irritability. Impuls e control is often leading to ris k taking, s ubs tance abus e, and or s elf-destructive behaviors. High levels of anxiety and panic are common. A variety of dis turbances in s ens e self, from the identity diffus ion s een in borderline to the alter identities of diss ociative identity disorder, reflects dis ruptions in the ps ychological integration of traumatic and nontraumatic aspects of self. E ating disorders are common in a s ubgroup of trauma and may als o relate to disorders of body image and identity. F requent somatization, conversion, and ps ychophys iological disorders may repres ent in the integration of ps ychic and s omatic of overwhelming recollections, intolerable affects, posttraumatic cognitive s chema, and intraps ychic conflicts. In addition, studies s uggest that childhood 1960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 182 of 302

abuse survivors with ps ychophysiological disorders , compared to controls , are more likely to have a lower threshold for experiencing phys iological phenomena as noxious or painful. C ons equently, initial clinical presentations in trauma victims of all kinds may encompas s or mimic a variety ps ychiatric conditions, including affective and anxiety disorders , somatoform disorders , personality dis orders , and ps ychos is . S ome of these dis orders may als o be comorbidly ass ociated with diss ociative identity es pecially P T S D, affective disorders , somatoform subs tance use dis orders, and a mixed personality most commonly with s ome combination of avoidant, obses sive-compuls ive, dependent, and borderline All systematic studies of the clinical phenomenology of diss ociative identity disorder emphasize the polys ymptomatic pres entations of these patients. T herefore, the detection and diagnosis of dis sociative identity disorder involve looking behind a confus ing plethora of symptoms for core diss ociative symptoms functional amnes ias, depersonalization and pass ive influence experiences, and identity alterations. T ables 17-14, 17-15, and 17-16 describe the symptom clus ters that are mos t commonly found in diss ociative identity dis order patients and s ome of the mental status questions that may elicit these s ymptoms in sus pected diss ociative identity disorder patients .

Table 17-14 Amnes ia and S ymptoms 1961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 183 of 302

B lackouts or time loss Dis remembered behavior F ugues Unexplained poss es sions Inexplicable changes in relations hips F luctuations in skills, habits, and knowledge F ragmentary recall of entire life his tory C hronic mistaken identity experiences Microdis sociations Mental s tatus examination ques tions for dis s oc iative amnes ia    If answers are pos itive, ask the patient to the event.    Make s ure to s pecify that the s ymptom does occur during an epis ode of intoxication.    (1) Do you ever have blackouts? B lank spells ?

1962 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 184 of 302

Memory laps es ?    (2) Do you los e time? Have gaps in your of time?    (3) Have you ever traveled a cons iderable without recollection of how you did this or where you went exactly?    (4) Do people tell you of things you have said done that you do not recall?    (5) Do you find objects in your poss es sion clothes, pers onal items , groceries in your grocery cart, books, tools, equipment, jewelry, vehicles, weapons , etc.) that you do not remember Out-of-character items? Items that a child might have? T oys? S tuffed animals ?    (6) Have you ever been told or found evidence you have talents and abilities that you did not that you had? F or example, musical, artis tic, mechanical, literary, athletic, or other talents ? Do your tastes s eem to fluctuate a lot? F or example, food preference, personal habits, taste in mus ic clothes, etc.    (7) Do you have gaps in your memory of your Are you miss ing parts of your memory for your history? Are you mis sing memories of some 1963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 185 of 302

important events in your life? F or example, weddings, birthdays, graduations, pregnancies, of children, etc.?    (8) Do you los e track of or tune out or therapy s es sions as they are occurring? Do find that, while you are lis tening to s omeone talk, you did not hear all or part of what was jus t s aid?    (9) What is the longes t period of time that you lost? Minutes? Hours ? Days? Weeks? Months ? Des cribe.

Adapted from Loewens tein R J : An office mental status examination for chronic complex symptoms and multiple personality dis order. P s ychiatr C lin North Am. 1991;14:567–604.

Table 17-15 Dis s oc iative Identity Dis order Proc es s S ymptoms P res ence of diss ociative identity disorder alter identities

1964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 186 of 302

S witching behaviors (identity alteration) Identity confusion P as sive influence s ymptoms /interference phenomena between alters    Made feelings from alter identity    Made impulses from alter identity    Made actions by alter identity    T hought ins ertion from alter identity    T hought withdrawal by alter identity    Alters ' voices commenting on behavior    Alters ' voices arguing Multimodal hallucinations or pseudohallucinations (may occur in a flas hback)    V isual    Auditory    T actile

1965 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 187 of 302

   Olfactory    G us tatory    S omatoform Dis sociative or pos ttraumatic thought dis order P os ttraumatic stress dis order–based cognitive distortions T rance logic Other thought process abnormalities    Disorganization due to s witching, pass ive    P osttraumatic s uspicious ness    Literal and concrete alternating with abstract Linguistic usage: refers to self as we, they, us , her, etc. Depersonalization and derealization symptoms    Depers onalization    Out-of-body experiences

1966 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 188 of 302

   Derealization    Déjà vu    J amais vu    Déjà-vécu    Dream-like states Mental s tatus examination ques tions for dis s oc iative identity dis order proc es s    If answers are pos itive, ask the patient to the event.    Make s ure to s pecify that the s ymptom does occur during an epis ode of intoxication.    (1) Do you act so differently in one s ituation compared to another s ituation that you feel like you were two different people?    (2) Do you ever feel that there is more than one you? More than one part of you? S ide of you? Do they s eem to be in conflict or in a struggle?    (3) Does that part (those parts) of you have its (their) own independent way(s) of thinking, perceiving, and relating to the world and the self? 1967 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 189 of 302

Have its (their) own memories , thoughts , and feelings?    (4) Does more than one of these entities take control of your behavior?    (5) Do you ever have thoughts or feelings , or that come from inside you (outs ide you) that you cannot explain? T hat do not feel like thoughts or feelings that you would have? T hat s eem like thoughts or feelings that are not under your (pass ive influence)?    (6) Have you ever felt that your body was in behavior that did not s eem to be under your control? F or example, saying things, going buying things, writing things, drawing or creating things , hurting yours elf or others , etc.? T hat your body does not seem to belong to you?    (7) Do you ever feel you have to s truggle another part of you that seems to want to do or to say s omething that you do not wish to do or to (8) Do you ever feel that there is a force part) inside you that tries to stop you from doing saying s omething?    (9) Do you ever hear voices, s ounds, or conversations in your mind? T hat s eem to be 1968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 190 of 302

discuss ing you? C ommenting on what you do? T elling you to do or not do certain things? T o hurt yours elf or others ? T hat s eem to be warning you trying to protect you? T hat try to comfort, support, or s oothe you? T hat provide important about things to you? T hat argue or say things that have nothing to do with you? T hat have names ? Men? W omen? C hildren?    (10) I would like to talk with that part (s ide, facet) of you (of the mind) that is called the “angry one” (the Little G irl, J anie, that went to Atlantic last weekend and s pent lots of money, etc.). C an part come forward now, pleas e?    (11) Do you frequently have the experience of feeling like you are outside yours elf, ins ide B es ide yourself, watching yourself as if you were another person?    (12) Do you ever feel disconnected from your body as if you (your body) were not real?    (13) Do you frequently experience the world around you as unreal? As if you are in a fog or a daze? As if it were painted? T wo-dimensional?    (14) Do you ever look in the mirror and not recognize yours elf? S ee someone else there?

1969 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 191 of 302

Adapted from Loewens tein R J : An office mental status examination for chronic complex symptoms and multiple personality dis order. P s ychiatr C lin North Am. 1991;14:567–604.

Table 17-16 Autohypnotic S ymptoms S pontaneous trance Deep enthrallment S pontaneous age regres sion Negative hallucinations Hidden obs erver phenomenon T rance logic (tolerance of logical incons is tency during a trance state) V oluntary analges ia/anes thes ia

1970 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 192 of 302

E ye roll, eye blinking, etc., with switching Mental s tatus examination ques tions for s pontaneous autohypnotic s ymptoms    (1) Do you frequently s pace out, trance out, out, withdraw from the world around you? by putting yours elf in a pleasant s cene or place in your mind? B y focus ing your attention on inside or outs ide of you? (s pontaneous trance)    (2) Do you get s o wrapped up in a book or a that you can completely block out everything else around you? As if the world could end, and you would s till be completely engros sed in that (enthrallment)    (3) Do you feel that you are different ages at different times ? Do you ever feel like you get Like you become a child or an adoles cent again? When this happens, does it feel like your body changes in s ize? Do you experience it in your only, or does your whole perception of yours elf the world change also? (spontaneous age regress ion)    (4) Do you ever not s ee or hear what is going around you? Do you or can you block out people and things altogether? (negative hallucinations)

1971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 193 of 302

   (5) Are you able to block out (ignore) physical if you want to? W holly? P artly? Always? (voluntary analgesia)

Adapted from Loewens tein R J : An office mental status examination for chronic complex symptoms and multiple personality dis order. P s ychiatr C lin North Am. 1991;14:567–604.

Memory and Amnes ia S ymptoms Dis sociative disturbances of memory are manifest in several basic ways and are frequently observable in settings (T able 17-14). As part of the general mental examination, clinicians s hould routinely inquire about experiences of losing time, black-out spells, and major gaps in the continuity of recall for pers onal information. P atients rarely s pontaneous ly report these experiences and require active P.1880 inquiry by the interviewer to uncover amnesia. P os itive res ponses s hould be documented with s pecific provided by the patient. In some ins tances , patients coming to or waking up in the mids t of some activity little or no recall of how they came to be involved in activity. In other instances, patients find evidence of having done or acquired things for which they have no recall. F riends and family members may tell them 1972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 194 of 302

significant things that they have said or done that they cannot remember. P atients may find that they have unknowingly traveled some dis tance (a fugue episode) that days or even weeks have pas sed for which the patients cannot account. Diss ociative time loss experiences are too extensive to be explained by forgetting and typically have s harply demarcated and offsets. It is important to es tablis h that s uch time experiences occur in the absence of intoxication or subs tance abus e, although high rates of drug and abuse in dis sociative patients may complicate this determination. P atients with severe diss ociative memory dis turbances also report perplexing fluctuations in skills, habits , or learned abilities , s uch as fluency in a foreign language athletic abilities. P atients report drawing a complete for skills or knowledge at times , whereas , at other they easily and reliably access the information in T his perplexing forgetfulness is believed to be related the diss ociative s tate-dependent disturbances of memory functions that have been documented in laboratory settings. Dis sociative patients often report s ignificant gaps in autobiographical memory, especially for childhood Dis sociative gaps in autobiographical recall are usually sharply demarcated and do not fit the normal decline in autobiographical recall for younger ages . F or example, patient may complain that he or s he cannot recall anything between 8 and 12 years of age, while readily available memories before and afterward. patient may report having no memories available for first 10 years of 1973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 195 of 302

P.1881 life. Available autobiographical memories may have a depers onalized quality, such that recalled events s eem be memories of a dream or as if the patient had seen happen to someone else. Ms. A. is a 33-year-old married woman, employed as a librarian in a s chool for disturbed children. S he ps ychiatric attention after discovering her 5-year-old daughter “playing doctor” with several neighborhood children. Although this event was of little cons equence, patient began to become fearful that her daughter would be moles ted. Ms . A. became panicked and increasingly obses sed with this idea, much to the bafflement of her husband. T he patient was seen by her internist and was treated with antianxiety agents and antidepres sants , but with little improvement. Ms. A. became increas ingly anxious, phobic, depres sed, and preoccupied. S he ps ychiatric consultation from s everal clinicians, but repeated, good trials of antidepres sants, antianxiety and s upportive ps ychotherapy resulted in limited improvement. After the death of her father from complications of alcoholis m, the patient became more symptomatic. He had been es tranged from the family the patient was approximately 12 years of age, owing to drinking and ass ociated antis ocial behavior. Ms. A. developed a variety of somatic complaints, headaches, abdominal pain, mens trual and (G I) problems , back pain, and sleep difficulties. medical workup was unrevealing, leading to diagnoses such as fibromyalgia, irritable bowel s yndrome, and 1974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 196 of 302

premenstrual tension. F amily and marital difficulties increased as the patient withdrew from her husband was increasingly dysfunctional in taking care of her children. W ork function als o deteriorated. P s ychiatric hospitalization was precipitated by the patient's arrest disorderly conduct in a nearby city. S he was found in a hotel, in revealing clothing, engaged in an altercation a man. S he denied knowledge of how she had come to hotel, although the man insisted that s he had come under a different name for a voluntary s exual On ps ychiatric examination, the patient des cribed amnes ia for the first 12 years of her life, with the feeling that her “life s tarted at 12 years old.” S he reported that, as long as s he could remember, she had an imaginary companion, an elderly black woman, who advis ed her kept her company. S he reported hearing other voices her head: s everal women and children, as well as her father's voice repeatedly speaking to her in a way. S he reported that much of her life since 12 years age was also punctuated by episodes of amnesia: for for her marriage, for the birth of her children, and for sex life with her husband. S he reported perplexing changes in s kills ; for example, she was often told that played the piano well but had no cons cious awarenes s that s he could do so. Her husband reported that s he always been “forgetful” of conversations and family activities. He also noted that, at times , s he would a child; at times , s he would adopt a southern accent; at other times , she would be angry and provocative. frequently had little recall of these episodes . Ques tioned more closely about her early life, the appeared to enter a trance and s tated, “I just don't want 1975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 197 of 302

be locked in the closet” in a child-like voice. Inquiry this produced rapid s hifts in s tate between alter who differed in manifes ted age, facial expres sion, voice tone, and knowledge of the patient's his tory. One identified its elf by a diminutive of the patient's name appeared child-like. Another s poke in an angry, filled manner and appeared irritable and preoccupied sexuality. S he discuss ed the epis ode with the man in hotel and stated that it was she who had arranged it. A third alter identified itself as a protective entity, experiencing its elf as an elderly African-American who commented sadly and philosophically about “this whole s ituation.” G radually, the alters described a of family chaos , brutality, and neglect during the firs t 12 years of the patient's life, until her mother, also achieved sobriety and fled her husband, taking her children with her. T he patient, in the alter identities, described episodes of physical abuse, sexual abuse, emotional torment by the father, her s iblings, and her mother. F amily s es sions with the mother and s iblings confirmed many of these reports, with the family recalling maltreatment that the patient did not recollect. T he patient's mother had bid the family never to s peak of earlier difficulties, hoping that everyone would “just the whole thing.” After additional as ses sment of family members, the patient's mother also met diagnos tic for dis sociative identity dis order, as did her older s is ter, who als o had been molested. A brother met diagnos tic criteria for P T S D, major depress ion, and alcohol dependence. T he patient improved significantly with ps ychotherapy 1976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 198 of 302

directed at s tabilization of her dis sociative identity disorder and P T S D. S he responded well to (Anafranil) with a marked reduction in obses sivecompuls ive and depres sive symptoms . F amily therapy helpful in stabilizing the patient's marriage and helping her hus band with the aftermath of the hos pitalization its precipitants . T he hus band also reported a family of abus e, although primarily directed at his mother and siblings . He had always s een hims elf as the family protector. T he patient's mother and s iblings were in treatment but were helped by the opening up of the family history and clarification of their diagnos es. At 3follow-up, the patient reported fus ion of mos t alters and marked diminution in diss ociative, somatoform, and symptoms, although s he s till required clomipramine for stabilization of mood and OC D symptoms. P.1882

Proc es s S ymptoms Dis sociative proces s symptoms include and derealization, diss ociative hallucinations, pas sive influence and interference experiences , and cognition (T able 17-15). S ome authorities include diss ociative alterations in identity under this category. S ymptoms of depersonalization and derealization are commonly reported by diss ociative identity disorder patients and may include profound out-of-body experiences . P atients frequently report feeling s paced or dis connected from thems elves and others . T he perceived as distant or unreal, with a hazy or foggy P atients may report feeling, at times , as if they exis t in 1977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 199 of 302

waking dream s tate. Out-of-body experiences take the form of watching ones elf from a distance as well as outer), as if obs erving another person, with or no ability to affect their actions . Dis sociative auditory hallucinations commonly take the form of voices heard as originating from within the (ps eudohallucinations), as oppos ed to coming from outside. Individual hallucinated voices typically have distinctive age and gender attributes. T hey may negatively about the patient, argue with each other, command the patient to perform certain acts , discus s neutral topics , or sometimes provide useful information comfort, or a combination of thes e. P atients generally recognize that the voices are hallucinations and may reluctant to reveal their exis tence for fear of being cons idered psychotic. Many patients report s ome ignore or disregard hallucinations , unles s they are Hallucinated voices often come to be identified with specific alter personality states . V is ual hallucinations typically take the form of detailed images with traumatic or frightening content. Other visual hallucinations may unders tood as depicting the alter identities or may even have a complex artistic quality. T actile, gustatory, and olfactory hallucinations may also occur, leading to misdiagnos es of s eizure disorder or other organic disorders . Intrusive pos ttraumatic flas hbacks and may als o be experienced as complex multimodal hallucinations . Negative hallucinations , in which external percepts and stimuli are not cons cious ly regis tered, are not P atients also report the volitional ability to block out various perceptions or s ens ations , including pain. Most 1978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 200 of 302

hallucinations , ps eudohallucinations, and negative hallucinations in diss ociative identity disorder patients likely homologous to phenomena that can be in deep trance states among highly hypnotizable individuals and are not a manifes tation of a process ps ychos is . P as sive influence and interference symptoms include many firs t-rank s chneiderian s ymptoms, such as thoughts, voices arguing with each other, influences playing on the body, thought withdrawal and ins ertion, and made feelings , impulses, and actions . T hese were once cons idered to be pathognomonic of schizophrenia, but they can also be found in patients affective, organic, and dis sociative disorders. P as sive influence symptoms now have been demonstrated to more common in dis sociative identity dis order patients than in ps ychotic mental dis orders. However, in diss ociative identity disorder, the agents of the pass ive influence symptoms are us ually experienced as not external, as in ps ychotic dis orders. In addition, may report s trong affects or impulses that they without a sens e of personal owners hip, but with a peremptory sense of intrusion and control. Dis sociative identity dis order patients generally do not have explanations for thes e experiences . T hey may feel confused, puzzled, or ashamed of them. commonly part of the explanation, such as “I feel like someone els e wants to cry with my eyes .” T he recognition that diss ociative patients frequently manifest s ubtle, but often clinically significant, cognitive impairments emerges from clinical research with ps ychological and cognitive test batteries . R es earch 1979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 201 of 302

projective testing finds distinctive cognitive process markers, including evidence of confus ing and contradictory res pons es to the s ame s timulus. res ponses to standardized projective tes ting can often helpful in distinguishing dis sociative patients from other diagnostic groups, s uch as patients with affective disorders , nondis sociative forms of P T S D, pers onality disorders , ps ychotic dis orders , and factitious dis orders.

Dis s oc iative Alterations in Identity C linically, dis sociative alterations in identity may firs t be manifested by odd first-person plural or third-person singular or plural s elf-references . In addition, patients refer to themselves using their own first names or depers onalized s elf-references , such as “the body,” describing themselves and others ; for example, “T he hurt the body s o s he was ups et. W e tried to protect but it didn't work.” P atients often des cribe a profound sens e of concretized internal division or personified internal conflicts between parts of thems elves . In some instances, thes e parts may have proper names or may designated by their predominate affect or function, for example, “the angry one” or “the wife.” P atients may suddenly change the way in which they refer to others, example, “the son” instead of “my s on.” A s et of behaviors , collectively referred to as s witching be haviors , may be manifes t during evaluation or sess ions. S witching behaviors include intrainterview amnes ias, in which the patient does not s eem to recall confused about the process and content of that T hese microdis sociative episodes may be manifested abrupt s hifts in train of thought or s udden inexplicable 1980 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 202 of 302

changes in affect or in rapport. A variety of physical including pronounced upward eye rolls or bursts of blinking and eyelid fluttering, may occur in conjunction with microdis sociative epis odes. T he patient's tone of voice and manner of speaking, posture, and demeanor may s how marked alteration. W hen clinicians evidence of pos sible microdiss ociative episodes, they should s eek to clarify what the patient is experiencing can recall with nondirective, open-ended ques tions T hese cognitive, behavioral, and phys ical shifts are manifestations of alter personality switching or overlap and interference between alter s tates , or both. T he personalities of dis sociative identity dis order patients best conceptualized as DB S , each organized around a prevailing affect, s ens e of s elf (often including a dis tinct body image), a s et of state-dependent autobiographical memories , and a limited behavioral repertoire. have long cautioned that alter pers onalities should not regarded as separate people. R ather, the alter are conceptualized as relatively stable and enduring patterns of behavior that are largely unintegrated with each other and are often in direct conflict. T he set of alter personality s tates, usually referred to pe rs onality s ys te m, cons titutes the pers onality of the individual. Mos t psychotherapeutic work is directed toward this larger personality system and thus toward individual as a whole. Much has been made of the ps ychological and phys iological differences among the alter personality s tates of individuals with dis sociative identity dis order, and popular accounts emphasize the presentational differences among alters . Laboratory studies s upport clinical accounts of significant 1981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 203 of 302

however, much general information and many and abilities are shared in common acros s alter states and indicate the fundamental unity of the mental proces ses of the diss ociative individual. T his provides foundation for therapeutic efforts directed at the development of a more cons cious ly integrated s ens e of self in the diss ociative identity disorder patient. Apparent differences in the organization and dynamics alter personality systems have been used to class ify diss ociative identity P.1883 disorder patients into various categories for more than century. T he validity of these class ifications remains to proven, but, as a group, diss ociative identity disorder patients s how cons iderable variability in the complexity and therapeutic tractability of their alter pers onality systems . S everal alter pers onality types are commonly reported, including child alter personalities; internalized persecutory alters , who inflict pain and may attempt to the individual; and depleted and depres sed host personality s tates, who function as the primary identity with res pect to the world at large. Alter personality often reflect painful ps ychological is sues for the and frequently take the form of polarized pairs representing antithetical pos itions , although alters representing more neutral and conflict-free proces ses commonly occur. In s ome diss ociative identity disorder individuals , virtually every as pect of mental life is structuralized and personified in this form.

S ymptoms R elated to S pontaneous 1982 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 204 of 302

Autohypnotic Phenomena Dis sociative identity dis order patients commonly exhibit describe symptoms of involuntary autohypnotic phenomena, cons is tent with their high scores on standardized hypnotizability scales (T able 17-16). include s pontaneous trance states that can be clinically disabling, s pontaneous or voluntary anes thes ia and analgesia, negative hallucinations , s pontaneous age regress ions, and the trance logic or literal-mindedness the hypnotized s ubject. Other similar s ymptoms with dis sociative process symptoms (hallucinations , thought disorder, child alter identities ) and P T S D symptoms (behavioral reexperiencing epis odes with multimodal hallucinations and age regres sion to the of the trauma).

Other As s oc iated S ymptoms B ecaus e diss ociative identity disorder is a trauma spectrum dis order, it is not surpris ing that the majority of these patients als o meet diagnos tic criteria P T S D by clinical criteria or by us ing s tandardized and diagnostic inventories (T able 17-17). Depending the study, 70 to 100 percent of diss ociative identity disorder patients have been shown to meet diagnostic criteria for P T S D by DS M-III-R , DS M-IV , and DS M-IV criteria.

Table 17-17 Dis s oc iative Identity Dis order-As s oc iated S ymptoms C ommonly Found in Dis s oc iative Identity Dis order 1983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 205 of 302

P os ttraumatic stress dis order s ymptoms    Intrus ive s ymptoms    Hyperarous al    Avoidance and numbing s ymptoms S omatoform symptoms    C onversion and pseudoneurological s ymptoms    S eizure-like episodes    S omatization disorder or B riquet's s yndrome    S omatoform pain symptoms    Headache, abdominal, musculoskeletal, pelvic    Undifferentiated s omatoform disorder    P s ychophysiological s ymptoms or disorders    As thma and breathing problems    P erimens trual disorders

1984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 206 of 302

   Irritable bowel syndrome    G as troesophageal reflux disease    S omatic memory Affective symptoms    Depres sed mood, dys phoria, or anhedonia    B rief mood swings or mood lability    S uicidal thoughts and attempts or s elf   G uilt and s urvivor guilt    Helpless and hopeless feelings Obsess ive-compuls ive s ymptoms    R uminations about trauma    Obs es sive counting, s inging    Arranging    W ashing    C hecking

1985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 207 of 302

Dis sociative identity dis order patients commonly exhibit multiple types of psychophys iological, somatoform, and conversion s ymptoms . F or example, acros s s tudies , 40 60 percent of diss ociative identity dis order patients also meet diagnos tic criteria for somatization dis order, and many others meet diagnostic criteria for somatoform disorder, somatoform pain disorder, or conversion dis order, or a combination of these. F inally, numerous recent studies have s hown a robust relations hip between certain forms of affective and an antecedent his tory of trauma, particularly childhood s exual abus e. Depres sion is increasingly unders tood as one of the outcomes following traumatic experiences . Accordingly, most dis sociative identity disorder patients meet criteria for a mood disorder, one of the depress ion spectrum dis orders. F requent, mood swings are common, but thes e are us ually due to posttraumatic and diss ociative phenomena, not a true cyclic mood dis order. T here may be cons iderable between P T S D symptoms of anxiety, dis turbed s leep, dysphoria and mood disorder s ymptoms . Obsess ive-compuls ive s ymptoms are also commonly 1986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 208 of 302

found in individuals with P T S D. Obs ess ive-compuls ive personality traits are common in diss ociative identity disorder, and intercurrent OC D symptoms are regularly found in diss ociative identity disorder patients , with a subgroup manifes ting s evere OC D symptoms. OC D symptoms commonly have a pos ttraumatic quality: checking repeatedly to be s ure that no one can enter house or the bedroom, compuls ive was hing to relieve a feeling of being dirty because of abuse, and repetitive counting or s inging in the mind to dis tract from anxiety over being abus ed, for example.

C hild and Adoles c ent Pres entations A growing clinical res earch literature documents the diagnosis and treatment of child and adolescent diss ociative dis orders, including dis sociative identity disorder. In many res pects, children and adolescents manifest the same core dis sociative symptoms and secondary clinical phenomena as adults. Age-related differences in autonomy and lifes tyle, however, may significantly influence the clinical expres sion of diss ociative s ymptoms in youth. F or example, amnes ias and perplexing forgetfulness are more in s chool situations rather than work or family life. children, in particular, have a less linear and les s continuous s ens e of time and are often not able to s elfidentify dis sociative discontinuities in their behavior. F ortunately, there are often additional informants, such teachers and relatives , available to help document diss ociative behaviors. A number of normal childhood phenomena, such as imaginary companions hip and elaborated daydreams , 1987 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 209 of 302

must be carefully differentiated from pathological diss ociation in younger children. F or example, preadoles cent children with dis sociative identity may manifes t less in the way of gross switching than adolescents or adults. T he clinical pres entation be that of an elaborated or autonomous imaginary companions hip, with the imaginary companions taking control of the child's behavior, often experienced P.1884 through pas sive influence experiences or auditory ps eudohallucinations, or both, that command the child behave in certain ways.

P athology and L aboratory E xamination A clinical mental s tatus examination based on the symptom clus ters described in T ables 17-14 17-15 1717-17 can be helpful in the diagnosis of diss ociative identity dis order. Ques tioning about amnes ic, autohypnotic, P T S D, affective, and s omatoform us ually precedes detailed inquiry about more overt symptoms related to the alter identities. C areful inquestioning about these phenomena may readily bring forth information about dis sociative identity dis order proces s symptoms . F or example, discuss ion of amnes ia experiences may readily lead to questions how purposive behaviors can occur without apparent memory. Discuss ion of P T S D s ymptoms may lead to manifestations of alter identities related to traumatic experiences . T he development and increas ing us e of screening 1988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 210 of 302

instruments and s tandardized diagnostic interviews contributed to the increas e in numbers of identified diss ociative identity disorder cas es s een over the last decade. Dis sociative identity dis order patients score over 30 on the DE S and the DE S -T . However, screening instrument and cannot be us ed to make a clinical diagnosis. T he S C ID-D-R is currently gold s tandard for diagnosis of diss ociative dis orders. major drawback of the S C ID-D-R is that it can take hours to adminis ter, especially if the patient has many positive res ponses . Accordingly, some clinicians rely shorter DDIS for its ease and speed of adminis tration. MID is a s elf-report inventory that may ass is t in of dis sociative identity dis order and other diss ociative disorders . T he C DC and A-DE S are two commonly used meas ures for as sess ment of dis sociation in children adoles cents , res pectively. T hey are reliable and valid meas ures in clinical and res earch populations. B efore the development of thes e clinical and as sess ment tools , hypnotic or amobarbital interviews often used to attempt diagnosis of diss ociative identity disorder. Due to the current academic and forens ic controvers ies s urrounding diss ociative dis orders and trauma memory, it is prudent to reserve thes e interventions for emergency situations when other methods of as sess ment have failed, for example, in a female patient who is emergently hospitalized after engaging in repeated, dangerous nocturnal fugues and who cannot account for thes e behaviors, des pite interviewing. T hese interventions should optimally be conducted by a clinician experienced in their use and in 1989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 211 of 302

the differential diagnosis of diss ociative dis orders . informed cons ent should be obtained for us e of thes e interventions for diagnos is of dis sociative identity and recall of traumatic experiences .

Differential Diagnos is On average, more than 6 years pass between first ps ychiatric contact and the diagnos is of diss ociative identity dis order. Although often portrayed as hysterics, only a s mall minority of dis sociative identity disorder patients pres ent in this way. Dis sociative disorder patients are typically reticent about revealing their diss ociative symptoms, es pecially hallucinations , amnes ia, and identity divisions . T hey mos t commonly present as relatively inhibited and obses sional, with affective and somatic complaints , and typically acquire three or more ps ychiatric diagnoses before their diss ociative identity disorder is recognized. A subgroup diss ociative identity dis order patients s how dynamics that are reminis cent of borderline pers onality disorder, for which s ome diss ociative identity disorder patients qualify as a s econdary diagnos is once P T S D diss ociative s ymptoms are stabilized. T he pres ence of auditory hallucinations , disturbed thinking and confusion due to amnes ic gaps, and s chneiderian firstsymptoms contributes to the misdiagnos is of schizophrenia in approximately one-half of diss ociative identity dis order patients at some point in their histories . R apid changes in affect ass ociated with alter personality s witching may sugges t a rapid-cycling disorder or schizoaffective disorder. T able 17-18 lists most common disorders that must be differentiated diss ociative identity disorder. However, becaus e many 1990 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 212 of 302

these dis orders may coexist with dis sociative identity disorder, as well as being mimicked by diss ociative disorder, differential diagnos is may be a complex

Table 17-18 Differential of Dis s oc iative Identity Dis order C omorbidity versus differential diagnos is Affective dis orders P sychotic disorders Anxiety disorders P os ttraumatic stress dis order P ers onality disorders C ognitive dis orders Neurological and s eizure dis orders S omatoform dis orders F actitious disorders Malingering 1991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 213 of 302

Other dis sociative disorders Deep-trance phenomena, such as the hidden observer or ego s tates

Fac titious , Imitative, and Malingered Dis s oc iative Identity Dis order C oncerns about factitious and malingered diss ociative identity disorder are common. R ecently, there are increasing reports of individuals claiming to have diss ociative identity disorder who do not meet criteria for dis sociative identity dis order when carefully as sess ed clinically or with s tructured interviews , s uch the S C ID-D-R . T here may be a mixture of factors this pres entation, including misdiagnos is , and as sumption of a social role of an abus e victim or a diss ociative identity disorder patient. Dutch res earchers have named this imitative dis s ociative ide ntity dis order when there does not appear to be conscious P atients may build their lives around their diagnos is are commonly supported by concerned others and by their therapists in s o doing. Indicators of fals ified or imitative diss ociative identity disorder are reported to include those typical of other factitious or malingering presentations . T hese include symptom exaggeration, lies, use of s ymptoms to 1992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 214 of 302

antis ocial behavior (e.g., amnesia only for bad amplification of symptoms when under obs ervation, refusal to allow collateral contacts , legal problems , and ps eudologia fantastica. G enuine dis sociative identity disorder patients are usually confused, conflicted, as hamed, and dis tres sed by their s ymptoms and history. T he nongenuine patients frequently show little dysphoria about their dis order. T hese imitative and factitious patients actually fit the of diss ociative identity disorder, with one exception: R igorous diagnostic efforts s how that they do not meet actual diagnostic criteria for diss ociative identity T he S C ID-D-R has been used to help distinguish from bogus diss ociative identity disorder in clinical and forens ic contexts. In addition, ps ychological a psychologis t experienced in evaluation of trauma, and diss ociation may als o be quite helpful P.1885 in differential diagnosis. On the S C ID-D-R , fabricated diss ociative identity disorder patients tend not to the typical comorbid conditions and symptoms with diss ociative identity disorder, such as amnesia, identity confus ion, and identity alteration, although they may report high levels of depers onalization and derealization. T hey often des cribe symptoms in a filled way (“I'm diss ociating” or “I'm switching”) and readily explain their subjective experience on follow-up questions on the S C ID-D-R or in clinical interviews . T here are no abs olute clinical indicators to differentiate imitative, factitious, or malingered diss ociative identity 1993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 215 of 302

disorder from the actual disorder. S ome bona fide diss ociative identity disorder patients become invested a dis sociative identity dis order identity or that of being trauma s urvivor as their main social role. T here is a subgroup of diss ociative identity disorder patients who present in a dramatic, histrionic fashion, unlike the majority of diss ociative identity disorder patients who reticent and s ecretive about their illness . T here are genuine diss ociative identity disorder patients who factitious histories , produce factitious cris es , and create factitious alter identities. S ome diss ociative identity disorder patients report that their only happy childhood experiences were while medically hospitalized. Like typical factitious dis order patients, they s eek out and maintain themselves as hos pital patients in psychiatric medical s ettings . Munchaus en syndrome and syndrome by proxy als o have been reported in identity dis order patients and in their first-degree Ms. F ., a 48-year-old divorced mother of three, was to a trauma disorder inpatient unit by her managed company for a cons ultation about diagnos is and treatment. Ms . F . had been diagnosed with dis sociative identity dis order after doing “inner child work” with her outpatient therapis t, Dr. Q., to whom Ms. F . reported an extensive history of childhood neglect, as well as and s exual abus e. Ms. F . had numerous suicidal ideation, as well as for epis odes of superficial mutilation. Ms. F . was on disability. S he did not care for children adequately and had been investigated s everal times by her state division of child welfare, who had recently placed her children in fos ter care. On arrival in the trauma unit, Ms . F . proclaimed to 1994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 216 of 302

and s taff that, “I have dis sociative identity dis order. I sexually abus ed.” S he did not s eem distress ed by these ideas. S he repeatedly s tated, “I'm s witching, I'm switching,” although s taff members, experienced with diss ociative identity dis order patients, did not obs erve of the typical s igns of diss ociative identity disorder switches. S taff noted that they had never observed a diss ociative identity disorder patient announce this way. Ms. F . became irritable when s taff attempted diss uade her from speaking in s uch a dramatic and way in the milieu. Ms. F . was evaluated clinically, obs erved by nursing the ward milieu, and given a battery of ps ychological including the DE S , the S C ID-D, as sess ments of P T S D, personality ass es sments . On the clinical evaluation, did not endors e complex chronic amnesia s ymptoms, amnes ia for her life history, spontaneous s elf-hypnosis , pass ive influence symptoms, or inner voices . S he episodes of depersonalization and derealization. S he reported only “child and baby alters ” but could des cribe little about them when ques tioned. S he would s ay like, “S ee, now I'm like a child. C an't you tell? T hat's my littles.” S he did not endorse any s ens e of fear, conflict, or inner struggle around switching nor were of the typical phenomena of switching noted at thes e times (e.g., eye roll; eye blinking; s ubtle s hifts in voice, posture, and facial express ion; momentary confus ion; intrainterview amnesia, and s o forth). S upposed alter identities did not s eem to have relatively independent ways of thinking, relating, perceiving, or remembering. Ms. F . des cribed a history of childhood chaos and in detail but became more stereotypically, 1995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 217 of 302

vague when dis cuss ing other types of childhood “T he man hurt me. I'm here to recover from it. It's jus t what happened to K . (a friend of the patient's from the inces t s urvivors' group). Dr. Q. says I have a long way in my healing. T hat's all. Isn't that enough? ” S he did seem dis tres sed, hesitant, or ashamed when alleged history of childhood s exual abus e. S he became angry when confronted with contradictions in her accounts , the dramatic nature of her presentation, and discrepancies between her history and her emotional reactions . Ms. F . appeared uninteres ted in individual or group ps ychotherapy that s ought to teach her more effective ways to manage s ymptoms and to increase effective coping. S he was angry when nursing s taff attempted to get her to take res ponsibility for managing her of anxiety and regres sion in a more proactive and adult fas hion. S he was infuriated when the unit social worker not see her role as attempting to find Ms . F . alternative housing or intervening with the state child welfare on her behalf. S taff contacted Dr. Q., who became angry and when ques tions were raised about the patient's clinical presentation and authenticity of her sexual abuse On ps ychological and diagnostic testing, Ms . F . did not endors e most items consistent with clinical other than depersonalization and derealization. S he did not display typical P T S D or dis sociative reactivity to inquiries about the abus e history, nor did s he meet diagnostic criteria for P T S D. S he did not s how typical of diss ociative identity disorder patients on stress ful tes t batteries or during a s erendipitous event 1996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 218 of 302

while being tested, when another patient suddenly required aggres sion management on the ward near the tes ting room. Other patients reacted with P T S D and diss ociative s ymptoms: panic, marked startle, trance, hiding, loss of reality orientation, ass umption of fetal position, rocking with hands over the face, into flas hback, and so forth. Ms . F . blithely continued tes ting with minimal reaction. At the conclus ion of the ass es sment, Ms . F . was with factitious disorder with psychological s ymptoms , mood dis order NOS , and personality dis order NOS histrionic, borderline, and dependent features . T he s taff struggled with the factitious diagnos is , because Ms . F . not appear to be consciously feigning dis sociative disorder in the strict sense and actually s eemed to in her self-reports of s witching and alter identities. Ms . and Dr. Q. were both res is tant to the new diagnostic formulation. Dr. Q. s tated that s he would ins is t that the managed care company s eek another expert opinion to correctly diagnose her patient.

C ours e and P rognos is Little is known about the natural history of untreated diss ociative identity dis order. A few cas e s tudies of partially treated patients followed up many years later suggest that the dis order becomes les s overt over with a decrease in florid diss ociative symptoms and intraps ychic conflict among the alter personality states . T hese cases , however, are too few and too s elected to generalize. S mall studies of diss ociative identity patients diagnosed in middle age and in geriatric populations have s hown that s evere diss ociative 1997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 219 of 302

disorder s ymptoms can pers is t or can appear in olderpatients. A relaps ing and remitting cours e is common. Als o, patients can more or less succes sfully mask or suppress symptoms for periods of time. B oth of these latter phenomena may be mis taken for complete spontaneous remiss ion of the disorder. S ome untreated dis sociative identity dis order are thought to continue involvement in abusive relations hips or violent P.1886 subcultures, or both, that may res ult in the of their children, with the potential for additional family transmis sion of the dis order. Many authorities believe some percentage of undiagnosed or untreated diss ociative identity disorder patients die by suicide or res ult of their ris k-taking behaviors . E xperience with a number of diss ociative identity disorder cas es sugges ts that there are s everal s ubgroups of dis sociative identity disorder individuals . T hes e range from thos e who at quite high levels for long periods of time to others have s everely impaired and dys functional life often beginning early in development. P atient pres entations and prognos is vary s omewhat the life s pan. C hildren with dis sociative identity dis order show many dis sociative s ymptoms and behaviors but typically have fewer and les s crystallized alter states that are less inves ted in their individuality. If diagnosed early, children often have an excellent prognos is , and many seem to have relatively res olutions when removed from abusive and neglectful environments . In adoles cence, alter personality states 1998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 220 of 302

become more dis tinct and more invested in their autonomy. Additional alter personalities as sociated life s tres ses, s uch as academic, athletic, s ocial, or challenges, may appear, and the pers onality s ys tem dynamics become more complicated and polarized. In general, adolescents have a poorer prognosis than children or adults, in part because they are often not inves ted in their treatment. B etter outcome with diss ociative identity disorder adolescents has been reported when the patients' families were success fully engaged in treatment. Y oung adults typically pres ent in crisis and have a layering of affective, somatic, posttraumatic, and personality dis order symptoms in addition to their core diss ociative pathology. F irst diss ociative identity dis order pres entations in diss ociative identity disorder patients frequently involve life event, s uch as the loss of a job, death of a parent, revictimization, s uch as a rape, that reactivates earlier conflicts and destabilizes the alter pers onality s ys tem. Achieving sobriety in a substance-abusing dis sociative identity dis order patient may precipitate overt identity dis order and P T S D pres entations . In adult there appear to be treatment-res ponsive and refractory s ubgroups of dis sociative identity dis order patients. T ime cours e of improvement also may vary, some patients improving relatively quickly and others requiring intensive treatment efforts over long periods time. P rognos is is poorer in patients with comorbid organic mental disorders , ps ychotic dis orders (not diss ociative identity dis order ps eudopsychos is), and severe illness es. R efractory s ubs tance abus e and eating 1999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 221 of 302

also sugges t a poorer prognos is . Other factors that indicate a poorer outcome include s ignificant antis ocial personality features, current criminal activity, ongoing perpetration of abus e, and current victimization, with refusal to leave abus ive relations hips. R epeated adult traumas with recurrent episodes of acute s tres s may s everely complicate clinical cours e. B oundary violations and abus e by a therapis t or ps ychiatris t may severely prolong the treatment cours e, because the of treatment now feels uns afe and precipitates intense posttraumatic reactivity. S evere pers onality disorders overinvestment in multiplicity as a way of life, in ps ychotherapy primarily to seek gratification, and a refusal to take res ponsibility for behavior change and symptom management are also generally as sociated a poorer prognos is . Number of alter personality s tates, however, has only a moderate effect on treatment

Treatment S tages and Goals C urrent treatment approaches to diss ociative identity disorder have evolved considerably with the conceptualization of diss ociative identity disorder as a complex developmental trauma disorder and as the spectrum of diss ociative identity disorder patients has been better appreciated. Appropriate treatment of the diss ociative identity disorder patient follows a phas ic model that is the current standard of care for posttraumatic disorders . T he phases include (1) a symptom stabilization, (2) an optional phase of depth attention to traumatic material, and (3) a phase integration or reintegration in which the dis sociative 2000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 222 of 302

identity dis order patient moves more completely away from a life adaptation bas ed on chronic traumatization victimization. Obvious ly, these phas es are relatively heuris tic, and as pects of each may be part of the S tabilization of the diss ociative identity disorder patient vital to permit more s uccess ful negotiation of all treatment. S tabilization focus es on s afety, stability, and management of core diss ociative identity dis order and comorbid symptoms . T he vas t majority of diss ociative identity dis order patients engage in some form of s elfdestructive behavior, including s uicide attempts, selfmutilation, eating disorders , s ubs tance abus e, ris k-taking activities, and involvement in abus ive, based relations hips. Many male, and some female, diss ociative identity disorder patients have difficulty aggres sion, violence, and homicidal tendency, perpetration of child abus e. It is incumbent on the to make these is sues the basic focus of treatment. In general, cognitive and behavioral approaches are framing these behaviors as part of a set of quas itrauma-related, homeostatic mechanis ms . E xperienced clinicians find that many diss ociative identity disorder patients can bring s elf-destructive and high-ris k under control. C ognitive and behavioral methods are to develop therapeutic agreements (also called s afety contracts ), s o that patients have a repertoire of to manage their difficulties ins tead of by selfE ating disorders , s evere s ubs tance abus e, abusive relationships , and perpetration of violence may more refractory to thes e methods and may require concurrent specialty treatment interventions and involvement of police, social s ervice, and community 2001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 223 of 302

agencies . S tabilization of s evere s ymptoms generally involves with posttraumatic s tres s and diss ociative symptoms. Dis sociative identity dis order patients frequently with highly disturbing P T S D s ymptoms, such as thoughts, imagery, s omatic sens ations, hyperarousal, flashbacks . T he latter may present as acute behavioral reexperiencing epis odes with loss of reality orientation more s ubtle and pervasive reliving experiences , or P atients may be overwhelmed by dis sociative hallucinations , amnes ia and fugue epis odes , pass ive influence experiences , or profound identity confus ion disorganization. S orting out genuinely comorbid from the plethora of posttraumatic, anxiety, affective, somatic symptoms commonly manifested by patients in cris is is important, as s ome disorders , for example, affective disorders , require additional interventions . As ses sment of available family and community supports is also important.

Ps yc hotherapy A s urvey of more than 300 clinicians treating identity disorder patients found that the vas t majority cons idered psychotherapy to be their primary and mos t efficacious treatment modality. S uccess ful for the dis sociative identity dis order patient requires the clinician to be comfortable with a range of ps ychotherapeutic interventions and a willingnes s to actively work to structure the treatment. T hes e include ps ychoanalytic psychotherapy, cognitive behavioral therapy, hypnotherapy, and a familiarity with the ps ychotherapy and psychopharmacological 2002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 224 of 302

management of the traumatized patient. C omfort with family treatment and systems theory is helpful in with a patient who subjectively experiences hims elf or herself as a complex s ys tem of selves with alliances, like relations hips, P.1887 and intragroup conflict. A grounding in work with with somatoform disorders may also be helpful in through the plethora of s omatic s ymptoms with which these patients commonly present.

Therapeutic E ngagement with Alter Identities E ffective stabilization in mos t diss ociative identity patients requires psychotherapeutic work with alter personality s tates. Many diss ociative identity patients are not able to s tabilize s ymptoms in the long term if the alter identities who control these s ymptoms not therapeutically engaged. C linicians new to identity dis order are frequently uncomfortable or perplexed by the need to work with individual alters how to do this without producing a chaotic regress ion. C ertain basic principles are important to understand. alter is any more or less real than any other alter or good or bad than another. All are aspects of a s ingle human being and have adaptive, ps ychological importance that needs to be heard and respected. All alters are held accountable and respons ible for the behavior of any part, even if experienced with amnes ia lack of s ubjective ownership. In the context of ps ychotherapy, alters can be unders tood as 2003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 225 of 302

developmentally concretized, trauma-based metaphors forms of organizing and mobilizing mental contents . unusual metaphors have many problematic cognitions and affects, as well as adaptive attributes, s uch as the personality s tate-dependent memory data des cribed previous ly. As s uch, the fullest participation of all symbols and s ources of knowledge, s kills , and is likely to produce the best outcome in ps ychotherapy. C oncerns about iatrogenesis are often rais ed in this context. Understanding the alters as forms of symbolization reduces this concern to a more routine ps ychotherapeutic task of understanding the meaning mental contents , rather than a suppres sion of s ome states as less authentic than others . At the s ame time, clinician mus t also be able to appreciate the patient's subjective reality in which the alter s elf-states are experienced as dis tinct s elves or even as separate T he therapist mus t be able to tolerate engaging with alters as if they are s eparated entities, while maintaining the understanding that the alters represent the structuring of psychological process es in form within a s ingle human mind. T he continuity, s tability, and respectful impartiality of therapist toward the different alter pers onalities provide an important therapeutic experience that helps the experience, examine, and integrate these dis sociated as pects of s elf. T he proces sing of negative life events , from the multiple pers pectives of different alter personality s tates, is an important part of the narrative reorganization of the patient's fragmented identity into more coherent whole. T he therapist usually is actively involved in negotiating between and among the various 2004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 226 of 302

alter identities to achieve therapeutic goals . T hes e can include negotiation of agreements to s top s elfbehaviors , to allow more adaptive interidentity function and communication, and to permit certain alters to participate more fully in therapy.

Initial Phas e of Dis s oc iative Identity Dis order Treatment T he initial phas e of treatment of the dis sociative disorder patient involves a number of s imultaneous and sequential tasks.

E DUC A TION A ND INF OR ME D It is important to educate the dis sociative identity patient about the disorder, its comorbidities, and the cours e of treatment. E ducative interventions help anxiety about s ymptoms that are often frightening and overwhelming, build a therapeutic alliance, and provide information that is the basis for a meaningful consent treatment. F urthermore, it is necess ary to educate the patient about the contentious and divisive debates that surround the diagnosis and treatment of diss ociative identity dis order in contemporary ps ychiatry and ps ychology. Other major iss ues in informed cons ent include the patient of potential risks and benefits of the alternative approaches, and their potential ris ks and benefits. T he patient should als o be informed about the current controvers ies about traumatic memory and its retrieval and explication in therapy. Additional informed cons ent s hould be obtained if formal hypnosis is used for administration of medications. T he patient should 2005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 227 of 302

couns eled that s ymptomatic worsening may occur treatment, particularly during phases in which memory material is worked with in depth (second phas e of treatment). S imultaneously, however, s ubjective amelioration of other s ymptoms may occur, with the patient achieving a better s ens e of control, mastery, self-coherence as the patient success fully works painful material. T his s ort of dialectical proces s is common in identity disorder treatment. It is often helpful to point out as part of the informed consent proces s. F or at times, the patient may feel a sense of s ubjective and the idea of having diss ociative identity disorder unreal and impos sible. At other times, the patient's of himself or hers elf as divided and enacting alter roles seems so compelling and overwhelming that no other diagnosis s eems pos sible. S imilarly, like many obsess ional individuals, identity disorder patients often respond positively to learning that the diss ociative and P T S D s ymptoms that they experience have a name and an organizing framework for diagnosis and treatment. T here is often relief at a diagnos is that fits the patient's s ubjective and experience, especially if there has been a long prior of uns ucces sful psychiatric treatment for other At the s ame time, patients may respond with dis tres s at the diss ociative identity disorder diagnos is, partly of media and popular s tereotypes , partly because it into s harper relief the meaning of painful symptoms, partly becaus e it brings more focus to the dis tres sing history of early trauma and problematic relationships family members . 2006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 228 of 302

Dis sociative identity dis order patients may need to be informed that treatment does not attempt to suppres s to des troy alter identities, but rather to allow engagement with them as vital as pects of the mind. P atients us ually want to get rid of alter identities and also terrified that the therapist will attempt to do so. experienced clinicians educate patients that treatment geared toward optimal function and adaptation and that there are us ually too many variables at the beginning treatment to predict whether it will necess arily res ult in unification of all s elf-divis ions. At the same most experienced clinicians s ee unification of all alter states as us ually providing the bes t long-term outcome diss ociative identity disorder. T he education and informed cons ent proces s is an ongoing one throughout treatment. Many of thes e need to be revisited as treatment proceeds and as the patient changes over treatment time.

B oundaries and Treatment Frame Most dis sociative identity dis order patients report that their traumatic life experiences us ually occur over long periods of time in the context of clos e personal relations hips with those who have hurt them. F urthermore, dis sociative identity dis order patients report many boundary violations in s ubsequent relations hips with teachers, therapis ts, medical profes sionals, and s ocial service workers , among F or thes e P.1888 patients, the role des cription of s ignificant others does 2007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 229 of 302

neces sarily predict their behavior, and relations hips are often s een as up for grabs . T he patient expects and that the clinician will violate boundaries . T here may be subtle (or not s o s ubtle) pull in the trans ference for the therapist to change the frame of treatment. P atients experience this as trying to make the inevitable that they do not have to endure the agony of waiting for things to go wrong. Accordingly, clinicians working with these patients must pay careful attention to is sues of treatment frame and appropriate and consistent boundaries . T hese include firm limits on the length of therapy s ess ions, acceptable behavior during sess ions, extent of extra sess ion contacts, and payment of fees, among many others. Interpretation of the patient's fears over the perceived inevitability of boundary violations is preferable to enacting them. C linicians working with diss ociative identity disorder patients should avoid boundary changes that make the patient “special,” the patient insis ts that only these interventions will T hese include holding or hugging the patient, holding patient's hand, accepting more than a token gift s uch card or a s mall piece of artwork, giving the patient gifts , phoning the patient while on vacation, and going for walks or other out-of-office contacts with the patient, among many others. T he dis sociative identity dis order patient may implore the therapist to make these sorts interventions . C linicians who feel overwhelmed by the treatment of these patients are more likely to accede to these importunings . It is important to recognize that the patient's reported history of abuse often involved being special to the abus er in some way. T hus , these transgress ions recreate this double-edged situation for patient. Once again, education of the patient about 2008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 230 of 302

appropriate boundaries is the mos t helpful clinical strategy. Many of the clinical and conceptual is sues that help treatment workable with these patients are not taught standard training programs for mental health profes sionals. C onsultation should be considered by clinicians who are new to working with this patient population, or if s talemates or unsolvable predicaments develop in treatment.

Development of S kills to Manage S ymptoms E xperienced therapists commonly rapidly introduce a variety of s ymptom management strategies into the treatment. T his neces sitates active s tructuring of to work on containment of s evere s ymptoms and skill building T his may involve imagery techniques to the intens ity of P T S D, s omatoform, and dis sociative symptoms, success ful stabilization of alter identities embody or are experienced as creating s ymptoms , and encouragement of collaboration, communication, and empathy among alter identities . In particular, clinicians work to attenuate the impact of P T S D rather than opening up this material prematurely. T he clinician s hould be clear that the ultimate res ponsibility for s ymptom and behavioral management outside of sess ions lies with the patient, who is viewed an active partner in the treatment. In this regard, diss ociative identity dis order patients often res pond to therapeutic contracting, taking more active res ponsibility for s afety or behavioral control between sess ions. T he therapist may prescribe homework for 2009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 231 of 302

patient to work on s ymptom management and internal communication between s es sions . T hese strategies often ess ential in countering the patient's tendency toward regress ion and demoralization. P atients often journal writing as a helpful adjunctive treatment that allows more controlled expres sion and communication among alter identities, fulfillment of homework as signments, and a more attenuated and distanced way of handling overwhelming subjective experiences .

C ognitive Therapy Dis sociative identity dis order patients may experience multitude of cognitive errors and distortions bas ed on traumatic life experiences and the ability of diss ociation interfere with reality tes ting. T ypical cognitive include (but are hardly limited to) the insistence that inhabit s eparate bodies and are unaffected by the of one another (delus ional separatenes s), that the is helpless to control himself or herself and requires the clinician to manage all difficulties , that the clinician is completely untrustworthy and mus t be not be allowed access to the patient's mind, that the patient is bad and deserved or caus ed childhood s exual abus e to occur, anger and violence are the s ame, that love and sex are same, that self-injury is safety, and that, becaus e and abuse are inevitable, it is best to invite them or them ones elf, so that at leas t their timing and intensity be better controlled. B ehind thes e cognitive dis tortions frequently lie exceptionally painful realizations and recollections. F or example, if the patient gives up the idea of 2010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 232 of 302

blameworthines s for childhood incestuous experiences, the reality must be faced that a beloved relative has the patient grievous harm and has treated the patient an object, not a person. Accordingly, many cognitive distortions are only slowly respons ive to cognitive techniques, and s ucces sful cognitive interventions may lead to additional dysphoria. A s ubgroup of diss ociative identity disorder patients not progres s beyond a long-term s upportive treatment entirely directed toward s tabilization of their multiple multiaxial difficulties. T o the extent that they can be engaged in treatment at all, these patients require a term treatment focus on symptom containment and management of their overall life dysfunction, as would the case with any other severely and pers is tently ill ps ychiatric patient population.

Trans ferenc e and Dis sociative identity dis order patients often manifes t a complex multilayered transference as a whole, as a of pers onality s tates , and as individual alter pers onality states . C ommonly, transference is dominated by trauma and abuse, with the therapis t most commonly experienced as potentially exploitative and abus ive or uninvolved or uncaring about the patient's difficulties or a helples s victim, like the patient faced with an other. Diss ociative identity disorder alters may literally envis ion the clinician as the embodiment of an abusive figure from the pas t, requiring active interventions to the patient separate the past from the pres ent. C ountertransference respons es may vary as well, with overinvolvement, detached hos tile s kepticis m, or a 2011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 233 of 302

of being exas perated, overwhelmed, and des killed quite common. C linicians may experience countertransferential autohypnotic and diss ociative phenomena during diss ociative identity disorder treatment that need to be recognized and managed. B urnout and secondary P T S D have been reported for therapists and treatment teams working with identity dis order patients, unless adequate attention is paid to limit setting, boundaries, and ass is tance to clinicians advers ely experiencing reports of extreme abusive trauma or overwhelmed by work with identity dis order patients.

S ec ond Phas e: Work on Traumatic Memories F or patients who can stabilize and form a reas onable working alliance in treatment, longer-term treatment involve the detailed, affectively intens e, proces sing of life experiences , es pecially traumatic experiences , and the transformation of the meaning of these experiences for the individual. Authorities emphasize that, in mos t cases, intensive, detailed ps ychotherapeutic work P.1889 with traumatic memories s hould only be initiated after patient has demonstrated the ability to use symptom management s kills independently, after the alter system can work together in a reasonably cooperative way, and after a solid therapeutic relations hip has been es tablis hed. T he patient should be able to give cons ent and should have a realistic understanding of 2012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 234 of 302

potential risks and benefits of intensive focus on material. P otential ris ks may include acute wors ening P T S D, affective, s omatoform, and self-destructive symptoms and s hort-term interference with daily Long-term benefits may include significant amelioration diss ociative and P T S D symptoms , decreases in self-divis ion, fusion of alter identities, and freeing of ps ychological energy for daily life. T he patient mus t be able to unders tand that the goal is integration of diss ociated thoughts, feelings, recollections, and perceptions, not the exhumation of memories per s e. F urthermore, the patient should not be in the mids t of acute life cris is or major life change, comorbid medical ps ychiatric disorders s hould be s tabilized, the patient have the ego s trength and psychos ocial res ources to withstand the rigors of the process , and there mus t be adequate res ources , s uch as support by significant to support the patient for additional s es sions (T able 17E xperienced clinicians attempt to structure carefully affectively intense s es sions focus ed on traumatic with attention being given to affect modulation, res tabilization of the patient before concluding the sess ion, and reasonable availability to as sist the supportively between ses sions . In addition, many may be needed to explicate fully the cognitive and emotional meaning of traumatic events , s o that they become part of the patient's repertoire of ordinary memories for life experience.

Traumatic Memories Media attention and legal cases have led to concerns the authenticity of traumatic recollections of 2013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 235 of 302

identity dis order patients. R ecent rigorous cas e s eries supported the experience of clinicians , who have found corollary information to corroborate recollections of diss ociative identity disorder patients or who have even unearthed data about traumas that the patient does not recall. B as ed on corollary information, however, s ome diss ociative identity disorder patients can be shown to misinterpret and mis represent contemporary or confabulate as pects of their pas t his tory. In addition, diss ociative patients are hardly immune to ordinary human emotions , such as greed, envy, wis hes for wis hes to evade cons equences for misbehavior, and desires to placate s ignificant others . All of thes e may complicate the patient's veracity, especially in potential financial gain, media attention, evasion of cons equences, and poss ible loss of family contacts , others . C onvers ely, collateral informants, s uch as members, may be subject to the s ame sources of unreliability as the index patient, and their input should weighed accordingly. Dis sociative identity dis order patients typically oscillate from regarding their recollections as all true to all false. S pecific alter identities may take oppos ing positions . clinician is best served by maintaining a s tance of neutrality toward the patient's recollections of his or her life. In this regard, it is generally mos t helpful for the clinician to identify for the diss ociative identity disorder patient his or her internal conflicts over the veracity of recollections and to invite an open airing of all points of view. R epeated discus sion of the complex factors that impact autobiographical recall may need to be part of ongoing informed consent process as treatment 2014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 236 of 302

progres ses . T he therapist s hould respond res pectfully and to all clinical material brought by the diss ociative disorder patient. P atients can be helped not to come to premature clos ure about their views of events. S ome diss ociative identity disorder patients come to life events quite differently as they become les s diss ociative over the course of treatment. clinicians must avoid validating memories for the or dis mis sing them out of hand, in the abs ence of collateral information. T herapy is mos t s ucces sful for diss ociative identity disorder patient if the clinician maintains the role of therapis t, not personal advocate, detective, or derisive s keptic.

Third Phas e: Fus ion, Integration, R es olution, and R ec overy Over the course of treatment, significant unification of diss ociated mental proces ses may be obs erved. Alters distinctnes s P.1890 and decrease compartmentalization of thoughts, memories , and affects. T he patient develops a more unified s ens e of s elf. T ransference is modified with these changes . Amnes ia and s witching become apparent. F usion of alters results in ps ychological of two or more entities at a point in time, with a experience of los s of all s eparatenes s. T he term is s ometimes us ed s ynonymously with fus ion but is generally defined as the proces s of undoing all forms of diss ociative division during treatment. S ome patients 2015 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 237 of 302

proceed to what appears to be a complete fusion of all alters , with a s hift in self-representation from that of a diss ociative identity dis order individual to one with a cons istent and continuous sense of s elf across all behavioral s tates . Many patients never attain a fus ion of their alter personalities but leave treatment they have achieved a therapeutic re s olution: relative stability, adequate function, and some measure of harmony among s elf-states . As this integrative process occurs , P T S D s ymptoms improve s ignificantly. P atients often experience a of energy toward everyday life and away from traumafocus ed ways of living. C ognitive distortions frequently subs tantially s ubside. At the s ame time, and integrative coping s trategies mus t be identified and subs tituted for diss ociative respons es to life stress ors. Loss es mus t be mourned, and the patient must be to connect and cope with the larger world in a more functional manner.

Hypnos is Des pite the controvers y about its us e, hypnosis was endors ed by approximately two-thirds of respondents ps ychotherapeutic adjunct in diss ociative identity treatment. Hypnotherapeutic interventions can often alleviate self-destructive impuls es or reduce s ymptoms, such as flashbacks , diss ociative hallucinations, and influence experiences . T eaching the patient selfmay help with cris es outside of sess ions. Hypnos is us eful for acces sing s pecific alter pers onality s tates their s equestered affects and memories . Hypnos is is us ed to create relaxed mental s tates in which negative 2016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 238 of 302

events can be examined without overwhelming anxiety. C linicians using hypnosis s hould be trained in its us e in general and in trauma populations. C linicians should aware of current controversies over the impact of on accurate reporting of recollections and s hould use appropriate informed cons ent for its use.

Ps yc hopharmac ologic al P harmacotherapy was the third most commonly treatment modality. Although double-blind, controlled clinical trials have not been conducted, a variety of medications are considered clinically effective with diss ociative identity disorder patients . G uidelines for us e of medications with diss ociative patients the need to identify s pecific treatment-res ponsive symptoms rather than attempting to treat the per se. Medications may be helpful in attenuating symptoms to as sist the patient in stabilizing during treatment. P atients should be advised that medication res ponse is likely to be partial, devising the best shock absorber s ys tem for the patient at a given time. In succes s is more likely if medication target symptoms present acros s a range of alter personality s tates rather than confined to one or a few pers onality s tates. Among the target symptoms cons idered mos t to medication are affective symptoms. In many these are s econdary symptoms and s how a more heterogeneous and les s robus t response than primary affective dis orders. Nonetheles s, antidepress ant medications are often important in the reduction of depres sion and s tabilization of mood. A variety of symptoms, especially intrus ive and hyperarous al 2017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 239 of 302

symptoms, are partially medication respons ive. G uided clinical experience and research with P T S D patients , clinicians report s ome s ucces s with S S R I, tricyclic, and monamine oxidase (MAO) antidepres sants , β-blockers , clonidine (C atapres ), anticonvuls ants, and benzodiazepines in reducing intrusive symptoms , hyperarous al, and anxiety in diss ociative identity patients. S leep disturbances and traumatic nightmares may als o be improved by medications , although should be cautioned that dis sociative identity dis order P T S D s leep disturbances may be particularly refractory medications and res pond best to cognitive and interventions directed at patients' severe P T S D nighttime or even to s leeping. R ecent res earch that the α1 -adrenergic antagonis t, prazos in (Minipres s), may be helpful for P T S D nightmares. C ase reports that aggres sion may res pond to carbamazepine in individuals if E E G abnormalities are present. Many diss ociative identity disorder patients show significant obses sive-compuls ive s ymptoms. T hes e patients may preferentially res pond to antidepres sants with antiobses sive efficacy. Open-label studies s uggest that naltrexone (R eV ia) may be helpful for amelioration of recurrent s elf-injurious behaviors in a s ubs et of traumatized patients . Ques tions are often rais ed about the efficacy of neuroleptic medications , particularly for s ymptoms hallucinations . Although neuroleptics are only minimally effective for quas i-ps ychotic symptoms , s uch as hallucinations , in many dis sociative identity dis order patients, low doses may be us eful in some cas es for anxiety and for the s ubtle cognitive s lippage found in 2018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 240 of 302

some dis sociative identity dis order patients. T he newer atypical neuroleptics , s uch as ris peridone (R is perdal), quetiapine (S eroquel), ziprasidone (G eodon), and olanzapine (Zyprexa), may be more effective and tolerated than typical neuroleptics for overwhelming anxiety and intrusive P T S D s ymptoms in dis sociative identity dis order patients. Occas ionally, an extremely disorganized, overwhelmed, chronically ill diss ociative identity dis order patient, who has not res ponded to of other neuroleptics, res ponds favorably to a trial of clozapine (C lozaril). In general, to date, dis sociative memory and process symptoms, as ps ychopharmacological targets in and of thems elves , have proven refractory to medications . Dis sociative-like symptoms and behaviors , however, be induced in some P T S D patients and normal with drugs (e.g., phencyclidine [P C P ], cannabinoids ), suggesting the presence of pharmacologically s ens itive neurobiological mechanis ms that may lead to future medications that may target diss ociative symptoms per

E lec troc onvuls ive Therapy During their long ps ychiatric careers of mis diagnosis treatment failure, many diss ociative identity disorder patients receive uns uccess ful trials of E C T . T his led to view that E C T was not an effective treatment in the population. One small clinical study of s everely diss ociative dis order patients, primarily with disorder NOS , s uggested that, for s ome patients, E C T helpful in ameliorating refractory mood dis orders and not wors en diss ociative memory problems as the DE S . C linical experience in tertiary care settings for 2019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 241 of 302

severely ill diss ociative identity disorder patients that a clinical picture of major depress ion with refractory melancholic features across all alter s tates predict a pos itive respons e to E C T . However, this is us ually only partial, as is typical for mos t s ucces sful somatic treatments in the diss ociative identity disorder population. T arget s ymptoms and somatic treatments for identity disorder are listed in T able 17-19.

Table 17-19 Medic ations for As s oc iated S ymptoms in Dis s oc iative Identity Dis order Medications and somatic treatments for P T S D, affective dis orders, anxiety disorders , and OC D    S elective s erotonin reuptake inhibitors (no preferred agent, except for OC D symptoms)    F luvoxamine (Luvox) (for OC D presentations )    C lomipramine (Anafranil) (for OC D    T ricyclic antidepres sants    Monoamine oxidas e inhibitors (if patient can reliably maintain diet s afely) 2020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 242 of 302

   E lectroconvuls ive therapy (for refractory depres sion with persis tent melancholic features acros s all diss ociative identity disorder alters)    Mood s tabilizers (more us eful for P T S D and than mood swings)    Divalproex (Depakote)    Lamotrigine (Lamictal)    G abapentin (Neurontin)    T opiramate (T opamax)    C arbamazepine (T egretol)    B enzodiazepines    C lonazepam (K lonopin) and lorazepam (Ativan) have bes t track records    Atypical neuroleptics    T ypical neuroleptics (if patient fails trials of atypicals)    β-B lockers (for P T S D hyperarousal s ymptoms)    C lonidine (C atapres ) (for P T S D hyperarous al 2021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 243 of 302

symptoms)    P razosin (Minipress ) (for P T S D nightmares) Medications for thought dis order    Atypical neuroleptics preferred Medications for acute dys control    Oral or intramus cular neuroleptics    Oral or intramus cular benzodiazepines Medications for sleep problems    Low-dose trazodone (Des yrel)    Low-dose mirtazapine (R emeron)    Low-dose tricyclic antidepres sants    Low-dose neuroleptics    B enzodiazepines (often les s helpful for sleep problems in this population)    Zolpidem (Ambien)    Anticholinergic agents (diphenhydramine 2022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 244 of 302

[B enadryl], hydroxyzine [V is taril])    C hloral hydrate (Aquachloral S upprettes) for inpatient use) Medications for self-injury, addictions    Naltrexone (R eV ia)

OC D, obs es sive-compuls ive disorder; P T S D, posttraumatic stress disorder. P.1891

Inpatient Treatment As with patients with other ps ychiatric diagnoses , inpatient hospitalization is most commonly us ed for treatment of diss ociative identity disorder patients who are acutely unsafe or completely des tabilized, or both. commonly, in the age of managed care, hos pitalization be us ed to provide a safe environment in which to do intens ive work with painful affects and memories . F or a number of reas ons , overt dis sociative identity dis order patients can have disruptive effects on the milieu of general ps ychiatric units and often stimulate divis ion conflict among staff about the best way in which to to the patient and the alter pers onalities . T ypically, the split is between the believers and the skeptics , often 2023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 245 of 302

paralleling the larger societal debates as well as the subjective conflict within the patient about belief in the diss ociative identity disorder diagnos is and the authenticity of traumatic memories . Inpatient programs specializing in the treatment of diss ociative and P T S D patients may be more succes sful, because they unified treatment approach in which rigorous and firm limit s etting are combined with s pecific supportive treatment interventions to as sist with diss ociative and P T S D s ymptoms. Inpatient treatment general hospital units is mos t succes sful if there is an attempt to bridge different opinions about dis sociative identity disorder to focus on a unified approach for ameliorating specific target s ymptoms to allow the to resume outpatient treatment in safety. In specialty and general hospital units, the patient be expected to respond to his or her legal name, or at one s pecific name, in the hospital milieu and in all therapeutic interactions , except individual or individual interactions with designated hos pital s taff. T he patient s hould be expected to be able to present in reasonably functional adult mode in the hospital, with regress ed, dysfunctional, or child alters res tricted to designated one-on-one encounters or private time in patient's room or quiet room. T he patient's activities in hospital (e.g., group therapy) s hould be limited to those which the patient can participate while following thes e guidelines. S ome dis sociative identity dis order patients may be s o overwhelmed or overstimulated in the that they need time in the quiet room. However, this become a permanent berth for the patient, who may to be weaned back into more routine hos pital activities 2024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 246 of 302

prevent a major regres sion. Dis sociative identity dis order patients may experience hospital cris is management strategies , s uch as quiet all-staff call, or res traints, as abusive. B ecaus e of this, patient should be urged to work proactively with staff to find reasonable clinical alternatives to help with dyscontrol. However, hos pital staff may need to use res traints or s imilar meas ures if the dis sociative identity disorder patient is acutely dangerous to s elf or others if les s restrictive alternatives have failed to dees calate situation. In specialty units , res traints are often us ed frequently with these patients than on general hospital units . S pecialty unit staff are us ually trained in helping diss ociative identity disorder patients use symptom management and containment s trategies to handle potential cris es to minimize us e of physical to control behavior. S ingle doses of intramuscular (IM) neuroleptics , such as 2 to 5 mg of haloperidol (Haldol) fluphenazine (P rolixin), with or without 1 to 2 mg of IM lorazepam (Ativan), may be helpful for management of acute dys control in dis sociative identity dis order by inducing sleep to allow a change in s tate once the patient reawakens. S ublingual olanzapine or zipras idone is a more cos tly alternative for this as suming monitoring for cardiac s ide effects of zipras idone. Anecdotal clinical reports sugges t that the latter drugs have lower rates of overs edation and extrapyramidal (E P S ) s ymptoms compared with older typical neuroleptics when us ed in this way. As with other types of patients, dis charge from hospital us ually occurs when the acute crisis has been the patient has made adequate gains in symptom 2025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 247 of 302

management s kills and internal communication to problems more adaptively, medications have been adjus ted to provide better treatment of comorbid disorders , the outpatient psychosocial environment has res tabilized s ufficiently, or a treatment agreement for outpatient safety has been reached that is cons is tent discharge to the next level of care, or a combination of these. T o s ome extent, tertiary care s pecialty trauma disorders programs may be given more leeway by party providers to help patients develop a broader symptom management s kills and to have time to work more intensively to s tabilize s ymptomatic alter P atients referred to thes e centers have commonly improve, des pite multiple previous general hospital B ecaus e of this, third-party payers may be slightly open to a longer s pecialty inpatient s tay to reduce the potential for additional hospitalization.

Partial Hos pitalization P artial hos pital treatment can be an effective modality the diss ociative patient if clinical interventions target trauma-based is sues and adaptations. S pecialized partial hos pital programs with groups emphasizing symptom containment, cognitive and behavioral interventions , development of life skills, and ps ychoeducation can be effective in helping s tabilize more s everely and persistently ill diss ociative patients, well as providing an intens ive stabilization experience higher-functioning diss ociative identity disorder

Adjunc tive Treatments G R OUP THE R A P Y 2026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 248 of 302

Authorities agree that, in therapy groups including ps ychiatric patients, the emergence of alter can be disruptive to the group process by eliciting fas cination or by frightening other patients. T herapy groups composed only of diss ociative identity disorder patients are reported to be more success ful, although groups must be carefully s tructured, must provide firm limits, and should generally focus only on here-andis sues of coping and adaptation.

F A MIL Y THE R A P Y F amily or couples therapy is often important for longstabilization and to addres s pathological family and marital process es that are common in dis sociative disorder patients and their family members . E ducation family and concerned others about dis sociative identity disorder and diss ociative identity disorder treatment help family members cope more effectively with diss ociative identity disorder and P T S D s ymptoms in loved ones . G roup interventions for education and of family members have also been found helpful. In particular, family members should be dis couraged from interacting with individual alters , calling them out, and relating to them as s eparate individuals. F amily should be helped to s upport the goal of the diss ociative identity dis order patient becoming a functional adult in adult relations hips and a functional parent to children. therapy may be an important part of couple's treatment, the diss ociative identity disorder patient may become intens ely phobic of intimate contact for periods of time, and s pouses may have little idea how to deal with this helpful way. 2027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 249 of 302

F amily therapy with the family of origin of the identity dis order patient is often extremely distress ing the diss ociative identity dis order patient. C are mus t be exercised in setting up such meetings, because some interactions with family members may lead to an acute decompensation in the dis sociative identity dis order patient. Accordingly, such contacts s hould be carefully structured for defined therapeutic purposes , and the patient should be well prepared for potential advers e reactions . However, s uch meetings may P.1892 be helpful in clarifying or resolving the conflictual emotions that diss ociative identity disorder patients frequently experience toward family members. C onfrontation of family members about pas t traumas in accusatory manner almost invariably has a dis as trous outcome for the diss ociative identity disorder patient family members . Accordingly, there is usually little for such interventions in diss ociative identity disorder treatment.

E Y E MOVE ME NT DE S E NS ITIZA TION R E P R OC E S S ING (E MDR ) E MDR is a treatment that has recently been advocated adjunctive treatment of P T S D. T here are the literature about the us efulness and efficacy of this modality of treatment, and published efficacy s tudies discrepant. No systematic studies have been done in diss ociative identity dis order patients using E MDR . reports sugges t that s ome diss ociative identity disorder patients may be des tabilized by E MDR procedures , 2028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 250 of 302

acutely increas ed P T S D and dis sociative s ymptoms. authorities believe that E MDR can be used as an adjunct for later phas es of treatment in well-stabilized diss ociative identity disorder outpatients.

S E L F -HE L P G R OUP S Dis sociative identity dis order patients usually have a negative outcome to s elf-help groups or 12-step groups for inces t survivors . Accordingly, most experienced clinicians strongly dis courage dis sociative identity patients' participation in thes e modalities . A variety of problematic iss ues occur in thes e s ettings , including intens ification of P T S D s ymptoms due to discus sion of trauma material without clinical safeguards , exploitation the diss ociative identity disorder patient by predatory group members , contamination of the dis sociative disorder patient's recall by group dis cuss ions of and a feeling of alienation even from these other sufferers of trauma and diss ociation.

E X P R E S S IVE A ND OC C UP A TIONA L THE R A P IE S E xpres sive and occupational therapies , s uch as art and movement therapy, have proven particularly helpful in treatment of diss ociative identity disorder patients . Art therapy may be used for help with containment and structuring of severe dis sociative identity dis order and P T S D s ymptoms, as well as to permit dis sociative disorder patients safer expres sion of thoughts, feelings, mental images, and conflicts that they have difficulty verbalizing. Movement therapy may facilitate normalization of body s ens e and body image for these 2029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 251 of 302

severely traumatized patients . Occupational therapy help the patient with focus ed, structured activities that be completed s ucces sfully and may help with and s ymptom management.

Outc ome S tudies S ingle-case des criptions of s ucces sful treatments for diss ociative identity dis order date back more than a century. S ystematic outcome s tudies , however, have appeared within the pas t few years . T he first such followed up 20 dis sociative identity dis order patients at average of 3 years after intake. T he majority were in treatment with therapists who were unfamiliar with diss ociative identity disorder. Nonetheles s, two-thirds the clinicians reported moderate to great improvement their patients . A history of severe retraumatization the cours e of treatment was ass ociated with poorer outcomes . In the Netherlands, a chart review study of diss ociative dis order patients in outpatient treatment for an average of 6 years found that clinical improvement related to the intensity of the treatment, with more comprehensive therapies having better outcomes . A us ing the DE S to track treatment progress of 21 diss ociative identity disorder inpatients found a drop in overall s cores over a 4-week hospitalization. T he larges t and most systematic treatment outcome reevaluated 54 diss ociative identity disorder inpatients years after dis charge to outpatient treatment. As a there were significant overall decreas es in ps ychopathology, including number of Axis I and Axis II disorders , decreased DE S s cores, decreas ed the B eck Depres sion Index and the Hamilton 2030 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 252 of 302

S cale, and decreas ed dis sociative s ymptoms on all of DDIS s ubs cales . P atients who were reported according to rigorous criteria were the mos t improved. T wo s tudies inves tigating cos t efficacy of diss ociative identity dis order treatment have concordant findings suggesting that outcome depends on clinical s ubgroup. T he more treatment-res ponsive group of diss ociative identity dis order patients s howed significant remiss ion symptoms within 3 to 5 years of beginning appropriate treatment. A second group with more alters and more personality dis order features showed good outcome required hospitalizations in addition to outpatient treatment. A third group, characterized by the longes t period of treatment before diss ociative identity disorder diagnosis, largest number of alters , and most disorder problems , had a much longer, more cos tly, more difficult cours e. Overall, however, treatment approaches s pecifically targeting diss ociative identity disorder s howed reductions in overall ps ychiatric treatment cos t after the firs t year, compared to prior treatment for these patients . S ome health maintenance organization (HMO) groups report that more intensive treatment benefits for diss ociative identity disorder patients have not only reduced overall ps ychiatric but also reduced cos ts for medical us e for somatoform symptoms. T hese preliminary s tudies have notable limitations , including the diverse and nons tandardized nature of therapy and lack of comparison groups . Nonetheles s, aggregate, they indicate that many dis sociative identity disorder patients improve with treatments focused on their diss ociative symptoms and that overall treatment 2031 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 253 of 302

costs may be s aved in the long term by using the trauma treatment model for thes e patients . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E DIS OR DE R NO T S P E C IF IE D

DIS S OC IATIVE DIS OR DE R OTHE R WIS E S PE C IFIE D P art of "17 - Dis sociative Dis orders " T he category of diss ociative dis order NOS covers all of conditions characterized by a primary diss ociative res ponse that do not meet diagnostic criteria for one of the other DS M-IV -T R diss ociative dis orders. disorder NOS cases must als o fail to exclus ively meet diagnostic criteria for acute stress dis order, P T S D, or somatization disorder, which all include dis sociative symptoms among their criteria. T hus, dis sociative NOS is regarded clinically as a heterogeneous diss ociative reactions , s ome of which are common expres sions of dis tres s in other cultures but are rare in W es tern societies . T here are few s ys tematic s tudies of dis sociative NOS patients. Most authorities believe that there are major dis sociative disorder NOS s ubgroups . F irst is a of patients s imilar in clinical presentation, life history, clinical cours e, and treatment respons e to those with diss ociative identity disorder but whose s ense of subjective self-divis ion does not meet the firs t DS M-IV criterion for a dis sociative identity dis order alter identity 2032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 254 of 302

personality s tate. R arely, a patient may pres ent with first two DS M-IV -T R criteria for diss ociative identity disorder, but without apparent amnesia. Most of thes e diss ociative identity disorder–like patients ultimately full criteria for diss ociative identity disorder, but s ome never exhibit clear alter identities or demonstrate diss ociative amnesia and continue to be diagnos ed diss ociative dis order NOS . T he other diss ociative dis order NOS s ubgroup is a heterogeneous collection of patients with a variety of diss ociative s ymptoms and P.1893 multiple comorbidities , usually accompanied by a pas t history of severe trauma at s ome time in life. One s tudy found that the dis sociative disorder NOS patients had scores that were intermediate between those of with dis sociative amnesia and those diagnosed with diss ociative identity disorder. Mr. P . is a 22-year-old unmarried man admitted to a ps ychiatric hospital for ass es sment and treatment after serious s uicide attempt following an altercation with his girlfriend. On admiss ion his tory and mental status examination, P . reported extensive involvement in an inner fantasy world to which he retreated when life became overwhelming. He had done poorly in school, des pite documented high intelligence, because of “spacing losing track of class work owing to intense S ometimes , his inner world was filled with frightening confusing images, but, mostly, it was a place of retreat. 2033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 255 of 302

reported rapid changes in his sense of age, acting like, adoles cent, and adult in alternation. He reported amnes ia for many years of his childhood, although he could recall some of it. He described ongoing amnesia experiences with disremembered behavior, changes in abilities, repeatedly spacing out while and loss of time. He denied the exis tence of fully developed alter identities but felt subdivided into that represented different emotions and age s tates . He not experience loss of sense of s elf across these state changes but experienced hims elf and was obs erved to behave differently when he reported changes in these states . He reported chronic dysphoric mood, anxiety, of falling as leep, nightmares, and panic when touched in certain ways, although he could not explain why this was . He had s ignificant OC D symptoms , compuls ively arranging things in particular ways and panicking if they were changed. He grew up in a family of “workaholic alcoholics .” All members of his own and extended family drank although Mr. P . experienced them as “more pleas ant” when drinking than when preoccupied with work. members frequently teas ed him brutally because of his emotional s ens itivity and anxiety. He denied sexual abus e or frequent phys ical discipline, although reported occas ionally being beaten or s truck by his parents . F or the most part, he was left to himself. F rom years of age to approximately 12 years of age, he was to religious s chools, day care, and camps. He reported inexplicable obsess ive preoccupations with those experiences , although he could not recall much about them, including whether anything distress ing, 2034 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 256 of 302

overwhelming, or traumatic had occurred in these settings . During the years in which he attended these schools and camps , he developed repeated rectal bleeding from anal fis sures and hepatitis B . No medical explanation was reportedly found for these illness es. An intensive psychological ass es sment battery, the Minnesota Multiphasic P ersonality Inventory personality inventories , projective tests , intelligence and the S C ID-D-R , s upported a diagnosis of disorder NOS , intens e preoccupation with traumatic imagery s imilar to P T S D patients, but without a clear history of trauma, and a s ubtle atypical thought Hypnotizability tes ting showed that Mr. P . scored high standardized hypnos is scaling. T reatment included a variety of cognitive behavioral strategies to provide alternatives to fantasy withdrawal when experiencing dysphoria or s trong affects. He was taught self-hypnosis to increas e control over spontaneously occurring hypnotic experiences. He res ponded well to trials of 150 mg of fluvoxamine daily and 20 mg of ziprasidone twice a day for mood, OC D, and thought confusion s ymptoms . He began to more recall of as pects of his early life for which he had been amnestic, including frightening images with content related to the religious s chool. F amily meetings were held with his parents to review the developmental history, for Mr. P . to addres s his concerns about his treatment during childhood, and to help improve his relations hip with his parents . He was discharged with diagnoses of dis sociative disorder NOS , anxiety NOS , and mood dis order NOS . P ersonality 2035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 257 of 302

was thought to include avoidant, dependent, and schizotypal features. A J apanes e s tudy of 19 diss ociative patients, normal and ps ychiatric controls, diagnosed with versions of the DE S and S C ID-D-R , found a s imilar of DE S scores as in non-J apanese samples . However, diss ociative dis order NOS s ubjects and fewer identity disorder s ubjects than expected were on the S C ID-D-R , although the highest DE S s cores found in the diss ociative dis order NOS patients . T he authors s peculated that different cultural attributions meanings of the s ubjective self and normal J apanes e encouragement of highly developed social and private selves might account for more dis sociative disorders being diagnos ed on the S C ID-D-R in J apanese

C ultural Variants of Dis s oc iative Dis orders Included within diss ociative dis order NOS are the many cultural variants of diss ociative trance. Anthropologists have identified forms of diss ociation within every that they have examined. In some ins tances , this takes form of specific trance state disorders ; in others, it is manifest in religious rites and rituals ; and, in s till others, is manifest in the form of traditional healing practices . of thes e forms of dis sociation are common in many Wes tern societies. Increas ingly, measures s uch as the and S C ID-D-R are being adapted for these cultures us ed to investigate thes e conditions. T he DS M-IV -T R also includes under diss ociative NOS (T able 17-20) those diss ociative reactions elicited coercive persuasive practices , such as torture, 2036 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 258 of 302

brainwas hing, thought reform, mind control, and indoctrination intended to induce an individual to relinquis h basic political, s ocial, or religious beliefs in exchange for antithetical ideas and beliefs. F inally, syndrome, a rare and poorly unders tood condition, characterized by the giving of approximate answers , is included in this category.

Table 17-20 DS M-IV-TR C riteria for Dis s oc iative Dis order Not Otherwis e S pec ified T his category is included for dis orders in which predominant feature is a diss ociative symptom disruption in the us ually integrated functions of cons ciousnes s, memory, identity, or perception of the environment) that does not meet the criteria any s pecific diss ociative dis order. E xamples the following:    (1) C linical pres entations s imilar to dis sociative identity dis order that fail to meet full criteria for disorder. E xamples include pres entations in (a) there are not two or more distinct pers onality states or (b) amnes ia for important pers onal information does not occur.    (2) Derealization unaccompanied by depers onalization in adults . 2037 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 259 of 302

   (3) S tates of diss ociation that occur in who have been s ubjected to periods of prolonged and intens e coercive persuasion (e.g., thought reform, or indoctrination while captive).    (4) Dis sociative trance dis order: s ingle or disturbances in the state of consciousness , or memory that are indigenous to particular locations and cultures . Dis sociative trance narrowing of awareness of immediate or s tereotyped behaviors or movements that are experienced as being beyond one's control. P os sess ion trance involves replacement of the customary s ens e of pers onal identity by a new identity, attributed to the influence of a spirit, deity, or other pers on and ass ociated with stereotyped involuntary movements or amnesia, is perhaps the most common diss ociative Asia. E xamples include amok (Indonesia), (Indonesia), latah (Malays ia), pibloktoq (Arctic), ataque de nervios (Latin America), and (India). T he dis sociative or trance disorder is not normal part of a broadly accepted collective or religious practice.    (5) Loss of cons cious nes s, stupor, or coma not attributable to a general medical condition.    (6) G ans er s yndrome: the giving of approximate answers to ques tions (e.g., 2 + 2 = 5) when not

2038 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 260 of 302

as sociated with dis sociative amnes ia or fugue.

   F rom American P s ychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P s ychiatric Ass ociation; 2000, with permiss ion. T he IC D-10 (T able 17-1) clas sifies all diss ociative (conversion) dis orders in one s ection, which includes conditions (trance and poss es sion disorders , convuls ions, and G ans er s yndrome) that are carried diss ociative dis order NOS in the DS M-IV -T R .

Dis s oc iative Tranc e Dis order Definition Dis sociative trance dis order is manifest by a marked alteration in the s tate of consciousness or by of the cus tomary sense of personal identity without the replacement by an alternate s ense of identity (T able 21). T here is often a narrowing of awarenes s of the immediate s urroundings or a selective focus on stimuli within the environment and the manifes tation of stereotypical behaviors or movements that the experiences as beyond his or her control. A variant of poss ess ion trance, involves s ingle or episodic in the state of cons cious nes s, characterized by the exchange of the pers on's cus tomary identity by a new 2039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 261 of 302

identity usually attributed to a spirit, divine power, deity, or another person. In this poss ess ed state, the exhibits stereotypical and culturally determined or experiences being controlled by the poss es sing T here mus t be partial or full amnesia for the event. T he trance or poss es sion s tate must not be a normally accepted part of a cultural or religious practice and caus e s ignificant dis tres s or functional impairment in or more of the usual domains . F inally, the dis sociative trance state mus t not occur exclusively during the of a ps ychotic dis order and is not the res ult of any subs tance or general medical condition.

Table 17-21 DS M-IV-TR R es earc h C riteria for Dis s oc iative Tranc e Dis order A. E ither (1) or (2):    (1) T rance, that is , temporary marked alteration the state of cons cious nes s or los s of customary of pers onal identity without replacement by an alternate identity, as sociated with at least one of following:    (a) Narrowing of awarenes s of immediate surroundings or unusually narrow and s elective focus ing on environmental s timuli

2040 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 262 of 302

   (b) S tereotyped behaviors or movements that experienced as being beyond one's control    (2) P os sess ion trance, a single or epis odic in the state of consciousness characterized by replacement of customary s ens e of personal by a new identity. T his is attributed to the of a s pirit, power, deity, or other pers on, as evidenced by one or more of the following:    (a) S tereotyped and culturally determined behaviors or movements that are experienced as being controlled by the poss ess ing agent    (b) F ull or partial amnes ia for the event B . T he trance or poss es sion trance s tate is not accepted as a normal part of a collective cultural religious practice. C . T he trance or poss es sion trance state causes clinically significant dis tres s or impairment in occupational, or other important areas of functioning. D. T he trance or poss es sion trance state does occur exclusively during the course of a ps ychotic disorder (including mood dis order with ps ychotic features and brief psychotic disorder) or identity dis order and is not due to the direct 2041 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 263 of 302

phys iological effects of a s ubs tance or a general medical condition.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. P.1894

A taque de Nervios Diagnos is and C linic al Features Ataque de ne rvios is the best s tudied example of the diss ociative trance s tate dis order form of dis sociative disorder NOS . It is characterized by s omatic such as fainting, numbnes s and tingling, fading of seizure-like convulsive movements , palpitations , and sens ations of heat rising through the body. Individuals may moan, cry out, curs e uncontrollably, attempt to thems elves or others , or fall down and lie with deathstillnes s. During the episode, there is a narrowing of cons ciousnes s and a lack of awarenes s of the larger environment. After the epis ode, the individual usually reports partial or full amnesia for the events and their actions. Attacks may occur only once, may be episodic, occasionally may become chronically recurring with significant functional impairment. F requency of ataque s 2042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 264 of 302

was correlated with DE S s cores in one s tudy.

E tiology T riggers s eem most often to involve family, marital, or other interpersonal conflicts or los ses . Alcohol, physical sexual violence, financial loss , or stress and fear may precipitate an attack. His tories of phys ical and s exual abuse are common but are not well correlated with frequency or severity of episodes . T he triggering event may initially evoke a s ens e of being overwhelmed, hopeless , and helpless . T his is followed by an abrupt in state of cons ciousnes s, with a narrowing of cons ciousnes s and the development of more florid symptoms. Attacks can last from minutes to days but us ually a few hours in duration.

E pidemiology C ontributing demographic factors include being female; being 45 years of age or older; being divorced, or widowed; having less than a high school education; living in poverty. In P uerto R ico, there is an es timated lifetime prevalence rate of approximately 14 percent for ataque de nervios .

Differential Diagnos is T here is often significant comorbidity with depress ion, anxiety disorders , agoraphobia, and P T S D. Ataque de ne rvios is differentiated from these dis orders by its diss ociative alterations in cons cious nes s and somatos ens ory motor disturbances . T his condition may a manifes tation of dis sociative identity disorder.

2043 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 265 of 302

Treatment E pisodes usually end with the intervention of others , may res train the victim if he or she is in danger or as saultive or may otherwise calm him or her. P raying, rituals , use of herb or alcohol rubs, or other folk interventions are common. In addition, the individual's distress and s ymptoms usually elicit increas ed s ocial support or prompt interventions to reduce the stress ors that precipitated the attack. In mos t ins tances, help is not s ought. In cases in which the triggering stress ors are deemed minor by the victim's s ignificant others or there are concerns about chronicity, the may be brought for psychiatric treatment. No clinical have been conducted as yet, but s ome success is with antidepres sant and antianxiety medications .

P os s es s ion Tranc e Diagnos is and C linic al Features Although the G reeks believed in divine poss es sion, it not part of their explanation for mental illness , P.1895 which was largely s ubsumed under the label of melancholia, thought to be a dis order of the black bile. Demonic poss es sion, as an explanation for distress and mental illnes s, appears to date to the firs t century AD in P alestine and was common in New T es tament writings . During the Middle Ages , demonic poss ess ion was widely regarded as the caus e of epilepsy. C anon law forbade the ordination of any individual who had been publicly pos ses sed for this 2044 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 266 of 302

reason. E ven as the medical nature of mental illness epilepsy became increas ingly documented, rejection of the diabolical notion of pos ses sion proceeded slowly and unevenly. T oday, there are numerous subcultures within the United S tates that believe in poss ess ion, demonic and divine, and practice exorcism spirit pos sess ion rituals. P oss ess ion trance is common many third-world cultures. Anthropological s tudies suggest that pos ses sion and exorcis m occur mos t commonly in oppres sive s ocieties in which there is alienation from the es tablis hment, and protes t or direct action is dangerous or unacceptable. T he initial onset of pos ses sion trance is often s imilar to of diss ociative trance s tate, with an acute triggering stress or followed s hortly thereafter by convuls ive or uncontrolled movements , trembling, flailing, or fainting. T hen, the individual may laps e into a stupor or may to be s truggling in the grip of an unseen force, when, suddenly, a dis tinctly different personality emerges . A dramatic physical and ps ychological transformation occur in the individual's face, voice, demeanor, and behavior. T he personality may identify itself as external to and distinct from the personality of the poss es sed S ometimes , it has to be tricked or coaxed into its elf. It may claim to be a deity, demon, s pirit, ghos t, deceased relative, or historic individual. T his imbued with these attributes, now focus es attention on the conflicts or s tres sors that triggered the poss es sion. may make demands or may sugges t s tructural within the s ocial group to eas e the precipitating conditions. If these demands are met, then the 2045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 267 of 302

entity agrees to relinquis h control of the victim. During period of poss es sion, the individual may exhibit strength, agility, or other abilities or may behave in a dangerous or threatening fashion. P oss es sion us ually las t hours to days . In some ins tances , it can chronically dis abling. S pirit poss es sion, although not a disorder where it is religious ly s anctioned, shares many similarities with poss ess ion trance. K nown to occur in many regions of world, es pecially wes tern Africa, the C aribbean, and America, s pirit poss ess ion is us ually induced through rituals characterized by rapid, loud drumming, feverish dancing, and, sometimes, native intoxicants. As the begins to catch, there is often a dramatic T he individual may s tagger, s way, or fall into the arms bystanders. T he body may tremble or convulse. T he may change, the voice may deepen, and another personality becomes apparent. B ys tanders may further transformation by dress ing the individual in clothing appropriate for the identified s pirit or otherwis e addres sing it in a worthy fashion. While pos ses sed, the individual may dance with even greater agitation and force or may circulate among the crowd, addres sing people, questioning their health, or making pointed suggestions . S ometimes, the individual becomes may s tutter or speak with a lisp, may soil him- or may use vulgar language. C eremonially induced spirit pos sess ion typically lasts minutes to hours , with an average duration of approximately 1 hour in one review. As with trance state disorder, the individual is largely amnesic his or her behavior and the events of the poss ess ion 2046 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 268 of 302

episode. In s ome instances, the individual acts as a mess enger of the powers . W ith one foot in the world of deities and the other among men and women, the mess enger exis ts in a halfway s tate between full poss ess ion and normal behavior and usually retains memory for the events of the pos sess ion.

E tiology Anthropological s tudies strongly implicate pers onal as a common precipitant. In such cas es, special paid to the mess ages and advice given by the power reported and interpreted by the audience. Dreams or visions may als o precipitate poss ess ion, although generally more fleeting events . S piritual leaders may spirit pos sess ion as a s ource of guidance for their communities or to locate lost individuals or s acred S ometimes , s pirit poss ess ion is experienced as a punis hment for profaning a s acred s ite or angering a In mos t instances, pos sess ion trance appears to be in service of reducing overwhelming s tres sors or acute cris is in the individual's life. It als o provides an opportunity to expres s forbidden impuls es , to behave in socially unacceptable ways, to ass ume cross -gender and to influence people important to the pos ses sed.

E pidemiology P os sess ion trance disorders have been des cribed in third-world countries . T he Indian ps ychiatric literature contains the most s ys tematic descriptions and larges t number of cas es . In India, poss es sion s yndrome or hysterical poss es sion is the mos t common form of diss ociative dis order, whereas diss ociative identity 2047 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 269 of 302

disorder is thought to be exceedingly rare. P revalence poss ess ion trance in India has been estimated to range from 1 to 4 percent of the general population, but the on which this estimate is based may not truly be representative. E pidemics of pos sess ion syndrome been reported in the context of larger s ocial crises.

Differential Diagnos is P os sess ion trance differs from dis sociative identity disorder in that (1) it is generally a sharply time-limited condition (us ually hours), (2) it is us ually related to immediate s tres sors , (3) the pos sess ing pers onality to differentiate its elf as external to the victim, and (4) poss ess ing personality is usually recognizable to its audience by its stereotypical speech and behavior. P os sess ion trance may be mis taken for a psychotic when clinicians are not familiar with the cultural of an individual's ethnic group. In the United S tates, some religious groups view the identities in diss ociative identity disorder as of demonic poss es sion. Dis sociative identity dis order patients from thes e s ubcultures may feel torn between religious pres sure from their family and friends and the views of their treating clinicians. C ommonly, thes e diss ociative identity disorder individuals have alter identities who subscribe to the religious view of their social group and other alters who do not. An additional complexity is that diss ociative identity disorder patients from these sociocultural milieus , and from other backgrounds as well, not uncommonly have s elf-states that identify themselves as demonic, angelic, or of spiritual types. In one s tudy of dis sociative identity 2048 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 270 of 302

disorder patients who had been subjected to exorcis m, outcome was uniformly negative, with marked clinical wors ening, increased mistrust of religious and clinical caregivers, and a more difficult overall treatment

Treatment Individuals with pos ses sion trance or spirit pos ses sion seldom s eek treatment outs ide of the individual's family ethnic group. Intervention is most likely to come from family or traditional healers , who may perform an if the individual appears to be in great dis tres s or danger. W hen psychiatric help is sought, the pres ence diss ociative identity disorder, a psychotic disorder, or an affective disorder s hould be as sess ed.

B rainwas hing Definition T he concept of brainwas hing or thought reform from W estern reactions to the S oviet C ommunis t s how trials of the late 1940s and alarm over C ommunis t methods of coercive political reeducation that were central to the ideology of Mao T s e-T ung. T hes e fears intens ified during the K orean conflict after many prisoners of war made anti-American s tatements . In a journalist, E dward Hunter (later identified as a Intelligence Agency [C IA] agent) proposed that the C hines e C ommunis ts had dis covered techniques to mental attitudes and beliefs, a process that he called brainwas hing. P.1896

2049 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 271 of 302

After the Armistice, a team of ps ychiatris ts and ps ychologists , including R obert J . Lifton and E dgar interviewed the returning prisoners . S imilar s tudies for the C IA als o obtained information from C ommunis t interrogators and former S oviet and C hines e pris oners . T hese studies concluded that the apparent of thes e prisoners , as well as of the victims of the show trials , was the res ult of extreme police techniques involving severe physical and ps ychological deprivation, followed by rewarding the s everely prisoners with the poss ibility of the end of their ordeal, well as food and warm clothing. T he reports concluded that the basic attitudes of the American pris oners in had not, in fact, been altered. However, the s ubs equent release of another group of prisoners (mis sionaries, bus iness men, doctors, and students) caught in C hina at the beginning of the war seem to s ugges t that some form of thought reform had occurred with these individuals , several of whom continued to fals ely insist that they were s pies. In a round of studies, Lifton, S chein, and others concluded changes in an individual's bas ic beliefs could occur in context of extreme phys ical, psychological, and social coercion. T he us e of extreme group pers uas ion by the C hinese C ommunists on political prisoners may have been influential in this outcome. C linical presentations of individuals s ubjected to extreme forms coercive pers uasion may resemble thos e of survivors other s orts of torture. One legacy of the fear of C ommunist brainwas hing was the unfortunate misuse of ps ychiatry and psychology the C IA and other U.S . government agencies from the 2050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 272 of 302

1940s and onward to develop methods of behavioral control, which was revealed in release of government documents and C ongres sional hearings in the 1970s . effort to combat or to preempt potential C ommunist use of mind control, the C IA s tudied or s upported studies of ps ychedelic drugs and other toxins and intoxicants , radiation, hypnos is , sens ory deprivation, repeated E C T treatments , and bizarre conditioning experiments, others , often on unwitting civilian or military s ubjects. At least one s ubject killed hims elf during an LS D and other psychiatric casualties have brought s uits the U.S . and C anadian governments because of caus ed them during C IA-funded experiments. According to reviews of C IA documents, s ome C IA apparently believed in the poss ibility of us ing hypnosis create as sas sins or s pies with hypnotically induced identities or amnes ia, or both, who could thus resist interrogation and torture. However, it has been that other C IA officials in charge of mind control experiments doubted that this could be done B ecaus e C IA officials des troyed many documents to these activities, it is not known to what extent thes e experiments were ever attempted. P opularized continue to s uggest that the U.S . government to create multiple-personality s pies. However, a careful reading of cases purported to demonstrate this show based on available information, most bear little to clinical dis sociative identity dis order. Allegations of brainwas hing or mind control resurfaced the late 1960s and 1970s in the context of religious movements. T his theory was als o advanced group of defens e psychiatric experts that included 2051 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 273 of 302

Wes t, Lifton, Martin Orne, and Margaret T . S inger in famous cas e of P atty Hearst, the heiress who was kidnapped, tortured, s exually abus ed, and held in prolonged solitary confinement by a radical cult-like group. After many months of this treatment, Hears t was said to have trans formed her identity into that of the revolutionary T ania, who aided her captors in criminal including bank robbery and murder. T he P atty Hearst was not convinced, however, and convicted Hearst the arguments of the defense psychiatric experts. S inger s ubs equently widely publicized her ideas about conditioning techniques that she believed were used by religious cults to render their members incapable of complex rational thought and unable to make a s eries of laws uits by ex-members agains t various religious cults , she testified that these techniques were capable of overpowering a pers on's free will and that group's control over a member could be total. T hes e sens ational trials instilled in the public the notion of brainwas hing as a common practice in religious cults . In respons e, a group of academics, primarily and s ociologis ts, challenged S inger, pointing out that members often came from dysfunctional families and joined cults to avoid the anxieties and res ponsibilities independence. P s ychiatrist Marc G alanter reframed the religious cult mind-control debate by advocating the neutral term charis matic religious s e cts and pointing that an individual's behavior within such a social group may reflect psychological adaptation rather than ps ychopathology. S urveys and studies of ex-cult indicated that the manner of leaving the group, or by being involuntarily deprogrammed, was a 2052 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 274 of 302

determinant of their subs equent as sess ment of they had been brainwas hed, with the latter the most to expres s this belief. In the context of a particularly s ensational case, the American P s ychological Ass ociation and American S ociological Ass ociation submitted amicus briefs the concept of brainwas hing as lacking scientific which has had the larger effect of ess entially nullifying legal status . Although the academic community has largely avoided the topic in the las t decade, the notion brainwas hing, in which individuals are rendered hypers ugges tible through hypnosis , drugs , or phys ical stress ors , and their belief s ys tems are transformed by special conditioning techniques , continues to fas cinate public and to be invoked by a few ps ychotherapis ts and others as evidence of occult or government At the s ame time, some researchers on destructive have continued to sugges t that cult membership an ego state or dis sociated s elf-as pect that allows the person to function ego-syntonically within the cult T his entity is not conceptualized as meeting diagnos tic criteria for a diss ociative identity disorder alter identity suggests a diagnos is of diss ociative dis order NOS . R es earch s tudies to attempt to fully explicate such are likely to be exceptionally difficult to perform. T he military stress studies of Morgan and colleagues however, that combinations of pain, hunger, cold, fear, s ens ory deprivation, and control over bodily and s ocial communication can profoundly alter an individual's state of consciousness , producing diss ociative s ymptoms . T he accompanying degree of identity alteration induced by s uch techniques remains 2053 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 275 of 302

be empirically established, but it s eems poss ible that diss ociative reactions could account for many of the ps ychological changes reported in captive individuals subjected to coercive interrogation and persuasion.

Diagnos is and C linic al Features Individuals who have been s ubjected to extreme techniques are at risk for pers is tent depersonalization poss ibly, other dis sociative s ymptoms, including trance-like behaviors, and emotional numbing. T hey exhibit reduced cognitive flexibility, behavioral and profound changes in values , attitudes , beliefs, and sens e of self. In some ins tances , an alter s elf state emerge that identifies with former tormentors and behaves in a fashion contrary to the individual's prior behavior. T his alter s elf us ually dis appears or weakens significantly when the individual is returned to s afety security but may be transiently reactivated by circums tances reminiscent of the traumatic events.

Treatment T here are no empirical studies of the treatment of individuals s ubjected to extreme coercion applied in the service of indoctrination of a belief s ys tem or an identity alteration. T he basic principles of phas ed treatment would seem to provide an organizing framework for treatment of these individuals , as it has victims of other forms of torture. T his begins with the creation of safety and s ymptom stabilization, along with educational information to help normalize the res ponse. T his is followed, when and if appropriate, by supportive but nonsuggestive exploration of the events 2054 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 276 of 302

and experiences to desens itize their memory and to integrate them better into the individuals' trans formed sens e of self. Any preexisting ps ychopathology likely is exacerbated by s uch experiences and P.1897 should be addres sed as the dis sociative s ymptoms F amily interventions may be necess ary as a result of duress and disruption accompanying the precipitating events and the s ocial effects of the profound changes the individuals ' attitudes, behaviors, and beliefs .

G ans er S yndrome Definition G ans er s yndrome is a poorly understood condition, reclas sified from a factitious dis order to a diss ociative disorder in the DS M-III, characterized by the giving of approximate ans wers (paralogia) together with a of cons cious nes s, and frequently accompanied by hallucinosis and other diss ociative, somatoform, or conversion s ymptoms . F irst des cribed by Dr. S . J . M. in an 1897 lecture entitled “A P eculiar Hysterical S tate,” who observed that the “most obvious s ign consists of inability to ans wer correctly the simples t questions are as ked to them even though by many of their they indicate that they have grasped a large part of the sens e of the question.” G ans er offered the example of patient who, when asked how many noses he had, “I don't know if I have a nose.”

Diagnos is and C linic al Features T he symptom of pas s ing ove r (vorbe ige he n) the 2055 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 277 of 302

answer for a related, but incorrect one, is the hallmark G ans er s yndrome. T he approximate ans wers often jus t miss the mark but bear an obvious relation to the indicating that it has been understood. W hen as ked old s he was , a 25-year-old woman ans wered, “I'm not Another patient, when asked how many legs a hors e replied “three.” If asked to do simple calculations (e.g., 2 = 5), for general information (the capital of the United S tates is New Y ork), to identify simple objects (a pencil key), or to name colors (green is grey), the G ans er gives erroneous but comprehens ible answers . T here is also a clouding of consciousness , us ually by disorientation, amnesias, los s of personal and s ome impairment of reality testing. V isual and auditory hallucinations occur in roughly one-half of the cases. Many of the cas e reports include his tories of injuries, dementia, or organic brain insults. examination may reveal what G ans er called hys te rical s tigmata, for example, a nonneurological analgesia or shifting hyperalges ia. Many authorities make a between G anser symptoms of approximate answers, which may occur in a number of psychiatric and neurological conditions , and G anser syndrome, which must be accompanied by other dis sociative s ymptoms, such as amnes ias , conversion s ymptoms, or trancebehaviors .

E pidemiology C as es have been reported in a variety of cultures , but overall frequency of such reports has declined with T his may reflect trends in diagnosis, cas e reporting, or genuine decline in cas es . In the clinical literature, men 2056 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 278 of 302

outnumber women by approximately 2 to 1. T hree of G ans er's first four cases were convicts, leading some authors to consider it to be a dis order of penal and, thus, an indicator of potential malingering. G ans er believed that he had adequately ruled out this and most authorities are convinced that thes e patients have a genuine disorder. S ubs equent cas e s eries that it occurs in other settings and is not unique to prisoners .

E tiology S ome cas e reports identify precipitating s tress ors , s uch personal conflicts and financial reverses, whereas note organic brain s yndromes, head injuries, seizures, medical or ps ychiatric illness . P s ychodynamic are common in the older literature, but organic are stress ed in more recent cas e s tudies. It is that the organic insults may act as acute s tres sors , precipitating the syndrome in vulnerable individuals. S ome patients have reported s ignificant his tories of childhood maltreatment and adversity.

Differential Diagnos is G iven the reported frequent history of organic brain syndromes, s eizures , head trauma, and psychosis in syndrome, a thorough neurological and medical evaluation is warranted. Differential diagnoses include organic dementia, depres sive pseudodementia, the confabulation of K orsakoff's s yndrome, organic and reactive psychoses. Diss ociative identity disorder patients occas ionally may als o exhibit G anser-like symptoms. 2057 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 279 of 302

Treatment T here have been no systematic treatment s tudies, the rarity of this condition. In most cas e reports , the patient has been hos pitalized and has been provided a protective and s upportive environment. In some instances, low doses of antips ychotic medications have been reported to be beneficial. C onfrontation or interpretations of the patient's approximate answers not productive, but exploration of poss ible stress ors be helpful. Hypnosis and amobarbital narcosynthesis also been us ed s ucces sfully to help patients reveal the underlying s tres sors that preceded the development of the syndrome, with concomitant ces sation of the symptoms. Usually, there is a relatively rapid return to normal function within days, although some cas es may take a month or more to res olve. T he individual is amnes ic for the period of the syndrome. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > F OR E NS IC IS S UE S AND DIS OR DE R S

FOR E NS IC IS S UE S AND DIS S OC IATIVE DIS OR DE R S P art of "17 - Dis sociative Dis orders " Individuals with dis sociative disorders pres ent a variety problems in criminal and civil law. In criminal law, defendants claiming to have diss ociative identity have been as sociated with highly publicized cases, primarily seeking exculpation through the insanity 2058 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 280 of 302

defens e. However, diss ociative identity disorder individuals have als o appeared as alleged victims or witness es in criminal actions . Many of thes e cas es been s ubject to intense media coverage. Malingered diss ociative identity disorder and amnesia are major concerns when claims of not guilty by reason of (NG R I) or diminis hed capacity for criminal acts are broached. However, less publicized diss ociative disorder defendants have been accused of driving intoxicated (DW I), s hoplifting, theft, check kiting, embezzlement, credit card fraud, child abus e and stalking, and many other crimes. T hey also may be plaintiffs , particularly in cas es involving interpersonal aggres sion: domestic violence, s talking, and rape. Dis sociative individuals also commonly appear in civil cases. T hey may be plaintiffs in a variety of tort suits , commonly malpractice litigation, s exual harass ment, therapist mis conduct complaints . T hey als o may workers' compens ation matters, dis ability litigation, and family law related to divorce and child cus tody evaluations , among many others. S ome diss ociative disorder patients have s ued alleged abusers, usually parents , claiming damages for previously forgotten childhood abuse us ing the delayed discovery rule. C onvers ely, individuals diagnosed with diss ociative disorders —us ually dis sociative identity dis order—have sued for malpractice, alleging that the diagnosis was erroneous or iatrogenically created and that the plaintiff was harmed by therapy focused on therapeutically induced fals e memories of childhood maltreatment on a belief in repress ed memory. S ome of the latter plaintiffs had previous ly sued or pros ecuted their 2059 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 281 of 302

for abus e before recanting and s uing their therapists! S tate juris dictions may differ among thems elves and the federal courts on a variety of legal is sues, s uch as diminis hed capacity, criminal intent, competence, of limitations, capacity to give testimony, and allowance tes timony about amnes ia for trauma. Different jurisdictions have been divergent in their approach to diss ociative individuals as well. At leas t one district rejected diss ociative identity disorder as a valid to be cons idered for an insanity defens e plea, but this ruling was revers ed on appeal. Other courts have in findings of criminal res ponsibility for dis sociative identity dis order individuals , bas ed on differing ways of viewing which alter was respons ible for the criminal P.1898 In the criminal arena, me ns rea, the s tate of mind culpability for criminal acts , may seem hard to in an individual who claims dens e amnes ia for crimes who experiences hims elf or herself as self-states that variously profes s or deny res ponsibility for criminal behavior. S ome legal scholars have suggested that diss ociative dis orders in the criminal courts rais e related to an actus reus defens e, bas ed on the inability control involuntary actions , as in crimes committed in epileptic or s omnambulis tic s tates. In this regard, in recent high-profile criminal cas e, depers onalization us ed success fully as a bas is for a finding of lack of res ponsibility due to involuntary action, claimed by a defendant who s hot and wounded an alleged past

Dis s oc iative Identity Dis order and 2060 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 282 of 302

L aw T he inters ection between the diagnosis of diss ociative identity disorder and the legal system has proven to be exceedingly controvers ial. T he contentious dis pute exis tence, the often sensationalized media attention, the need to rule out simulation or malingering have the forens ic evaluation of dis sociative identity dis order difficult to perform and to defend. In criminal matters, most common claims are that (1) diss ociative identity disorder defendants do not have control over or are not cons cious of their alter pers onalities and therefore be held res ponsible for their actions ; (2) diss ociative identity dis order defendants are not competent, they cannot recall the actions of their alter self-states therefore cannot participate in their own defens e; and diagnosis of diss ociative identity dis order makes it impos sible for a defendant to conform to the law or to know right from wrong. E videntiary questions , including the admis sibility of material gathered with hypnotic or amobarbital interviews and the reliability or relative independence of testimony by different alter identities, have rais ed difficult legal ques tions . In general, trial and appeals courts in s tate and federal jurisdictions have ruled that diss ociative identity meets F rye or Daubert criteria, or both, so that it may us ed legitimately as a criminal defens e, and so that diss ociative identity disorder individuals can testify in court in alter identities and in dis sociative states . In many cas es, courts have s truggled with the the alter identities, confus ing their cognitions and behaviors with thos e of s eparate pers ons and failing to view the alters as me ntal cons tructs with relatively 2061 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 283 of 302

independent cognitions , affects , and memory s ys tems with a capacity for behavioral and role enactment. In fact, one extreme legal theory has posited that diss ociative identity dis order self-states s hould be like s eparate individuals, so that thos e uninvolved in criminal behavior would, by definition, be absolved of res ponsibility, and a finding of not guilty by reason of insanity would be mandated. C onversely, clinicians experienced in the treatment of diss ociative identity disorder have found that holding the whole human res ponsible for the behavior of any part is far more lead to clinical progres s and increased function. An attempt to abs olve or to excuse the patient of res ponsibility for maladaptive or antisocial behaviors is to lead to s piraling regress ion and es calating Accordingly, thes e authorities have recommended that clinical s tandard of holding the whole human being res ponsible for the behavior of any part be the for any legal cons ideration of diminished respons ibility criminal conduct in the diss ociative identity disorder individual. An affirmative case should be made that the diss ociative identity dis order defendant meets the standard for legal ins anity or diminis hed capacity, just would be the case for any psychiatric defense. S imilarly, forens ic commentators have argued that it is vital not to confus e the behavior of an individual experiencing hims elf or herself as an alter identity with mental s tates and behaviors of separate persons. authorities s uggest careful attention to avoid reification the diss ociative identity dis order alters and a focus on symptoms and mental state of the whole individual at 2062 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 284 of 302

time of the criminal act. T here is no pathognomonic presentation of diss ociative identity disorder in the criminal setting. However, authorities s uggest that genuine diss ociative identity disorder defendants are more likely to s how a complex alter s ys tem, not just a good–bad alter dichotomy. fide diss ociative identity dis order individuals may have bizarre explanations for why and how they (in alter identities ) committed crimes , not jus t “the bad one did Authorities als o describe a number of diss ociative disorder defendants as minimizing their psychiatric symptoms and attempting to avoid being labeled ps ychiatrically ill, although a few exaggerate bona fide diss ociative identity disorder s ymptoms . G enuine diss ociative identity disorder defendants may behave in self-defeating and problematic ways that may the success of their defens es . Mr. A. was arrested and charged with the murder of his long-time gay lover. T he circums tances of the cas e complex and bizarre. Mr. A. called the police on the of the murder claiming that his lover was holding him hostage and was going to kill him. He stated that his was heavily armed and was prepared to kill police if they s tormed the hous e. A S pecial W eapons and (S WAT ) team was dis patched, contacted Mr. A. by and s pent the next s everal hours attempting to talk him out of the hous e. He spoke with them in a child-like identified hims elf by a diminutive of his actual name, described hiding in a clos et with his pet. He appeared completely terrified, repeatedly stating that he was to be killed, that “the man” was dangerous and armed, 2063 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 285 of 302

that he would be shot if he attempted to flee. the police s tormed the hous e, located Mr. A. hiding a couch, and found his lover in the bedroom, dead of multiple gunshot wounds. B allis tics tes ts and other forens ic evidence indicated that Mr. A. had shot his who had been killed before the phone call to the police was initiated. At the time of his arres t, Mr. A. claimed memory of the shooting, although he did describe a frightening altercation earlier in the evening in which he stated that his lover had threatened to kill him for an alleged infidelity (which Mr. A. denied). Mr. A.'s attorney sought a finding of incompetence, because Mr. A. could not as sist in his defense owing to of recall of the s hooting. A court-appointed forensics had Mr. A. transferred to a state forens ics facility for as sess ment. T here, Mr. A. engaged in a variety of confusing, and s elf-defeating behaviors. He was overly compliant, defiant and oppos itional, child-like confused, and provocative and angry. On occasion, he identified hims elf by different names . Diagnos ed with a personality disorder and P T S D related to the shooting, was declared competent, even though he continued to claim amnesia for the crime. T he defense attempted to portray the shooting as s elf-defens e but could offer no direct information about it becaus e of the reported amnes ia. T he court limited psychiatric testimony concerning Mr. A.'s amnes ia. Mr. A. was convicted of murder, although, as the trial progres sed, his behavior became increasingly bizarre the courtroom. He threw water at the district attorney, stood up and s houted at the judge, and became combative with the court guards, resulting in additional 2064 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 286 of 302

charges of as sault. In the cours e of the s entencing proceeding, he became even more confused, child-like, and inappropriate. During a jailhouse conference with attorney, Mr. A. apparently began to s witch s tates , identified hims elf by different names , and referred to hims elf in the third pers on s ingular and the firs t person plural. He began to recount a bizarre his tory of the shooting in which several alter identities claimed res ponsibility for “protecting the little guy” (an alleged child alter) from the murderous as sault of the dead Mr. A. recounted a long his tory of infidelity and sexual, and emotional torment by the lover. He hinted history of childhood maltreatment by his father. P.1899 T he alters switched rapidly back and forth, with the Mr. A., apparently unable to recall what was said by the other alters . He appeared terrified, ins isting that this not happening to him and demanding that his attorney not bring this material into court. Mr. A. began to claim that his attorney was untrus tworthy and not helping him adequately in his legal defens e. W hen in the alter Mr. A. described fears of other pris oners in the jail. He elaborated a variety of paranoid ideas about plots him and vowed to defend hims elf agains t the other prisoners . Defense inves tigators found only limited evidence supporting the claims of maltreatment or infidelity by murdered lover. T he defendant's family s ide-stepped questions about childhood abuse, although they confirmed that the father was a violent, rageful, who experienced war-related P T S D and had been 2065 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 287 of 302

several times for violent behavior. Additional defens e forens ic ass es sment, including extensive ps ychiatric evaluation, psychological as sess ment, and formal as sess ment of malingering, res ulted in an opinion s upporting a diagnos is of diss ociative identity disorder. T he alter identities were particularly bizarre and paranoid in their thinking. on all the evidence, it was unclear if the lover was shot owing to Mr. A.'s paranoia or under conditions of actual threat, or both. Under state law, the defens e forens ic evaluation s upported a finding of incompetence owing Mr. A.'s inability to control dysfunctional s witching, and paranoia, leading to inability to as sist his attorney in the sentencing procedure. T he court rejected the claim of incompetence. Mr. A. was s entenced to 50 years in Appeals are proceeding claiming that, under state law, insanity defens e s hould have been allowed at trial. Mr. B . was arrested and charged with rape and murder approximately 48 hours after he released his to her home. He had kidnapped the victim after her uncons cious and driving her to his hous e. T here, tortured her bizarrely over 10 hours , culminating in a of sexual acts, the las t of which was a vaginal rape. this, his mood s eemed to change, and the victim found him less malevolent than he had been. Up until then, had been certain that s he would be killed. S he persuaded him to releas e her with a promise that she would not call the police. S he did not keep this and Mr. B . was quickly found and arres ted. All police contacts during the arres t and initial interrogation were audiotaped or videotaped. Mr. B . admitted the ass ault to the police and become 2066 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 288 of 302

increasingly despondent and distress ed. E ventually, he was transferred to a state hospital forensics unit fear that he would commit s uicide. S ubsequently, Mr. was implicated in two other attempted rapes in the previous year, which he als o admitted. In the course of as sess ment by state and defense ps ychiatris ts and ps ychologists , Mr. B . began to des cribe a “bad person” lived inside him and who had “taken over” and “made commit the crimes of which he was accused. He a complex s eries of hallucinations , preoccupation with rape fantas ies done by the “bad person,” and loss of interes t in life over the year preceding the rape. He claimed that he was s o preoccupied by these fantasies he ignored many bas ic aspects of daily life. Defens e health experts made a diagnosis of diss ociative identity disorder, s exual s adism, and major depress ion. T hey opined that the defendant was not guilty by reason of insanity, based on the “bad person” doing the crimes the defendant's los s of contact with reality in the year before arres t. R eview of Mr. B .'s past revealed a documented history severe phys ical abus e, emotional abus e, and neglect perpetrated by his mentally ill mother and alcoholic Mr. B .'s history was noteworthy for a virtually lifelong ps ychiatric disturbance characterized by a with rape, s exual sadism, and murder. He hinted that might have attempted rapes at other times in his life. Additional experts hired by the s tate evaluated Mr. B . several days . T hey performed the S C ID-D-R and other ps ychometric diagnos tic as ses sments. In neither the clinical nor the ps ychometric as sess ment did Mr. B . describe typical dis sociative identity dis order 2067 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 289 of 302

such as amnes ia, depers onalization, spontaneous autohypnotic phenomena, s witching, internal voices , internal pass ive influence, or somatization nor did he report P T S D s ymptoms. T he pers onified entities in his mind did not have relatively independent ways of thinking, behaving, or remembering nor did they clearly take control of Mr. B .'s behavior. T hey were more like fantas y characters, rather than alter self-states . Mr. B . described ideas of influence and reference at times emanating from others in his environment, periodic paranoid thinking, and s ocial isolation. Unus ual and idios yncratic thinking was observed at times during the interviews . He proclaimed remorse for his crimes but, clos er ques tioning, actually seemed rather pleas ed hims elf for completing the rape. T he history of recent, extreme s ocial withdrawal was belied by the acknowledgment that he had traveled out of s tate, several women, and actually prepared his house for the year preceding his arrest. He acknowledged the difference between right and wrong and taking evas ive actions to avoid arres t, in all alleged states of P ros ecution experts made DS M-IV Axis I diagnoses of schizotypal personality disorder with antis ocial traits; dis sociative disorder NOS , due to the bizarre preoccupations; sexual s adis m; and major depress ive disorder, in partial remis sion. T hey concluded that Mr. did not meet criteria for a diagnos is of diss ociative disorder nor did he meet s tate criteria for NG R I. Mr. B . guilty and is now serving 25 to 50 years in state prison. T herapists may find thems elves treating dis sociative identity disorder patients who face criminal charges for minor crimes , s uch as s hoplifting, check forgery, credit 2068 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 290 of 302

card fraud, and DW I. It may be impos sible for the hire an independent forens ic expert. In these cases , clinician may be unable to avoid providing a written or appearing in court to testify at the reques t of the or the patient's attorney. T he clinician should educate hims elf or herself about the role of the treating profes sional tes tifying on behalf of a patient. T he should be clear with the attorney and the patient on the differing roles of the forensic expert and the treating clinician and the potential ris ks that may ens ue if the primary therapist is made to tes tify. It may be difficult the therapist to s eparate the roles of the advocate for a disturbed patient from that of a forensic examiner. However, the clinician should take s eriously the importance of protecting the public from the patient. C linically, the forens ic situation may be us eful to unders core for the patient the respons ibility of the person for behavior committed in diss ociated s tates of cons ciousnes s and to gain better adherence to behavior from antisocial alter identities.

A mnes ia for C riminal B ehavior F rom a legal s tandpoint, amnesia alone is generally not cons idered a sufficient factor to generate a finding of incompetence to stand trial or a verdict of not guilty by reason of ins anity. Accordingly, it is dis advantageous malingerer to make amnesia claims in the hopes of achieving a success ful ps ychiatric defens e. C ase have found that perpetrators claimed diss ociative in 30 to 40 percent of homicide cas es and in a less er percentage of other violent crimes. Although is often s us pected in s uch cases , many of thes e did little to avoid being charged with a crime, and s ome 2069 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 291 of 302

even called the authorities thems elves. In general, the cases with apparent true diss ociative amnesia were characterized by an unpremeditated P.1900 as sault in a state of high emotional arous al on a victim clos ely related to the perpetrator. T here is no absolute way to differentiate true amnes ia from malingering. Malingerers have been to continue their deception even during hypnotically or barbiturate-facilitated interviews . Malingered amnesia more common in individuals pres enting with dramatic forms of generalized or circums cribed dis sociative or fugue, or both. Many of the amnesia cases in the clas sical literature were des cribed as occurring in a context of financial, s exual, and legal problems or in soldiers who wis hed to escape from combat. On the hand, in the clinical cas e reports , many malingerers confess ed their deceptions spontaneously or when confronted by the examiner. A variety of procedures have been sugges ted to differentiate objectively between actual and malingered amnes ia. At this point, none has achieved a definitive status in differentiating among thes e conditions . T he forens ic approach outlined in the following dis cus sion should be us ed to as sess individuals claiming amnes ia in the criminal court context, buttres sed, when indicated, by s pecific diagnostic ass es sment including ps ychometric s cales to detect malingering. Individuals with dis sociative fugue may also be legal is sues . T he fugue may occur in the context of 2070 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 292 of 302

ps ychos ocial stress ors , s uch as combat, financial or indis cretions, fears of violent behavior toward others , so on. When the individual is dis covered, he or s he face a variety of legal problems on return home.

Forens ic A s s es s ment of Dis orders In the ass es sment of poss ible diss ociative dis order in criminal defendants, as well as plaintiffs or defendants the civil arena, a number of guidelines may be helpful: F ollow bas ic principles of rigorous independent as sess ment. (2) Undertake a comprehens ive all available documentary materials concerning the defendant and the cas e. (3) R eview all available past ps ychiatric, s ocial s ervice, and related materials . (4) It often best to perform a standard diagnostic the defendant before introducing s pecialized testing. In some cases , it may be desirable to videotape or the interview following forensic guidelines; the latter be mandatory in some states if hypnosis is involved in as sess ment. (5) Avoid s uggestive or leading ques tions during forensic ass ess ment of pos sible diss ociative disorders . (6) A longitudinal life-history interview may us eful in cases in which malingered amnesia or diss ociative identity disorder is s uspected: Ask the defendant to relate his or her entire life history, with the firs t memory and proceeding forward up to the present time, following up information as neces sary in neutral manner. (7) After completion of the basic as sess ment, formal ps ychological tes ting, including interviews as sess ing malingering, s pecialized disorders interviews (e.g., the S C ID-D-R ), or neurops ychiatric testing, or a combination of thes e, 2071 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 293 of 302

be done. (8) Interviews with corollary sources (e.g., family) may be necess ary to corroborate the history in addition to written records. (9) Use forensic guidelines hypnotically facilitated or drug-facilitated interviews . G uidelines for hypnotically facilitated forens ic have been publis hed by the American S ociety for Hypnos is . T hese should only be performed by forens ic examiners trained in their us e.

Dis s oc iative-Dis ordered P laintiff In the few cases in which the iss ue has been litigated, several s tate trial and appeals courts have allowed tes timony of dis sociative identity disorder plaintiffs, despite their tes tifying in dis sociative or self-hypnotic states . Nonetheles s, involvement of adult dis sociative patients as plaintiffs in legal cases frequently res ults in advers e impact on the patient's clinical cours e. T his due to the negative effect of the adversarial system on patient, who may have a highly idealized view of what occur; an increas ed s ens e of los s of control due to the continual delays inherent in the legal process ; the up of the patient's psychiatric history and clinical status the courts ; and, s ometimes , the inherent difficulties in proving allegations of crimes or civil wrongs with a severely ps ychiatrically ill, periodically amnestic, complaining witness who may become overwhelmed, confused, or unconvincing during depos ition or in court. Highly symptomatic patients in the s tabilization phas e therapy may have a particularly difficult time in the system. C linicians s hould carefully review with the patient the potential clinical risks and benefits of proceeding with 2072 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 294 of 302

legal cas es . In addition to the concerns enumerated previous ly, therapy for the iss ues that brought the to treatment mostly gets put on hold, except insofar as illuminates the patient's s truggles in the legal system. primary focus becomes a s upportive treatment bas ed helping the patient maintain relative s tability during the case. T he patient may need ongoing education about nature of the advers arial process , the purpose of legal procedures, such as depositions, and the role of various participants . T he clinician may also need to act an intermediary with attorneys and the police, to help them understand the patient's psychopathology and relative s trengths and liabilities during various parts of proceedings. It is inadvis able for the clinician to act as expert witness in such a context, although the clinician may be examined as a fact witnes s. S ome patients elect not to go forward with criminal or proceedings, such as prosecuting a rape, becaus e of realis tic dread of the difficulty that they will face in S ome prosecutors and police als o s hy away from going forward in such matters becaus e of the inherent in these cases , even without a dis sociative plaintiff. drop charges, or, when poss ible, s eek a plea bargain avoid a court proceeding. In the civil arena, diss ociative patients have brought a variety of tort actions, mos t commonly malpractice agains t prior psychiatric and medical treaters . S ome patients have reluctantly decided not to go forward because of the previous ly mentioned iss ues . W hen the statute of limitations permits, some patients have postponed litigation until they were clinically better stabilized. 2073 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 295 of 302

In the current legal climate, tort suits against family members for abus e, based on delayed recall, are likely be bitterly contested, even when there is independent, reliable confirmatory evidence of the abus e. F rom a perspective, there is no requirement that adults who childhood abus e confront their alleged abusers or prosecute them to heal. Unles s carefully thought out clinically, these sorts of confrontations often result in a poor outcome for accusers and accused. T he longclinical focus is us ually more appropriately placed on patient's res olving his or her conflicted, ambivalent attachment to the accus ed abus ive relative. W hen this better res olved, the press ure for confrontation diminis hes substantially, or, if dis closure to family members occurs , it is handled in a way that is more to lead to resolution, not exacerbation of difficulties .

Fals e Memory L itigation T he premis es of fals e memory litigation are s everalfold: It is always below the s tandard of care to diagnose and treat diss ociative identity disorder or dis sociative or both, becaus e thes e disorders do not exist, and (2) clinicians should have known this and s hould have informed patients of this before undertaking their treatment. (3) T he underlying premis e of treatment of diss ociation and amnesia is to recover memories of P.1901 abuse by whatever means neces sary. (4) Adjunctive therapeutic techniques, such as imagery, hypnosis , journaling, and amobarbital interviews, are inherently high-ris k procedures that are liable to contaminate the 2074 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 296 of 302

memories of patients and to produce iatrogenically diss ociative identity dis order or diss ociative amnes ia, both. (5) Inpatient s pecialty treatment for these leads to contamination of patient autobiographical accounts and a contagion of iatrogenically created diss ociative identity disorder. T o be s ure, some treatments of apparent diss ociative disorders , both inpatient and outpatient, have been characterized by misdiagnos is; failure of informed focus on recall of trauma memories to the exclus ion of symptom stabilization and proper treatment staging; misuse of hypnosis, medications , imagery, or pharmacologically facilitated interviews ; failure to appreciate the complexities of human memory; infliction of the therapist's ideology on the patient (e.g., fundamentalist C hristianity, belief in certain cons piracy theories); failure to manage inpatient milieus to intens ive discus sion of trauma material among and lack of appropriate therapeutic boundaries. Nonetheles s, the extreme fals e-memory hypothes es ignore the abundant recent research on diss ociation trauma and dis regard the complexity of the is sues to trauma, memory, and diss ociation reviewed in prior sections . Most of these cases are handled by a small group of attorneys and plaintiffs' experts who join with local couns el to develop the cas e. It is important to alert attorneys and ins urance companies that these are not regular malpractice cas es, but a s pecialized type of litigation that us ually requires a specialized defens e, experts familiar with thes e cases. Many attorneys and insurance companies are unaware of the forens ic track 2075 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 297 of 302

record of the attorneys and experts that typically are involved in these cas es . On the other hand, ins urance companies often choos e to settle thes e cas es, even if is a reas onable defense, rather than risk the uncertain financial expos ure of litigation. Unfortunately, this tactic may actually encourage s imilar suits, because plaintiffs ' attorneys often prefer the certainty of s ettlement to the vagaries of trial. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "17 - Dis sociative Dis orders " Alcohol-related dis orders are described in S ection Amnes tic dis orders, other cognitive disorders , and disorders due to a general medical condition are in C hapter 10. Neurops ychiatric as pects of head presented in S ection 2.5. Dis sociative mechanisms are discuss ed in C hapter 6 on ps ychoanalytic theory. Dis sociative disorders in children and adoles cents are discuss ed in S ection 49.7. T he diagnostic dis tinction between dis sociative disorders and other mental is clarified in C hapter 12 on schizophrenia and in 14 on anxiety dis orders . C hapter 15 on the somatoform disorders provides a detailed description of the s omatic symptoms that, in this chapter, are viewed as manifestations of diss ociation. E xpanded descriptions the various psychotherapeutic approaches appear in 2076 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 298 of 302

C hapter 30, and biological therapies are described in C hapter 31. C ulture-bound syndromes are discus sed in C hapter 27. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > R E F E R E NC

R E FE R E NC E S *Anderson MC , Ochs ner K N, K uhl B , C ooper J , E , G abrieli S W , G lover G H, G abrieli J DE : Neural underlying the suppress ion of unwanted memories . S cience. 2004;303:232–235. B ehnke S H: C onfusion in the courtroom: How have ass es sed the criminal res ponsibility of with multiple pers onality disorder. Int J L aw 1997;20:293–310. B remner J D, Marmar C R . T rauma, Me mory, and Dis s ociation. V ol 54. W ashington, DC : American P sychiatric P ress ; 1998. B rown D, S cheflin AW , Hammond DC . Me mory, T re atme nt, and the L aw. New Y ork: Norton; 1998. B rown DW , F ris chholz E J , S cheflin AW : Iatrogenic diss ociative identity disorder: An evaluation of the scientific evidence. J P s ychiatry L aw. 1999;27:549– B rown DW , S cheflin AW , Whitfield C L: R ecovered memories : T he current weight of the evidence in science and in the courts. J P s ychiatry L aw. 156. 2077 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 299 of 302

C hambers R A, B remner J D, Moghaddam B , S M, C harney DS , K rystal J H: G lutamate and posttraumatic stress disorder: T oward a ps ychobiology diss ociation. S emin C lin Ne urops ychiatry. 281. C oons P M: Dis sociative disorders not otherwis e specified: A clinical investigation of 50 cases with suggestions for typology and treatment. 1992;5:187–195. Dorahy M: Dis sociative identity dis order and dysfunction: T he current state of experimental and its future directions . C lin P s ychol R e v. 795. E llenberger HF . T he Dis covery of the Uncons cious . Y ork: B as ic B ooks ; 1970. F isher C : Amnes ic states in war neurosis: T he ps ychogenesis of fugue. P s ychoanal Q . 468. F reyd J J . B etrayal T rauma: T he L ogic of F orge tting C hildhood Abus e . C ambridge, MA: Harvard P res s; 1996. G leaves DH, May MC , C ardena E : An examination diagnostic validity of dis sociative identity dis order. P s ychol R ev. 2001;21:577–608. K is iel C , Lyons J : Dis sociation as a mediator of 2078 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 300 of 302

ps ychopathology among s exually abus ed children adoles cents . Am J P s ychiatry. 2001;158:1034– K luft R P . Dis sociative identity dis order. In: G abbard ed. T re atme nt of P s ychiatric Dis orde rs . 3rd ed. V ol Was hington, DC : American P s ychiatric P res s; 2001:1653–1693. *Lanius R A, W illiams on P C , B oksman K , Dens more G upta M, Neufeld R WJ : B rain activation during driven imagery induced dis sociative res ponses in A functional magnetic res onance imaging B iol P s ychiatry. 2002;52:305–311. Lanius R A, W illiamson P C , Dens more M, B oksman Neufeld R W J , G ati J S , Menon R : T he nature of memories : A 4-T fMR I functional connectivity Am J P s ychiatry. 2004;161:36–44. Lewis DO, Y aeger C A, S wica Y , P incus J H, Lewis Objective documentation of child abuse and diss ociation in 12 murderers with diss ociative disorder. Am J P s ychiatry. 1997;154:1703–1710. Markowitsch HJ : P s ychogenic amnes ia. 2003;20:S 132–S 138. *Morgan C A, Hazlett G , W ang S , R ichardson E G , P P , S outhwick S S : S ymptoms of diss ociation in experiencing acute, uncontrollable s tres s: A inves tigation. Am J P s ychiatry. 2001;158:1239–

2079 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 301 of 302

Nijenhuis E R S . S omatoform Dis s ociation: Me as urement, and T he ore tical Is s ues . As sen, van G orcum; 1999. P utnam F W. Diagnos is and T re atme nt of Multiple P ers onality Dis orde r. New Y ork: G uilford; 1989. P utnam F W. Dis s ociation in C hildren and Deve lopme ntal P e rs pe ctive . New Y ork: G uilford; R einders AA, Nijenhuis E R S , P aans AMJ , K orf J , Willems en AT M, den B oer J A: One brain, two Neuroimage . 2003;20:2119–2125. S ilberg J L: F ifteen years of diss ociation in children: W here do we go from here? C hild Maltre at. 2000;5:119–136. *S imeon D, K nutels ka M, Nelson D, G uralnik O: unreal: A depers onalization dis order update of 117 cases. J C lin P s ychiatry. 2003;64:990–997. S piegel DE . T he diss ociative dis orders. In: T asman G oldfinger S , eds . Ame rican P s ychiatric P res s R eview of P s ychiatry. V ol 10. W ashington, DC : P sychiatric P ress ; 1991. S teinberg M. Handbook for the As s es s me nt of Dis s ociation: A C linical G uide. W ashington, DC : P sychiatric P ress ; 1995. van Ijzendoorn MH, S chuengel C : T he 2080 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

17

Page 302 of 302

diss ociation in normal and clinical populations : analytic validation of the Diss ociative E xperiences (DE S ). C lin P s ychol R e v. 1996;16:365–382. *V ermetten E , Loewenstein R J , Zdunek C , W ils on K , B remner J D: C ortisol, memory and the hippocampus P T S D and DID. B iol P s ychiatry. 2002;51 145S .

2081 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

01/01/2009

Page 1 of 185

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 18 - Norma l H uma n S exua lity and S exual and G ender Identity > 18.1a Normal Human S exuality and S exual Dys functions

18.1a Normal Human S exuality and S exual Dys func tions Virginia A. S adock M.D. P art of "18 - Normal Human S exuality and S exual and G ender Identity Disorders" S exual behavior is diverse and determined by a interaction of factors . It is affected by one's relationship with others, by life circums tances , and by the culture in which one lives. An individual's sexuality is enmeshed other personality traits, with his or her biological and with a general s ens e of self. It includes the of being a man or a woman and reflects developmental experiences with sex throughout the life cycle. encompas ses all thos e thoughts , feelings, and connected with s exual gratification and reproduction, including the attraction of one person to another. A rigid definition of normal s exuality is difficult to draw and is clinically impractical. It is eas ier to define s e xuality—sexual behavior that is des tructive to others , that is markedly cons tricted, that cannot be directed toward a partner, that excludes s timulation of primary s ex organs, and that is inappropriately with guilt or anxiety. 2082 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 2 of 185

T here have been myriad advances in the field of in the areas of pharmacology and psychology and in study of the interaction of s ex and the s ocial milieu. S ignificant new developments are the availability of medications that enable men to gain and maintain erections later in their lives and hormonal therapies allow women to have pleasurable coitus postmenopaus ally. T hese medications have helped the taboo against sex in elderly adults. T heories on the ps ychology of sex have examined compulsive s exual behavior—not an official diagnosis in the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ). T he last major s tudy of sex in United S tates was conducted in 1994, consisting of a survey of sexual practices that placed the s exual of Americans in a social context.

HIS TOR Y C ultural mores regarding sexual behavior have varied throughout the history of W estern civilization. Attitudes have oscillated between the liberal and the puritanical, between the acceptance and the repress ion of human sexuality. S ince the 1960s , the prevalent attitudes sex in the United S tates have been markedly liberal. However, recent s tudies indicate a trend toward more cons ervative values . T hat s hift is attributed the fear of acquired immune deficiency syndrome One poll reported that 40 percent of Americans are concerned about contracting AIDS and are altering sexual behavior becaus e of that fear. T he greates t was expres sed by young adults , who are now more to use condoms as a precaution and to choose their partners with greater care. In 1997, the rate of teenage 2083 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 3 of 185

pregnancy declined for the first time in 40 years, and, 1998, the number of teenagers who had s exual fell below 50 percent for the firs t time in a decade. Nonetheles s, currently, one in five teenagers has s ex before the age of 15 years. C onservative segments of society emphas ize abstinence before marriage as the answer to the fear of AIDS . T he recurrence of attitudes in respons e to the threat of illnes s has history. T he s exual liberality of the R enais sance ended when syphilis s wept the E uropean continent and a major argument for chas tity among proponents of the R eformation. Other factors that predispose to more res trictive mores are periods of economic reces sion tend to bring people to more puritanical positions. F ew these is sues have been res olved definitively in the form new social mores , however, and the permis sive the sexual revolution of the 1960s and 1970s exert a effect on current s exual behavior. T he advent of effective birth control methods and legalized abortion clearly differentiated the pleas ure of sexual activity from its procreative function. T he movement attacked the double standard for acceptable sexual behavior for men and women, encouraged to accept sexual res ponsibility for the gratification of needs , and challenged s ociety to reevaluate male and female roles. T he women's movement also focus ed attention on rape and incest. G erontologis ts elderly people alike have drawn attention to the s exual needs of the aged. Middle-clas s adolescents became sexually active, and gay rights groups urged their s exual orientation and s ucceeded in 1980 when homos exuality was dropped as a diagnostic category in 2084 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 4 of 185

the third edition of the DS M (DS M-III). C oncurrent with the cultural changes of the s exual revolution was the growth in scientific research into phys iology and sexual dysfunctions. William Masters V irginia J ohns on publis hed their pioneering work on phys iology of s exual res pons e in 1966 and reported on their program for treating sexual complaints in 1970. medical centers now have programs s pecifically the treatment of sexual dys functions. His torically, problems of s exual conflict and s exual dysfunction have been the province of ps ychiatry. S uch pioneers as Havelock E llis (F ig. 18.1a-1), R ichard E bing (F ig. 18.1a-2), and S igmund F reud focus ed on human sexuality. Later, others focus ed more on sexual phys iology and dysfunctions. T he work of C harles K ins ey (F ig. 18.1a-3), who publis hed S exual B ehavior in the Human Male in 1948 and its volume, S exual B ehavior in the P.1903 Human F e male , 5 years later, was the most extens ive performed in human sexuality in America up to that T he current approach to sexual dysfunctions reflects cultural and s cientific developments of recent years, development of s pecific techniques for the treatment of these problems, the his torical interes t of ps ychiatry in area, and the recognition of its importance in practice.

2085 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 5 of 185

FIGUR E 18.1a-1 Havelock E llis, 1859-1939. In his S tudie s in the P s ychology of S e x (1896), E llis recorded examples of normal and abnormal s exuality. It remains clas sic in the field of s exology. (C ourtes y of New Y ork Academy of Medicine.)

2086 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 6 of 185

FIGUR E 18.1a-2 R ichard von K rafft-E bing (1840-1903), ps ychiatris t who publis hed a clas sic text, P s ychopathia S exualis (1898), in which he documented every sexuality, including zoophilia, necrophilia, urolagnia, lust murder, among others . C as e reports were s o lurid detailed that early editions were published in Latin. (C ourtesy of New Y ork Academy of Medicine.)

2087 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 7 of 185

FIGUR E 18.1a-3 Alfred K ins ey. (C ourtes y of Ins titute R es earch, B loomington, IN.)

NOR MA L S E X UA L ITY 2088 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 8 of 185

Anatomic al and Phys iologic al B as es K nowledge about the organs of sexuality and the phys iological sequence of male and female res ponse is neces sary for an informed unders tanding of the s exual dysfunctions. In fact, s ince the 1990s, greater been placed on the genetic, neuroanatomical, and neurochemical model of human sexuality than on ps ychological and social factors. R esearch in s exual differentiation, including the genetics of gonadal development and hormonal influences on sexuality is great interest, and new findings in thes e areas of development are occurring rapidly.

Male A natomy T he external genitalia of the normal adult man include penis , s crotum, tes tes , epididymis , and parts of the vas deferens. Internal components include the vas ejaculatory ducts, and pros tate gland. F reud referred to the penis as the executive organ of sexuality. S ince antiquity, culture has represented the penis in a variety of art forms. In ancient G reece, the of Dionysus, P riapus, and the s atyrs used the phallus recurrent s ymbol of fertility and rejuvenation. T he word pe nis has been traced from the Latin, meaning “tail” or “to hang” and refers to the pendant position of organ in its res ting or flaccid s tate. T he size of the varies within a fairly constant range, but sex over the years have dis agreed on the dimensions of range. All agree, however, that concern over the s ize of penis is practically universal among men. Masters and J ohns on report a range of 7 to 11 cm in the flaccid 2089 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 9 of 185

P.1904 and 14 to 18 cm in the erect s tate. Of particular interes t their observation that the flaccid dimension bears little relation to the erect dimension, as the s maller penis proportionally more than the larger one (F ig. 18.1a-4).

FIGUR E 18.1a-4 T he penis in the flaccid and erect with average size as surveyed and drawn by Dickinson. (F rom Dickins on R L. Atlas of H uman S e x Anatomy. 2nd B altimore: W illiams & W ilkins; 1949, with permiss ion.) C ircumcis ion, a procedure in which the prepuce is removed, has been practiced for centuries as a religious by J ews and Moslems and is a common medical in the United S tates today. T he circumcis ed penis, with expos ed glans, was once believed to be less s ens itive because of cornification of the epithelium. In laboratory 2090 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 10 of 185

studies, however, res earchers have found no tactile thres hold between the circumcis ed penis and uncircumcised penis . Intravaginally, the prepuce of the uncircumcised penis remains retracted behind the during penile thrusting, dis pelling the myth that premature ejaculation may be more common in uncircumcised men because of increas ed s timulation caus ed by preputial movements . In 1999, the American Academy of P ediatrics recommended that male circumcis ion not be performed as a routine procedure except for religious reasons. S ome studies of s exual dysfunctions, however, found a higher incidence of problems in uncircumcis ed men, but no caus al relations hip was determined. E jaculation is the forceful propulsion of s emen and fluid from the epididymis, vas deferens, seminal and prostate into the urethra. T he dilation of the urethra and the pas sage of fluid into the penile urethra provide the man with a sensation of impending climax, emis sion phas e of the ejaculatory proces s. Indeed, the prostate contracts , ejaculation is inevitable. T he ejaculate is then propelled through the penile urethra contractions of the s triated pelvic and perineal T his phas e of ejaculation is ess entially under somatic efferent control. T he ejaculate cons is ts of teaspoon (2.5 mL) of fluid and contains approximately million sperm cells. It is believed that the larger the ejaculate, the more pleas urable the orgas m, but this is highly s ubjective. T he sense of pleasure that accompanies orgas m is thought to be a cortical experience.

2091 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 11 of 185

F emale A natomy T he external genitalia of the normal woman, also called the vulva, include the mons pubis, major and minor clitoris, glans , vestibule of the vagina, and vaginal T he internal s ys tem includes the ovaries , fallopian uterus , and vagina. T he word vagina comes from the Latin word meaning “sheath.” T he vagina is us ually collapsed, a potential than an actual s pace. Approximately 8 cm long, the extends from the cervix of the uterus above to the vestibule of the vagina or vaginal opening below. In virgins, a membranous fold, the hymen, s eparates the vestibule and opening from the res t of the vaginal T he mucous membrane lining the vaginal walls res ts in numerous trans verse folds. T o accommodate the penis during sexual intercours e, the vagina expands in both length and width. After menopaus e, because es trogen concentrations decreas e, the vagina los es of its elas ticity. Hippocrates firs t described the clitoris in the medical literature, referring to it as the s ite of s exual excitation. Masters and J ohnson described the clitoris as the female s exual organ, because orgas m depends phys iologically on adequate clitoral s timulation. Anatomically, the clitoris has a nerve net that is proportionally three times as large as that of the penis . Alfred K insey found that when women masturbate, prefer clitoral stimulation. T hat finding was refined by Masters and J ohnson, who reported that women the shaft of the clitoris to the glans , because the glans 2092 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 12 of 185

hypers ens itive if s timulated exces sively. T he clitoral prepuce is contiguous with the labia and, during coitus , the penis does not s timulate the directly. R ather, penile thrusting exerts traction on the minor lips, which, in turn, stimulate the clitoris for orgasm. During heightened excitement, jus t before orgasm, the clitoris retracts under the clitoral hood because of contraction of the is chiocavernos us R etracting, the clitoris moves away from the vaginal which makes clitoral–penile contact imposs ible. T he the clitoris varies considerably and is unrelated to the sexual respons ivenes s of a particular woman. In 1950, E rns t G raefenberg described an area the female urethra in the anterior wall of the vagina that has come to be called the G s pot. Approximately 0.5 to cm in size, it becomes engorged during s exual Many women report that s timulation of the area is pleas urable and, in s ome, can induce orgasm. believed that the tiss ue here was analogous to the prostate and might account for the s purt of fluid during orgasm reported by some women, s imilar to male ejaculation.

Innervation of S ex Organs Innervation of the sexual organs is mediated primarily through the autonomic nervous system (ANS ). P enile tumes cence occurs through the synergistic activity of neurophys iological pathways. A paras ympathetic (cholinergic) component mediates reflexogenic via impuls es that pas s through the pelvic splanchnic nerves (S 2, S 3, and S 4). A thoracolumbar, mainly sympathetic pathway transmits ps ychologically induced 2093 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 13 of 185

impulses. B oth paras ympathetic and s ympathetic mechanisms are thought to play a part in relaxing the smooth mus cles of the penile corpora cavernosa, allows the penile arteries to dilate and caus es the blood that res ults in penile erection. R elaxation of cavernos al s mooth mus cles is aided by the release of oxide, an endothelium-derived relaxing factor. C litoral engorgement and vaginal lubrication als o res ult from parasympathetic stimulation that increas es blood flow genital tiss ue. E vidence indicates that the sympathetic (adrenergic) system is res ponsible for ejaculation. T hrough the hypogastric plexus , adrenergic impulses innervate the urethral crest, the mus cles of the epididymis , and the muscles of the vas deferens , seminal ves icles , and S timulation of the plexus caus es emiss ion. In women, sympathetic s ys tem facilitates the s mooth mus cle contraction of the vagina, urethra, and uterus that during orgasm. T he ANS functions outside of voluntary control and is influenced by external events (e.g., stress , drugs ) and internal events (hypothalamic, P.1905 limbic, and cortical s timuli). C onsidering these it is not surpris ing that erection and orgasm are so vulnerable to dys function (T able 18.1a-1).

Table 18.1a-1 R es pons es of S ex Organs to Autonomic Nerve 2094 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 14 of 185

 

Adrenergic Impuls es

C holinergic Impuls es

E ffec tor Organs

R ec eptor R es pons es Type

R es pons es

Urinary bladder

 

 

 

   Detrus or

β2

R elaxation (us ually)

C ontraction

   T rigone and sphincter

α1

C ontraction

R elaxation

Ureter

 

 

 

   Motility and tone

α1

Increase

Increase

Uterus

α1 , β2

P regnant: contraction ( α1 ), relaxation ( β2 ); nonpregnant:

V ariable

2095 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 15 of 185

relaxation ( β2 ) S ex male

α1

E jaculation

E rection

S kin

 

 

 

C ontraction

 

Localized secretion

G eneralized secretion

   P ilomotor α1 muscles    S weat glands

α1

Adapted from G oodman G ilman A, R all T W , Nies T aylor P , eds. G oodman and G ilman's T he P harmacological B as is of T he rapeutics . 8th ed. New P ergamon; 1990.

E ndoc rinology F rom the time of conception, hormones play a major in human s exual development. Unlike the fetal gonads, which are under chromos omal influence, the fetal genitalia are very s usceptible to hormones. mediates the development of the undifferentiated mesodermal wolffian ducts into the male vas deferens, epididymis , and s eminal vesicles. Dihydrotes tos terone, produced from tes tosterone, induces the penis and 2096 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 16 of 185

scrotum. T he raphe in men corresponds to the location of the vaginal orifice in women (F ig. 18.1a-5).

2097 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 17 of 185

FIGUR E 18.1a-5 Differentiation of male and female external genitalia from indifferent primordia. Male differentiation occurs only in the pres ence of androgenic stimulation during the firs t 12 weeks of fetal life. (F rom Wyk and G rumbach, 1968. R eprinted from B robeck J R , B es t and T aylor's P hys iological B as is of Me dical ed. Williams & W ilkins , B altimore; 1973, with E xogenous hormonal adminis tration can cause genital development inconsis tent with the fetal s ex development. F or ins tance, if the pregnant mother receives sufficient exogenous androgen, a female fetus poss ess ing an ovary can develop external genitalia res embling thos e of a male fetus . F etal, maternal, or exogenous hormones administered to a pregnant may all affect development of the external genitalia of fetus. Deprived of male and female gonads and the res pective hormones , testosterone and estrogen, the human adult does not develop normal s econdary characteristics , is incapable of reproduction, and, in the case of the woman, does not develop a mens trual T es tos terone is the hormone believed to be connected with libido in both men and women. In men, s tres s is invers ely correlated with tes tos terone blood concentration. Other factors , such as sleep, mood, and lifes tyle, influence circulating levels of the hormone. releas e of tes tos terone in men is under the control of hypothalamic-gonadal-pituitary axis. T he hormone is secreted in a pulsatile manner and in a diurnal rhythm, with the highes t levels occurring in the morning and the lowest levels in the evening. Normal concentrations 2098 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 18 of 185

from 270 to 1,100 ng/dL. Decreas ed testosterone concentrations are apparent by age 50 years and at the rate of approximately 100 ng/dL per decade. However, many healthy, aging men never become hypogonadal. It has als o been s ugges ted that the sens itivity of androgen receptor s ites decreases in men. Androgen administered to men complaining of loss of potency and loss of libido is usually unsuccess ful tes tos terone concentrations are below normal, and adminis tration to women may precipitate disturbing virilization. Many clinicians correct the hormone of the postmenopausal period with estrogen therapy. T estosterone has been us ed in combination es trogen in women who do not res pond to estrogen alone. T he combination is es pecially useful in treating headache, depres sion, and reduced libido. Oxytocin, secreted by the hypothalamus, stimulates lactation and uterine contractions and may enhance sexual activity. P lasma oxytocin concentrations increas e in men and women during orgasm. Diethylstilbestrol (DE S ), an androgenic s teroid, was prescribed in the 1950s and 1960s for pregnant women with threatened abortion. However, the drug had untoward effects on the children (es pecially female children) born to these mothers . R eports of cervical uterine abnormalities were reported in women and reproductive tract abnormalities were reported in men. T he children (called DE S P.1906 daughte rs and s ons ) organized a National DE S 2099 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 19 of 185

P rogram sponsored by the National C ancer Institute to provide information on the potential medical problems confronting those born to DE S mothers (F ig. 18.1a-6).

FIGUR E 18.1a-6 T wins born to a mother who received ethis terone during pregnancy. Note the enlarged clitoris each child. (C ourtesy of R obert B . G reenblatt, M.D., V irginia McNamarra, M.D.)

G enetic s G enes are involved in gonadal differentiation, res ulting the formation of the bipotential gonad into either a or ovary. T he best-defined gene in this proces s is S R Y determining region of the Y chromosome), located on 2100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 20 of 185

short arm of the Y chromos ome. Other genes als o play smaller role, such as W T 1 (W ilms' tumor 1), S F -1 (s teroidgenic factor 1), S O X 9, DAX 1, and MIS -12 inhibiting s ubs tance 12). Defects or mutations in these genes cause failures in gonadal differentiation that produce clinical s yndromes known as inters e x F igure 18.1a-7 describes s ome genetic factors involved the determination of male s ex.

2101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 21 of 185

2102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 22 of 185

FIGUR E 18.1a-7 A complex s eries of s teps must occur gonadal differentiation. A number of genes are critical to appropriate male genital development. S R Y (s exdetermining region of the Y chromosome), a gene on short arm of the Y chromosome, is a testis-determining factor. T he S O X 9 gene is als o important in male sexual differentiation. DAX 1, an orphan member of a nuclear hormone receptor family located on the X chromosome, interacts with steroidogenic factor 1 (S F -1). Other involved in male gonadal differentiation include the suppress or gene W T 1 (W ilms' tumor 1), and the inhibiting s ubs tance gene (MIS ) and its receptor, MIS (F rom F ederman DD: P erspective: T hree facets of differentiation. N E ngl J Me d. 2004;350:323-324, with permis sion.)

C entral Nervous S ys tem and S exual B ehavior C ortex T he cortex is involved both in controlling s exual and in process ing sexual stimuli that may lead to activity. One study using positron emiss ion tomography (P E T ) s cans to monitor the brain activity of men in their while they were s hown various films , including a documentary, a comedy, and a s exually explicit film, that s ome areas of the brain were more active during sex film than they were during the other films . T hese included the orbitofrontal cortex, which is involved in emotions , the left anterior cingulate cortex, which is involved in hormone control and s exual arous al, and 2103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 23 of 185

right caudate nucleus, whose activity is a factor in sexual activity follows arous al.

L imbic S ys tem E xperimentation with animals has demonstrated that limbic s ys tem is directly involved with elements of functioning. In all mammals, the limbic system is in behavior required for self-preservation and the preservation of the species . C hemical or electrical s timulation of various sites of the limbic s ys tem, the lower part of the s eptum and the contiguous medial preoptic area, the fimbria of the hippocampus , the mammillary bodies , and the anterior thalamic nuclei have all elicited penile erection. T he hippocampus is believed to influence genital tumes cence and affect the regulation of the releas e of gonadotropins . S timulation of the amygdala in primates initiates oral (chewing, lip s macking) and then genital (penile erection) behavior. R es earchers have stated the clos enes s of these functions may derive from the evolutionary fact that the olfactory sense was s trongly involved in both feeding and mating. T hey speculate the evolution of the third subdivis ion of the limbic may reflect a shift in importance from olfactory contact visual communication in sociosexual behavior.

B rains tem B rainstem sites exert inhibitory and excitatory control spinal s exual reflexes . One site, the nucleus paragigantocellularis, has been identified as important inhibitory control of climax-like respons es in men and is suspected to be involved in female physiology as well. 2104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 24 of 185

nucleus projects directly to pelvic efferent neurons in lumbosacral spinal cord, apparently caus ing them to secrete s erotonin, which is known to inhibit orgas ms. lumbosacral cord also receives strong projections from other s erotonergic nuclei in the brains tem, the raphe nuclei, pallidus, magnus , and parapyramidal region.

B rain Neurotrans mitters A vast array of neurotransmitters is produced by the including dopamine, epinephrine, norepinephrine, and serotonin, among others. All affect sexual function. F or example, an increas e in dopamine is pres umed to libido. S erotonin produced in the upper pons and midbrain is pres umed to have an inhibitory effect on sexual function. Oxytocin, the neurohormone involved the milk ejection reflex, is also releas ed with orgas m believed to reinforce pleasurable activities . B as ic and clinical res earch on brain neurotransmitters and effects on behavior (including s ex) are rapidly fields . P.1907

S pinal C ord As des cribed in the innervation of s ex organs, sexual arousal and climax are ultimately organized at the level. S ensory s timuli related to s exual function are conveyed via afferents from the pudendal, pelvic, and hypogastric nerves . T hese afferents terminate in the medial portions of the dorsal horn and in the medial central gray matter of the s pinal cord. S everal s eparate experiments sugges t that s exual reflexes are mediated 2105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 25 of 185

spinal neurons in the central gray region of the lumbosacral segments .

P S YC HOS E XUA L ITY S exuality and total personality are so entwined that it is virtually impos sible to s peak of s exuality as a separate entity. T he term ps ychos exual is therefore us ed to personality development and functioning, as thes e are affected by s exuality. P s ychos e xual applies to more sexual feelings and behavior, and it is not s ynonymous with libido in the broad F reudian s ens e. F reud's generalization that all pleasurable impulses activities are originally s exual has given lay people a somewhat distorted view of sexual concepts and has ps ychiatris ts a confused picture of motivation. F or example, some oral activities are directed toward obtaining food, and others are directed toward sexual gratification. B oth activities are pleas ureand us e the s ame organs , but they are not, as F reud contended, both necess arily s exual. Labeling all seeking behaviors s e xual obviates specifying precis e motivation. P eople may also us e sexual activities to nonsexual needs , s uch as dependency, aggres sion, and s tatus . Although s exual and nonsexual impulses jointly motivate behavior, the analys is of behavior depends on unders tanding the underlying individual motivation and their interactions. S exuality is more than physical sex, coital or noncoital, and less than all behaviors directed toward gaining

Ps yc hos exual Fac tors S exuality depends on four interrelated ps ychos exual 2106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 26 of 185

factors : s exual identity, gender identity, s exual and s exual behavior. T hese factors affect personality, development, and functioning. S exual ide ntity is the pattern of a person's biological characteristics : chromosomes, external and internal genitalia, hormonal compos ition, gonads , and sex characteris tics. In normal development, these characteristics form a cohesive pattern that leaves individuals in no doubt about their sex. G e nde r ide ntity is an individual's sense of maleness or femalenes s. B y the age of 2 or 3 years , almost a firm conviction that “I am a boy” or “I am a girl.” identity results from an almos t infinite series of clues derived from experiences with family members , peers , teachers, and from cultural phenomena. F or instance, infants tend to be handled more vigorous ly and female infants tend to be cuddled more. F athers s pend more with their infant sons than with their daughters, and also tend to be more aware of their s ons ' adoles cent concerns than of their daughters ' anxieties. B oys are likely to be physically dis ciplined than girls are. A sex affects parental tolerance for aggres sion and reinforcement or extinction of activity and of aesthetic, and athletic interes ts. P hys ical derived from a pers on's biological s ex (e.g., physique, shape, and phys ical dimensions ) interrelate with an intricate system of stimuli, including rewards , and parental gender labels, to es tablis h gender goals . R ecent studies of children with inters ex conditions drawn attention to a phys iological basis for gender identity. In particular, they have focus ed on the masculinization or feminization of the fetal brain. 2107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 27 of 185

S exual orie ntation describes the object of a person's impulses: heterosexual (oppos ite sex), homosexual sex), or bisexual (both s exes). T he overwhelming of people have a heterosexual orientation. In the S tates, 2.8 percent of men and 1.4 percent of women identify themselves as homosexual. T hes e numbers compatible with figures from W estern E uropean as well. However, a higher percentage of pers ons have at least one s ame-sex experience in their lives . Additionally, homos exuals congregate in urban areas, the incidence of homosexuality in some large cities is high as 8 or 9 percent. S exual behavior includes desire, fantasies, purs uit of partners , autoeroticis m, and all the activities engaged expres s and gratify sexual needs . It is an amalgam of ps ychological and phys iological respons es to internal external s timuli. P.1908

Mas turbation Masturbation usually is a normal precurs or of objectrelated sexual behavior and a form of sexual pleas ure generally las ts throughout a person's lifetime. No other form of sexual activity has been as univers ally spite of being s everely condemned by many cultures long periods of time. In the class ical period, G reco-R oman writers and authorities , s uch as G alen, recommended a healthful practice for both men and women. T he categorization of masturbation as s inful in W estern derives from J udeo-C hris tian attitudes . Masturbation is 2108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 28 of 185

sometimes called onanis m after Onan in the Old T es tament, who was s lain for spilling his seed upon the ground. Many biblical s cholars today posit that this punis hment was not a result of his mas turbation, but because he did not obey J ehovah's commandment to his brother's wife as his own. T he prohibition against masturbation was reinforced by C hris tian C hurch particularly by S t. Augustine, who preached celibacy held that s ex was appropriate only for purpos es of procreation. Ambivalence about mas turbation also in E as tern cultures . S ome Hindus and the ancient believed that loss of semen resulted in reduction of a male ess ence. However, the prohibitive emphas is was ejaculation and not on manipulation of the genitalia. F emale masturbation was better tolerated or ignored. F or many years, s cience held attitudes toward masturbation that were as negative as many religious views. W hat had been viewed as sinful came to be pathological (F ig. 18.1a-8). F or example, in the 1800s , K rafft-E bing believed that masturbation could lead to insanity. C urrently, and in the second half of the 20th century, a liberal attitude toward s exual behavior, including masturbation, has prevailed. R es earch by in the 1940s into the prevalence of masturbation that nearly all men and three-fourths of all women masturbate sometime during their lives . Mas ters and J ohns on dis cuss ed techniques of mas turbation in the 1960s and identified the s haft of the clitoris as the preferred site of masturbation for women. In the 1990s , study of sexual practices in America found that masturbation was the first pos tpubertal sexual practice most men and of approximately 50 percent of women. 2109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 29 of 185

S tudies in E urope noted an increas ed incidence in masturbatory activity in both young men and women in the 1980s and, es pecially, in the 1990s, as compared 1960s . In thes e s tudies , most of the women had experienced masturbation before their firs t coital experience, following a pattern of s exual development that has long been typical for men. Additionally, both and women practiced masturbation regardles s of they were in a s teady relations hip. T hus, masturbation come to be s een as a s eparate s ource of s exual that is not in conflict with partnered s ex.

FIGUR E 18.1a-8 A four-pointed urethral ring, which us ed to prevent masturbation during the 19th century. engraving shows how the ring was tied to the penis. 2110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 30 of 185

S adock B J , K aplan HI, F reedman AM. T he S exual B altimore: W illiams & W ilkins; 1976, with permiss ion.) Masturbation is a ps ychopathological s ymptom only it becomes a compuls ion beyond an individual's willful control. T hen, it is a symptom of disturbance not is sexual, but becaus e it is compulsive. It is also symptomatic of sexual problems when it is the only activity of a person who has an available intimate However, mas turbation is a univers al and healthy component of psychos exual development.

S E X UA L L E A R NING A ND S E X UA L B E HA VIOR T he sex drive is innate and varies in intens ity in people, but much sexual behavior is learned. E arly experiences , particularly thos e during puberty and adoles cence, can have an imprinting effect. If they are strongly ass ociated with pleas ure and release of they are likely to be repeated and the person is conditioned to a particular form of sexual express ion. In the normal pers on, sexual learning and continue throughout the life cycle, the repertoire of behavior expands , and the behaviors are compatible cultural norms.

C hildhood S exual learning begins in childhood. In a broad sense, learning occurs through parent–child interaction, including the meeting of the infant's needs , cuddling, the reinforcement or discouragement of gender2111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 31 of 185

as sociated activities. C uddling and appropriate touching engender emotional s ecurity and positive feelings in infants toward their bodies. T hat physicality the groundwork for a healthy body image that is a component of sexual s elf-es teem. A good body image derives from mas tery of early physical activity and a positive parental approach to tas ks s uch as toilet G enital self-stimulation is a normal activity of babies . It particularly pronounced between the ages of 15 and 19 months, and it is part of the general interes t of children their bodies. T he activity is reinforced by the sens ations it produces . As youngs ters acquire curios ity about their own and others' genitalia motivates episodes of exhibitionism or genital exploration. Unless the child is unduly shamed, s uch experiences continued pleas ure from sexual stimulation. C hildren als o learn by watching the interaction of their parents . T hey obs erve demonstrations of phys ical (although usually not the sex act itself), and they are sens itive to the sexual undertone of flirtation, bantering, seductive interchange. S exual learning in childhood is advers ely affected by exploitative, abus ive adults . Inces tuous activity, with or without penetration, or s exual abus e by other adults (babys itter, other older relatives , teachers, coaches, damaging to the child. It may precipitate s exual dysfunction in adult life, as well as promiscuity and problems with intimacy. It may produce delinquent activities and behavioral problems in adolescence, as as learning problems in school. S ome children are inappropriately stimulated s hort of 2112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 32 of 185

outright incest or genital fondling. T hey are the objects extremely s eductive parents. T ermed eroticize d they frequently become s exually precocious . C hildren who view the primal s cene —the term F reud to des cribe a child seeing sex between their parents — be traumatized. T his is particularly the cas e if they coital s ounds and movements as a phys ical aggres sion between the parents. P.1909

Adoles c enc e With the approach of puberty, the upsurge of sex hormones, and the development of s econdary sex characteristics , s exual curiosity is intensified. are physically capable of coitus and orgas m but are inhibited by social res traints . T he dual, often conflicting press ures of es tablis hing their s exual identities and controlling their sexual impulses produce a strong phys iological sexual tension in teenagers that demands releas e, and mas turbation is a normal way to reduce tension. In general, boys learn to masturbate to orgas m earlier than girls and mas turbate more frequently. C ons equently, many boys integrate their sexuality as autonomous characteristic earlier than s ome girls . An important emotional difference between the adoles cent and the younger child is the pres ence of coital during mas turbation in the adoles cent. T hes e fantas ies an important adjunct to the development of sexual identity; in the comparative s afety of the imagination, adoles cent learns to perform the adult s ex role. that accompany masturbation vary and reflect 2113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 33 of 185

ps ychodynamics ; however, in general, fantas ies differ the sexes . B oys res pond to vis ual stimuli of nude or dress ed women and images of explicit physical acts. report res ponding to romantic s tories in which a man demonstrates intens e pass ion for and commitment to a woman. T heir fantas ies focus more on touching, and the partner's res pons e than on vis ualizing an sexual act. In addition to mas turbation, adolescents learn sexually through cares sing and kis sing with partners . In early adoles cence, s ex play may involve a partner of the sex for a short period of time for heterosexuals and for homos exuals. Adolescence is also when one's body becomes more definitive and a sense of s exual and s exual desirability begins to develop. P eer by the same sex and by the oppos ite sex is of importance. E ngaging in s exual talk and jokes , kis sing, touching genitalia, experimenting with degrees of and experimenting with different partners or with one partner are part of the proces s of learning about T hese experiences reinforce the adolescent's s ens e of being a s exual boy or girl.

Firs t C oitus T he firs t coitus is a rite of pas sage for both sexes. T he modal age for firs t coitus in the United S tates is 16 for boys and 17 years for girls . C urrently, both peer press ure and individual sex drive impel or young adults to participate in their first coital experience. In the past, virginity conferred status on young pers on. T oday, many young people feel embarrass ed or inadequate if they are virgins. A s mall 2114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 34 of 185

backlas h is present in some groups in which sign premarital chas tity pledges in a public forum. Also, survey by the C enters for Dis ease C ontrol reported that percent of male teenagers had intercours e in 1998, from 57 percent in 1991. T he corresponding number girls was 48 percent, down from 51 percent. Many adoles cents are choos ing to have oral sex instead of in their intimate relations. F or boys, anxiety about firs t coitus relates to Will he be able to get an erection, to penetrate the to las t for some period of time before he ejaculates ? vulnerable in his masculine pride and may fear being judged inadequate by his female partner and his male peers. F irst coitus for a girl has been s urrounded by cultural ambivalence and concern about the meaning of her virginity and her as sumption of the risk of pregnancy res ponsibility for the next generation. T hat risk has eased by the availability of contraceptive methods . Development of the birth control pill in the 1960s societal attitudes about premarital sex for women and created a more permis sive climate. T he cohort of who came of age s exually after the late 1960s report a much higher frequency of premarital intercours e than women before that time. However, only 30 percent of young women us e contraception with their first sexual mate and many use it inconsistently. In effect, many women deny that they are planning to have sex by not being prepared in terms of contraception, reflecting cultural ambivalence about their s exual activity. S tudies have shown that firs t coitus is mos t likely to be positive experience for girls with s trong feelings for 2115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 35 of 185

partners . In general, women report a greater need to experience s ex in the context of an affectionate relations hip than do boys.

Adulthood B y their late 20s, 70 percent of men and 85 percent of women have formed a union, either exclusive or marriage. T he sexual impulse is catalytic in forming maintaining adult love relationships . Ideally, a mature sexual relations hip encompas ses the capacity for and love for one's partner. As sexual access ceases to be problematic, more is focus ed on the activity itself. Interference with s exual activity arises from the time and energy required for the pursuit of careers , child rearing, and other family and community obligations . Nonetheles s, studies reveal a much higher frequency of s exual interaction among married persons than among s ingle persons. T he frequency for married persons is three times a month, many couples relating sexually twice a week. T he frequency of s exual interaction, four or more times a exis ts among cohabiting couples. K is sing, intercourse, and masturbation are frequent activities. E ven after a permanent s exual relations hip been established, masturbation remains a healthy during the illnes s or abs ence of a partner or when intercours e is unsatis factory. Masturbation s hould only cons idered maladaptive when it is a compuls ive activity when it is preferred to partner interaction. Many adults have some experience with oral s ex. S tudies s how although it is not a regular activity for most couples , people are likely to engage in it occasionally 2116 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 36 of 185

their lifetimes. T he incidence of the practice of and fellatio are the s ame; the lifetime prevalence is 75 percent of sexually active people. Anal s ex is not part the repertoire of regular sexual activities for mos t men women in the United S tates . Although a s izable (25 percent of men and 20 percent of women) report experience of anal s ex, very few repeat the practice. In general, a graph of s exual practices does not form a curve. Most curves of s exual behavior are s trongly with many pers ons indulging in a particular behavior or, conversely, very few people doing s o.

Middle A ge During middle age, the frequency of marital intercours e may decline. T he rates of interaction depend more on interes t, and the middle-aged man may devote much of his energy to his career at this point. T he decline in interaction often reflects deeroticization of the woman because of her wife–mother role. F amiliarity als o contributes to a decreas ed pass ion, and s ome men difficulty connecting marital sexual activity with the scripts they elaborated during their adoles cence. C onvers ely, a couple's experience of each other makes them comfortable and augments their s kill at mutual arousal. F or women, interest in sexual competence typically increases at this time. A woman's erotic and s exual commitment are s trongly connected to of attachment toward her partner and the s ecurity of being in a loving relations hip. With late middle age, the biological drive decreas es in intens ity. It takes the man longer to reach orgas m, he longer refractory period, and he requires more 2117 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 37 of 185

to achieve an erection. T he P.1910 woman mus t adjus t to the hormonal fluctuations of her perimenopaus al years, and s he, too, requires more stimulation to become aroused. Although medications available to address these specific phys iological they do not eliminate all need to adjus t to the aging proces s. In terms of family dynamics, children often the hous e for work or further education at this time. fact plus freedom from concern regarding unwanted pregnancy may enhance sexual activity for pers ons have more time to direct attention toward each other renew their life as a couple. However, middle age is the period of ris ing extramarital activity, although the frequencies of s uch occurrences low—75 percent of men and 85 percent of women faithful throughout the lifetime of their marriages . Offer has explained that the patterning of extramarital sexual activity for both sexes continues to expres s patterns of ps ychos exual development: F or men, it predominantly has the capacity for that in adolescence was directly related to the pursuit sexual fantasies and the homosocial validation of masculinity. F or women, on the other hand, it quest for circumstances that justify and confirm a self-image rather than a quest for orgas ms . In the context of a loving, communicative, and relations hip, a decreased frequency of sexual does not herald the onset of extramarital affairs or threaten the stability of the marriage. 2118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 38 of 185

Old A ge An estimated 70 percent of men and 20 percent of over age 60 years are sexually active; s exual activity is us ually limited by the absence of an available partner. Longitudinal studies have found that the s ex drive does not decrease as men and women age; in fact, some an increas ed sex drive. Masters and J ohns on reported sexual functioning among thos e in their 80s. E xpected phys iological changes in men include a longer time for erection to occur, decreased penile turgidity, and ejaculatory s eepage; in women, decreas ed vaginal lubrication and vaginal atrophy are ass ociated with es trogen levels. Medications can also adversely affect sexual behavior. A s ignificant finding was that the more active a pers on's sex life was in early adulthood, the likely it is to be active in old age.

C UR R E NT TR E NDS A s tudy conducted by the Univers ity of C hicago in T he National Health and S ocial Life S urvey, was the and the most authoritative sex s urvey. B ased on a representative U.S . population between the ages of 18 59 years, it found the following: 1. E ighty-five percent of married women and 75 of married men are faithful to their s pouses . 2. F orty-one percent of married couples have sex week or more, compared with 23 percent of s ingle persons. 3. C ohabiting single pers ons have the mos t s ex of all, twice a week or more. 2119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 39 of 185

4. T he median number of sexual partners over a for men is s ix; for women, two. 5. A homosexual orientation was reported by 2.8 of men and 1.4 percent of women, with 9 percent of men and 5 percent of women reporting that they at least one homosexual experience after puberty. 6. V aginal intercours e was considered the most appealing type of s exual experience by 83 percent men and 78 percent of women. 7. Among married partners, 93 percent are of the race, 82 percent are of similar educational level, 78 percent are within 5 years of each other's age, and percent are of the s ame religion. 8. B oth men and women who, as children, had been sexually abus ed by an adult were more likely, as to have had more than 10 s ex partners , to engage group s ex, to report a homosexual or bis exual identification, and to be unhappy. 9. Less than 8 percent of the participants reported sex more than four times a week, approximately thirds said they had sex a few times a month or and approximately three in ten have sex a few year or less . 10. Approximately one in four men and one in ten masturbate at leas t once a week, and masturbation less common among those 18 to 24 years of age among those 24 to 34 years of age. 11. T hree-quarters of the married women said they or always had an orgasm during sexual compared with 62 percent of the s ingle women. 2120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 40 of 185

Among men, married or s ingle, 95 percent s aid us ually or always had an orgasm. 12. More than half of the men s aid that they thought about s ex every day or several times a day, with only 19 percent of the women. 13. More than four in five Americans had only one partner or no partner in the past year. G enerally, African Americans reported the mos t s exual and As ian Americans the fewest. Another report, bas ed on the s ame data and published 2001 discus sed sexual dysfunction and sexual and public health policies . F indings include the 1. T hirty-nine percent of men and 41 percent of have a sexual dysfunction and have experienced decreased well-being and quality of life as a res ult. 2. F ifteen percent of male res pondents, single before marriage or after a divorce, who experimented sexually, had multiple partners , and s ought multiple areas of s timulation (e.g., erotic videos, nude paid s ex) composed the core group implicated in maintenance of s exually transmitted diseas e in the population at large. 3. T he likelihood of a pregnant girl younger than 18 of age opting to have an abortion increased dramatically with the educational level of her

P HYS IOL OG IC A L R E S P ONS E S Normal men and women experience a sequence of 2121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 41 of 185

phys iological res ponses to sexual s timulation. In the detailed des cription of thes e res ponses, Mas ters and J ohns on obs erved that the phys iological proces s increasing vas ocongestion and myotonia tumes cence subs equent release of the vascular activity and muscle tone as a result of orgasm detumescence. T ables and 18.1a-3 describe the female and male sexual cycles , res pectively. DS M-IV -T R defines a four-phase res ponse cycle: phase I, desire; phas e II, excitement; III, orgas m; phas e IV , resolution.

Table 18.1a-2 Female S exual R es p C yc lea Organ

E xc itement Phas e

Orgas mic Phas e

R es olutio Phas e

Mental

Lasts several minutes to several hours ; heightened excitement before 30 secs to 3 mins

3–15 secs

10–15 min no orgasm to 1 day

S kin

J ust before

Well-developed

F lush

2122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 42 of 185

flush

disappears revers e or of appearanc inconsiste appearing of on soles o feet and palms of hands

B reasts Nipple erection in two-thirds of women, venous congestion and areolar enlargement; size to one-fourth more than normal

B reasts may become tremulous

R eturn to normal in approxima 0.5 hour

C litoris

No change

S haft retur to normal

orgasm: flush inconsistently appears ; maculopapular ras h on abdomen and s preads anterior chest wall, face, neck; can include shoulders and forearms

E nlargement in diameter of

2123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 43 of 185

position in 10 secs ; detumesce in 5–30 mi if no orgas detumesce takes seve hours

glans and shaft; jus t before shaft retracts into prepuce

Labia majora

Nullipara: elevate and flatten agains t perineum

No change

Nullipara: increase to normal siz 1–2 mins

 

Multipara: congestion and edema

 

Multipara: decrease t normal siz 10–15 min

Labia minora

S ize increase two to three times more than normal; change to pink, red, red before orgasm

C ontractions of proximal labia minora

R eturn to normal wit 5 mins

V agina

C olor change to dark

3–15 C ontractions of

E jaculate forms

2124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 44 of 185

transudate appears 10– secs after arousal; elongation and ballooning; lower third cons tricts before

lower third at intervals of 0.8 sec

pool in upp two thirds; congestion disappears seconds o no orgasm 20–30 min

Uterus

Ascends into false pelvis ; labor-like contractions begin in heightened excitement just before orgasm

C ontractions throughout orgasm

C ontractio ceas e, and uterus descends normal position

Other

Myotonia

Loss of voluntary muscular control

R eturn to baseline status in seconds to minutes

 

A few drops mucoid secretion

R ectum: rhythmic contractions of

C ervix colo and s ize return to

2125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 45 of 185

 

B artholin's glands during heightened excitement

sphincter

normal, an cervix descends seminal po

C ervix swells slightly and is pass ively elevated with uterus

Hyperventilation and

 

aA

desire phas e cons isting of s ex fantasies and des ire to sex precedes the excitement phas e.

Table 18.1a-3 Male S exual R es pons Organ

E xc itement Phas e

Orgas mic Phas e

R es olut Phas e

Mental

Lasts several minutes to several hours ; heightened

3–15 secs

10–15 m no orgas to 1 day

2126 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 46 of 185

excitement before 30 secs to 3 mins S kin

J ust before orgasm: flush inconsistently appears ; maculopapular ras h originates on abdomen and s preads anterior chest wall, face, and neck, and can include shoulders and forearms

Wellflush

F lush disappe revers e appeara inconsis appearin of pers p on soles and palm hands

P enis

E rection in 30 secs by vasoconges tion of erectile bodies of corpus cavernos a of shaft; los s of

E jaculation: emis sion marked by to four contractions of 0.8 sec of vas, seminal prostate; ejaculation

E rection involutio 10 secs variable refractor period; f detumes in 5–30

2127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 47 of 185

S crotum and tes tes

erection may occur with introduction of as exual stimulus — loud nois e; with heightened excitement, size of glans and diameter of penile shaft increase

proper marked by contractions of 0.8 sec of urethra and ejaculatory spurt of 12–20 in. at age 18, decreasing age to at 70

T ightening lifting of sac and elevation of tes tes ; with heightened excitement, 50% increase size of testes over unstimulated state and flattening agains t perineum, signaling

No change

Decreas baseline because of vasocon tes ticula scrotal d within 5– mins aft orgasm; involutio take s ev hours if orgasmi releas e place

2128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 48 of 185

impending ejaculation C owper's glands

2–3 Drops of mucoid fluid that contain viable s perm are secreted during heightened excitement

No change

No chan

Other

B reasts : inconsistent nipple erection with heightened excitement before orgas m

Loss of voluntary muscular control

R eturn t baseline 5–10 mi

 

 

R ectum: rhythmic contractions of sphincter

 

 

Myotonia: semispastic contractions of facial, abdominal,

Heart rate: up 180 beats /min

 

2129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 49 of 185

intercostal muscles  

 

B lood up to 40–100 mm s ys tolic; 20–50 mm diastolic

 

 

T achycardia: to 175 beats /min

 

 

 

B lood ris es to 20–80 mm s ys tolic; 10–40 mm diastolic

R es piration: up to 40 res pirations/min

 

 

R es piration: increased

 

 

aA

desire phas e cons isting of s ex fantasies and des ire to precedes the excitement phas e.

Phas e I: Des ire P hase I is a psychological phas e distinct from any identified s olely through phys iology and reflects the 2130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 50 of 185

ps ychiatris t's fundamental concern with motivations , drives , and personality. It is characterized by s exual fantas ies and the conscious des ire to have sexual P.1911

Phas e II: E xc itement P hase II is brought on by psychological s timulation (fantas y or the presence of a love object), physiological stimulation (stroking or kiss ing), or a combination of the two. It cons is ts of a s ubjective s ens e of pleasure and objective s igns of sexual excitement. T he excitement phase is characterized by penile tumes cence leading erection in men and vaginal lubrication in women. T he nipples of both s exes become erect, although nipple erection is more common in women than in men. T he woman's clitoris becomes hard and turgid, and her minora become thicker as a res ult of venous Initial excitement may last several minutes to s everal hours. W ith continued s timulation, the man's testes increase in s ize 50 percent and elevate. T he woman's vaginal barrel shows a characteristic cons triction along outer third, known as the orgas mic platform. T he elevates and retracts behind the symphys is pubis ; is not eas ily access ible. However, stimulation of the caus es traction on the labia minora and the prepuce, there is intrapreputial movement of the clitoral shaft. B reast s ize in the woman increases 25 percent. engorgement of the penis and vagina produces specific color changes, particularly in the labia minora, which become bright or deep red. V oluntary contractions of muscle groups occur, rate of heartbeat and res piration 2131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 51 of 185

increases, and blood press ure rises . Heightened excitement las ts 30 s econds to several minutes.

Phas e III: Orgas m P hase III cons is ts of peaking s exual pleas ure, with of s exual tens ion and rhythmic contraction of the muscles and pelvic reproductive organs. A subjective sens e of ejaculatory inevitability triggers the man's orgasm, and forceful emiss ion of s emen follows. T he orgasm is also as sociated with four to five rhythmic of the pros tate, seminal vesicles, vas, and urethra. In women, orgas m is characterized by 3 to 15 involuntary contractions of the lower third of the vagina and by sustained contractions of the uterus , flowing from the fundus downward to the cervix. B oth men and women have involuntary contractions of the internal and anal s phincter. T hes e and the other contractions during orgasm occur at 0.8-second intervals. Other include voluntary and involuntary movements of the muscle groups, including facial grimacing and spas m. B lood pres sure ris es 20 to 40 mm (both diastolic), and the heart rate increas es up to 160 beats minute. Orgas m las ts from 3 to 25 s econds and is as sociated with a slight clouding of cons cious nes s.

Phas e IV: R es olution R es olution consists of the dis gorgement of blood from genitalia (detumes cence), which brings the body back its res ting s tate. If orgas m occurs, resolution is rapid; if does not occur, resolution may take 2 to 6 hours and as sociated with irritability and dis comfort. R es olution through orgas m is characterized by a subjective s ens e 2132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 52 of 185

well-being, general relaxation, and mus cular relaxation. After orgasm, men have a refractory period that may from s everal minutes to many hours ; in this period, cannot be s timulated to further orgas m. T he refractory period does not exis t in women, who are capable of multiple and success ive orgas ms . P.1912 S exual res ponse is a true ps ychophys iological Arousal is triggered by both psychological and phys ical stimuli, levels of tension are experienced both phys iologically and emotionally, and, with orgas m, normally a s ubjective perception of a peak of phys ical reaction and release. P s ychos exual development, ps ychological attitude toward s exuality, and attitudes toward one's s exual partner are directly involved with affect the physiology of human sexual res ponse.

A B NOR MA L S E X UA L ITY A ND DYS F UNC TIONS S even major categories of sexual dys function are lis ted DS M-IV -T R : (1) sexual desire disorders , (2) s exual disorders , (3) orgas m disorders , (4) sexual pain (5) s exual dysfunction due to a general medical (6) s ubstance-induced s exual dysfunction, and (7) dysfunction not otherwise specified.

Definition In DS M-IV -T R , s exual dysfunctions are categorized as disorders . T he syndromes listed are correlated with the sexual phys iological res ponse, which is divided into the four phases discus sed above. T he es sential feature of 2133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 53 of 185

sexual dys functions is inhibited in one or more of the phases, including disturbance in the s ubjective s ens e pleas ure or desire or disturbance in objective or experience (T ables 18.1a-4 and 18.1a-5). E ither disturbance can occur alone or in combination. S exual dysfunctions are diagnosed only when they are the part of the clinical picture. T hey can be lifelong or acquired, generalized or s ituational, and due to ps ychological factors , phys iological factors , or factors . If they are attributable entirely to a general medical condition, substance us e, or advers e effects of medication, then s exual dysfunction due to a general medical condition or s ubs tance-induced s exual dysfunction is diagnosed.

Table 18.1a-4 DS M-IV-TR Phas es the S exual R es pons e C yc le and As s oc iated S exual Phas es

C harac teris tic s

Dys function

1. Desire

Dis tinct from any identified solely through phys iology and reflects the patient's

Hypoactive sexual desire disorder; avers ion disorder; hypoactive

2134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 54 of 185

motivations , drives , and personality; characterized by sexual fantasies and the desire to have sex.

sexual desire disorder due to a general medical condition (man or woman); subs tanceinduced s exual dysfunction impaired des ire

2. S ubjective s ens e E xcitement of sexual and accompanying phys iological changes; all phys iological res ponses noted in Masters and J ohns on's excitement and plateau phases combined in this phase.

F emale s exual arousal male erectile disorder (may also occur in stages 3 and male erectile disorder due to a general medical condition; dyspareunia to a general medical condition (man or woman); subs tanceinduced s exual dysfunction

2135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 55 of 185

impaired 3. Orgasm

P eaking of pleas ure, with releas e of sexual tension and rhythmic contraction of the perineal mus cles and pelvic reproductive organs .

F emale orgasmic disorder; male orgasmic disorder; premature ejaculation; other s exual dysfunction due to a general medical condition (man or woman); subs tanceinduced s exual dysfunction impaired orgasm

4. R es olution

A s ens e of relaxation, wellbeing, and relaxation; men are refractory to orgasm for a period of time that increases with age,

P os tcoital dysphoria; postcoital headache

2136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 56 of 185

women can have multiple orgasms without a refractory period.

aDS M-IV -T R

cons olidates the Mas ters and excitement and plateau phases into a single excitement phas e, which is preceded by the (appetitive) phas e. T he orgasm and res olution phases remain the s ame as originally described Masters and J ohnson.

Table 18.1a-5 S exual Not C orrelated with Phas es of S exual R es pons e C yc le C ategory

Dys functions

S exual pain disorders

V aginismus (woman)

 

Dys pareunia (woman and man)

2137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 57 of 185

Other

S exual dysfunctions not otherwis e specified. E xamples :

 

1. No erotic sensation des pite phys iological res ponse to s exual stimulation (e.g., orgasmic anhedonia)

 

2. F emale analog of premature ejaculation

 

3. G enital pain occurring during masturbation

According to the tenth revision of Inte rnational C las s ification of Dis e as e s and R e late d He alth 10), s e xual dys function refers to a pers on's inability to “participate in a s exual relationship as he or s he would wis h.” T he dysfunction is expres sed as a lack of des ire pleas ure or as a phys iological inability to begin, or complete s exual interaction. B ecause s exual ps ychos omatic, it may be difficult to determine “the relative importance of ps ychological and/or organic factors .” S exual dysfunction such as lack of des ire can occur in men and women, but women more often complain of “subjective quality” of the experience than of the a s pecific respons e.” IC D-10 advis es looking “beyond presenting complaint to find the most appropriate 2138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 58 of 185

diagnostic category.” T able 18.1a-6 presents the IC Ddiagnostic criteria.

Table 18.1a-6 IC D-10 Diagnos tic C riteria for S exual Dys func tion, C aus ed by Organic Dis order or Dis eas e G 1. T he s ubject is unable to participate in a relations hip as he or she would wis h. G 2. T he dysfunction occurs frequently, but may absent on some occas ions . G 3. T he dysfunction has been pres ent for at least months. G 4. T he dysfunction is not entirely attributable to any of the other mental and behavioral disorders IC D-10, physical disorders (such as endocrine disorder), or drug treatment. C omments Meas urement of each form of dys function can be based on rating s cales that as sess severity as frequency of the problem. More than one type of dysfunction can coexist.

2139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 59 of 185

Lac k or los s of s exual des ire A. T he general criteria for sexual dys function met. B . T here is a lack or loss of sexual desire, diminution of seeking out s exual cues, of thinking about s ex with as sociated feelings of desire or appetite, or of sexual fantas ies . C . T here is a lack of interest in initiating s exual activity either with a partner or as solitary masturbation, res ulting in a frequency of activity clearly lower than expected, taking into account and context, or in a frequency very clearly from previous much higher levels . S exual avers ion and lac k of s exual enjoyment S exual aversion A. T he general criteria for sexual dys function met. B . T he prospect of s exual interaction with a produces sufficient aversion, fear, or anxiety that sexual activity is avoided, or, if it occurs , is with strong negative feelings and an inability to experience any pleasure.

2140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 60 of 185

C . T he avers ion is not the result of performance anxiety (reaction to previous failure of sexual res ponse). Lack of s exual enjoyment A. T he general criteria for sexual dys function met. B . G enital res ponse (orgas m and/or ejaculation) occurs during sexual s timulation but is not accompanied by pleas urable sensations or of pleasant excitement. C . T here is no manifes t and pers is tent fear or during sexual activity (s ee s exual aversion). Failure of genital res pons e A. T he general criteria for sexual dys function met. In addition, for men: B . E rection s ufficient for intercours e fails to occur when intercours e is attempted. T he dysfunction takes one of the following forms :    (1) full erection occurs during the early stages lovemaking but dis appears or declines when 2141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 61 of 185

intercours e is attempted (before ejaculation if it occurs);    (2) erection does occur, but only at times when intercours e is not being considered;    (3) partial erection, ins ufficient for intercours e, occurs, but not full erection;    (4) no penile tumescence occurs at all. In addition, for women: B . T here is failure of genital response, failure of vaginal lubrication, together with inadequate tumes cence of the labia. T he takes one of the following forms :    (1) general: lubrication fails in all relevant circums tances ;    (2) lubrication may occur initially but fails to for long enough to allow comfortable penile entry;    (3) situational: lubrication occurs only in some situations (e.g., with one partner but not another, during mas turbation, or when vaginal intercours e not being contemplated). Orgas mic dys func tion 2142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 62 of 185

A. T he general criteria for sexual dys function met. B . T here is orgas mic dys function (either abs ence marked delay of orgas m), which takes one of the following forms :    (1) orgasm has never been experienced in any situation;    (2) orgasmic dysfunction has developed after a period of relatively normal respons e:       (a) general: orgas mic dysfunction occurs in all situations and with any partner;       (b) s ituational:          for wome n: orgas m does occur in certain situations (e.g., when masturbating or with certain partners ); for me n, one of the following can be applied:          i) orgas m occurs only during sleep, never the waking s tate;          ii) orgas m never occurs in the pres ence of partner;          iii) orgas m occurs in the presence of the 2143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 63 of 185

but not during intercours e. Premature ejaculation A. T he general criteria for sexual dys function met. B . T here is an inability to delay ejaculation sufficiently to enjoy lovemaking, manifes t as of the following:    (1) occurrence of ejaculation before or very after the beginning of intercourse (if a time limit is required: before or within 15 s econds of the beginning of intercours e);    (2) ejaculation occurs in the absence of erection to make intercourse pos sible. C . T he problem is not the res ult of prolonged abstinence from sexual activity. Nonorganic vaginis mus A. T he general criteria for sexual dys function met. B . T here is spasm of the perivaginal muscles , sufficient to prevent penile entry or make it uncomfortable. T he dysfunction takes one of the 2144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 64 of 185

following forms :    (1) normal res ponse has never been    (2) vaginis mus has developed after a period of relatively normal res ponse:       (a) when vaginal entry is not attempted, a sexual respons e may occur;       (b) any attempt at sexual contact leads to generalized fear and efforts to avoid vaginal entry (e.g., s pas m of the adductor mus cles of the Nonorganic dys pareunia A. T he general criteria for sexual dys function met. In addition, for women: B . P ain is experienced at the entry of the vagina, either throughout s exual intercourse or only when deep thrus ting of the penis occurs. C . T he disorder is not attributable to vaginismus failure of lubrication; dyspareunia of organic should be clas sified according to the underlying disorder.

2145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 65 of 185

In addition for men: B . P ain or dis comfort is experienced during res ponse. (T he timing of the pain and the exact localization s hould be carefully recorded.) C . T he discomfort is not the res ult of local factors . If physical factors are found, the should be clas sified els ewhere. E xc es s ive s exual drive No research criteria are attempted for this R es earchers studying this category are recommended to design their own criteria. Other s exual dys function, not c aus ed by dis order or dis eas e Uns pecified s exual dys function, not c aus ed organic dis order or dis eas e

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion. With the poss ible exception of premature ejaculation, sexual dysfunctions are rarely found s eparate from 2146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 66 of 185

ps ychiatric syndromes. S exual disorders may lead to or res ult from relational problems, and patients invariably develop an increasing fear of P.1913 failure and self-cons ciousnes s about their s exual performance. S exual dysfunctions are frequently as sociated with other mental disorders , s uch as disorders , anxiety dis orders , personality disorders , and schizophrenia. In many instances, a sexual dys function may be diagnosed in conjunction with another disorder; in other cas es, however, it is only one of signs or symptoms of the psychiatric disorder. A s exual dis order can be symptomatic of biological problems , intrapsychic conflicts, interpers onal or a combination of thes e factors. S exual function can affected by s tres s of any kind, by emotional disorders , by a lack of sexual knowledge.

Taking a S exual His tory As with all psychiatric interviews, taking a sexual not only is a time to gather information, but it als o the development of a positive doctor–patient T he development of rapport requires an accepting atmos phere and a nonjudgmental attitude on the part the therapist toward the patients' s exual values , ideas , practices . T he sexual history is more structured than the rest of ps ychiatric interview, although patients are encouraged take their own lead in areas of great personal In general, the therapis t s tructures the interview s o that both recent and early sexual histories are covered. T he 2147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 67 of 185

therapist mus t as certain the specific current sexual complaint, the patient's s exual practices and pattern of interaction with partners , the patient's s exual goal and fantas ies , the patient's mas turbatory his tory, the or extent of extramarital relations hips, and the degree commitment to the marriage or the partner. P atients describe their view of the problem and when it began. If married, the courts hip, honeymoon, and reproductive history are examined in detail. P remarital expectations, mutual phys ical attraction, periods of s eparation, the of contraception used, and the effect of children on the couple's s exual life are covered. T he s atis fying as pects the marriage must also be dis cus sed. T he patient is particularly asked to evaluate the partner's contribution the present distress . E arly s exual development and education are also thoroughly discus sed. T he interviewer asks for the patient's view of the parents ' marriage as s een in retrospect and as perceived in childhood. R elations hips peers, s iblings, and important familial figures other than parents are als o explored. P articular attention is paid to ways in which affection was expres sed in the family the degree of phys ical contact between family T he sexual climate in which the patient grew up is s een through reported parental attitudes , memories of games played as a child, the way in which the patient learned sexual facts , the s pecifics of religious training, reactions to masturbation and nocturnal emiss ions or menarche, dating patterns , an adolescent rebellious and any s ignificant premarital involvements . E thnic background and the s ocioeconomic level of the primary family are also taken into account. As the 2148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 68 of 185

interview progres ses, the patient's self-image emerges. T he interviewer mus t be sensitive to any event that exceptional in the patient's s exual life in either a destructive or a highly pleasant manner and s hould particular note of the people who contributed to the patient's s exual education, identity, and mores . T he interviewer mus t also ask s pecific ques tions to information that may be outs ide the patient's view of socially acceptable, s uch as premarital and affairs , group s ex, homos exual involvements, and abortions. T he sexual orientation of the pers on being interviewed should be as certained, and questions to same-sex interactions explored. All interviews review high-ris k sexual behavior regardles s of sexual orientation, as transmis sion of the human immunodeficiency virus (HIV ) occurs in all groups . Additionally, the iss ue of s exual abuse mus t be particularly becaus e a his tory of abus e predisposes to development of s exual dysfunction. S imilar disorders exist among both homos exual and heteros exual partners, with variations imposed by anatomical differences . F or example, P.1914 P.1915 although penile–vaginal dys function cannot be among homos exuals , penile–anal dys function may R egardless of s exual orientation, each phas e of the cycle applies equally to same-sex and heterosexual partners , and the methods and principles for treatment 2149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 69 of 185

es sentially similar. T aking a s ex his tory is summarized T able 18.1a-7.

Table 18.1a-7 Taking a S ex I. Identifying data    A. Age    B . S ex    C . Occupation    D. R elations hip s tatus —single, married, times previously married, separated, divorced, cohabiting, s erious involvement, casual dating (difficulty forming or keeping relations hips s hould be as ses sed throughout the interview)    E . S exual orientation—heteros exual, or bis exual (this may als o be as certained later in interview) II. C urrent functioning    A. Unsatis factory to highly s atis factory    B . If unsatis factory, why? 2150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 70 of 185

   C . F eelings about partner s atis faction    D. Dysfunctions? —e.g., lack of desire, erectile disorder, inhibited female arous al, anorgas mia, premature ejaculation, retarded ejaculation, pain as sociated with intercours e (dys function below)       1. Onset—lifelong or acquired          a. If acquired, when?          b. Did ons et coincide with drug use (medications or illegal recreational drugs ), life stress es (e.g., loss of job, birth of child), difficulties ?       2. G eneralized—occurs in most situations or most partners       3. S ituational          a. Only with current partner          b. In any committed relations hip          c. Only with masturbation          d. In socially proscribed circums tance (e.g., affair) 2151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 71 of 185

         e. In definable circumstance (e.g., very late night, in parental home, when partner initiated play)    E . F requency—partnered s ex (coital and sex play)    F . Des ire/libido—how often are s exual feelings, thoughts, fantasies, dreams , experienced (per week, etc.)?    G . Description of typical sexual interaction       1. Manner of initiation or invitation (e.g., phys ical? Does same person always initiate? )       2. P resence, type, and extent of foreplay kiss ing, cares sing, manual or oral genital       3. C oitus? P os itions us ed?       4. V erbalization during sex? If s o, what kind?       5. Afterplay? (whether sex act is completed or disrupted by dys function); typical activities (e.g., holding, talking, return to daily activities, s leeping)       6. F eeling after s ex: relaxed, tense, angry,    H. S exual compulsivity? (intrusion of sexual 2152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 72 of 185

thoughts or participation in s exual activities to a degree that interferes with relationships or work, requires deception, and may endanger the III. P as t sexual history    A. C hildhood s exuality       1. P arental attitudes about s ex—degree of openness or reserve (ass es s unus ual prudery or seductiveness )       2. P arents' attitudes about nudity and       3. Learning about s ex          a. F rom parents (Initiated by child's parent volunteering information? W hich parent? What was child's age? )? S ubjects covered (e.g., pregnancy, birth, intercourse, menstruation, nocturnal emis sion, mas turbation)?          b. F rom books, magazines , or friends at or through religious group?          c. S ignificant mis information          d. F eeling about information       4. V iewing or hearing primal s cene— 2153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 73 of 185

      5. V iewing s ex play or intercours e of person than parent       6. V iewing s ex between pets or other animals    B . C hildhood s ex activities       1. G enital s elf-stimulation before Age? R eaction if apprehended?       2. Awareness of s elf as boy or girl—B athroom sens ual activities (regarding urine, feces , odor, enemas)?       3. S exual play or exploration with another (playing doctor)—T ype of activity (e.g., looking, manual touching, genital touching)? R eactions or cons equences if apprehended (by whom? )? IV . Adolescence    A. Age of onset of puberty—development of secondary s ex characteris tics, age of menarche girl, wet dreams or first ejaculation for boy (preparation for and reaction to)    B . S ens e of self as feminine or masculine— image, acceptance by peers (oppos ite sex and sex), sense of s exual des irability, ons et of coital fantas ies 2154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 74 of 185

   C . S ex activities       1. Masturbation—Age begun? E ver punished prohibited? Method us ed, accompanying frequency (questions about mas turbation and fantas ies are among the mos t s ens itive for to answer)?       2. Homosexual activities —Ongoing or rare experimental episodes ? Approached by others ? If homos exual, has there been any heteros exual experimentation?       3. Dating—casual or steady; description of crush, infatuation, or firs t love       4. E xperiences of kiss ing, necking, petting (“making out” or “fooling around”), age begun, frequency, number of partners, circumstances, (s ) of activity       5. Orgasm—When first experienced (may not experienced during adolescence)? W ith masturbation, during s leep, or with partner? W ith intercours e or other s ex play? F requency?       6. F irs t coitus—age, circums tances , partner, reactions (may not be experienced during adoles cence), contraception and/or safe sex precautions used 2155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 75 of 185

V . Adult sexual activities (may be experienced by some adoles cents)    A. P remarital s ex       1. T ypes of s ex play experiences —frequency sexual interactions , types and number of partners       2. C ontraception and/or safe s ex precautions us ed       3. F irs t coitus (if not experienced in adoles cence)—age, circums tances , partner       4. C ohabitation—age begun, duration, description of partner, sexual fidelity, types of activity, frequency, s atis faction, number of cohabiting relations hips, reas ons for breakup(s )       5. E ngagement—age; activity during engagement period with fiancé(e), with others ; length of engagement    B . Marriage (if multiple marriages have explore s exual activity, reas ons for marriage, and reasons for divorce in each marriage)       1. T ypes and frequency of sexual describe typical s exual interaction (s ee above). S atisfaction with s ex life? V iew of partner's 2156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 76 of 185

      2. F irs t sexual experience with s pouse— What were the circumstances? W as it s atis fying? Dis appointing?       3. Honeymoon—S etting, duration, pleas ant or unpleasant, s exually active? F requency? C ompatibility?       4. E ffect of pregnancies and children on sex       5. E xtramarital s ex—Number of incidents, emotional attachment to extramarital partners? F eelings about extramarital sex       6. P ostmarital masturbation—F requency? on marital sex?       7. E xtramarital s ex by partner—effect on interviewee       8. Ménage à trois or multiple s ex (swinging)       9. Areas of conflict in marriage (e.g., finances , divis ion of res ponsibilities, priorities) V I. S ex after widowhood, separation, divorce— celibacy, orgas ms in sleep, masturbation, sex play, intercours e (number of and relationship partners ), other 2157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 77 of 185

V II. S pecial is sues    A. History of rape, incest, sexual or physical    B . S pousal abuse (current)    C . C hronic illness (phys ical or ps ychiatric)    D. History or presence of s exually transmitted diseases    E . F ertility problems    F . Abortions, mis carriages, or unwanted or illegitimate pregnancies    G . G ender identity conflict—(e.g., wearing clothes of opposite s ex)    H. P araphilias —(e.g., fetis hes , voyeuris m, sadomas ochis m)

R ating S c ales In addition to the interview, several ques tionnaires are available to as ses s sexual function. T hey were primarily to evaluate illness or medication-related on sexual functioning. T he mos t commonly used s cales the Arizona S exual E xperience S cale, the B rief S exual 2158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 78 of 185

F unction Ques tionnaire, the C hanges in S exual F unctioning Questionnaire, the Derogatis S exual Inventory, and the R ush S exual Inventory. T he s cales in length, reliability, validity, and method of adminis tration. S ome are rated by the patients others by the therapis t. T he formats include structured semistructured approaches. T he scales differ in symptoms ass es sed, the dysfunctions they target, and time frame they cover.

S exual Des ire Dis orders DS M-IV -T R divides sexual desire disorders into two hypoactive sexual desire dis order, characterized by a deficiency or lack of s exual fantasies and des ire for activity, and s exual aversion disorder, characterized by avers ion to and avoidance of genital contact with a partner. T he former condition is more common than the latter.

Hypoac tive S exual Des ire Dis order Hypoactive s exual des ire dis order (T able 18.1a-8) is experienced by both men and women; however, they not be hampered by any dysfunction once they are involved in the sex act. C onversely, hypoactive des ire be us ed to mask another sexual dysfunction. Lack of may be express ed by decreased frequency of coitus , perception of the partner as unattractive, or overt complaints of lack of des ire. Upon ques tioning, the is found to have few or no s exual thoughts or fantasies, lack of awarenes s of s exual cues, and little interest in initiating sexual experiences .

2159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 79 of 185

Table 18.1a-8 DS M-IV-TR Diagnos tic C riteria for S exual Des ire Dis order A. P ersis tently or recurrently deficient (or abs ent) sexual fantasies and desire for sexual activity. judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context the person's life. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he s exual dys function is not better accounted by another Axis I dis order (except another sexual dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:

2160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 80 of 185

   Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. S ometimes , biochemical correlates are as sociated with hypoactive desire. A recent s tudy found markedly low serum tes tos terone concentrations in men complaining this dys function when they were compared with normal controls in a s leep laboratory situation. Als o, a central dopamine blockage is known to decrease des ire. T he for sexual contact and s atisfaction varies among persons, as well as in the s ame pers on over time. In a group of 100 couples with stable marriages, 8 percent reported having intercours e less than once a month. In another group of couples, one-third reported lack of sexual relations for periods averaging 8 weeks. In a of a general medical practice in E ngland, 25 percent of sample reported no sexual activity mos t of the time. It 2161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 81 of 185

been estimated that 20 percent of the total population have hypoactive sexual desire disorder. T he complaint more common among women. P atients with desire problems often have good ego strengths and use inhibition of des ire defens ively to protect agains t unconscious fears about s ex. Lack of can also res ult from chronic s tres s, anxiety, or Abs tinence from s ex for a prolonged period s ometimes suppress es the sexual impulse. Des ire problems may be an express ion of hos tility toward the partner or deteriorating relations hip. T he presence of desire depends on s everal factors : biological drive, adequate s elf-es teem, previous good experiences with sex, the availability of an appropriate partner, and a good relationship in nonsexual areas one's partner. Damage to any of those factors may diminis hed des ire. Hypoactive s exual des ire dis orders often become during puberty and may remain a lifelong condition. A general medical workup s hould be conducted to rule medical cause, which, if present, would be, according DS M-IV -T R , diagnos ed as male or female s exual disorder due to a general medical condition. Mr. and Mrs . K . pres ented for therapy becaus e of the complaints regarding lack of s exuality in their marriage. Mr. K . s tated that he rarely felt sexual desire at all and this problem was not restricted to the marriage or lack desire for his wife. In the cours e of the workup, the proved to have multiple sexual dysfunctions, including dyspareunia on the part of the wife and erectile on the part of the husband, as well as lack of desire. 2162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 82 of 185

and Mrs. K . were in their early 50s, had been married years , and had no children. Mrs . K . had had s ome ps ychotherapy and was currently on medication for recurrent depres sion. T he couple had similar backgrounds —both were immigrants from an E as tern E uropean country. Hus band and wife had both attained P h.D.s , valued education highly, and were s ucces sful their res pective fields. Mrs. K . had emigrated with her family. S he was the of five children and had been res ponsible for taking her younger siblings . S he received little nurturing and had been the recipient of considerable emotional abuse from her mother. Of particular importance, she been s exually abus ed by an elderly neighbor. S he discuss ed this in therapy for the first time s ince the incident occurred. Mr. K . had come to the United alone in his late adolescence. He had been s eparated his parents in early childhood and was raised by dis tant relatives . In spite of their lack of intimacy, the couple strong sense of loyalty to each other and s hared a culture and values. T hey practiced the behavioral exercis es as directed, Mrs. K . was very pleased by the touching and attention received. S he practiced using s ize-graduated dilators her dyspareunia and eventually allowed digital penetration of her vagina by her husband. Mr. K . freer in his discuss ions of sex, including voicing his that it was dirty. He used 50 mg of s ildenafil (V iagra) to facilitate his erections and felt much better about when he was able to maintain them. T he couple approached therapy as they had approached s chool, diligently and cons cientious ly. Although their s exual 2163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 83 of 185

interaction remained rather rigid— planned for the time each week—they were pleas ed with their progress individually and as a couple. T hey were able to sexual pleasure manually and have had s ome intercours e.

S exual A vers ion Dis order S exual ave rs ion dis orde r (T able 18.1a-9) is defined in IV -T R as a “persis tent or recurrent and extreme and avoidance of, all or almos t all, genital s exual with a s exual partner.” S ome researchers cons ider the between hypoactive desire disorder and s exual disorder blurred, and, in s ome cases, both diagnos es appropriate. Low frequency of sexual interaction is a symptom common to both disorders . T he clinician think of the words “repugnance” and “phobia” in to the patient with s exual aversion disorder. F reud conceptualized sexual avers ion as the res ult of during the phallic ps ychos exual phase and unresolved oedipal conflicts. S ome men, fixated at the phallic development, fear the vagina and believe that they will castrated if they approach it (a concept F reud called vagina de ntata), becaus e they believe unconscious ly the vagina has teeth. Hence, they avoid contact with female genitalia entirely.

Table 18.1a-9 DS M-IV-TR Diagnos tic C riteria for S exual Avers ion Dis order 2164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 84 of 185

A. P ersis tent or recurrent extreme aversion to avoidance of all (or almost all) genital s exual with a s exual partner. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he s exual dys function is not better accounted by another Axis I dis order (except another sexual dysfunction). S pe cify type:    Lifelong type    Acquired type S pe cify type:    S ituational type    Generalized type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

2165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 85 of 185

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

T he disorder may result from a traumatic sexual such as rape or childhood abuse, from repeated painful experiences with coitus , P.1916 P.1917 or from early developmental conflicts that have left the patient with uncons cious connections between the impulse and overwhelming feelings of shame and guilt. T he disorder may als o be a reaction to a perceived ps ychological as sault by the partner and to relations hip difficulties . Mr. and Mrs . J . were 38 and 36 years old, respectively, when they presented for treatment, stating they had not had coitus for 3 years . T hree years previously, Mrs . J . revealed that she had been having an extramarital for 2 months, which she then ended. At that time, s he her hus band that s he had been unhappy with their lovemaking. Upon hearing of her affair, the hus band was angry and 2166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 86 of 185

refused to approach his wife sexually. W hen he finally so, s he would allow caress ing of her body but not her genitalia, although s he was willing to stimulate him sexually. At this point, the hus band also had an affair, stopped when he realized it would not s olve his with his wife, and s he then agreed to enter s ex therapy. When they pres ented for sex therapy, their sexual interaction cons is ted of mutual kiss ing and her manual stimulation of his penis until he reached orgas m. In the individual interviews that were part of the evaluation of the case, Mrs. J . reiterated that she found husband's lovemaking unsatis factory but did not have a problem allowing other men to caress her genitalia and could have coitus with other men. Mr. J . had been traumatized by his wife's rejection and s exual betrayal, he, in turn, was averse to touching her genitalia or attempting intromiss ion. T his was a case in which both partners suffered from sexual avers ion dis order. T he husband feared touching wife in an explicitly s exual way, the wife was averse to touching her genitalia, and both spouses avoided F or both partners , the dysfunction was acquired and situational.

S exual Arous al Dis orders DS M-IV -T R divides the sexual arous al disorders into female s exual arous al dis order, characterized by the persis tent or recurrent partial or complete failure to or maintain the lubrication–swelling respons e of s exual excitement until the completion of the sexual act, and male erectile disorder, characterized by the recurrent persis tent partial or complete failure to attain or 2167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 87 of 185

an erection until the completion of the sex act. T he diagnosis takes into account the focus , the intens ity, the duration of the s exual activity in which the patient engages. If s exual s timulation is inadequate in focus , intens ity, or duration, the diagnosis s hould not be

F emale S exual A rous al Dis order Women who have excitement phas e dysfunction often have orgas mic problems as well. In one series of happily married couples , 33 percent of the women described difficulty in maintaining sexual excitement. Other data indicate that 14 to 19 percent of women chronic lubrication difficulties , whereas 23 percent have intermittent problems with lubrication. In s tudies of postmenopaus al women, complaints of pers is tent or intermittent lubrication difficulties increas e to 44 Numerous ps ychological factors are as sociated with female s exual inhibition. T hes e conflicts may be through inhibition of excitement or orgas m and are discuss ed under orgasmic phas e dysfunctions. In women, arous al dis orders are as sociated with or lack of des ire. Less res earch has been done on physiological of dysfunction in women than of dysfunction in men, there have been conflicting res ults. Mas ters and found normally responsive women to des ire sex premenstrually. Dysfunctional women, however, be more res ponsive immediately after their periods . Another group of dys functional women felt the greatest sexual excitement at the time of ovulation. S ome indicates that dys functional women are les s aware of phys iological res pons es in their bodies, s uch as 2168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 88 of 185

vasoconges tion, during arousal. T here are s ome medical causes for female sexual disorder. Alterations in tes tos terone, estrogen, and thyroxine concentrations have been implicated. Medications with antihis taminic or anticholinergic properties les sen vaginal lubrication and interfere with arousal. Also, postmenopausal women require longer P.1918 stimulation for lubrication to occur, and there is less vaginal trans udate after menopaus e. An artificial lubricant is frequently useful in this situation. T able 18.1a-10 presents the diagnos tic criteria for sexual arous al dis order.

Table 18.1a-10 DS M-IV-TR Diagnos tic C riteria for Female S exual Arous al Dis order A. P ersis tent or recurrent inability to attain, or to maintain until completion of the s exual activity, an adequate lubrication–swelling respons e of sexual excitement. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he s exual dys function is not better accounted 2169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 89 of 185

by another Axis I dis order (except another sexual dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

2170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 90 of 185

Male E rec tile Dis order Male erectile disorder (T able 18.1a-11) is also called dys function and impote nce . A man with lifelong male erectile dis order has never obtained an erection for vaginal insertion. In acquired male erectile dis order, however, the man s ucces sfully achieved vaginal penetration at s ome time in his s exual life but, later, cannot do so. In s ituational male erectile dis order, the can have coitus in certain circums tances but not in others —for example, a man may function effectively a pros titute but not with his wife. K insey estimated that few men (2 to 4 percent) are dysfunctional at age 35 but 77 percent are dys functional at age 80 years . T en percent of the men in the University of C hicago s tudy reported an experience with erectile dys function in the past year, and between 15 and 20 percent experienced anxiety about performing. More recently, it was that the incidence of erectile dys function in young men approximately 8 percent. However, this s exual may first appear later in life. Masters and J ohnson a fear of impotence in all men over 40 years of age, the res earchers believed reflects the mas culine fear of of virility with advancing age. (As it happens, however, erectile dys function is not a regularly occurring phenomenon in aged men; good health and an sexual partner are more clos ely related to continuing potency than is age per s e.) T he chief complaint of between 35 and 50 percent of all men treated for disorders is erectile dys function.

Table 18.1a-11 DS M-IV-TR 2171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 91 of 185

Diagnos tic C riteria for Male Dis order A. P ersis tent or recurrent inability to attain, or to maintain until completion of the s exual activity, an adequate erection. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he erectile dys function is not better for by another Axis I disorder (other than a s exual dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify: 2172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 92 of 185

   Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. In general, the psychological conflicts that cause dysfunction are related to an inability to express the impulse becaus e of fear, anxiety, anger, or moral prohibition. Lifelong dys function is a more s erious but common condition than acquired erectile dis order and less amenable to treatment. Many developmental factors have been cited as contributing to erectile dis order. Any experience that hinders the ability to be intimate, that leads to a feeling inadequacy or distrust, or that develops a sense of unloving or unlovable may res ult in this problem. dysfunction in an ongoing relations hip may reflect difficulties between the partners, particularly if one cannot communicate his or her needs or angry feelings a direct and cons tructive manner. S uccess ive episodes impotence are reinforcing, with the man becoming increasingly anxious about his next sexual encounter. R egardless of the original cause of the dys function, his anticipatory anxiety about achieving and maintaining erection interferes with his pleas ure in s exual contact 2173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 93 of 185

his ability to respond to s timulation, thus perpetuating problem. Mr. Y . came for therapy after his wife complained about their lack of sexual interaction. T he patient avoided sex because of his frequent erectile dysfunction and painful feelings of inadequacy he suffered after his “failures.” presented as an articulate, gentle, and s elf-blaming P.1919 He was faithful to his wife but masturbated frequently. fantas ies involved explicit sadis tic components, hanging and biting women. T he contras t between his angry, aggress ive fantas ies and his loving, cons iderate behavior toward his wife symbolized his conflicts about sexuality, his masculinity, and his mixed feelings about women. He was diagnos ed with erectile dys function, situational type.

Orgas mic Dis orders F e male orgas mic dis order (also known as inhibite d orgas m, or anorgas mia) is defined as the recurrent and persis tent inhibition of the female orgasm, manifested the abs ence or delay of orgas m after a normal sexual excitement phas e that the clinician judges to be in focus , intens ity, and duration. W omen who can orgasm with noncoital clitoral stimulation but cannot experience it during coitus in the abs ence of manual clitoral s timulation are not neces sarily categorized as anorgas mic. P hysiological research on the female s exual res ponse demonstrated that orgasms caus ed by clitoral 2174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 94 of 185

are physiologically identical to those caused by vaginal stimulation. F reud's theory that women mus t give up clitoral s ensitivity for vaginal sensitivity to achieve maturity is now considered misleading, although s ome women s ay that they gain a s pecial s ens e of from an orgasm precipitated by coitus. S ome attribute to the psychological feeling of clos eness engendered the act of coitus , but others maintain that the coital orgasm is a physiologically different experience. Many women achieve orgasm during coitus by a combination manual clitoral stimulation and penile vaginal Lifelong female orgas mic dis order exists when a has never experienced orgasm by any kind of Acquired orgas mic dysfunction exis ts if a woman has previous ly experienced at least one orgas m regardles s the circums tances or means of stimulation, whether by masturbation or during s leep while dreaming. K insey found that the proportion of married women over 35 of age who had never achieved orgasm by any means only 5 percent. T he incidence of orgasm increases with age. According to K ins ey, the firs t orgasm occurs in adoles cence in approximately 50 percent of women. res t us ually experience orgas m by s ome means as older. Lifelong female orgas mic disorder is more among unmarried women than among married women; 39 percent of the unmarried women over age 35 years K insey's s tudy had never experienced orgasm. orgasmic potential in women older than 35 has been explained on the bas is of les s ps ychological inhibition, greater sexual experience, or both. Also, orgasmic cons istency has been correlated with marital although caus e and effect have not been determined. 2175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 95 of 185

the Univers ity of C hicago study, three-fourths of the married female res pondents usually or always orgasm during sex, compared with two-thirds of the women. One woman in ten complained of difficulty in achieving orgas m. Mr. and Mrs . Z. were a childles s couple, both in their 20s. S he was a college ins tructor, and he was a writer. T he couple had been married for 4 years and to therapy with a mutual complaint of steadily less ening sexual frequency. During the year before they were seen, they had had intercours e s ix times . In the initial interview, Mrs . Z. that s he had never been able to have an orgas m with husband and had never experienced an orgas m during intercours e. Her frus tration made her increas ingly reluctant to have coitus and caus ed her to reject her husband s exually. Mrs . Z. could mas turbate to orgasm while indulging in masochistic fantasies, but s he did so very infrequently. S he was the oldest of four children, rais ed by rigid, intellectual, and undemons trative parents . S he stated she had been a very docile child and adolescent but openly rebelled in marrying her hus band. Her parents disapproved of him becaus e he came from a different religious background. Mrs. Z.'s father particularly and relations between Mr. Z. and his father-in-law were strained. Mrs . Z. s tated that s he often felt caught them. Mr. Z. was the middle child and the only boy in a family three s iblings. T here was a 20-year age difference his parents, and the father was not actively involved 2176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 96 of 185

the children. He felt that he had always been his favorite. Mr. and Mrs . Z. met in college, and, although neither sexually experienced, they were strongly attracted to another and indulged in enjoyable s exual play s hort of intercours e. Mrs. Z. perceived her husband as a very as sertive man and was impress ed by the way he stood to her family. When he completed s chool a year ahead Mrs. Z., he broke off the relations hip with her. During year, Mrs. Z. became involved with another man and enjoyed s exual play with him. S he did not have with him but s ometimes came to orgasm through manipulation. At the time of her graduation, she ended this relations hip and managed to regain Mr. Z.'s T he couple married 6 months after her graduation. Intercours e was a disappointment to Mrs. Z. from the beginning. S he felt unfulfilled, and her husband felt rejected and inadequate. In therapy, the couple's premarital expectations were discuss ed. In effect, each had expected more from the other, and, in reality, each had some problem with pas sivity. S everal s es sions were also spent with relations with the in-laws . Mrs. Z. was encouraged give priority to her relations hip with her husband, and Z. was encouraged to face and restrain his with her father. T hey responded to the behavioral exercises that were pres cribed. At the time of their discharge from therapy, the couple was having one to two times a week. Mrs . Z. could not reach during intercourse but could frequently achieve climax after coitus through manual s timulation. Acquired female orgas mic disorder is a common 2177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 97 of 185

in the clinical population. One clinical treatment facility described nonorgasmic women as approximately four times more common in its practice than patients with all other s exual dis orders. In another study, 46 percent of women complained of difficulty in reaching orgasm, 15 percent des cribed an inability to have orgas m. T he overall prevalence of inhibited orgasm in women is es timated to be 30 percent. Numerous ps ychological factors are as sociated with female s exual inhibition—fears of impregnation, by the sexual partner, or damage to the vagina; toward men; and feelings of guilt regarding sexual impulses. S ome women equate orgasm with los s of or with aggres sive, destructive, or violent behavior. those impuls es may be express ed through inhibition of excitement or orgasm. T he express ion of orgas mic inhibition varies. S ome women feel unentitled to gratify thems elves and cannot masturbate to climax. Others self-stimulation but cannot reach orgas m with a partner present. C ultural expectations and societal res trictions women are also relevant. Nonorgasmic women may be otherwis e s ymptom-free or may experience frustration variety of ways, including s uch pelvic complaints as abdominal pain, itching, and vaginal dis charge, as well increased tension, irritability, and fatigue. T he criteria for female orgasmic dis order are presented in 18.1a-12.

Table 18.1a-12 DS M-IV-TR Diagnos tic C riteria for Female Orgas mic Dis order 2178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 98 of 185

A. P ersis tent or recurrent delay in, or abs ence of, orgasm after a normal sexual excitement phas e. Women exhibit wide variability in the type or intens ity of stimulation that triggers orgas m. T he diagnosis of female orgasmic dis order s hould be based on the clinician's judgment that the orgasmic capacity is less than would be for her age, sexual experience, and the adequacy sexual s timulation s he receives. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he orgasmic dysfunction is not better for by another Axis I disorder (except another dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type

2179 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 99 of 185

   S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. P.1920

Male Orgas mic Dis order In male orgas mic disorder (previous ly called inhibite d orgas m; also called re tarde d ejaculation), a man climax during coitus with great difficulty, if at all. A man cons idered to have lifelong orgasmic disorder if he has never ejaculated during coitus . T he dis order is as acquired if it develops after previous normal (T able 18.1a-13).

Table 18.1a-13 DS M-IV-TR Diagnos tic C riteria for Male Orgas mic Dis order 2180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 100 of 185

A. P ersis tent or recurrent delay in, or abs ence of, orgasm after a normal sexual excitement phas e during sexual activity that the clinician, taking into account the person's age, judges to be adequate focus , intens ity, and duration. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he orgasmic dysfunction is not better for by another Axis I disorder (except another dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:

2181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 101 of 185

   Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. S ome s uggest that orgasm and ejaculation s hould be differentiated. C ertainly, inhibited orgas m mus t be differentiated from retrograde ejaculation, in which ejaculation occurs but the seminal fluid pass es into the bladder. T his condition always has an organic caus e. R etrograde ejaculation can develop after genitourinary surgery and is als o ass ociated with medications that have anticholinergic adverse effects , as the phenothiazines, particularly thioridazine T he incidence of male orgas mic disorder is much lower than the incidences of premature ejaculation and dysfunction. Masters and J ohnson reported only 3.8 percent in one group of 447 sexual dysfunction cases. problem is more common among men with obses sivecompuls ive disorders (OC Ds ) than among others . Male orgasmic disorder may have phys iological causes and occur after surgery of the genitourinary tract, s uch as prostatectomy. Male orgas mic dysfunction may also be as sociated with P arkinson's disease and other disorders involving the lumbar or s acral s ections of the 2182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 102 of 185

spinal cord. T he antihypertensive drugs guanethidine monos ulfate (Ismelin) and methyldopa (Aldomet) have been implicated in retarded ejaculation. P henothiazines have als o been ass ociated with the dis order, as have almos t all the antidepres sants . T ransient retarded ejaculation may occur with exces sive alcohol intake or with hyperglycemia. S trictly organic cases and that are symptomatic of other Axis I ps ychiatric are not to be included in the diagnosis. P rimary male orgas mic disorder indicates a more ps ychopathology. T he man often comes from a rigid, puritanical background; he perceives s ex as sinful and genitals as dirty and may have cons cious or inces t wis hes and guilt. Usually, difficulties with exis t that extend beyond the area of sexual relations . S ome cas es involve men with adult attention-deficit disorder. It is as though these men are so eas ily that they cannot focus on the pleas urable sensations of arousal cons is tently enough to attain a degree of excitement necess ary for orgas m. Another theory holds that men with retarded ejaculation are preoccupied with sex, unus ually voyeuris tic, and easily arous ed. their elaborate fantasies of exceptionally beautiful or driven women and atypical s exual activities require to work unus ually hard to achieve orgasm in more sexual encounters. In an ongoing relationship, s econdary ejaculatory inhibition frequently reflects interpers onal difficulties . disorder may be the man's way of coping with real or fantas ized changes in the relationship. T hos e changes include plans for a pregnancy about which the man is ambivalent, the los s of s exual attraction to the partner, 2183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 103 of 185

demands by the partner for greater commitment as expres sed by s exual performance. In s ome men, the inability to ejaculate reflects unexpres sed hostility women. In a version of the dysfunction, some men experience partial inhibition of ejaculation. T hes e men experience slow dribbling of ejaculation (not related to age) rather than an ejaculatory s purt. T hey usually do not the pleas urable s ens ations of orgas m. A couple presented with the man as the identified suffering from an inability to ejaculate with intercourse. T he problem was of recent onset and had s tarted after the couple decided to have a baby. T he man was years of age and the woman was 39 years of age. they had been married for 2 years and had agreed to children when they married, the hus band had put off trying to have a child. He had started a new bus iness time the couple married and felt a great deal of press ure. T he wife had been s ympathetic to his but, as her 40th birthday loomed, she insis ted that they to conceive. T he hus band express ed his understanding and agreed but promptly developed the symptoms of retarded ejaculation. He was diagnos ed with male orgasmic disorder, acquired type. P.1921

P remature E jac ulation In pre mature e jaculation, the man recurrently achieves orgasm and ejaculates before he wishes to do s o. no definite time frame within which to define the 2184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 104 of 185

dysfunction. T he diagnosis is made when the man regularly ejaculates before or immediately after the vagina or after minimal sexual s timulation. T he clinician s hould consider factors that affect duration of excitement phas e, s uch as age, novelty of the s exual partner, and the frequency and duration of coitus. and J ohnson conceptualized the dis order in terms of couple and cons idered a man a premature ejaculator if could not control ejaculation long enough during intravaginal containment to satis fy his partner in at half of their epis odes of coitus . T his definition ass umes the female partner is capable of an orgas mic respons e. with other dysfunctions, the disturbance is diagnosed if it is not caus ed exclus ively by medical factors or is symptomatic of any other Axis I s yndrome. P remature ejaculation is more common today among college-educated men than among men with les s education and is thought to be related to their concern partner satisfaction. It is es timated that 30 percent of male population have the dys function, and 40 percent of men treated for s exual dis orders have premature ejaculation as the chief complaint. Difficulty in ejaculatory control may be ass ociated with anxiety regarding the s ex act. B oth anxiety and are mediated by the s ympathetic nervous system. ps ychological factors that have been noted include guilt, a history of parent–child conflict, interpersonal hypers ens itivity, and perfectionism or unrealis tic expectations about sexual performance. C urrent res earch als o s uggests that a subgroup of premature ejaculators (particularly those with a lifelong history of premature ejaculation) may be biologically 2185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 105 of 185

predis pos ed to this dys function. S ome res earchers that certain men are cons titutionally more vulnerable to sympathetic s timulation, hence, they ejaculate rapidly. Others have found a s horter bulbocavernosus reflex latency time in men with lifelong premature ejaculation than in men who had acquired the dys function. P remature ejaculation als o may result from negative cultural conditioning. T he man who has mos t of his sexual contacts with prostitutes, who demand that the act proceed quickly, or in situations in which dis covery would be embarrass ing, such as in an apartment with roommates or in the parental home, may become conditioned to achieving orgas m rapidly. In ongoing relations hips , the partner has some influence on the premature ejaculator. A stress ful marriage exacerbates disorder. T able 18.1a-14 gives the diagnostic criteria premature ejaculation.

Table 18.1a-14 DS M-IV-TR Diagnos tic C riteria for Premature E jac ulation A. P ersis tent or recurrent ejaculation with minimal sexual s timulation before, on, or s hortly after penetration and before the pers on wishes it. T he clinician mus t take into account factors that affect duration of the excitement phas e, s uch as age, novelty of the s exual partner or s ituation, and 2186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 106 of 185

frequency of s exual activity. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he premature ejaculation is not due to the direct effects of a substance (e.g., from opioids). S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation.

2187 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 107 of 185

and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

S exual Pain Dis orders Dys pareunia Dys pare unia refers to recurrent and persistent pain intercours e in either a man or a woman. In women, the dysfunction is related to and often coincides with vaginis mus . R epeated episodes of vaginismus may dyspareunia and vice vers a, but, in either cas e, caus es mus t be ruled out. Dyspareunia s hould not be diagnosed as such when a medical basis for the pain is found or when (in a woman) it is as sociated with vaginis mus or with lack of lubrication. T he true incidence of dyspareunia is unknown, but it been es timated that 30 percent of surgical procedures the female genital area res ult in temporary Additionally, among women seen in s ex therapy clinics , the complaint is more common in women with a history rape or childhood s exual abus e. Dynamic factors are usually cons idered caus ative, although s ituational factors probably account for more secondary dysfunction. P ainful coitus may res ult from 2188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 108 of 185

tense vaginal muscles. T he pain is real and makes intercours e unbearable or unpleas ant. Anticipation of further pain may caus e the woman to avoid coitus altogether. If the partner proceeds with intercours e regardless of the woman's s tate of readines s, the is aggravated. Dys pareunia can also occur in men, but it is and us ually as sociated with a medical condition such P eyronie's diseas e, prostatitis, or gonorrheal or infections. V asoconges tion during sexual activity orgasmic releas e also may lead to discomfort. R arely, men experience pain on ejaculation (pos tejaculatory disorder). T his pain is caus ed by an involuntary spasm the perineal mus cles that may be due to psychological conflicts about the sex act or may be an advers e effect some antidepres sant medications . T able 18.1a-15 lists diagnostic criteria for dyspareunia. In DS M-IV -T R , dys pareunia due to a gene ral me dical condition is us ed when the medical condition is the s ole or major caus al factor.

Table 18.1a-15 DS M-IV-TR Diagnos tic C riteria for A. R ecurrent or pers is tent genital pain as sociated with sexual intercours e in either a man or a B . T he disturbance causes marked distress or 2189 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 109 of 185

interpersonal difficulty. C . T he disturbance is not caus ed exclusively by vaginis mus or lack of lubrication, is not better accounted for by another Axis I dis order (except another sexual dysfunction), and is not due exclusively to the direct physiological effects of a subs tance (e.g., a drug of abuse, a medication) general medical condition. S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. 2190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 110 of 185

and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Vaginis mus V aginis mus is an involuntary and persistent the outer one-third of the vagina that prevents penile insertion and intercourse. T he res ponse may be demonstrated during a gynecological examination involuntary vaginal cons triction prevents introduction of the speculum into the vagina, although some women have vaginis mus during coitus . T he diagnosis is not if the dys function is caus ed exclus ively by medical or surgical factors or if it is symptomatic of another Axis I ps ychiatric syndrome (T able 18.1a-16). V aginismus is prevalent than anorgas mia. It most often afflicts highly educated women and those in the higher groups . A milder form of the dysfunction, in which vaginal tightnes s makes penile entry difficult, is experienced by more women on an intermittent or basis .

Table 18.1a-16 DS M-IV-TR Diagnos tic C riteria for 2191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 111 of 185

A. R ecurrent or pers is tent involuntary s pas m of musculature of the outer third of the vagina that interferes with s exual intercourse. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he disturbance is not better accounted for by another Axis I dis order (e.g., s omatization and is not due exclus ively to the direct effects of a general medical condition. S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors 2192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 112 of 185

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

A woman suffering from vaginis mus may consciously to have coitus but unconsciously prevents penile into her body. A sexual trauma, s uch as rape, may vaginis mus . W omen who have experienced pain with nonsexual bodily traumas , through accidents or of illnes s or s urgery, may become s ens itized to the penetration. W omen with ps ychosexual conflicts P.1922 may perceive the penis as a dangerous weapon. P ain the anticipation of pain at the first coital experience vaginis mus in some women. A s trict religious that as sociates sex with s in is frequently noted in such cases. Others have problems in the dyadic woman who feels emotionally abus ed by her partner protes t in this nonverbal fashion. Miss B . was a 27-year-old, s ingle woman who therapy because of an inability to have intercourse. described episodes with a recent boyfriend in which he had tried vaginal penetration but had been unable to enter. T he boyfriend did not have erectile dysfunction. 2193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 113 of 185

Miss B . experienced desire and was able to achieve through manual or oral stimulation. F or almost a year, and her boyfriend had s ex play without intercours e. However, he complained increas ingly about his at the lack of coitus , which he had enjoyed in previous relations hips . Mis s B . had a cons cious fear of and dreaded going to the gynecologist, although she able to us e tampons when she menstruated. S he was diagnosed with vaginismus , lifelong type.

S exual Dys func tion Due to a G eneral Medic al C ondition T he category s exual dysfunction due to a general condition covers s exual dysfunction that results in distress and interpers onal difficulty when there is from the history, physical examination, or laboratory findings of a general medical condition judged to be caus ally related to the sexual dysfunction (T able 18.1a-

Table 18.1a-17 DS M-IV-TR Diagnos tic C riteria for S exual Dys func tion Due to a General Medic al C ondition A. C linically significant s exual dys function that res ults in marked distress or interpers onal predominates in the clinical picture.

2194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 114 of 185

B . T here is evidence from the his tory, phys ical examination, or laboratory findings that the dysfunction is fully explained by the direct phys iological effects of a general medical C . T he disturbance is not better accounted for by another mental dis order (e.g., major depres sive disorder). S ele ct code and term bas ed on the predominant sexual dys function:    Female hypoactive s exual des ire dis order to… [indic ate the general medical c ondition]: deficient or absent s exual des ire is the feature    Male hypoac tive s exual des ire dis order due [indic ate the general medical c ondition]: if deficient or absent s exual des ire is the feature    Male erectile dis order due to… [indic ate the general medic al c ondition]: if male erectile dysfunction is the predominant feature    Female dys pareunia due to… [indic ate the general medic al c ondition]: if pain as sociated intercours e is the predominant feature

2195 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 115 of 185

   Male dys pareunia due to… [indic ate the medical condition]: if pain as sociated with intercours e is the predominant feature    Other female s exual dys func tion due to… [indic ate the general medical c ondition]: if other feature is predominant (e.g., orgas mic disorder) or no feature predominates    Other male s exual dys func tion due to… [indic ate the general medical c ondition]: if other feature is predominant (e.g., orgas mic disorder) or no feature predominates C oding note: Include the name of the general medical condition on Axis I (e.g., male erectile disorder due to diabetes mellitus ); also code the general medical condition on Axis III.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Male E rec tile Dis order Due to a Medic al C ondition Many studies have focus ed on the relative incidences ps ychological and organic male erectile disorder. 2196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 116 of 185

indicate that 50 to 80 percent of men with erectile have an organic bas is for the disorder. P hysiologically, erectile dys function may be due to a variety of medical caus es (T able 18.1a-18). In the United S tates , it is that two million men cannot gain erections becaus e suffer from diabetes mellitus ; an additional 300,000 are dysfunctional becaus e of other endocrine diseases; 1.5 million are dys functional as a res ult of vas cular 180,000 because of multiple s cleros is; 400,000 traumas and fractures leading to pelvic fractures or cord injuries ; and another 650,000 as a result of radical surgery, including prostatectomies , P.1923 colos tomies, and cys tectomies . In addition, the clinician should be aware of the poss ible pharmacological medication on s exual functioning. T he increased of organic causes for erectile dys function in the past 15 years may partly reflect the increased us e of and antihypertens ive medications . Advers e effects of medication may impair male s exual functioning in a of ways . C as tration (removal of the testes ) does not lead to sexual dys function, depending on the pers on. E rection may still occur after castration via a reflex arc pass es through the s acral cord erectile center. It is triggered when the inner thigh is s timulated.

Table 18.1a-18 Dis eas es and Medic al C onditions Implic ated in E rec tile Dys func tion 2197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 117 of 185

Infectious and parasitic diseases

Neurological disorders

   E lephantias is

   Multiple s cleros is

   Mumps

   T rans verse myelitis

C ardiovascular disease

   P arkinson's diseas e

   Atherosclerotic disease

   T emporal lobe epileps y

   Aortic aneurysm

   T raumatic and spinal cord dis eas es

   Leriche's

   C entral nervous s ys tem tumor

   C ardiac failure

   Amyotrophic lateral sclerosis

R enal and disorders

   P eripheral neuropathy

   P eyronie's

   G eneral paresis

   C hronic renal failure

   T abes dorsalis

2198 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 118 of 185

   Hydrocele and varicocele

P harmacological contributants

Hepatic dis orders

   Alcohol and other dependence-inducing subs tances (heroin, methadone, morphine, cocaine, amphetamines , and barbiturates )

   C irrhos is (us ually as sociated with alcohol P ulmonary

   P rescribed drugs (ps ychotropic drugs , antihypertens ive drugs, es trogens , and antiandrogens )

   R espiratory failure

 

G enetic dis orders

P oisoning

   K linefelter's syndrome

   Lead (plumbism)

   C ongenital penile vascular and structural

   Herbicides

2199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 119 of 185

abnormalities Nutritional dis orders

S urgical procedures

   Malnutrition

   P erineal pros tatectomy

   V itamin

   Abdominal–perineal res ection

E ndocrine dis orders

   S ympathectomy (frequently interferes with ejaculation)

   Diabetes mellitus

   Aortoiliac s urgery

   Dysfunction of the pituitary-adrenaltes tis axis

   R adical cystectomy

   Acromegaly

   R etroperitoneal lymphadenectomy

   Addis on's dis ease

Miscellaneous

   C hromophobe adenoma

   R adiation therapy

   Adrenal neoplasia

   P elvic fracture

   Myxedema

   Any s evere s ys temic 2200

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 120 of 185

disease or debilitating condition    Hyperthyroidism

 

P HY S IOL OG IC A L TE S TS A number of procedures, benign and invas ive, are help differentiate psychogenic erectile dysfunction. T he procedures include monitoring nocturnal penile tumes cence (erection that occurs during s leep) as sociated with rapid eye movement; monitoring tumes cence with a s train gauge; meas uring blood press ure in the penis with a penile plethys mograph or ultras ound (Doppler) flow meter, both of which as sess blood flow in the internal pudendal artery; and pudendal nerve latency time. Neurological impairment penile function may be indicated by decreas ed perception in the penis . Other diagnos tic tes ts that delineate organic bas es for erectile disorder include glucose tolerance test, plasma hormone ass ays , liver thyroid function tests, prolactin and follicle-stimulating hormone (F S H) determinations, and cystometric examinations. Invasive diagnos tic studies include arteriography, infus ion cavernos onography, and radioactive xenon penography. Invasive procedures require expert interpretation and are used only for 2201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 121 of 185

who are candidates for vas cular reconstructive

ME DIC A L VE R S US P S Y C HOG E NIC C A US E S A good his tory is crucial to determining the caus e of male erectile dis order. If a man reports having spontaneous erections at times when he does not plan have intercourse, having morning erections or only sporadic erectile dys function, or having good erections with masturbation or with partners other than his us ual one, then organic causes for his disorder can be cons idered negligible, and cos tly diagnostic procedures can be avoided. W hen a medical bas is for erectile dysfunction is found, psychological factors often contribute to the dys function, and psychiatric treatment may be helpful. S ome diabetics, for instance, may experience psychogenic erectile dysfunction.

Dys pareunia Due to a G eneral C ondition An estimated 30 percent of all surgical procedures on female genital area result in temporary dys pareunia. In addition, 30 to 40 percent of women with the complaint who are s een in sex therapy clinics have pelvic Organic abnormalities leading to dys pareunia and vaginis mus include infected hymenal remnants or congenitally imperforate or unus ually thick hymens; episiotomy scars; B artholin's glands infections; various forms of vaginitis and cervicitis ; tes tos terone vulvodynia; vaginal treatment, such as radiation or that has caus ed scarring; dermatological dis order, such lichens sclerosis or lichens planus; and endometrios is . 2202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 122 of 185

P os tcoital pain reported by women with myomata and endometriosis P.1924 is attributed to the uterine contractions during orgasm. P os tmenopaus al women may have dyspareunia of thinning of the vaginal mucos a and reduced Dys pareunia can also occur in men, but it is and is us ually as sociated with an organic condition P eyronie's diseas e, which cons is ts of s clerotic plaques the penis that cause penile curvature.

Hypoac tive S exual Des ire Dis order to a G eneral Medic al C ondition Des ire commonly decreases after major illnes s or particularly when body image is affected after s uch procedures as mastectomy, ileos tomy, hysterectomy, prostatectomy. Illness es that deplete a person's chronic conditions that require physical and adaptation, and s erious illnes ses that may cause the person to become depress ed can all res ult in a marked less ening of sexual desire in both men and women. In some cases, biochemical correlates are ass ociated hypoactive sexual desire disorder (T able 18.1a-19). A recent study found markedly lower s erum tes tos terone concentrations in men complaining of low des ire than normal controls in a sleep laboratory s ituation. Drugs depres s the central nervous system (C NS ) or decreas e tes tos terone production can decreas e desire.

Table 18.1a-19 Neurotrans mitter E ffe 2203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 123 of 185

 

Dopamine

S erotonin

Adrenergic

Ch

E rection

++

+/-

α, β

+/-

 

 

 

-+

 

2204 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 124 of 185

E jaculation +/and orgasm

+

+

+/-

 

 

α1

 

 

+/- minimal or no effect; + facilitates effect; - inhibiting ef oxidase inhibitor.

Other Male S exual Dys func tion Due G eneral Medic al C ondition T he category other male s e xual dys function due to a me dical condition is us ed when some dys functional other than thos e discus sed above predominates (e.g., orgasmic disorder) or no feature predominates. Male orgasmic dysfunction may have physiological causes can occur after s urgery on the genitourinary tract, such prostatectomy. It may also be ass ociated with 2205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 125 of 185

disease and other neurological disorders involving the lumbar or s acral s ections of the s pinal cord. T he antihypertens ive drug guanethidine monos ulfate, methyldopa, the phenothiazines , the tricyclic drugs , serotonin reuptake inhibitors , among others, have been implicated in retarded ejaculation. Male orgas mic must als o be differentiated from retrograde ejaculation, which ejaculation occurs but the s eminal fluid pas ses backward into the bladder. R etrograde ejaculation has an organic caus e. As mentioned above, it can after genitourinary s urgery and is also as sociated with medications with anticholinergic adverse effects, such the phenothiazines.

Other F emale S exual Dys func tion a G eneral Medic al C ondition T he category other fe male s exual dys function due to a ge neral me dical dis orde r is us ed when some feature than those discus sed above (e.g., orgasmic dis order) predominates or no feature predominates . S ome conditions—specifically, such endocrine diseases as hypothyroidism, diabetes mellitus, and primary hyperprolactinemia—can affect a woman's ability to orgasms.

S ubs tanc e-Induc ed S exual T he diagnosis s ubs tance-induce d s exual dys function is when evidence from the his tory, phys ical examination, laboratory findings indicates s ubstance intoxication or withdrawal when dysfunction follows the us e of prescribed medication. Distress ing sexual dysfunction occurs within a month of s ignificant s ubs tance 2206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 126 of 185

or withdrawal (T able 18.1a-20). S pecified subs tances include alcohol; amphetamines or related s ubs tances ; cocaine; opioids; s edatives , hypnotics, or anxiolytics; other or unknown substances.

Table 18.1a-20 DS M-IV-TR Diagnos tic C riteria for Induc ed S exual Dys func tion A. C linically significant s exual dys function that res ults in marked distress or interpers onal predominates in the clinical picture. B . T here is evidence from the his tory, phys ical examination, or laboratory findings that the dysfunction is fully explained by subs tance use manifested by either (1) or (2):    (1) the symptoms in C riterion A developed or within a month of, substance intoxication    (2) medication use is etiologically related to the disturbance C . T he disturbance is not better accounted for by sexual dys function that is not s ubs tance-induced. E vidence that the s ymptoms are better accounted for by a s exual dys function that is not s ubs tance-

2207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 127 of 185

induced might include the following: the precede the onset of the s ubs tance use or dependence (or medication us e); the s ymptoms persis t for a s ubs tantial period of time (e.g., approximately a month) after the ces sation of intoxication, or are s ubs tantially in excess of what would be expected given the type or amount of subs tance used or the duration of us e; or there is other evidence that s uggests the exis tence of an independent non–subs tance-induced s exual dysfunction (e.g., history of recurrent non– subs tance-related episodes ). Note: T his diagnos is should be made instead of diagnosis of substance intoxication only when the sexual dysfunction is in exces s of that us ually as sociated with the intoxication s yndrome and the dysfunction is sufficiently s evere to warrant independent clinical attention. C ode [S pecific substance]-induced s exual dysfunction:    Alcohol; amphetamine [or amphetamine-like subs tance]; cocaine; opioid; sedative, hypnotic, anxiolytic; other [or unknown] substance S pe cify if:    With impaired des ire 2208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 128 of 185

   With impaired arous al    With impaired orgas m    With s exual pain S pe cify if:    With ons et during intoxic ation: if the criteria met for intoxication with the s ubs tance and the symptoms develop during the intoxication syndrome

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. Abused recreational s ubs tances affect sexual function various ways. In s mall doses, many s ubs tances sexual performance by decreas ing inhibition or anxiety by temporarily elevating mood. However, continuous impairs erectile, orgasmic, and ejaculatory capacities. abuse of s edatives , anxiolytics, and, particularly, nearly always depress es desire. Alcohol may fos ter the initiation of sexual activity by removing inhibitions, but it impairs performance. C ocaine and amphetamines similar effects . Although no direct evidence indicates sexual drive is enhanced by stimulants , the us er 2209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 129 of 185

has a feeling of increas ed energy and may become sexually active. Ultimately, dys function occurs. Men go through two stages: prolonged erection without ejaculation and then a gradual loss of erectile capacity. R ecovering substance-dependent patients may need therapy to regain s exual function. In part, this is one of psychological readjus tment to a nondependent state. Many substance abusers have always had difficulty intimate interactions. Others have miss ed the that would have enabled them to learn social and skills becaus e they spent their crucial developmental under the influence of some substance.

Pharmac ologic al Agents Implic ated S ex Dys func tion Many pharmacological agents , particularly thos e us ed ps ychiatry, have been as sociated with an effect on sexuality. In men, thes e effects include decreased s ex drive, erectile failure (impotence), decreas ed volume of ejaculate, and delayed or retrograde ejaculation. In women, decreas ed s ex drive, decreased vaginal lubrication, inhibited or delayed orgas m, and absent vaginal contractions may occur. Drugs may also enhance the s exual res ponse and increase the s ex but this effect is less common than are inhibiting

A ntips yc hotic Drugs Antips ychotic drugs that block adrenergic and receptors are accompanied by advers e s ex effects . C hlorpromazine (T horazine), thioridazine, (S telazine), and haloperidol (Haldol) are potent anticholinergic agents that impair erection and 2210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 130 of 185

in men and inhibit vaginal lubrication and orgasm in women. C hlorpromazine and thioridazine also block adrenergic receptors. T hioridazine has a particular P.1925 effect of caus ing retrograde ejaculation, in which the seminal fluid backs up into the bladder rather than propelled through the penile urethra. P atients still have pleas urable s ens ation of orgas m, but it is dry. W hen urinating after orgas m, the urine may be milky white because it contains the ejaculate. T he condition is but harmless and may occur in up to 50 percent of taking the drug. P aradoxically, rare cases of priapism been reported with antips ychotics . S econd-generation antips ychotic drugs , s uch as quetiapine (S eroquel), lower incidence of s exual side effects.

S elec tive S erotonin R euptake T he most commonly prescribed group of are the s elective serotonin reuptake inhibitors (S S R Is ). Advers e s exual effects may occur with this group of because of increased s erotonin concentration. A of the sex drive and difficulty reaching orgas m occur in both s exes. Of the S S R Is , the most frequent s exual effects are seen with paroxetine (P axil), next with fluoxetine (P rozac), and the least with sertraline S imilar symptoms have been ass ociated with (Luvox), citalopram (C elexa), and es citalopram R eversal of negative s exual side effects has been with cyproheptadine (P eriactin), an antihis tamine with antis erotonergic effects ; amantadine (S ymmetrel), a dopamine agonis t; yohimbine (Y ocon), a central α2 2211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 131 of 185

adrenergic receptor antagonis t us ed in treating male erectile dis order; and methylphenidate (R italin) and dextroamphetamine (Dexedrine), which are and have adrenergic effects. T here are reports of (V iagra), a nitric oxide enhancer us ed to treat erectile dysfunction, overcoming orgas mic problems with the S S R Is. B uspirone (B uS par) helps s ome overcome advers e s exual effects of S S R Is , poss ibly it is 5-hydroxytryptamine type A (5-HT A ) agonist or because it suppress es S S R I-induced elevation of

Heteroc yc lic A ntidepres s ants T he tricyclic and tetracyclic antidepres sants have anticholinergic effects that interfere with erection and delay ejaculation. B ecause the anticholinergic effects among the cyclic antidepress ants, thos e with the side effects (e.g., desipramine [Norpramin]) produce fewest s exual s ide effects . T he effects of the drugs in women have not been s tudied s ufficiently; however, few women seem to complain of any effects . S elegiline (E ldepryl) is a selective monoamine oxidase B (MAO B ) inhibitor reported to increase sex drive, by dopaminergic activity and increased production of norepinephrine. S ome men report a pleas urable increas ed sensitivity of glans with this class of drugs that does not interfere erection, although it delays ejaculation. In some cas es , however, the tricyclic drug caus es a painful ejaculation, perhaps as the res ult of interference with s eminal propulsion caus ed by interference with urethral, vas, and epididymal s mooth muscle contractions. C lomipramine (Anafranil) has been reported to 2212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 132 of 185

sex drive in some individuals.

Monoamine Oxidas e Inhibitors T he MAOIs affect biogenic amines broadly. they produce impaired erection, delayed or retrograde ejaculation, vaginal dryness , and inhibited orgasm. T ranylcypromine (P arnate) has a paradoxical sexually stimulating effect in s ome individuals , poss ibly as a of its amphetamine-like properties.

G eneral E ffec ts of A ntidepres s ants B ecaus e depres sion is ass ociated with a decreas ed varying levels of s exual dys function and anhedonia are part of the dis eas e proces s. T his phenomenon makes as sess ment of dys function as a res ult of s exual side difficult in patients taking the drugs. S ome patients improved sexual function as their depres sion improves with antidepres sant medication. S ometimes, s exual effects disappear with time, perhaps becaus e a amine homeostatic mechanis m comes into play. In cases, antidepress ants without as sociated side effects sexual dys function are substituted, s uch as bupropion (W ellbutrin), nefazodone (S erzone), or mirtazapine (R emeron). T here have been rare, individual reports of orgasmic dysfunction with the latter two drugs . Mrs. J . presented with the complaint of inability to orgasm. Her problem dated from the time, 18 months previous ly, when she had been placed on fluoxetine. B efore that time, she had been able to achieve orgas m through masturbation and in the majority of her s exual interactions with her husband. 2213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 133 of 185

Mrs. J . tried s everal other S S R Is , as well as (E ffexor), but the side effect of anorgasmia pers is ted. Unfortunately, none of the us ual antidotes to S S R Ianorgas mia proved effective, and the patient did not res pond well to antidepress ants of other categories. was able P.1926 to achieve orgas m with the aid of a vibrator, even while she was on an S S R I. S ex therapy, in this case, encouraging her husband to accept inclus ion of the vibrator in their s ex play and reass uring him that its us e was not a reflection of his lovemaking skills. Mrs. J . diagnosed as having s ubs tance-induced s exual dysfunction.

L ithium Lithium regulates mood and, in the manic state, may reduce hypersexuality, poss ibly via dopamine S ome patients have reported impaired erection.

P s yc hos timulants P sychos timulants are s ometimes us ed in the treatment depres sion and include such drugs as amphetamine methylphenidate, which rais e plasma concentrations of norepinephrine and dopamine. Libido is increas ed; however, with prolonged use, men may experience a of des ire and erections. One study found that sulfate facilitated arous al in functional women.

α-A drenergic and β-A drenergic A ntagonis ts 2214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 134 of 185

Adrenergic receptor antagonists are us ed to treat hypertens ion, angina, and certain cardiac arrhythmias . T hey diminish tonic s ympathetic nerve outflow from vasomotor centers in the brain. As a result, they can impotence, decrease the volume of ejaculate, and retrograde ejaculation. C hanges in libido have been reported in both sexes . S ugges tions have been made us e the s ide effects of drugs therapeutically. T hus, a that delays or interferes with ejaculation (s uch as fluoxetine) might be used to treat premature

A ntic holinergic s T he anticholinergics block cholinergic receptors and include s uch drugs as amantadine and benztropine (C ogentin). T hey can produce drynes s of the mucous membranes (including thos e of the vagina) and erectile dysfunction.

A ntihis tamines Drugs s uch as diphenhydramine (B enadryl) have anticholinergic activity and are mildly hypnotic. As a they may inhibit s exual function. C yproheptadine, although an antihistamine, als o has potent activity as a serotonin antagonist. It is used to block the advers e s exual effects produced by S S R Is, such as orgasm and erectile dysfunction.

A ntianxiety A gents T he major class of antianxiety drugs is the benzodiazepines (e.g., diazepam [V alium]). T hey act γ-aminobutyric (G AB A) receptors, which are believed involved in cognition, memory, and motor control. 2215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 135 of 185

B ecaus e they decrease plasma epinephrine they diminish anxiety, thus improving s exual function in individuals inhibited by anxiety.

A lc ohol Alcohol s uppress es C NS activity generally and, hence, produce erectile dis orders in men. Alcohol has a direct gonadal effect that decreases testosterone in men; paradoxically, it can produce a s light increase tes tos terone concentrations in women. T his may for increas ed libido in women after drinking small of alcohol. Long-term us e of alcohol reduces the ability the liver to metabolize estrogenic compounds; in men, produces signs of feminization (e.g., gynecomastia as res ult of testicular atrophy).

Opioids Opioids such as heroin have such adverse sexual erectile failure and decreased libido. Altered may enhance the sexual experience in occasional

Halluc inogens T he hallucinogens include lysergic acid diethylamide (LS D), phencyclidine (P C P ), ps ilocybin (from s ome mushrooms), and mes caline (from peyote cactus). In addition to inducing hallucinations, thes e drugs caus e of contact with reality and an expanding and of consciousness . S ome us ers report that the s exual experience is s imilarly enhanced; others experience anxiety, delirium, or ps ychos is , which clearly interferes with sex function.

2216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 136 of 185

C annabis T he altered state of cons ciousnes s produced by may enhance s exual pleasure for some individuals. Its prolonged use depress es tes tos terone concentrations.

B arbiturates and S imilarly A c ting B arbiturates are sedative-hypnotics that may enhance sexual res ponsivenes s in persons who are sexually unrespons ive because of anxiety. T hey have no direct effect on the s ex organs, but they do alter which s ome individuals find pleas urable. T hey are to abus e and may be fatal when combined with alcohol other C NS depres sants. Methaqualone (Quaalude) acquired a reputation as a sexual enhancer that had no biological bas is in fact. It is no longer marketed in the United S tates .

S exual Dys func tion and S exual Dis order Not Otherwis e S pec ified DS M-IV -T R us es two categories —sexual dys function otherwis e s pecified and s exual dis order not otherwis e specified. T he diagnos tic criteria are listed in T ables 21 and 18.1a-22, respectively. T he dis tinction between two categories is unclear, however, and there is between them. Many sexual disorders are not as sexual dys functions or as paraphilias. T hes e disorders are rare, poorly documented, not eas ily clas sified, or not s pecifically des cribed in DS M-IV -T R . 10 has a s imilar res idual category for problems related sexual development or preference (T able 18.1a-23).

2217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 137 of 185

Table 18.1a-21 DS M-IV-TR Diagnos tic C riteria for S exual Dys func tion Not Otherwis e S pec ified T his category includes sexual dys functions that not meet criteria for any s pecific s exual E xamples include    1. No (or substantially diminis hed) s ubjective feelings des pite otherwis e normal arousal and orgasm    2. S ituations in which the clinician has that a sexual dysfunction is pres ent but is unable determine whether it is primary, due to a general medical condition, or substance induced

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 18.1a-22 DS M-IV-TR Diagnos tic C riteria for S exual 2218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 138 of 185

Dis order Not Otherwis e T his category is included for coding a s exual disturbance that does not meet the criteria for any specific s exual disorder and is neither a sexual dysfunction nor a paraphilia. E xamples include    1. Marked feelings of inadequacy concerning sexual performance or other traits related to s elfimpos ed standards of masculinity or femininity    2. Dis tres s about a pattern of repeated s exual relations hips involving a success ion of lovers who are experienced by the individual only as things be us ed    3. P ers is tent and marked distres s about sexual orientation

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 18.1a-23 DS M-IV-TR Diagnos tic C riteria for 2219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 139 of 185

Ps yc hologic al and B ehavioral Dis orders As s oc iated with Development and Orientation T his s ection is intended to cover those types of problems that derive from variations of sexual development or orientation, when the s exual preference per s e is not necess arily problematic abnormal. S exual maturation dis order T he patient suffers from uncertainty about his or gender identity or sexual orientation, which anxiety or depres sion. E go-dys tonic s exual orientation T he gender identity or sexual preference is not in doubt, but the individual wis hes it were different. S exual relations hip dis order T he abnormality of gender identity or sexual preference is respons ible for difficulties in forming maintaining a relationship with a s exual partner. Other ps ychos exual development dis orders

2220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 140 of 185

Ps yc hos exual development dis order,

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. E xamples of s uch unclass ified dis orders include who experience the phys iological components of excitement and orgas m but report no erotic sensation even anes thesia and the male experience of orgas m flaccid penis. T he orgas mic woman who desires but not experienced multiple orgasms can be class ified this heading as well. Als o, disorders of exces sive than inhibited function, such as compulsive might be diagnos ed under atypical dysfunction. Other sexual practices exist that are not listed in DS M-IV example, behaviors that attempt to enhance s exual arousal by oxygen deprivation (hypoxyphilia) or other deviant methods . Atypical dysfunction als o might be to cover complaints engendered by couple, rather than P.1927 individual, dys function—for example, a couple in which one partner prefers morning s ex and the other more readily at night or a couple with unequal of des ire.

C ompuls ive S exual B ehavior 2221 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 141 of 185

T he concept of compuls ive s exual behavior (T able 24), or sex addiction, was developed in the 1980s to describe persons who compuls ively seek out sexual experiences and whos e behavior becomes impaired if cannot gratify their s exual impuls es . T he concept of addiction is derived from the model of addiction to such as heroin or addiction to behavioral patterns such gambling. Addiction implies ps ychological dependence, phys ical dependence, and a withdrawal symptom if the subs tance (e.g., the drug) is unavailable or the (e.g., gambling) is frustrated.

Table 18.1a-24 S igns of S exual Addic tion or C ompuls ive S exual B ehavior 1. Out-of-control behavior 2. S evere adverse consequences (medical, legal, interpersonal) due to s exual behavior 3. P ersistent pursuit of self-destructive or highsexual behavior 4. R epeated attempts to limit or stop s exual 5. S exual obs ess ion and fantas y as a primary mechanism

2222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 142 of 185

6. Need for increasing amounts of sexual activity 7. S evere mood changes related to sexual (e.g., depres sion, euphoria) 8. Inordinate amount of time s pent in obtaining being sexual, or recovering from sexual 9. Interference of s exual behavior in social, occupational, or recreational activities

Data from C arnes P . Don't C all It L ove . New B antam B ooks, 1991. DS M-IV -T R does not use the terms s e x addiction or compuls ive s e xual be havior, nor is this dis order recognized or accepted. Nevertheless , the person entire life revolves around s ex-seeking behavior and activities, who s pends an excess ive amount of time in behavior, and who often tries to stop s uch behavior but cannot do so is well known to clinicians. S uch pers ons show repeated and increasingly frequent attempts to a s exual experience, and deprivation evokes distress . In the author's view, s ex addiction is a useful concept heuristically becaus e it can alert the clinician seek an underlying caus e for the manifest behavior.

P os tc oital Dys phoria P os tcoital dysphoria is not listed in DS M-IV -T R . It 2223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 143 of 185

during the res olution phase of s exual activity, when individuals normally experience a s ens e of general being and mus cular and psychological relaxation. individuals , however, experience postcoital after an otherwis e s atis factory s exual experience, they become depress ed, tens e, anxious , and irritable and ps ychomotor agitation. T hey often want to get away the partner and may become verbally or even abusive. T he incidence of the disorder is unknown, but more common in men than in women. Its s everal relate to the person's attitude toward s ex in general the partner in particular. It may occur in adulterous s ex with pros titutes , when there is a profound fear of or when individuals cannot experience sex without cons equent s trong feelings of guilt. T he fear of sexually transmitted disease caus es some pers ons to postcoital dys phoria. T reatment requires insightps ychotherapy to help patients unders tand the unconscious antecedents to their behavior and

Unc ons ummated Marriage A couple involved in an uncons ummated marriage never had coitus and are typically uninformed and inhibited about s exuality. T heir feelings of guilt, s hame, inadequacy are increas ed by their problems, and they experience conflict between their need to seek help their need to conceal their difficulty. C ouples pres ent the problem after having been married s everal months several years . Mas ters and J ohns on reported an unconsummated marriage of 17 years ' duration. F requently, the couple does not s eek help directly, but woman may reveal the problem to her gynecologis t on 2224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 144 of 185

visit os tensibly concerned with vague vaginal or other somatic complaints. On examining her, the may find an intact hymen. In s ome cases, however, the wife may have undergone a hymenectomy to res olve problem. Inquiry by a physician who is comfortable in dealing with s exual problems may be the first opening frank dis cus sion of the couple's dis tres s. Often, the of the medical vis it is a dis cuss ion of contraceptive methods or even a reques t for an infertility workup. presented, the complaint often can be s ucces sfully T he duration of the problem does not significantly the prognos is or the outcome of the case. P.1928 T he caus es of unconsummated marriage are varied: sex education, s exual prohibitions overly s tres sed by parents or s ociety, problems of an oedipal nature, immaturity in both partners, overdependence on families , and problems in sexual identification. orthodoxy, with s evere control of sexual and s ocial development or the equation of s exuality with sin or uncleanliness , has also been cited as a dominant Many women involved in an uncons ummated marriage have dis torted concepts about their vaginas . T hey may fear that the vagina is too small or too s oft, or they may confuse the vagina with the rectum, leading to feelings being unclean. T he man may share in those distortions about the vagina and, in addition, perceive it as to himself. S imilarly, both partners may have dis tortions about the man's penis, perceiving it as a weapon, as large, or as too small. Many patients can be helped by simple education about genital anatomy and 2225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 145 of 185

by suggestions for s elf-exploration, and by correct information from a phys ician. T he problem of the unconsummated marriage is bes t treated by seeing members of the couple. Dual-sex therapy has been markedly effective. However, other forms of conjoint therapy, marital counseling, traditional ps ychotherapy a one-to-one basis , and counseling from a s ensitive phys ician, gynecologis t, or urologis t are all helpful.

B ody Image P roblems S ome individuals are as hamed of their bodies and experience feelings of inadequacy related to s elfstandards of mas culinity or femininity. T hey may ins is t sex only during total darkness , not allow certain body to be s een or touched, or s eek unnecess ary operative procedures to deal with their imagined inadequacies. dysmorphic dis order should be ruled out.

Don J uanis m S ome men who appear to be hypers exual, as shown their need to have many s exual encounters or us e their sexual activities to mask deep feelings of inferiority. S ome have uncons cious homos exual which they deny by compuls ive s exual contacts with women. After having s ex, most Don J uans are no interes ted in the woman. T he condition is also referred as s atyrias is or as a form of sex addiction.

Nymphomania Nymphomania signifies exces sive or pathological for coitus in a woman. T here have been few s cientific studies of the condition. T hose patients who have been 2226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 146 of 185

studied usually have had one or more s exual dis orders, us ually including female orgasmic dis order. T he often has an intense fear of los s of love. S he attempts satis fy her dependency needs rather than to gratify her sexual impuls es through her actions . It is s ometimes clas sified as a form of sex addiction.

F antas ies Other atypical dis orders are found in individuals who one or more s exual fantas ies about which they obses s, guilty, or are otherwise dysphoric. As indicated in T able 18.1a-25, however, the range of common sexual is broad.

Table 18.1a-25 C ommon S exual Fantas ies a Men

Women

Heteros exual

 

R eplacement of es tablis hed partner

R eplacement of es tablis hed partner

 

F orced sexual encounters with men

F orced sexual

Observing s exual

2227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 147 of 185

encounters with  

Idyllic encounters with unknown men

Observing s exual activity

 

S exual encounters men

S exual encounters with women

G roup sex

 

Homos exual

 

Images of male

F orced sexual encounters with

F orced sexual encounters with men

 

 

Idyllic encounters with es tablis hed partner

S exual encounters women

 

Idyllic encounters with unknown men

S exual encounters with men

2228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 148 of 185

 

Memories of pas t experiences

G roup sex

S adistic imagery

aListed

in order of occurrence. A 1994 s tudy that one in five persons experienced a s ame-sex sexual fantasy at s ome time in their lives. Adapted from Masters W, S chwartz M: T he and J ohns on treatment program for dis satisfied homos exual men. Am J P s ychiatry.

P ers is tent and Marked Dis tres s S exual Orientation Dis tres s about sexual orientation is us ually by diss atisfaction with homos exual arousal patterns , a desire to increas e heterosexual arousal, and s trong negative feelings about being homosexual. Occas ional statements to the effect that life would be eas ier if the person were not homos exual do not constitute and marked distress about s exual orientation. T reatment of sexual orientation distress is One s tudy reported that with a minimum of 350 hours ps ychoanalytic therapy, approximately one-third of approximately 100 bisexual and homosexual men achieved a heterosexual reorientation at 5-year followbut that study was challenged and never replicated. 2229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 149 of 185

B ehavior therapy and avoidance conditioning have als o been used, but a bas ic problem with technique is that the behavior may be changed in the laboratory setting but not outs ide the laboratory. P rognos tic factors weighing in favor of heteros exual reorientation for men include being younger than 35 years , having s ome experience of heterosexual and having a high motivation for reorientation. Another s tyle of intervention is directed at enabling the person with persis tent and marked distress about orientation to live comfortably as a homosexual without shame, guilt, anxiety, or depres sion. G ay counseling centers are engaged with patients in s uch treatment programs. At pres ent, outcome studies of such centers have not been reported in detail. F ew data are available about the treatment of women persis tent and marked distress about sexual and those are primarily s ingle-case studies with outcomes .

P os tc oital Headac he P os tcoital headache is a headache immediately after and may last for s everal hours. It is us ually des cribed throbbing and is localized in the occipital or frontal T he caus e is unknown but may be vascular, due to contraction (tens ion), or psychogenic. C oitus may precipitate migraine or clus ter headaches in persons.

Orgas mic A nhedonia Orgas mic anhedonia is a condition in which the pers on had no phys ical s ens ation of orgasm, even though the 2230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 150 of 185

phys iological component (e.g., ejaculation) remains Medical causes, s uch as s acral and cephalic lesions interfere with afferent pathways from the genitalia to cortex, must be ruled out. P sychic caus es us ually extreme guilt about experiencing s exual pleasure— feelings produce a type of diss ociative res pons e that is olates the affective component of the orgas mic experience from cons cious nes s. P.1929

F emale P remature Orgas m Data on female premature orgasm are lacking; no category for premature orgas m in women is included in DS M-IV -T R . However, in the Univers ity of C hicago percent of women felt they reached orgasm too quickly.

Mas turbatory P ain S ome individuals may experience pain during masturbation. Organic caus es should always be ruled A s mall vaginal tear or early P eyronie's disease may produce a painful sensation. T he condition should be differentiated from compulsive mas turbation. P eople masturbate to the extent that they do phys ical damage their genitals and eventually experience pain during subs equent mas turbatory acts. C ertain mas turbatory practices have resulted in what been called autoe rotic as phyxiation, which is us ually clas sified as a paraphilia (hypoxyphilia). T he practices involve masturbating while hanging by the neck to heighten erotic s ens ations and the intensity of the through the mechanis m of mild hypoxia. Although they 2231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 151 of 185

intend to release themselves from the noos e after an es timated 500 to 1,000 pers ons a year accidentally thems elves by hanging. Most who indulge in the are men; transves tis m is often as sociated with the and most deaths occur among adolescents. S uch masochistic practices are us ually as sociated with mental disorders , such as schizophrenia and major disorders .

TR E A TME NT T he treatment of sexual disorders has evolved since the 1970s , when Masters and J ohnson focus ed attention of the ps ychiatric community on s exual disorders . Innovations in treatment reflect the results of res earch and changes in the patient population. F or example, in the late 1960s, most cases of erectile dysfunction were cons idered psychological in origin, approximately 20 percent of erectile problems having organic caus e. C urrently, the numbers are revers ed, the majority of cases cons idered to res ult from a phys iological problem. Actually, many cas es are of origin. S imilarly, early patients in s ex therapy were as sumed to s uffer, in part, from lack of sexual and culturally reinforced negative attitudes toward s ex. S ince the 1970s, the public has received a great deal accurate information about sex through the media, and cultural attitudes regarding s exual behavior have markedly more liberal. P atients now have more and greater sexual s ophistication. T heir dys functions a complex etiology frequently involving psychodynamic and relational is sues. P roblems of des ire are s een with increasing frequency and are among the mos t cases for therapists. C ouple is sues involve problems of 2232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 152 of 185

trus t, intimacy, lack of s exual attraction, and s truggles dominance. F inally, along with the rest of ps ychiatry, therapy has experienced medicalization. B iological treatment approaches have developed rapidly. An approach that allows the us e of s everal techniques sequentially or in combination may be necess ary. B efore entering therapy, the patient s hould have a thorough medical evaluation, including a medical phys ical examination, and appropriate laboratory when neces sary. If a medical caus e for the dis order is found, treatment should be directed toward that caus e. B efore 1970, the mos t common treatment of sexual dysfunction was individual psychotherapy. C lass ic ps ychodynamic theory cons iders s exual inadequacy to have its roots in early developmental conflicts , and the sexual disorder is treated as part of a more pervasive emotional disturbance. T reatment focus es on the exploration of unconscious conflicts, motivation, and various interpers onal difficulties . T herapy as sumes that removal of the conflicts will allow the sexual to become structurally acceptable to the patient's ego thereby find appropriate means of satisfaction in the environment. Unfortunately, the symptom of s exual dysfunction frequently becomes s econdarily and persis ts after res olution of the other problems evolving from the patient's pathology. T he addition of behavioral techniques is often necess ary to cure the problem.

Dual-S ex Therapy T he theoretical basis of the dual-sex therapy approach 2233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 153 of 185

the concept of the marital unit or dyad as the object of therapy. T he method of dual-sex therapy was and developed by Masters and J ohnson. Dual-sex does not accept the idea of a sick half of a patient B oth individuals are involved in a relations hip in which there is s exual dis tres s, and, thus , both must the therapy program. T he sexual problem often reflects other areas of disharmony or mis understanding in the marriage. T he marital relations hip as a whole is treated, with sexual functioning as a part of that relationship. communication in sexual and nonsexual areas is a goal of treatment. P sychological and phys iological of sexual functioning are discus sed with an educational attitude. S ugges tions are followed in the privacy of the couple's home. Initial histories are taken to determine suitability for this type of treatment. E vidence of major underlying ps ychopathology s uggests further ps ychiatric and participation in the program may be deferred until patient seems better able to benefit from it. C oncurrent ps ychotherapy with a psychiatrist while participating in dual-sex therapy is s ometimes recommended. E ach patient is interviewed individually early in the of treatment. A complete sexual history is obtained, is later reflected back to the couple to help them unders tand their present problem. T he individual also help the therapist understand the patients' lifes tyle and allow for sugges tions that fit into that lifes tyle.

B ehavioral E xerc is es 2234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 154 of 185

T reatment is s hort term and behaviorally oriented. exercises are prescribed to help the couple with their particular problem. S exual dysfunction often involves a fear of inadequate performance; thus, couples are specifically prohibited from any sexual play other than prescribed by the therapist. Initially, intercourse is interdicted, and couples learn to give and receive pleas ure without the pres sure of performance. exercises usually focus on heightening s ens ory to touch, s ight, s ound, and s mell. During these exercises, called s e ns ate focus couple is given much reinforcement to less en anxiety. T hey are urged to us e fantas ies to dis tract them from obses sive concerns about performance, which is s pectatoring. T he needs of both the dysfunctional and the nondysfunctional partner are cons idered. If partner becomes s exually excited by the exercises, the other is encouraged to bring him or her to orgas m by manual or oral means . T his procedure is important to the nondysfunctional partner from sabotaging the treatment. Open communication between the partners urged, and the express ion of mutual needs is R es istances, such as claims of fatigue or not enough to complete the exercis es , are common and mus t be with by the therapist. G enital s timulation is eventually added to general body stimulation. T he couple is sequentially taught to try various pos itions for without necess arily completing the act and to use of stimulating techniques before they are permitted to proceed with intercours e. T he specific exercises vary with differing presenting complaints , and s pecial techniques are us ed to treat 2235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 155 of 185

various dys functions. In cas es of vaginis mus, for the woman is advised to dilate her vaginal P.1930 opening with her fingers or with s ize-graduated vaginal dilators as part of the therapy. In cas es of premature ejaculation, an exercis e known as the s que e ze us ed to raise the thres hold of penile excitability. In this exercise, the man or the woman stimulates the erect until the earlies t s ens ations of impending orgas m and ejaculation are felt. P enile s timulation is then s topped abruptly, and the coronal ridge of the penis is forcibly squeezed for several s econds . T he technique is several times. A variation is the s top–s tart te chnique , in which s timulation is interrupted for s everal seconds but squeeze is applied. Masturbation to the point of orgasm raises the threshold of excitability to a more tolerant s timulation level. T he man is encouraged to on sensations of excitement rather than dis tract hims elf from them. T his makes him more familiar with his excitement pattern and lets him feel in control rather overwhelmed by s ens ations of arous al. C ommunication between the partners is improved because the man let his partner know his level of sexual excitement so she can s queeze the penis before the ejaculatory has s tarted. S ex therapy has been s uccess ful with premature ejaculators ; however, a s ubgroup of dysfunctional men may need pharmacotherapy as well. A man with s exual des ire dis order or erectile dis order sometimes told to masturbate to demons trate that full erection and ejaculation are poss ible. A woman with lifelong female orgas mic dis order is directed to 2236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 156 of 185

masturbate, s ometimes us ing a vibrator. K egel's may be introduced to s trengthen the pubococcygeal muscles —that is , the woman is encouraged to contract abdominal and perineal mus cles during mas turbation coitus. W hen a man has erectile dis order, the woman be ins tructed to s timulate or tease his penis. T he s ame technique is us ed with men who s uffer from retarded ejaculation, with stimulation s ometimes involving a vibrator. R etarded ejaculation is managed by ejaculation initially and gradual vaginal entry after stimulation to the point of near ejaculation.

Treatment G oals T he overall goal of treatment is to initiate an proces s, to diminis h the fears of performance felt by sexes, and to facilitate communication in sexual and nonsexual areas . T herapy sess ions follow each new exercise period, and problems and s atisfactions (both sexual and nons exual) are discus sed. S pecific and new exercises geared to the individual couple's progres s are reviewed in each s es sion. G radually, the couple gains confidence and learns (or relearns ) to communicate verbally and sexually. Dual-sex therapy most effective when the s exual dys function exists apart from other psychopathology.

Hypnotherapy Hypnotherapists focus s pecifically on the anxietyproducing s ymptom—that is , the particular sexual dysfunction. S ucces sful use of hypnosis helps the gain control over the symptom that has been lowering self-es teem and disrupting ps ychological homeostasis. 2237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 157 of 185

P atient cooperation is first obtained and encouraged during a s eries of nonhypnotic ses sions with the designed to develop a s ecure doctor–patient and a s ense of physical and ps ychological comfort on part of the patient and to es tablis h mutually desired treatment goals. During that time, the therapist the patient's capacity for the trance experience. T he nonhypnotic s ess ions als o permit the clinician to take a careful ps ychiatric history and do a mental status examination before beginning hypnotherapy. focus es on s ymptom removal and attitude alteration. In trance state, patients can entertain ideas incongruent their usual (nonhypnotized) perceptions of reality. are ins tructed in developing alternative means of with the anxiety-provoking situation (i.e., the sexual encounter). F or example, a woman with vaginis mus is given the posthypnotic s uggestion that she will feel no pain intercours e and will be able to relax the mus cles surrounding her vagina. If compliance with the is s ucces sful, s he can deal with the anxiety produced the sex act. S he is also taught new attitudes , s uch as entitled to sexual pleas ure. Under hypnos is , her fear or anger at sexual contact can be examined, and she how her emotions are expres sed by involuntary vaginal spas ms . S ome patients res pond particularly well to the us e of hypnosis and indirect sugges tion. T hese techniques them to retain a greater sense of control over their situation. T ypically, patients are ins tructed to conjure images and develop ideas antithetical to their dysfunctional respons es. F or example, a woman with 2238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 158 of 185

arousal disorder may firs t agree to concentrate on that caus es her to salivate. S he is then told that, just as has made her mouth water by focusing on stimulating images, she can effect the lubricating respons e of her vagina by focus ing on images s he finds erotic or At the s ame time, the therapis t helps her deal with her anxieties about a positive sexual respons e. P atients also taught relaxing techniques to us e before sexual relations . With these methods to alleviate anxiety, the phys iological res pons es to s exual stimulation can more readily result in pleas urable excitation and discharge. Hypnos is may be added to a bas ic individual ps ychotherapy program to accelerate the impact of ps ychotherapeutic intervention.

B ehavior Therapy B ehavior therapists as sume that sexual dysfunction is learned, maladaptive behavior. B ehavioral approaches were initially des igned to treat phobias. In cas es of dysfunction, the therapist s ees the patient as phobic of sexual interaction. Us ing traditional techniques, the therapist sets up a hierarchy of anxiety-provoking situations for the patient, ranging from the leas t threatening to the mos t threatening. Mild anxiety may experienced at the thought of kis sing, and mass ive may be felt when imagining penile penetration. T he behavior therapis t helps the patient master the anxiety through a standard program of s ys tematic T he program is des igned to inhibit the learned anxious res ponse by encouraging behaviors antithetical to T he patient firs t deals with the least anxiety-producing situation in fantas y and progress es by steps to the anxiety-producing situation. Medication, hypnos is , or 2239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 159 of 185

special training in deep muscle relaxation is sometimes us ed to help with the initial mas tery of anxiety. Ass ertivenes s training helps teach patients to express sexual needs openly and without fear. E xercis es in as sertivenes s are given in conjunction with sex and patients are encouraged both to make sexual and to refus e to comply with requests perceived as unreas onable. S exual exercis es may be pres cribed for patients to perform at home, and a hierarchy may be es tablis hed, starting with activities that proved mos t pleas urable and s ucces sful in the pas t. One treatment variation involves the participation of the patient's s exual partner in the des ens itization program. T he partner, rather than the therapist, pres ents the hierarchical items to the patient. In such situations , a cooperative partner is neces sary to help the patient gains made during treatment ses sions to s exual activity home. B ehavior therapy techniques have been particularly effective in treating women with s evere inhibition of excitement and orgas m when s uch feelings were accompanied by strong feelings of anxiety, anger, or disgust.

Group Therapy Methods of group therapy have been used to examine both intrapsychic and interpers onal problems in with sexual disorders . T he therapy group provides a support P.1931

2240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 160 of 185

system for patients who feel ashamed, anxious , or about a particular sexual problem. It is a useful forum which to counteract sexual myths, correct and provide accurate information regarding sexual anatomy, physiology, and varieties of behavior. G roups for the treatment of sexual disorders can be organized in s everal ways . Members may all s hare the same problem, s uch as premature ejaculation; may all be of the same sex and have different sexual problems ; or groups may be compos ed of both men women who are experiencing different s exual G roup therapy may be an adjunct to other forms of therapy or the prime mode of treatment. G roups organized to cure a particular dysfunction us ually have behavioral approach. F or example, patients with anorgas mia may participate with others who have the same problem in a s hort-term, intensive group S exual his tories , feelings of inadequacy, and concerns about body image are shared. S pecific phys iological information, s ometimes with the aid of audiovisual materials , is presented to the group members . are given homework as signments (e.g., they may be instructed to mas turbate). A combination of group and group press ure helps s ome of the participants complete as signments they might otherwis e avoid. As short-term group process nears termination, members encouraged to talk about their experiences with their partners . G roups have als o been effective when compos ed of sexually dysfunctional married couples . T he group provides an opportunity to gather accurate information, provides consensual validation of individual 2241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 161 of 185

and enhances self-es teem and s elf-acceptance. S uch techniques as role-playing and ps ychodrama may be in treatment. T hes e groups are not indicated for which one partner is uncooperative, has s evere or ps ychosis , or has a s trong repugnance for explicit audiovis ual materials or a s trong fear of groups.

Integrated S ex Therapy One of the most effective treatment modalities is the of sex therapy integrated with supportive, or ins ight-orientated ps ychotherapy. Adding ps ychodynamic conceptualizations to the behavioral techniques used to treat sexual dysfunctions allows treatment of patients with s ex dis orders ass ociated with other psychopathology. Also, this type of therapy is appropriate for patients with hypoactive desire Ins ight-oriented therapy helps them deal with problems their interpersonal relationships or intrapsychic conflicts that frequently are at the root of the problem. T he and dynamics that emerge in patients in analytically oriented s ex therapy are the same as thos e that ps ychoanalytic therapy—relevant dreams, fear of punis hment, aggress ive feelings , difficulty with trus ting the partner, fear of intimacy, oedipal feelings , and fear genital mutilation. T wo cas es follow that demonstrate s ome of these dynamics. A 34-year-old widow pres ented for therapy with a chief complaint of vaginis mus. Her marriage of 3 years , had been unconsummated, ended when her husband killed in a car accident. Approximately 1 year after s he 2242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 162 of 185

her hus band, the patient became involved with a man. S he was very attracted to him and became highly aroused during their s exual encounters. Although s he could reach orgas m through manual or oral s timulation, she could not tolerate penetration. Although s he never cons idered therapy when s he was married, in s pite of husband's requests to do s o, she was motivated to help for her problem, because she felt s ure her lover leave his wife for her if they could share a more sexual experience. T he patient's vaginis mus res ulted partly from developmental conflicts. Her parents had been loving cons tricted people who came from different socioeconomic backgrounds . T heir values often and they frequently fought over their daughter as s he entered adoles cence. T he mother insis ted that she academic cours e in high s chool to prepare for college, whereas the father pushed a “more practical” business program. T he patient s ided with her mother and felt her father, whom s he had always perceived as cold, became more dis tant than before. S ome of her difficulties were due to unresolved oedipal problems ; both her husband and her lover were more 20 years older than s he was , and her lover (reflecting parental s ituation) was married to a woman who was succes sful than he was . In addition, s he had identified some of her mother's negative feelings about men. T he mother had once told the patient s he hoped that she would be spared marriage. V aginismus protected the patient from the clos eness with men that she wanted but unconsciously perceived as hurtful and dangerous . 2243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 163 of 185

A 56-year-old man came for treatment because of an erectile disorder. In general, he functioned better in extramarital affairs than in his marriage. Although he his wife and cons idered her an attractive woman, he believed that she was not interes ted in s ex. He could achieve an erection with her, and he gradually s topped approaching her s exually. His wife felt deprived by their lack of s exual relations and frequently mas turbated. T he patient had been a sickly child, with a mother he described as devoted but s mothering. He remembered cuddling him in bed until he was 8 years old, and he that s he was inappropriately affectionate in general embarrass ed me”). At the s ame time, he remembered father as an earthy man and had a childhood of hearing his mother ask his father, “How could you, could you? ” T he patient believed it had been his res ponse to a sexual overture or act. In part, his derived from his unconscious oedipal ass ociations to wife, which made her taboo for him as a s ex partner. women to whom he res ponded had to be blatantly and s ignal their acceptance of him before he would risk advance. T herapy involved both individual sess ions the patient and joint s es sions with him and his wife. C ommunication, which had been s trained partly of the sexual distance between them, was encouraged, and a behavioral approach was us ed to reestablish phys ical interaction. Individual work focused on his ps ychological problems. T he dynamics and the emotional difficulties evident in these vignettes are seen every day by psychiatrists . P sychiatrists can readily abs orb the techniques of s ex therapy into their treatment armamentarium, just as 2244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 164 of 185

have modified and absorbed any number of s pecialized techniques, from class ic analytical dynamic the us e of pharmacotherapy, group therapy and behavioral and other directive modalities . T he combined approach of individual and s ex therapy is by the general ps ychiatris t, who carefully judges the optimal timing of s ex therapy and the ability of patients tolerate the directive approach that focuses on their difficulties .

B iologic al Treatment Methods B iological treatments , including pharmacotherapy and surgery, have applications in s pecific cases of sexual disorder. Advances in biological treatment methods , particularly pharmacological methods of treating sexual dysfunction have s ignificantly augmented the catalogue P.1932 of therapeutic approaches . Most of the recent involve male s exual dys functions . C urrent s tudies are under way to tes t pharmacological treatment of s exual dysfunctions in women.

Pharmac otherapy A variety of drugs have been explored in the treatment sexual dysfunction. T he major new medications are oxide enhancers such as s ildenafil (V iagra); oral prostaglandin (V as omax); alprostadil (C averject), an injectable phentolamine; and a transurethral alpros tadil (MUS E ), all us ed in the treatment of erectile dis order.

2245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 165 of 185

Nitric Oxide E nhanc ers Nitric oxide enhancers facilitate the inflow of blood to penis necess ary for an erection. T he phys iological mechanism of penile erection involves release of nitric oxide in the corpus cavernosum during sexual Nitric oxide activates the enzyme guanylate cyclase, increases cyclic guanos ine monophos phate and produces smooth muscle relaxation in the corpus cavernos um that allows the penile ves sels to dilate and admit blood. T he firs t drug developed, s ildenafil, the effect of nitric oxide by inhibiting the enzyme that degrades cyclic guanosine monophos phate. T hus , sildenafil augments the natural proces s involved in and maintaining an erection during s exual stimulation. drug takes effect approximately 1 hour after inges tion, its effect can last up to 4 hours . S ildenafil has no effect the abs ence of s exual s timulation. T he most common adverse events ass ociated with sildenafil are headaches, flus hing, and dys pepsia. sildenafil users s ee things in a blue tint for several after taking the medication; becaus e of this, airline have been prohibited from taking the drug so that this visual artifact does not interfere with s afe landings. T he of sildenafil is contraindicated for people taking organic nitrates. T he concomitant action of the two drugs can res ult in large, s udden, and s ometimes fatal drops in systemic blood press ure. T he U.S . F ood and Drug Administration (F DA) has posted 130 deaths in which sildenafil was listed as an as sociated medication and advis es caution in prescribing s ildenafil to men with a recent (6-month) his tory of myocardial infarction, life-threatening arrhythmia, significant hypotension or 2246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 166 of 185

hypertens ion, cardiac failure, angina, or retinitis pigmentos a. However, the F DA has reiterated that it is safe drug. S ildenafil is not effective in all cases of dysfunction. It fails to produce an erection rigid enough penetration in approximately 50 percent of men who had radical prostate s urgery or in thos e with longstanding, ins ulin-dependent diabetes. It is also in certain cases of nerve damage. T wo new nitric oxide enhancers similar to sildenafil— vardenafil (Levitra) and tadalafil (C ialis )—have been developed. T adalafil has an effective therapeutic of 36 hours compared to s ildenafil and vardenafil, are effective for approximately 4 hours . Oral phentolamine has proved effective as a potency enhancer in men with minimal erectile dysfunction. It prove useful for men with cardiac problems , as contraindicated for men using organic nitrates, but it is currently approved by the F DA. Apomorphine is also tes ted as an oral remedy for erectile dys function.

A lpros tadil In contras t to the oral medications, injectable and transurethral alpros tadil act locally on the penis and produce erections in the abs ence of s exual stimulation. Alprostadil contains a naturally occurring form of prostaglandin E . P ros taglandins are composed of hydroxy fatty acids , and they have wide biological influences. Although some pros taglandins are vasoconstrictive, pros taglandin E 1 , found in alprostadil, powerful vas odilating agent, especially in local vascular areas, such as the corpus cavernos um of the penis. drug caus es direct s mooth mus cle relaxation of penile 2247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 167 of 185

vess els and erectile tiss ue; this reaction lowers the res is tance of the corpus and significantly increas es flow to the penis. T he firm erection produced within 2 to minutes by increas ed blood flow may last as long as 1 hour. T reatment consists of the patient's self-injection alpros tadil into the corpus before coitus. T his technique easily taught and relatively painles s. Infrequent effects include penile bruising and changes in liver function test res ults , which are readily reversible when man s tops the injections. However, poss ible hazardous sequelae exist, including priapism and sclerosis of the small veins of the penis. Another s ubs tance being tried vasoactive intestinal polypeptide (V IP ). Intracavernous injection of V IP causes erection and has a parasympathomimetic effect. S ome res earchers that this substance, which has been found in the hypothalamus and the female genital organs, is the es sential factor in male and female arous al. In E urope, phenoxybenzamine (Dibenzyline) is us ed to produce erections by injection into the penis. S erious adverse effects include priapis m and pain accompanying the injection, and the drug is not allowed as a therapy in United S tates . Alprostadil can also be delivered via the urethra, eliminating the need for s elf-injection. S ome men prefer the local, nonsystemic effects of alpros tadil to oral sildenafil; others prefer s ildenafil becaus e it s eems like a nonpharmacologically aided respons e to them their partners. A small trial found a topical cream in alleviating erectile dysfunction. T he cream cons ists three vas oactive s ubs tances that are a mixture of ergot alkaloids. Alpros tadil is a us eful treatment for patients 2248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 168 of 185

whom nitric oxide enhancers are contraindicated (e.g., patients who are taking nitrate-containing medication). is also of us e in patients who do not tolerate the side effects of other drugs. T he pharmacological treatments des cribed above are us eful in treatment of erectile dys function of various caus es: psychogenic, neurogenic, arterial insufficiency, venous leakage, and mixed. T he following cas e demonstrates the use of pharmacotherapy to treat dysfunction of ps ychogenic origin. Mr. B . and Ms. C . (his fiancée) presented for sex with Mr. B . having experienced erectile dys function for months, as well as a lifelong history of premature ejaculation. Mr. B . was a 42-year-old profes sional, and C . was a 38-year-old corporate executive. S he had been married; it was to be his s econd marriage. Mr. B .'s s exual his tory was remarkable for a late first (age 25) and a general s exual ins ecurity that with his profes sional confidence and social poise. Ms. was sexually res ponsive, in s pite of a history of anxiety attacks for which she had been treated in the pas t. early sexual activity together had been frequent and satis fying to both, in s pite of his prematurity. After a few months, however, s he began to complain about both premature ejaculation and the secrecy of their relations hip. Although Mr. B . was legally separated they became involved, he was worried about divorce negotiations if his spouse learned about his new relations hip. T reatment revealed that he found the in their relations hip exciting. T he two were treated with integrated s ex therapy, a 2249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 169 of 185

combination of behavioral and insight-oriented techniques, and made s ubs tantial progress . T hey succes sfully controlled the premature ejaculation by practicing the s queeze technique (i.e., forcibly the coronal ridge of the penis P.1933 before ejaculation to increas e the threshold of penile sens itivity). In genital-cares sing s ess ions. Mr. B .'s returned, and he could maintain a good erection to with manual and oral s timulation. However, he to los e his erection when he attempted vaginal penetration. It was decided to s upplement with intracavernos al injections of alpros tadil (s ildenafil not yet available). Ms. C . was pres ent when he was instructed in the injection technique and s upported the proces s. Mr. B . was delighted with the res ults, and, month of pharmacologically ass is ted coitus , he succes sfully achieved penetration without ass is tance. C urrently, he has coitus once a week, with occasional of s ildenafil rather than intracavernos al injection when is feeling s tres sed. T he availability of a medication to his erectile problem significantly relieves his anxiety. E rectile dysfunction of psychological or mixed origin should not be treated by medication alone, even the dysfunction can be corrected pharmacologically. drugs should be used in conjunction with, not as a replacement for, s ex therapy. In s ome cas es, erectile dysfunction serves as a defens e against uncons cious conflicts that mus t be faced when the s exual symptom removed as result of medication. In some cas es , the 2250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 170 of 185

patient deals with his conflicts by s imply not us ing the medications prescribed for his erectile problem. Also, patients in long-standing or marital relations hips the cooperation of their partners for this treatment to be effective. Although most women are very to their partner's des ire for treatment, several concerns occur with some frequency: the element of romance is important part of sexual interaction for many women, pharmacological as sistance of erections may eliminate that s ens e of romance; the woman, or the couple, may bemoan the lack of s pontaneity when part of the s ex act; and s ome women feel deprived of feedback about their des irability. J oint s es sions help couple cope with thes e is sues .

S ildenafil Us e in Women T he phys ical s ign of s exual excitement in women is lubrication. T hat lubrication is a trans udate believed to res ult from increased vasoconges tion of the extens ive capillary net in the vaginal walls. T he same mechanism—vasoconges tion—res ults in erection in man. R es earchers believe that sildenafil may facilitate blood flow in women jus t as it does in men and, thus , women with inhibited excitement of ps ychological or phys iological origin a pharmacological remedy for their dysfunction. S ome reports suggest that women find it preferable to apply sildenafil in a cream base to the labia, and vagina. However, as in men, treatment may need to be combined with psychological modalities to be effective. R ecognition of sexual excitement may be more for women than it is for men. F or example, in s tudies of 2251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 171 of 185

res ponse to pornography, men and women underwent phys iological measurements of excitement after visual stimuli. In these studies, men were more accurate in correlating their s ubjective sense of arous al (i.e., than were women (i.e., lubrication).

Other Pharmac ologic al Agents Numerous other pharmacological agents have been to cure the various sexual disorders. Intravenous methohexital sodium (B revital) has been us ed in desensitization therapy. Antianxiety agents may have some application in tense patients, although these can also interfere with the sexual res ponse. T he side of antidepress ants, particularly the S S R Is and tricyclic drugs, which include delayed orgasm, have been us ed prolong the s exual respons e in patients with premature ejaculation. T his approach is particularly useful in refractory to behavioral techniques or who may have phys iologically determined premature ejaculation. T he of antidepres sants has been advocated in the patients who are phobic of sex and in those with a posttraumatic stress disorder (P T S D) after rape. T he taking s uch medications must be carefully weighed agains t their poss ible benefits. B romocriptine (P arlodel) us ed in the treatment of hyperprolactinemia, which is frequently as sociated with hypogonadis m. S uch cases first worked up to rule out pituitary tumors. a dopamine agonist, may improve sexual function impaired by hyperprolactinemia. Y ohimbine is an α-adrenergic receptor antagonis t that may cause dilation of the penile artery and improve erections . R ecreational drugs, including cocaine, 2252 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 172 of 185

amphetamines, alcohol, and cannabis , are cons idered enhancers of sexual performance. Although they may provide the us er with an initial benefit because of their tranquilizing, disinhibiting, or mood-elevating effects, cons istent or prolonged use of any of these substances impairs s exual functioning. G ins eng has been reported to have androgenic effects. One report described the case of a mother who large amounts of gins eng during her pregnancy, in androgenization of the neonate, who was born with pubic hair and enlarged testes. Other drugs that have been us ed by women to alleviate arousal dysfunction include oral phentolamine, topical prostaglandin E , oral oxytocin, ginkgo biloba, and ps ychos timulants , including caffeine. Many of these have not been approved for treatment of female sexual dysfunction and must be prescribed with caution. Dopaminergic agents have been reported to increas e libido and improve sex function. T hos e drugs include Ldopa, a dopamine precurs or, and bromocriptine, a dopamine agonis t. T he antidepres sant bupropion has dopaminergic effects and has increas ed sex drive in patients. S elegiline, an MAOI, is s elective for MAO B dopaminergic. It improves s exual functioning in older persons.

Hormone Therapy Androgens increas e the sex drive in women and in with low testosterone concentrations . W omen may experience virilizing effects , s ome of which are (e.g., deepening of the voice). In men, prolonged use 2253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 173 of 185

androgens may produce hypertens ion and prostatic enlargement. T estosterone is most effective when parenterally; however, effective transdermal are available. Oral preparations are ass ociated with increased ris k of hepatotoxicity. G onadotrophin-releas ing hormone (G nR H), also known luteinizing hormone -re le as ing hormone (LHR H), the releas e of luteinizing hormone, which increas es tes tos terone s ecretion in both s exes. G nR H is used as inhalant in E urope. It s timulates des ire and increas es potency. B ecause G nR H is released normally in a fas hion, portable infus ion pumps have been developed that s imulate pulsatile delivery. An excess of G nR H suppress es estrogen and tes tos terone; thus , the therapeutic us e of G nR H is limited by a narrow window. Women who use estrogens for replacement therapy or contraception may report decreas ed libido; in s uch combined preparation of es trogen and testos terone been used effectively. E strogen its elf prevents thinning the vaginal mucous membrane and facilitates T es tos terone is given to women around the world in form of tablets, implants, patches , and creams. In the United S tates , methyltestosterone pills and creams are the primary methods of adminis tration. T es tos terone is primarily adminis tered to (occurring surgically or naturally) women, but deficiency als o exis ts in premenopaus al women. P.1934

2254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 174 of 185

Mrs. M. presented for therapy alone with a chief of pain on intercours e dating from the onset of menopaus e 14 months before coming for treatment. husband knew of her visit but did not accompany her, he was away on one of many routine and frequent business trips. S exual intercours e was infrequent becaus e of his travel s chedule, but their s ex play was varied and, menopaus e, Mrs. M. had enjoyed sex. Mrs. M. found sexual interactions with her hus band gratifying. S he strong libido and would masturbate when Mr. M. was away. Mrs. M. was on oral hormone replacement therapy, had helped but had not eliminated the pain she had intercours e. In cons ultation with her gynecologis t, the occasional us e of hormone cream was added to her treatment regimen. Additionally, s he was instructed to vaginal dilators routinely when Mr. M. was away. T his not for purposes of masturbation, which for her clitoral s timulation, but for routine stretching of the vagina. Nonhormonal vaginal cream was prescribed for the couple to use with intercourse. T he combination of oral hormone replacement therapy, vaginal creams, the routine us e of vaginal dilators served to eliminate M.'s pain. S he was diagnosed with dyspareunia, type. P heromones are sexual s cents that are found in and may be present in humans. T hey produce dramatic sex-seeking behavioral patterns in animals (e.g., male following female deer in estrus , mounting behavior in primates). Human pheromones are believed to be acting fatty acids pres ent in vaginal s ecretions and 2255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 175 of 185

sweat. In one s tudy, women were cons is tently more attracted to items impregnated with a chemical derived from male sweat (α-andros tenol) than to control items . another study, the sweat of women was preserved in underarm pads they changed daily, and the date each was worn was correlated with the women's menstrual cycle. A second group of women was as ked to smell pads as they were rubbed above their upper lips , knowing what they were and recognizing no s cent but alcohol pres ervative us ed on the pads . Depending on whether they were exposed to pads from the early or part of the first group's (the wearers) menstrual cycle, second group (the s niffers ) saw their own menstrual shortened or lengthened. T his area is still being res earched.

A ntiandrogens and A nties trogens E strogen and proges terone are antiandrogens that been used to treat compuls ive s exual behavior in men, us ually in s ex offenders. Medroxyprogesterone acetate (Depo-P rovera), us ed primarily as a contraceptive in women, inhibits the secretion of gonadotrophins. It is us ed in men with compuls ive s exual behavior to reduce libido by tes tos terone levels. C yproterone acetate is a strong antiandrogen used in E urope to treat sex offenders. At dosages of 100 to 200 mg a day, the sex drive within 2 weeks . T amoxifen (Nolvadex) is used to treat breast cancer has antiestrogenic properties . In some women, libido may result from the unopposed testosterone C lomiphene (C lomid) is an ovulatory s timulant us ed in 2256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 176 of 185

women with ovulatory mens trual cycles des iring pregnancy. C lomiphene increases release of pituitary gonadotrophins , and s ome women may report libido. Neither of these drugs, however, is used as a treatment for decreased libido in women.

Mec hanic al Treatment Approac hes S teal S yndrome In male patients with arteriosclerosis (especially of the distal aorta, known as L e riche's s yndrome ), the be los t during active pelvic thrus ting. T he need for increased blood in the gluteal mus cles and others by the ilial or hypogas tric arteries takes blood away from the pudendal artery and, thus, interferes with blood flow. R elief may be obtained by decreas ing thrusting, which is also aided by the woman-superior position.

Vac uum P ump V acuum pumps are mechanical devices that patients without vas cular disease can us e to obtain erections. blood drawn into the penis after the creation of the vacuum is kept there by a ring placed around the base the penis . T his device has no advers e effects, but it is cumbersome, and partners must be willing to accept its us e. S ome women complain that the penis is redder cooler than when erection is produced by natural circums tances , and they find the process and the res ult objectionable. A vacuum pump with the marketing name E ros was devis ed for women to precipitate a clitoral erection. It 2257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 177 of 185

works s imilarly to the vacuum pump used to create erections in men, although no band is placed around clitoris once erection is obtained. T he pump is not neces sary for intercours e to occur; it was devised to enhance female excitement, but its effectivenes s has been s tudied rigorously.

S urgic al Treatment Male P ros thes es S urgical treatment is infrequently advocated, but improved penile prosthetic devices are available for with inadequate erectile res ponse who are res is tant to other treatment methods or who have medically deficiencies. T here are two main types of prosthesis: a semirigid rod pros thesis that produces a permanent erection that can be positioned close to the body for concealment and an inflatable type that is implanted its own res ervoir and pump for inflation and deflation. latter type is des igned to mimic normal phys iological functioning. P lacing a penile prosthes is in a man who lost the ability to ejaculate or to have an orgas m as a of medical caus es will not res tore those functions. Men with pros thetic devices have generally reported satis faction with their s ubs equent s exual functioning, their wives report much less satis faction. P res urgical couns eling is strongly recommended so that the couple has a realistic expectation of what the pros thes is can their s ex lives . P os tsurgical counseling may als o be neces sary to help the couple adapt to their ability to have intercourse. T hey may experience a high level of anxiety if their sex life had been inactive for a prolonged period before surgery. P ros thetic devices 2258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 178 of 185

been ass ociated with severe advers e effects, including perforation, infection, urinary retention, and persistent pain. S ome s urgeons are attempting revascularization of the penis as a direct approach to treating erectile res ulting from vascular disorders . S uch s urgical are indicated in patients with corporal s hunts that allow normally entrapped blood to leak from the corporal spaces, leading to inadequate erections (steal Limited reports exis t of prolonged success with the technique. E ndarterectomy can be of benefit if occlusive dis eas e is respons ible for the erectile dysfunction. Another medical treatment being s tudied for erectile disorders is electros timulation at the base of the penis . Initial reports indicate minimal phys ical discomfort in patients receiving this therapy. However, respons e to treatment is incons istent, and a problem exis ts in terms maintaining erections . At the present time, the seems to have no benefits.

F emale P roc edures S urgical approaches to female dysfunctions include hymenectomy in the case of dys pareunia in an unconsummated P.1935 marriage, vaginoplas ty in multiparous women complaining of les sened vaginal sens ations, or freeing clitoral adhesions in women with inhibited excitement. S uch s urgical treatments have not been carefully 2259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 179 of 185

and s hould be considered cautious ly.

Outc ome Demons trating the effectiveness of the varieties of sex therapy is just as difficult as ass ess ing the outpatient ps ychotherapy in treating other problems . As with other dis orders, the more severe the ps ychopathology ass ociated with a problem of long duration, the more adverse the outcome is likely to be. Masters and J ohnson first reported positive res ults for behavioral treatment approach in 1970. T hey studied failure rates of their patients (defined as failure to revers al of the basic s ymptom of the presenting dysfunction). T hey compared initial failure rates with 5year follow-up findings for the same couples. Although some have criticized their definition of the percentage presumed success es , other s tudies have confirmed the effectivenes s of their approach. T he most difficult treatment cas es involve couples with severe marital discord. C ases involving problems of intimacy, excess ive dependency, or excess ive hostility also complex. Other challenges are pos ed by patients impulse dis orders, unres olved homos exual conflicts , or fetishis tic defens es. P atients phobic of sex also pres ent treatment difficulties , as do patients diagnos ed with lifelong dys functions . Des ire disorders are particularly difficult to treat. T hey require longer, more intensive therapy than s ome other disorders , and their outcomes very variable. When behavioral approaches are used, empirical that are s upposed to predict outcome are more easily 2260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 180 of 185

is olated. Using these criteria, for instance, couples who regularly practice as signed exercises appear to have a much greater likelihood of s ucces sful outcome than do more resis tant couples or those whos e interaction sadomas ochis tic or depres sive features or blame and projection. F lexibility of attitude is als o a positive prognostic factor. Overall, younger couples to complete s ex therapy more often than older couples . C ouples whos e interactional difficulties center on their problems , such as inhibition, frus tration, or fear of performance failure, are also likely to respond well to therapy. In general, methods that have proved effective singly combination include training in behavioral s exual skills, systematic desensitization, directive marital counseling, traditional ps ychodynamic approaches, group therapy, and pharmacotherapy. Although most prefer to treat a couple for sexual dysfunctions, treatment of individual persons has als o been s ucces sful. T he frequency of sess ions is not a significant factor in treatment T hus, whether patients have intens ive daily therapy period of 2 weeks , weekly therapy, or biweekly therapy appears to have little effect on the outcome of Als o, the use of one therapist to treat a couple instead dual-sex cotherapy team is nearly as effective and more practical. P atients s een today are frequently older when they present for therapy, more informed about s ex, and likely to have dis orders of mixed etiology than were seen in the mid-1970s . Moreover, numerous new biological treatments are now available for into s ex therapy treatment programs . T oday, a 2261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 181 of 185

treatment regimen and an eclectic approach to s exual disorders will res ult in a favorable outcome in the great majority of cas es.

S UG G E S TE D C R OS S Homosexuality is discus sed in S ection 18.1b, are dis cuss ed in S ection 18.2, and gender identity disorders are dis cus sed in S ection 18.3. S exual covered in S ection 18.4. T he neuropsychological and neurops ychiatric as pects of HIV infection are covered S ection 2.8. C ouples therapy is discus sed in S ection and biological and other pharmacological therapies are discuss ed in C hapter 31. T he phys ical and s exual children, including inces t, is covered in S ection 49.3.

R E F E R E NC E S Araoz DL: Uses of hypnos is in the treatment of ps ychogenic s exual dys functions . P s ychiatr Ann. 1986;16:102. Ass alian P , Margoles e H: T reatment of induced s ide effects. J S e x Marital T he r. 1996;22:3. B rady J P : B ehavior therapy and s ex therapy. Am J P s ychiatry. 1976;133:896. C hes sick R D: T hirty unres olved ps ychodynamic questions pertaining to feminine ps ychology. Am J P s ychothe r. 1988;42:86. *Delgardo P L, McG auey C A, Moreno F A, Laukes C , G elenberg AJ : T reatment s trategies for depress ion 2262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 182 of 185

sexual dys function. J C lin P s ychiatry. 1999;17:22. E llis A. S tudie s in the P s ychology of S ex. New Y ork: P res ton Hous e; 1936. F ederman DD: P erspective: T hree facets of sexual differentiation. N E ngl J Me d. 2004;350:323–324. G oldstein I, Lue T , P adma-Nathatan H, R os en R , WD, W icker P A: T he sildenafil study group, oral in the treatment of erectile dys function. N E ngl J 1996;338:1397. Herman J , LoP iccolo J : C linical outcome of sex Arch G e n P s ychiatry. 1983;40:443. K egeles S M, Adler NE , Irwin C E : S exually active adoles cents and condoms : C hanges over one year knowledge, attitudes and use. Am J P ublic He alth. 1988;78:460. K oppelman M, P arry B L, Hamilton J A, Alogna S W , Loreaux P L: E ffect of bromocriptine on affect and in hyperprolactinemia. Am J P s ychiatry. K oren G : Maternal gins eng us e as sociated with androgenization. J AMA. 1990;264:2866. K rafft-E bing R . P s ychopathia S exual. Munich: S eitz; 1984. *Laughman E , G agnon J , Michael R , Michaels S . 2263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 183 of 185

Ame rica. C hicago: University of C hicago P res s; Leitenberg H, Detzer M, S rebnik D: G ender in masturbation and the relation of masturbation experience in preadoles cence and/or early to sexual behavior and s exual adjus tment in young adulthood. Arch S ex B ehav. 1993;22:87. Linet OI, Ogrinc F G (for the Alpros tadil S tudy E fficacy and safety of intracavernosal alpros tadil in with erectile dysfunction. N E ngl J Me d. Loosen P T , P urdon S E , P avlou S N: E ffects on modulation of gonadal function in men with gonadotropin-releas ing hormone antagonis ts . Am J P s ychiatry. 1994;151:271. MacLaughlin DT , Donahoe P K : Mechanisms of S ex determination and differentiation. N E ngl J Me d. 2004;350:369. *Masters W H, J ohns on V E . Human S e xual B os ton: Little, B rown; 1970. *Masters W H, J ohns on V E . Human S e xual B os ton: Little, B rown; 1970. P adma-Nathan H, Hells trom WJ G , K ais er F E , Lue T F , Nolten W E , Norwood P C , P eters on C A, R , T am P Y , P lace V A, G es undheit N (for the Urethral S ystem for E rection [MUS E ] S tudy G roup): T reatment of men with erectile dys function with 2264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 184 of 185

transurethral alpros tadil. N E ngl J Me d. 1997;336:1. *P urnine DM, C arey MP , J orgensen R S : G ender differences regarding preferences for s pecific heteros exual practices . J S e x Marital T he r. R hoden E L, Morgentaler A: R is ks of testosteronereplacement therapy and recommendations for monitoring. N E ngl J Me d. 2004;350:482. *R iley AJ : Life-long absence of sexual drive in a as sociated with 5-dihydrotes tos terone deficiency. J Marital T he r. 1999;25:13. *R osen R C , Lane R M, Menza M: E ffects of S S R Is function: A critical review. J C lin P s ychopharmacol. 1999;19:67. *S adock V A. T he treatment of ps ychos exual dysfunctions: An overview. In: G rins poon L, ed. P s ychiatry 1982. T he Ame rican P s ychiatric Annual R e vie w. W ashington, DC : American P res s; 1982. S adock V A. G roup ps ychotherapy of ps ychos exual dysfunctions. In: K aplan HI, S adock B J , eds . C omprehe ns ive G roup P s ychothe rapy. B altimore: Williams & W ilkins ; 1983:286. S eagraves R T , S eagraves K B : Human s exuality and aging. J S e x E duc T he r. 1995;21:88.

2265 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

Page 185 of 185

S emans J H: P remature ejaculation: A new S outh Me d J . 1956;49:353. S hrainer-E ngel P , S chiavi R : Lifetime individuals with low s exual des ire. J Ne rv Ment Dis . 1986;174:646. S tein DJ , Hollander E , Anthony DT , S chneier F R : S erotonergic medications for sexual addictions, and paraphilias. J C lin P s ychiatry. 1992;53:267. S ternbach H: Age as sociated tes tos terone decline in men: C linical is sues for ps ychiatry. Am J P s ychiatry. 1998;155:10. T hase M, R eynolds C , G lanz L, J ennings J R , S weitz K upper DJ , F rank E : Nocturnal penile tumes cence in depres sed men. Am J P s ychiatry. 1987;144:89. Waldinger MD, Hengeveld W H, Zwinderman A, B : E ffect of S S R I antidepress ants on ejaculation: A double-blind, randomized, placebo-controlled study with fluoxetine, fluvoxamine, paroxetine and J C lin P s ychopharmacol. 1998;189:274. Wiley D, B orts W M: S exuality and aging—us ual and succes sful. J G e rontol. 1996;51:22.

2266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

01/01/2009

19

Page 1 of 107

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > 19 - E ating Disorder

19 E ating Dis orders Arnold E . Anders en M.D J oel Yager M.D. E ating dis orders are disorders of eating behavior primarily from an overvaluation of the desirability of weight loss that result in functional medical, and s ocial impairment. T hese dis orders repres ent dysfunctional, emotional, cognitive, and behavioral strategies for coping with is sues in development, mood disturbances , interpersonal relations hips, and conflicts, becoming s elf-sustaining illnes ses , us ually in context of overvalued beliefs internalized from sociocultural norms promoting the benefits of thinnes s shape change. Des pite their often innocuous, culturally syntonic origins, eating disorders have undoubtedly present in various forms for thousands of years , but prevalence has increased s ubs tantially since the T hey now present as common serious clinical E ating dis orders have some of the highest rates of premature mortality in ps ychiatry—up to 19 percent within 20 years of ons et among those initially requiring hospitalization. T he syndrome bulimia nervosa was firs t described as part of the eating disorders spectrum only 1979, but hindsight s uggests it has been present as anorexia nervosa, often occurring below the level of common recognition becaus e of the lack of vis ible 2267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 2 of 107

starvation. T he official recognition of binge-eating is even more recent, although forms of compulsive overeating have been recognized throughout his tory. A few principles concerning eating disorders will guide discuss ion. F irst, eating dis orders are syndromes, of symptoms that have a fairly predictable cours e and sometimes well-es tablis hed treatments, but they are unders tood at the fundamental level of a specific etiology. S econd, as with some other ps ychiatric diagnosing eating disorders involves imposing limits on what are dimens ional features , such as weight loss and attitudes toward weight and s hape. Although eating disorders as formally defined by the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) afflict approximately 3 to 5 percent of the female population approximately one-third as many men, s ubs yndromal forms of eating disorders are widely present and caus e great distress , es pecially in the quality of life of who struggle to achieve the widespread overvalued for thinnes s in women and lean muscularity in men. F urthermore, eating dis orders are culture-bound with varying prevalence according to s ocial norms in different cultures and countries—a vas tly different situation from schizophrenia or manic-depres sive whos e rates of prevalence are ess entially uniform the world. T hird, eating disorders rarely pres ent as sole diagnostic entities ; they are almos t always by significant comorbid disorders on Axis I and Axis II. C linicians have made rapid progress in earlier of eating disorders , and several evidence-based treatments have been validated. F amilies , teachers , 2268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 3 of 107

athletic and dance coaches, and clinicians are all more aware of thes e disorders than they were before the 1980s when anorexia nervosa firs t became a media and the syndrome of bulimia nervos a was just widely publicized. B efore this time, anorexia nervosa, es pecially, was cons idered a rare and obs cure times dismiss ed as a willful and voluntary fad, afflicting upper-clas s white girls . Anorexia nervosa before 1980 only slowly recognized, if at all, usually after extensive “rule-out” medical inves tigations. T he death of the K aren C arpenter in 1983 represents a watershed in awarenes s, as her death from anorexia nervosa on public cons ciousnes s the presence and serious ness the disorder. 

DE F INIT IONS



NOS OLOG Y



E P IDE MIOLOG Y



E T IOLOG Y



V ULNE R AB ILIT Y : P R E DIS P OS ING F AC T OR S



P R E C IP IT AT ING F AC T OR S



S US T AINING F AC T OR S



INIT IAT ING AND S US T AINING



DIAG NOS IS AND C LINIC AL F E AT UR E S



DIAG NOS T IC C OMOR B IDIT IE S





LAB OR AT OR Y E XAMINAT ION AND C LINIC AL P AT HOLOG Y DIF F E R E NT IAL DIAG NOS IS 2269

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 4 of 107



C OUR S E AND P R OG NOS IS



T R E AT ME NT OF E AT ING DIS OR DE R S



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DE F INIT ION

DE FINITIONS P art of "19 - E ating Dis orders " T he two major categories of eating dis orders are nervos a and bulimia nervos a, but partial and syndromes abound, and transitions from one to form of these dis orders —for example, from anorexia nervos a to bulimia nervosa, or full syndromes to subclinical s yndromes—is common. T he term anorexia nervos a is derived from the G reek for “loss of appetite” and a Latin word implying nervous origin. T he words us ed to label anorexia nervosa, and eating dis orders in general, vary greatly from language language, with rich implications . T he G erman term for anorexia nervosa, puberte ts maigres ucht (thinness of adoles cents), captures only a portion of the dis order but, in some ways, is a clearer term linguis tically than anorexia nervosa, the term now embedded in the language. T he F rench have called anorexia nervosa anorexie mentale (mental anorexia) and anorexie (hysterical anorexia) and define eating disorders as “disorders of alimentation.” Anorexia nervosa is a syndrome characterized by three 2270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 5 of 107

es sential criteria. T he first is a s elf-induced s tarvation significant degree—a be havior. T he s econd is a drive for thinness and/or a morbid fear of fatness —a ps ychopathology. (T he es sential psychopathology tightly linked to overvalued beliefs , primarily the overvaluation of thinnes s. T he drive for thinnes s ps ychopathological motif has been emphas ized more Americans , beginning with Hilde B ruch, whereas the morbid fear of fatness , the phobic avoidance of normal weight, has been emphasized more by the B ritish.) T he third criterion is the presence of medical s igns and symptoms resulting from s tarvation—a phys iological s ymptomatology. (In the pas t, amenorrhea for three or more months consecutively was s pecifically required. A sounder approach is to document significant general medical symptomatology secondary to s tarvation rather than only reproductive hormone abnormality). Anorexia nervos a is often, but not always, ass ociated with disturbances of body image, the perception that one is distress ingly large des pite obvious medical starvation. distortion of body image is dis turbing when pres ent, but not pathognomic, invariable, or required for diagnos is . P.2003 more s ummary integrative transdiagnos tic theme in all anorexia nervosa subtypes and subsyndromal variants the highly disproportionate emphas is placed on as a vital s ource, s ometimes the only source, of selfes teem, with weight, and to a les ser degree, shape, becoming the overriding and consuming day-long preoccupation of thoughts , mood, and behaviors . T wo s ubtypes of anorexia nervosa exis t with much 2271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 6 of 107

and frequent transitions between them, especially from the res tricting subtype to the binge and/or purge In the class ic his torical form of anorexia nervosa, approximately 50 percent of cas es , food intake is res tricted (us ually with attempts to cons ume fewer than 300 to 500 calories per day and no fat grams ), and the patient may be relentles sly and compuls ively with overus e athletic injuries. In the second s ubtype, and/or purge, patients alternate attempts at rigorous dieting with intermittent binge or purge episodes , with the binges , if pres ent, being either s ubjective (more the patient intended, or due to social press ure, but not enormous) or objective. P urging repres ents a compens ation for the unwanted calories , most often accomplis hed by self-induced vomiting, frequently by laxative abuse, les s frequently by diuretics, and occasionally with emetics. S ometimes repetitive occurs without prior binge eating, after ingesting only relatively few calories. T he term bulimia nervos a derives from the terms for hunger” in G reek and “nervous involvement” in Latin. B ulimia nervosa repres ents in many ways a failed at anorexia nervos a, sharing the goal of becoming very thin, but occurring in an individual less able to s ustain prolonged semi-starvation or s evere hunger as cons istently as clas sic res tricting anorexia nervos a T hese eating binges provoke panic as individuals feel their eating has been out of control. T hey experience significant panic-laden conflict between their phys iologically driven eating behavior from hunger, on one hand, and the deep-seated desire to be thin on the other hand, with the anxiety heightened by the 2272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 7 of 107

morbid fear of fatnes s. T he unwanted binges, creating ps ychological and phys ical distress , in turn lead to secondary attempts to avoid the feared weight gain by variety of compens atory behaviors, s uch as purging or excess ive exercise. Later, the binges tend to be more typically initiated by dysphoria and often become intractable at that point. Occasionally, a bulimia patient begins directly by purging, often after media information describes purging in detail, s ometimes after inappropriate teaching efforts focusing on s ymptoms , after receiving a “tip” from a friend s uggesting that purging is a quick way to lose weight. B inge epis odes (defined as repeated epis odes of overeating large quantities of food that is generally of dense caloric content rapidly and us ually privately, to guilt, anxiety about becoming fat, low s elf-es teem, frequently gas tric distress ) are behaviors shared several eating disorder s ubtypes . R egular binge and/or purge epis odes may occur with low body weight (in case it is class ified as a subtype of anorexia nervos a), normal weight individuals (mos t typically bulimia or in overweight persons as manifes tations of bingedisorder (without any compens ation). In bulimia compens ation for binge epis odes is carried out mos t commonly by purging through self-induced vomiting or laxative abuse (approximately 80 percent of cases ), a s econd subtype of bulimia nervosa (20 percent), it is carried out by “other compens ation”—us ually even stricter dieting or heroic exercise or both. P atients who binge eat but do not compens ate in any after binge eating are often medically overweight or obese, generally somewhat older (30s to 50s), and are 2273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 8 of 107

likely to be male as female. T hes e patients meet binge-eating dis order, an eating dis order subtype currently considered a res earch diagnos is within eating dis orders not otherwise specified, a category logically cons tituting a third subtype of bulimia nervosa, not a res idual or “atypical” category. In general, presenting with bulimia nervosa for s pecialized differ from thos e untreated in the community, where of nonpurging s yndromes equal thos e of the purging forms. T he term binge , ess ential for the diagnosis of bingesyndromes, pres ents challenges in definition, although these may be more pertinent for res earch purposes for actual clinical practice. T he exact dis tinction s ubje ctive binge (eating more than one ostens ibly or physiologically requires, even if a s mall amount) and objective binge (eating what anyone would cons ider to abnormally large amounts [often 2,000 to 5,000 food that is usually sweet and high in fat; food is eaten quickly to the point of medical and/or ps ychological distress , often in private, and is mos t times as sociated secrecy or s hame) is undecided, as they blend into other. S ubsyndromal eating dis orders and variants that lack required diagnostic feature of the current criteria are cons idered to belong to the category of eating dis orde r otherwis e s pecifie d. T his category is overly large, often representing 30 to 50 percent of admis sions to experienced eating disorder programs . P atients with eating dis order not otherwis e s pecified are no less ill no les s respons ive to treatment than those with or bulimia nervos a, but the category is confus ing in its 2274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 9 of 107

terminology and implication. C urrently, approximately percent of patients with eating dis order not otherwis e specified would fit into a slightly revised, more based scientific approach to diagnos is of anorexia primarily, and bulimia nervosa to a less er extent. Understanding definitions of eating disorders requires appreciating the concept of overvalued beliefs . many clinicians alternately view the ps ychopathology underlying the abnormal eating of eating-disordered patients as being either obsess ive-compuls ive in deriving from delusional beliefs, neither concept adequately captures or repres ents the characteristic es sential ps ychopathology s een most commonly in disorders . Overvalued beliefs, which are behind most of world terrorism, are als o the driving force behind eating dis orders. O ve rvalued beliefs are defined as culturally normative beliefs that have been ass igned disproportionate and ruling pass ion in an individual's and come to dominate that individual's thinking, emotions , and behaviors . T he behaviors res ulting from these overvalued beliefs are, at their extremes , ris ky life threatening, whether the behaviors are dangerous the individual (anorexia nervosa) or to others T hese beliefs are not fixed and fals e, as are beliefs delus ions, nor are they ego-dystonic thoughts or as required for a diagnos is of obsess ive-compuls ive disorder (OC D). T hinking about losing weight is normative in American s ociety. However, regulating every waking moment and mood around the overriding importance of slimnes s and how to achieve it ps ychopathological category bes t described as an overvalued belief. Unders tanding the nature and 2275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 10 of 107

of overvalued beliefs seems es sential for treating disorders in a comprehensive and enduring manner. Using this functional definition of eating disorders — abnormalities of eating behavior driven by overvalued beliefs that lead to medical, s ocial, and ps ychological cons equences—eating dis orders have a long his tory. R oman practice of gorging and vomiting in “purgatoriums” at fancy dinners was not an eating disorder, but s imply culturally condoned gluttony. to real eating disorders were P.2004 the fas ting practices of the G nostic sect of C hris tian the fourth century who s elf-starved because of the that material objects , including food, were evil. In the practice of their as ceticis m, they spent years on top of pillars in the desert consuming very little food, to the of severe self-starvation. During the Middle Ages , were generally treated as s econd-clas s citizens, with exception of those demonstrating exceptional holines s. F emale holiness in that era was mos t commonly by denial of the body through chastity, self-denial, and, es pecially, fas ting to the point of emaciation. In these instances, the patterns of res trictive eating became sustaining and ego-syntonic, immune to pleas or change from thos e around, forming the core of lifelong identities , even if life was s hortened by these acts. R eas onable attempts to as sign eating disorder through biographical analysis to his torical figures such Lord B yron are interes ting exercis es, but thes e are dis tinctly less s ecure than thos e based on early reports of s pecific cas es . R ichard Morton, physician to 2276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 11 of 107

court of E ngland, des cribed two cas es in 1689—a boy a girl—that conformed reasonably well to current diagnostic criteria for anorexia nervos a. T hese two were young people with “cares of the mind” who took to fas ting and were noted to s uffer emaciation without medical causation. Although more contemporary medical identification of anorexia nervosa was hinted at in several reports from phys icians in the early 1800s , it was most clearly almos t at the same time, by S ir W illiam G ull in London Dr. C harles Las égue in F rance in the 1860s and phys icians described cases of self-starvation, primarily upper-clas s young girls , but “occasionally seen… in at the same age,” “distinguishing them clearly from with medical causation.” S ir W illiam described anorexia nervos a with the clarity pos sible only in an era in which treatments were les s available and time for clinical observation was greater. In his words , “T he want of appetite is, I believe, due to a morbid mental state.” He prescribed “food… adminis tered at intervals varying invers ely with the exhaustion and emaciation. T he inclination of the patient mus t be in no way cons ulted. patient should be fed at regular intervals and by persons who would have moral [i.e. psychological] control over them, relations and friends being generally the wors t attendants .” T he keen obs ervation may s till applicable in certain instances. Laségue captured the dilemma of a family of anorexics, noting that the patient was not res pons ive to either “entreaties or menaces ,” sound couns el to families and phys icians . T he s ocial isolation of these patients was captured as well: “the circle within which 2277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 12 of 107

revolved the ideas and s entiments of the patient more narrowed… what dominates in the mental is … almos t a condition of contentment truly pathological… she is not ill-pleas ed with her condition.” He anticipated the future warning of Hilde B ruch to letting patients quickly “eat their way out of hos pital” by cautioning that “as a general rule we must look forward a change for the better only taking place s lowly.” In the late 1800s, anorexia nervosa was temporarily confused with postpartum pituitary necros is, leaving a lasting, even if dis proved, as sumption that s ome abnormality of endocrine function was implicated in the origin of anorexia nervosa. E arly in the 20th century, the pendulum of etiological as sumptions s wung toward early, primitive hypothes es, leading to searches for ps ychoanalytic themes, s uch as “fear of oral impregnation,” and then attempts to work through thes e s exual conflicts with ps ychoanalytic methods . A much more contemporary, ps ychodynamically oriented approach was initially formulated by Hilde B ruch in the 1950s . In the 1960s, modem era of phenomenological description and pragmatic treatment of anorexia nervosa relatively free theoretical bias was initiated in E ngland by G erald Arthur C ris p, P ierre B eumont, and others . R us sell described bulimia nervos a in 1979, using the ne rvos a to unite the two forms of the eating dis orders spectrum—the self-starving syndrome of anorexia and the newly recognized binge–purge disorder— ps ychopathologically. B ulimia nervosa was initially described as “an ominous variant of anorexia nervosa,” later descriptions incorporated the s yndrome of bulimia 2278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 13 of 107

nervos a at normal weight. T he recognition of bulimia nervosa was hidden for a number of reasons, including the shame and secrecy sufferers, who were reluctant to reveal these symptoms even while being treated for other related comorbid disorders , such as depress ion; the seemingly normal weight of most bulimic patients; and the lack of for help. T he “night-eating binge s yndrome,” by often unremembered binge eating while still in s ome stage of s leep, is even more difficult to diagnos e, but increasingly is recognized as a true variant. Des pite the relatively recent formal des cription of bulimia nervosa, evidence-based treatment s trategies have emerged quickly and have proven more effective than thos e for anorexia nervosa. T he recent his tory of eating disorders has focused on several areas , including (1) better delineation of the noncompens ating binge-eating disorder, (2) clearer descriptions of the prevalence and syndrome characteristics of eating disorders in men, and (3) recognizing the contributions of genetic and other predis pos ing neurobiological factors interacting with sociocultural norms . Only recently has there been recognition that the overvalued beliefs driving men with eating dis orders may vary cons iderably from thos e women. It is almos t entirely in men that a s till-evolving diagnostic s ubtype—a mirror image of anorexia called re vers e anorexia nervos a —is found, the distorted perception that one is too thin, too small, and not muscular enough despite even heroic and outwardly s ucces sful efforts at mus cular development. His torical trends in food availability have s hifted 2279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 14 of 107

significantly. In the 18th and 19th centuries , food was readily available only to the prosperous . In general, was les s social press ure for extreme thinness , except upper-clas s families in which women corseted merciles sly to achieve impos sibly thin waists . B y the 20th century, fatty, palatable foods were available to populations in Western countries , and, paradoxically, fat foods became particularly cheap and available for many low-income populations . Obes ity has become more prominent among all social clas ses, particularly poorer populations . C oncurrently, press ures to be thin, weight control efforts , and eating disorders as clinical problems have become increasingly ass ociated with affluent s ocieties. It has been hypothesized that there always been a small number of cas es of anorexia that are primarily genetic in origin, and this core group been augmented s ubs tantially by the influence of sociocultural norms that mandate thinnes s, res ulting in current prevalence of anorexia nervos a, which blend of genetic and sociocultural factors . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > NO S O LOG Y

NOS OL OGY P art of "19 - E ating Dis orders " Nos ology, the art and s cience of class ification, remains challenging in eating disorders for several reasons. disorders are, firs t of all, culture-bound dis orders primarily within cultures that promote s pecific norms for body weight and shape. T heir core features are 2280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 15 of 107

uniform acros s cultures , but, unlike s chizophrenia, their prevalence varies widely acros s cultures . S econd, disorders are bes t des cribed as s yndromes, not as fundamentally P.2005 unders tood dis eases with proven etiologies and mechanisms. Questions regarding the etiology and pathophys iological mechanisms of eating dis orders are still hotly debated without clear agreement as to the relative contributions of ps ychos ocial and biomedical factors . In general, a multifactorial caus ation is C omplexities in class ification of eating disorders can be appreciated by recognizing the different names us ed anorexia nervosa in different languages and over time. Although the term anorexia ne rvos a derives from S ir William G ull's pres entation to the clinical s ociety of in 1873, this appellation represents only one attempt at capturing the nature of the dis order by a name an etiology. Many countries now use the term anorexia ne rvos a but, for the es sential meaning of the disorder, rely on the prevailing criteria listed in either DS M-IV -T R the tenth revis ion of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d H ealth 10). Although labeling the self-starving form as anorexia nervos a is, for now, a fait accompli, the propriety of this term is in question, as the dis order does not result from true “anorexia,” or los s of appetite, especially at the in contras t to the anorexia of cancer or acquired deficiency syndrome (AIDS ). No abnormality of brain mechanism mediates any initial los s of appetite, 2281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 16 of 107

the proces s leading to the full s yndrome of anorexia nervos a; appetite los s occurs only in the s evere s tate emaciation, sus tained perhaps by ketos is, but the of medical anorexia is quite variable. T he term ne rvos a is embedded in the E nglis h language, until there is consensus for a more us eful descriptive E nglis h phras e. T he term bulimia nervos a better the core behavioral feature of that syndrome. E ven the location of eating dis orders in the DS M-IV -T R has changing views on clas sification. In third edition of the DS M (DS M-III) and the revised third edition of the DS M (DS M-III-R ), eating disorders were clas sified under disorders of childhood or adolescence, perhaps, in contributing to previous underdiagnos is of later-onset cases. It was only in DS M-IV -T R that eating disorders moved to a s eparate and independent section. T he case could be made that all s ubtypes of eating disorders could be most usefully regarded as part of an overarching unitary s yndrome—simply, eating in view of the common natural his tory of trans itions one s ubtype of eating disorder to another. A transdiagnos tic approach appreciates the s hared underlying features of all eating dis orders—an overvaluation of thinness or s hape change, sus tained abnormal eating behavior, and functional impairment medically, socially, and ps ychologically. A approach also can shape an integrative treatment approach to all eating disorders , with layered additional specifics for each subtype. T here is als o merit, retaining s ome identity among the several eating variants bas ed on differences in predis position and cours e. T he “lumping” versus “splitting” approaches to 2282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 17 of 107

clas sification of eating dis orders both have merits and drawbacks . Ultimately, a more scientific approach to clas sification must await more fundamental of etiology and mechanism. P revious efforts to class ify eating dis orders as mood disorders have been found wanting becaus e disorders “breed true,” without evolving into mood disorders or other dis orders . Attempts to unders tand eating disorders as primary forms of OC D have also faltered. T hey have res is ted clas sification as ps ychotic disorders , des pite hints at this etiology in earlier before more rigorous modern definitions of such as the U.S .–U.K . s tudy of schizophrenia. incompletely unders tood, eating disorders , as a unitary group or as separate s ubtypes , are clearly dis tinct ps ychiatric disorders not s ubsumed into any other ps ychiatric disorder. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > E P IDE MIO LOG

E PIDE MIOL OGY P art of "19 - E ating Dis orders " E pidemiology concerns the prevalence and incidence disorder, as well as the sum of factors as sociated with onset and course of that disorder. T he thornies t is sues related to accurate epidemiology of eating disorders been threefold: (1) the changing definition of what cons titutes an eating dis order, (2) the previous presentation of eating dis orders by their phys ical 2283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 18 of 107

cons equences in forme frus te s as medical disorders , the lack of recognition by health profes sionals until recently of even clear cas es of eating disorders widespread lack of clear diagnostic criteria and reliable as sess ment methods, especially for the cases in males , minorities, and matrons . T he is sue for determining the epidemiology of eating disorders , as with a number of other disorders , is where to draw the line s eparating the large majority of women and men who are merely diss atisfied with their weight and s hape from thos e who have the full syndromes. S eventy percent of young women, by highschool age, not only des ire thinnes s, but als o practice dieting behavior. W ith young men, equal dis satis faction with body s ize and s hape reigns , but the des ire to weight in the form of lean mus cle mass matches the to los e weight. It is s imply normative for mos t women, increasingly for men, to at leas t give lip service to the to los e weight. Defining eating dis orders epidemiologically involves problems s imilar to thos e that occur when defining hypertens ion, another dis order that involves using somewhat arbitrarily imposed categories —presumably built on s tatistical probabilities of current and future impairment and risk—to separate clinically s ignificant cases from others . A helpful trend in general medicine been to move from hypertensive versus not or diabetic versus not diabetic cases to the s pectrum of normal to prehypertens ive to clear clinical With these caveats and examples in mind, there is cons ens us that approximately 1 percent of young have class ic anorexia nervosa and that 2 to 4 percent 2284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 19 of 107

young women meet criteria for bulimia nervos a as in DS M-IV -T R . T he healthiest end of the spectrum is composed of individuals with normal eating and no preoccupation with weight or shape (approximately 15 percent; “normal controls” are difficult to find for on eating behavior), and then there are thos e who are simply preoccupied with weight and body image (70 percent of the general population), and finally there are distinctly dis ordered individuals with partial or full disorders interfering with normal development or daily life. Approximately 20 percent of college women experience trans ient bulimic symptoms at some point during their college years, and approximately 5 percent have mild forms of anorexia nervos a. Likewise, approximately 17 percent of high s chool boy wrestlers meet s hort-term criteria for an eating dis order during active s ports s eas on. Although the number of college students with eating disorders remains relatively the specific individuals who have an eating dis order on admis sion to college are not always the individuals who have features of an eating dis order on graduation. T ransient eating disorder symptoms are common. T he lifetime prevalence of individuals with an eating disorder is approximately three times that of current prevalence. Much argument has taken place about whether eating disorders are increas ing in incidence. bulk of studies s uggest a true increase in new cases, es pecially of bulimia nervos a, recognizing that the current prevalence rates probably represent a combination of actual new cases and better recognition previous ly undiagnosed cases. P.2006 2285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 20 of 107

T he larges t background epidemiological factor predis pos ing to eating disorders is a culture that values slimnes s and, in the cas e of men, lean muscularity. preoccupation can only take place in large numbers in population when there is s ufficient food to make poss ible, and, concomitantly, when social norms stigmatize overweight individuals . T here is little ps ychological purchase to be gained from selfin a poor, developing country in which starvation is common. As a society becomes more prosperous , with increased availability of densely caloric foods (fats and sugar), and increas ingly values s limness and lean muscularity, eating disorders increase in prevalence, starting with a few individuals who are perhaps predis pos ed, such as appears to be the case in days , and progres sing to a much larger contemporary population who come to see dieting as a seemingly obligatory rite of pas sage to a s tate of thinnes s to be mandatory for success or happines s. Obes ity is much more common in lower- than uppersocioeconomic clas ses in American s ociety, and stigmatization of obes ity is common, sugges ting that, although anorexia nervos a is becoming more widely distributed among cultures and social clas ses, s ome women s till s ee anorexia nervos a as a badge of upperstatus . However, this thesis does not hold for bulimia nervos a. R ecent studies s uggest that bulimic symptomatology is equally pres ent in all clas ses . E ating dis orders are among the most gender-divergent disorders in ps ychiatry, but the divergence is 2286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 21 of 107

narrower than previous ly believed. P revious estimates the ratio of men to women for eating dis orders were typically 1 in 20 to 1 in 10. E xcellent recent communitybased epidemiological s tudies , however, found a ratio two women to one man for the combination of full- and partial-syndrome anorexia nervosa, and a ratio of three one for bulimia nervosa. T his s tudy s ugges ts that a large unidentified population men with eating dis orders exists in American s ociety that the gender ratios present in clinical s ettings do not reflect actual community prevalence. T he trend for men during the 1970s to follow women in increas ingly slimnes s appears to have been reversed in the 1980s, perhaps because of the increasingly common media pictures of emaciated gay males with AIDS that began appearing in the media at that time. S ince then, in both the gay and heterosexual male communities, there has been an increasing value placed on lean mus cularity than on thinness alone, with the ideal in the gay community being more lean mus cularity rather than the caricature of huge muscular development. B eing a gay man is a documented ris k factor for developing an disorder, but the mediating variable relates to the ideal body image of virtually impos sible phys ical perfection, the sexual orientation or behavior of the man. R ecently, clinicians have come to recognize a s till incompletely defined but clinically s ignificant dis order, occurring primarily in men, that is in many ways the mirror image typical anorexia nervos a, called re vers e anorexia, (linguistically ugly, albeit descriptive), body dys morphic dis order (most common), or, most s ensationally, the complex. In these disorders , which are often 2287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 22 of 107

by steroid abuse, men perceive that they are still too in size or too thin, despite huge objective muscle development. T his variant of life-dominating body dysmorphic dis order is characterized by a des ire for impos sibly low body fat along with huge, clearly muscle mas s. B inge-eating dis order appears in approximately 25 of patients who s eek medical care for obes ity and in 50 75 percent of thos e with s tage III obes ity. It is in s ome the most subtle eating dis order and the lates t to be described because of patients ' lack of dramatic purging behavior, seemingly blending in with obes ity is erroneously, but commonly, attributed to lack of will. Although eating disorders have been des cribed in ranging from prepubertal ages to those in the ninth decade of life, peak ons ets most commonly occur in early and late teens. E xtremely early cases —in those younger than 5 to 7 years—almos t certainly repres ent patterns of abnormal eating behaviors that differ from anorexia nervosa and bulimia nervosa and are due to caus es, such as medical or neurological conditions . may als o represent childhood behavioral express ions anger, defiance, and fear or may represent attempts to control family dynamics , such as occurs with breath holding. S adly, s ome emaciated young children without obvious medical illness may s uffer from parental deprivation of food (Munchausen syndrome by proxy). Lastly, finicky appetites can be taken too serious ly by worried parents. Although worries about weight and shape, with res ulting dieting behaviors, are being seen earlier ages, true anorexia nervos a and, less bulimia nervosa, as defined here, do not occur below 2288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 23 of 107

age at which children can internalize fat phobias or overvalue social norms of slimnes s. A type of imitative eating dis order occurs in young children who mirror abnormal eating behaviors s een in parents , such stepping on a scale frequently or trying to induce after a meal. A final epidemiological theme is that eating dis orders rarely s een as solitary psychiatric disorders . T hey are almos t invariably ass ociated with two to four additional comorbid diagnos es on Axis I and Axis II of DS M-IV es pecially mood, anxiety, obsess ive-compuls ive, body dysmorphic, and s ubs tance abus e disorders on Axis I personality vulnerabilities and disorders on Axis II. Anorexia nervosa, restricting subtype, is usually with C lus ter C personality dis order, whereas bulimia nervos a is more likely to occur with C lus ter B traits or disorders . T he probability of having s ome diagnosable personality dis order is significantly greater in with eating dis orders than it is in the general T he cours e and prognosis of any given case is strongly influenced by these comorbid conditions , particularly nature and intensity of any pers onality disorders or preexisting mood disorders , anxiety dis orders , or Mood dis orders are es pecially common in bulimia with es timates of 50 to 70 percent comorbidity being typical. C aus al relations hips and interactions , including poss ibility of some s hared vulnerabilities between disorders and eating dis orders, are complex and controvers ial. In approximately equal numbers does depres sion precede bulimia nervos a, bulimia nervosa precede depres sion, and the two conditions appear concomitantly. C las sic s tudies have documented that 2289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 24 of 107

emotional blunting, social is olation, and frank may result from s evere weight los s alone. T able 19-1 summarizes some of the epidemiological factors eating disorders .

Table 19-1 E pidemiologic al R is k Fac tors R elated to E ating C ultural: S ocietal endorsement of weight loss dieting Gender: W omen > men (2:1 to 3:1 in community; 10:1 to 20:1 in clinical series ) Age: P eaks occur at early and late teen years , onset can be prepubertal through 8th decade. Prevalenc e: Anorexia nervosa, approximately young women; bulimia nervos a, 2–4% of young women (full s yndromes, DS M-IV -T R /IC D-10) Family dis orders : E ating dis orders, affective disorders , obesity Family patterns : E nmes hed or disengaged S oc ioec onomic clas s : Anorexia, pos sibly ↑ social class ; bulimia, independent of s ocial clas s

2290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 25 of 107

Pers onality role: ↑ probability of a personality disorder; anorexia, ↑ with C lus ter C ; bulimia, ↑ C lus ter B Prior ps ychiatric dis turbanc e: C hildhood and adoles cent anxiety, mood, and obs es sivecompuls ive disorders Pubertal age: ↑ with early puberty, especially pubertal obesity, for girls Monozygotic to dizygotic ratio: 3:1 Monozygotic twin c oncordanc e: ≥ 50% R ural vs . urban: ↑ with move from rural to setting S exual orientation: ↑ with gay orientation; poss ibly ↓ with les bian orientation Medic al c omorbidity: P os sible ↑ with type I diabetes mellitus (controversial) Prior phys ic al, emotional, or s exual abus e: Nons pecific ↑ in all ps ychiatric dis orders, not specifically eating disorders Premature mortality: 0–19% on 10- to 20-yr up after hos pitalization (medical causes , clos ely 2291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 26 of 107

followed by s uicide); anorexia nervosa plus dependent diabetes mellitus ↑ mortality 10 times either anorexia or diabetes alone Voc ational, avocational ris ks : B allet, modeling, amateur wres tling, vis ual media roles, sports (female gymnas tics, figure s kating), sports (jockey, cross -country running, lightweight crew)

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > E T IOLO G Y

E TIOL OGY P art of "19 - E ating Dis orders " C urrent etiological thinking about eating dis orders involves s everal principles and an integrating F irst, eating disorders are disorders of eating behavior. other factors may be pres ent (overvaluation of body image dis tortion), but, without abnormal eating, there is no diagnosable dis order. E ating dis orders represent in s ome ways a “highjacking” of normal neurobiologically regulated eating behaviors , which become distorted and overridden until the abnormal eating pattern becomes autonomous , res ponding to the continued drive for thinness and the neurobiological conditioning about normal weight. S econd, although 2292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 27 of 107

analogy may eas ily P.2007 be overdone, s imilarities exist between eating and drug abuse in that abnormal eating, whether selfstarvation or binge–purge behaviors, produce immediate emotional changes that include initial relief dysphoria and production of excitement but res ult in more dysphoria, a vicious circle. T hird, biological theories are popular and are being actively res earched, no convincing evidence yet exis ts that disorders derive primarily from preillness s tructural or functional abnormalities of the brain; eating disorders , however, do res ult in profound consequences to the not neces sarily all fully revers ible. T he s earch for brain abnormalities as the caus e of eating dis orders is unders tandable but may prove too simplis tic. A more complex, multifactorial etiological approach may better account for current data. G enetic contributions are certainly involved, es timated from 40 to 60 percent, but less so in a deterministic manner, as with Huntington's chorea or even bipolar dis order, and more likely in a contributory manner, by increas ing the pres ence and strength of risk factors , such as pers evering, s ens itive, fearful, or impuls ive personality traits , or through more easily dis rupted regulation of s erotoninergic when dieting occurs. T hus, eating dis orders may pres ently be best conceptualized as probabilistic, as overdetermined disorders with multiple contributing causes, none of which—besides dieting behavior—is now known to be absolutely ess ential. T he most compelling perspective 2293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 28 of 107

recognition that eating disorders probably derive from a clus ter of predis pos ing vulnerability factors (imagine kindling wood) reacting to precipitating events , those occurring during vulnerable “windows” in development (the match for the fire to start), and are maintained by s ustaining social, psychological, and biomedical reinforcements (the wind, oxygen, and lack rain that keep the fire burning). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > V ULNE R AB ILIT Y : P R E DIS P O S ING

VUL NE R AB IL ITY: PR E DIS POS ING FAC TOR S P art of "19 - E ating Dis orders " It is doubtful that individuals who are not predis pos ed with typical known ris k factors can develop true eating dis orders, even with dieting behavior. F or an extroverted young woman with an internal rather external locus of control who grew up in a balanced, supportive family, who poss es ses high ass ertiveness , self-accepting body image, is average in weight, and no family history of affective dis order or obes ity is a doubtful candidate for an eating disorder, even if she practices brief dieting to meet job (e.g., modeling) or avocational (e.g., ballet) requirements.

B iologic al Vulnerability B iological theories of the etiology of eating disorders began hundreds of years ago and culminated in the 2294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 29 of 107

1800s with the pronouncement that anorexia nervos a caus ed by postpartum pituitary necros is . Although this theory was soon disproved, a variety of s ubsequent theories have been advanced focus ing on putative biological underpinnings—for example, the hypothes is that s ome predis pos ing hypothalamic abnormality evidenced by amenorrhea. However, convincing have demons trated in volunteers willing to starve thems elves to 15 percent or more below their normal weights that virtually all the endocrine abnormalities characteristic of anorexia nervosa are abs ent before starvation, only appear as weight declines , and return normal when weight is restored. S everal lines of evidence s uggest genetic vulnerability, including high rates of familial trans mis sion. T win demonstrate a high concordance in monozygotic twins, approximately three times higher than in dizygotic suggesting that both genetic and ps ychos ocial contributions are operative. Monozygotic twins are documented to have a 50 to 80 percent concordance for eating disorders . E xactly what is being inherited remains controversial. G enetic factors definitely contribute, probably through multiple effects on temperament, cognitive s tyle, pers onality, moodregulating tendencies , s et points for weight, and predis pos itions toward phys ical activity. R es trictinganorexia nervosa, in contrast to bulimia nervosa, may require a s pecific genetic endowment of perseverance, sens itivity, perfectionis m, and low impulsivity to allow development of s us tained food restriction and maintenance of a severely starved s tate, impos sible for most people who are offered options to eat. Impuls ive 2295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 30 of 107

extroverted personality s tyles increase the probability binge eating–purging dieting cycles . P ersonality, a heritable variable, plays a major role in the probability developing any eating dis order and its specific subtype. T he identification of genetically derived animal models anorexia nervosa is als o intriguing. T ake, for example, sow” disease. During breeding experiments , sows that s tarved themselves produced thinner hogs. Active searches are under way to identify genes that may contribute to the development of models, including research on knock-out gene models, increasing or decreas ing genes related to fear and avoidance. T he complexity of the tas k of identifying specific genetic contributions to eating dis orders is enormous. T o date, more than 200 genes have been identified that contribute to eating, activity, and weight regulation alone in simple s pecies, with new regulatory genes or gene interactions s uch as daf-2 cons tantly described. P.2008 C ontemporary theories have pointed to putative mechanisms, largely bas ed on observations that individuals with anorexia nervosa have abnormal cerebrospinal fluid (C S F ) serotonin levels when ill, that may not completely revers e on partial weight gain. date, no firm data are available s howing that s erotonin abnormalities exis t in vulnerable populations before the onset of an eating dis order. However, thes e hints have stimulated s tudies into the pos sibility that variations in genetically mediated s erotonin regulation may be important predisposing factors, perhaps increasing 2296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 31 of 107

vulnerability to stress ful situations , a more indirect and interactive mechanism of diathes is interacting with during vulnerable periods . Although molecular genetic research of thes e disorders in its infancy, promis ing areas for inves tigation have already pointed to the potential importance of serotonin mechanisms, among others . G enetically interesting loci and polymorphis ms have been as sociated with genes the 5-hydroxytryptamine type 1B (5-HT 1B ), type 2A (5HT 2A ), and type 2C (5-HT 2C ) receptors , uncoupling 2 (UC P 2) and 3 (UC P 3), beta-type estrogen receptor, hS K C a3 potass ium channel, and human agouti protein. illus trate, a polymorphism in the coding region of the for the 5-HT 2C receptor s ubtype resulting in a cysteine serine s ubs titution has been reported in 23.7 percent of adoles cent girls reporting weight los s compared to 7.7 percent of normal-weight girls . In studies of the human agouti-related protein gene (related to an orexigenic neuropeptide), two alleles have been found to be in complete linkage disequilibrium and are s ignificantly enriched in anorectic patients (11 percent; P = .015) compared to controls (4.5 percent). S everal large-scale linkage and ass ociation s tudies are under way. T o areas of particular interes t have been identified on at chromosomes 1, 2, and 13. B ut, on the whole, the percentage of occurrence explained by thes e s pecific genetic ass ociations is still quite s mall. P opulation suggest that genetic factors may, overall, contribute approximately 50 percent or more to the appearance of anorexia nervosa and bulimia nervosa. T heories regarding potentially preexisting functional or structural brain dys functions have been proposed, but, 2297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 32 of 107

yet, no convincing preexisting abnormalities have been revealed or replicated. More research in this area can expected with the availability of s ophisticated imaging technology, with the goal of eventual pros pective of the brain imaging and neurobiological functioning of individuals who later develop eating disorders . T he most notable biological vulnerability factors are related to dieting and its attendant undernutrition. its elf is a major s tres sor to the nervous s ys tem, one for which the typical individual is evolutionarily prepared multiple mechanis ms to defend life in the s etting of famine, but it is nonetheles s stres sful in that it involves rearranging virtually every as pect of cognition and metabolism.

Temperament, P s yc hologic al, and S oc ial Vulnerability F amily trans mis sion repres ents a major vulnerability for eating disorders , with a family his tory of eating disorders , affective spectrum disorders , anxiety OC Ds , and obes ity contributing approximately equally. Mood dis orders are approximately four times more common in families of eating-disordered individuals in the community at large. T he exact mechanism by this family his tory predis pos es to eating disorders is unknown. Mood and anxiety disorders and OC Ds in childhood the early appearance of perfectionistic pers onality traits appear to be major vulnerability factors for the development of eating disorders , es pecially anorexia nervos a. In young girls with s haky self-es teem, teas ing family or friends, or comments and directives from 2298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 33 of 107

authority figures (doctors , nurses , teachers , coaches) regarding need to change weight and shape contribute vulnerability. Not uncommonly, children are weighed in clas s or by a s chool nurse for no credible reas on, with frequent long-term distress res ulting. Overall, twin suggest that approximately 17 to 46 percent of the variance in both anorexia nervosa and bulimia nervos a be accounted for by nons hared environmental factors . V ocational and avocational interes ts interact with other vulnerability factors to increase the probability of developing eating disorders . In young women, participation in strict ballet s chools increases the probability of developing anorexia nervos a at least sevenfold. In high s chool boys , wres tling is ass ociated a prevalence of full or partial eating-disordered during wrestling season of approximately 17 percent, a minority developing an eating disorder and not improving s pontaneous ly at the end of training. these athletic activities probably s elect for and persevering youth in the firs t place, press ures regarding weight and shape generated in thes e s ocial milieus reinforce the likelihood that these predis pos ing factors will be channeled toward eating dis orders. T he influence of family functioning s tyle as a potential predis pos ing factor remains controvers ial. No s ingle, specific family functioning style appears to be either a neces sary or sufficient requirement for developing an eating dis order. As in mos t psychiatric disorders , family dysfunctional styles appear to act as nons pecific vulnerability factors and also hamper recovery. routine blaming of families or the ass umption that they caus ative factors for an eating dis order in a child has 2299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 34 of 107

receded along with the invidious concept of the “schizophrenogenic” mother or the autis m-promoting parents . G iven the presence of other vulnerability enmes hed families that provide youth little room to individuate may be more likely to foster the emergence adoles cents with anorexia nervosa. S o-called negative expres sed emotion in families, in which blame and criticis m are heaped on the patient by other family members, may add cons iderable nons pecific s tres ses other vulnerabilities . T rauma aris ing from childhood or adoles cent phys ical, emotional, or s exual abus e clearly contributes to the likelihood that thes e abus ed individuals will later some ps ychiatric dis order, but not specifically an eating disorder. T here is no evidence that s exual abuse alone major cause of bulimia nervos a. T he unscientific of ass uming that sexual abus e underlies bulimia and us ing “recovered memories” to support this theory have produced much suffering and malpractice. Of when pres ent, a s exual abus e history requires and s ympathetic attention and decisions about “uncovering” versus “working through” techniques, with expert guidance. T he extent to which media simply mirror society or play active roles in contributing to societal overvaluation of thinness and dieting and the increased prevalence of eating dis orders remains controvers ial. R ecent studies from F iji sugges t that the introduction of popular television programs highlighting slimnes s and stigmatizing obes ity launched wides pread dieting behavior and new eating-disordered cases in that were previously unconcerned with thes e is sues . 2300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 35 of 107

R acial and ethnic factors per se offer no protection or predis pos ition to eating dis orders. T he only conferred by s pecific racial or ethnic groups is related the degree to which thos e groups promote weight los s shape change. A gay orientation in men is a proven predis pos ing factor, not becaus e of s exual orientation sexual behavior per se, but becaus e norms for albeit muscular slimnes s, are very strong in the gay community, only s lightly lower than for heteros exual women. In contrast, a lesbian orientation may P.2009 be slightly protective, as les bian communities may be more tolerant of higher weights and a more normative natural distribution of body shapes than their female counterparts. T he potential contribution of ins ulin-dependent as a predis pos ing factor to eating disorders remains uncertain. T he largest studies s uggest no actual eating dis orders in young individuals with type I but data are controvers ial, and the presence of insulindependent diabetes mellitus in a patient with anorexia nervos a may dis guise the eating disorder, and it complexifies treatment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > P R E C IP IT AT ING F AC T O

PR E C IPITATING FAC TOR S P art of "19 - E ating Dis orders " 2301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 36 of 107

Although no single predis pos ing factor is necess ary or sufficient by itself to lead to an eating disorder, the likelihood that an eating disorder will occur seems to be related to the number and s everity of predisposing risk factors . In almos t all patients , a s ympathetic and history will reveal one or a s mall number of events (often engraved indelibly in the patient's that interacted with thes e predisposing factors to the illness when the patient reacted to the event(s) with dieting behavior—us ually with food res triction, often exercise in addition, and rarely with initial purging only. approximately 95 percent of cas es , the eating dis order precipitated by dieting. In approximately 5 percent of cases, initial weight loss may be inadvertent accident requiring jaw wiring, flu, ulcer, etc.), but after some weight loss occurs for medical reas ons , s ocial or s elf-observation with a scale or mirror soon the des irability of the weight los s, and the patient now actively directs further weight loss by voluntary dieting. E ven less common is an iatrogenic onset, but this happens in teenagers . Once eating dis order patients firmly internalized a morbid fear of fatness based on overvalued belief in the neces sity for s limnes s, the is locked in until it becomes, in practice, autonomous self-perpetuating. F urthermore, blending exces sive exercise with dieting behavior appears to create a particularly risky combination. In another animal model activity anorexia, rats that are simultaneous ly food res tricted and given unrestricted access to an exercis e wheel often run themselves to death rather than eat. Numerous events have been identified as frequent precipitating factors for eating dis orders. T he mos t 2302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 37 of 107

common include events around puberty, es pecially if puberty is early and accompanied by higher-thanbody weight and the individual is sensitive to criticis m. R epugnance toward menses and s exuality in general is historically recognized to predis pos e to anorexia Many patients can identify the specific place, time, and content of the teasing, criticism, or even wellremarks about weight that launched the eating T hese defining moments remain clearly etched in the individual's mind, usually accompanied by feelings of shame or humiliation and followed by determination to reduce body weight. After much contemplation of the hurtful remarks or comparison with others who are thinner, the future eating-disordered patient growing dis satisfaction with body image, and dieting or without intens e phys ical activity begins in earnest. Depending on the temperament, pers evering traits, and impulsivity of the individual, the subtype of the eating disorder is generally predictable. A move to a new location, changes in schools, social or academic competition with peers , romantic disappointments , family illnes s or death, and the urging coaches , teachers, or phys icians to los e weight are all common precipitating factors . S exual abuse may be a precipitating event for a number of ps ychiatric including eating disorders. F amily discord, the ons et of mood dis order leading to a s elf-critical and worsened image, or spurts of weight gain from any s ource may stimulate dieting behavior as a means of increasing sens e of pers onal control, s us taining factors for weight loss attempts . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

2303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 38 of 107

> T able of C ontents > V olume I > 19 - E ating Dis orders > S U S T AINING F AC T O

S US TAINING FAC TOR S P art of "19 - E ating Dis orders " Most individuals who initiate severe dieting and experience various degrees of subclinical eating symptoms do not go on to develop full-blown, eating dis orders meeting full diagnostic criteria. Many serious dieters experience early, trans ient eating symptoms and either retreat to intermittent or subs yndromal s ymptoms or s top the abnormal eating behaviors completely as a learning experience. T he sustainers of sustained eating disorders involve a combination of external social reinforcements and internal, psychological, or physiological reinforcers. S ocial praise commonly provides external for further weight los s in s elf-critical, self-doubting, perfectionistic, pers evering individuals who have lost some weight through dieting or exercis e or both. S uccess ful weight los s may offer the first s ense of internally effective s elf-control when the proces s of puberty is overwhelming, when childhood is mourned, when adulthood appears unattractive and fearful, and when perfectionis tic tendencies prove inadequate for challenges of adolescence. Anorexia nervosa is an implicitly sanctioned pseudos olution to the exis tential challenges of adolescence. W ith rigid control of weight, the proces s s eems to be more controllable. After significant weight has been los t through dieting or purging, attempts at healthy eating may, in fact, 2304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 39 of 107

uncomfortable medical s ymptoms in the s hort run, such gastric bloating or fluid retention, that, in turn, lead to renewed dieting bas ed on the experience that normal eating is painful and imposs ible. T he exact which altered phys iological process es sus tain eating disorders are only s peculative. T hey putatively involve changes in opioids , neuropeptides , serotonin, leptin, ghrelin, cholecystokinin, neuropeptide Y , and other neurobiological molecules involved in the regulation of eating, hunger, satiety, and body weight. Negative express ed emotion in families may contribute poor prognosis by offering anorexia nervosa as a moderator of disturbing family emotions and anorexia can act as a regulator of family dynamics , unconsciously reinforcing its role as a neces sity for in certain families . F actors that s us tain anorexia and bulimia nervosa differ to s ome extent. In some instances, bulimia nervos a appears to repres ent failed attempts at res tricting anorexia nervos a in individuals have les s perseverance and less perfectionism than who purely restrict. In respons e to severe hunger, eating is naturally compensatory, and it is more likely to occur when dietary dis cipline is not s us tainable, particularly in individuals with impulsive traits . In other instances, binge eating initially occurs in res ponse to frus tration and dysphoric moods in attempts to quell or soothe these distress ing emotional states . P urging episodes , s imilarly, may offer brief periods of like states that temporarily remove the individual from other plaguing negative thoughts and moods . W hat appears to sustain bulimia nervosa is that binges and purges become elaborated into all-purpos e 2305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 40 of 107

for dealing with dys phoric states of any kind. After us ed repeatedly to deal with hunger and dysphoric bingeing and purging behaviors simply become habits . B iochemically, animal s tudies sugges t that intermittent, excess ive s ugar intake may induce mechanisms endogenous P.2010 changes in opioid regulation, and thes e process es may also contribute to sustaining binge-eating behavior. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > INIT IAT ING AND S US T AIN P S Y C HO P AT HOLO G Y

INITIATING AND PS YC HOPATHOL OGY P art of "19 - E ating Dis orders " Anorexia nervosa often appears to serve as a longstrategy for coping maladaptively with maturational including press ures to develop a personal identity, and with difficult situations in family and social functioning. E ating dis orders of adoles cent onset are mos t ps eudosolutions to core challenges of adolescence as delineated by E rik E rikson—in other words , the of developing a coherent pers onal identity rather than experiencing role diffus ion. S ome early adoles cents rudely s urprised when coping mechanis ms they had previous ly been us ing to s ucces sfully contend with 2306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 41 of 107

preadoles cent is sues of work and tas k completion no longer adequately manage adolescent challenges and chaos . In res pons e, some of the more s ens itive, perfectionistic, and compuls ive adoles cents may identities oriented around having anorexia nervosa. succumb to one type of “quick fix” for developing an adoles cent identity, devoting themselves to becoming thin or, in the case of boys , lean and mus cular. T he motivations behind eating dis orders are always in that they involve attempts to deal with the process of development, emotions , family dynamics, social relations hips , and internal s elf-regulation. Although early psychoanalytic theories regarding fear oral impregnation and other historically fanciful formulations appear irrelevant, if not quaint, more ps ychodynamic theories seem more applicable to disorders , es pecially thos e based on object relations self-ps ychology. However, they still remain more to systematically operationalize and have not yet been adequately validated. T herapies based on thes e formulations have been propos ed and may have but, at least in research circles, they have not yet the wider support accorded to cognitive-behavioral therapies or interpersonal therapy. P sychodynamic conflicts almost certainly contribute to eating disorders as predis pos ing and sustaining but adequately elucidating these phenomena has remained methodologically hard to pin down. K ey ps ychodynamic components vary from patient to family to family, and between genders . A relatively appealing, although not firmly proven, hypothes is is clus ter of ps ychodynamic themes is caus ally 2307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 42 of 107

the majority of eating dis orders. F or example, and exis tential fears are very commonly involved with eating dis orders, and res tricting-type anorexia nervos a seemingly provides es cape from onrushing negative visions of the emerging s exuality and other biological social challenges of adoles cence. C oncurrently, other psychodynamic themes concern sens itive personalities deal with childhood narciss is tic injuries, seeking s afety and avoiding injury from phys ical, emotional, and sexual abuse through s elfstarvation and disappearing into “nothingness ,” from the material world. G ender-as sociated ps ychodynamics reveal that boys not only fear the exis tential anguis hes of adolescents, but als o fear far beyond medical reality, perhaps more than girls do. B oth bingeing and purging offer short-term s olutions problem s olving (or problem avoidance) before they insidiously turn into long-term s ources of medical and ps ychological distress . Despite being ego-dystonic in individuals , bulimic symptoms have to be unders tood coping mechanisms, albeit ineffective ones , for dealing with real is sues in mood regulation, such as anxiety, depres sion, anger, boredom, loneliness , and ennui; interpersonal relations ; s elf-protection; family and continued worries over body weight. Later-onset dis orders differ thematically from those earlier onsets. F or example, older adult men may slim to increas e their s exual desirability to extramarital partners , enhance their upward mobility at work, or improve their image in vis ual media. S ome men s lim to become more acceptable to gay partners. Later ons et women may represent attempts at emotional s elf2308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 43 of 107

regulation when previously unres olved iss ues present thems elves , s uch as fractured relations hips, perceived of attractiveness , or feelings of ineffectivenes s or lack control. Although much dis agreement pervades unders tanding of eating disorders , the phenomenology eating dis orders, especially the core ps ychopathology involving overvalued beliefs in the des irability of weight loss for some reas on, has not changed s ince its first description. T he ps ychopathology of eating dis orders involves overvalued beliefs , but the content of these overvalued beliefs may differ in different cultures . A chronic and s ustained eating disorder is as much a as an “enemy.” E ating dis orders may satisfy human needs, albeit in a manner that ultimately fails , simultaneously provides a “profes sion,” an identity, and organizing principle for daily life. B as ically, overvalued beliefs reflect the ps ychology of the fundamentalis t zealot—in the cas e of eating-disordered patients, thes e beliefs are centered around s hape, weight, and fear of in society. T hey may take on religious tones in some individuals that hearken back to earlier eras when as ceticism was praised. G enerally, the overvalued ideas are not entirely to challenge with evidence-based ps ychological and do not generally attain the level of incorrigible, unfals ifiable truth of fixed delusions . R ather, they are fluid with time. Depending on the patient's level of and motivation to change, the ability to objectively on thes e overvalued ideas s hifts . Ultimately, recovery requires the capacity to sense these ideas as intrus ive unwanted, as ps eudosolutions rather than failures . T he 2309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 44 of 107

core abnormal beliefs of eating dis orders have the potential for being challenged and discarded in favor of adaptive coping skills and healthy methods of internal regulation. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DIAG NOS IS AND C LINIC AL F E AT U

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "19 - E ating Dis orders " T he diagnosis of an eating dis order is straightforward can be confidently accomplished with moderate knowledge and experience by directly identifying the eating dis order through the ps ychiatric his tory and status examination, without extens ive medical Anorexia nervosa is present when (1) an individual voluntarily reduces and maintains an unhealthy degree weight loss or fails to gain weight proportional to (2) an individual experiences an intens e fear of fat and/or a relentless drive for thinnes s des pite medical starvation; (3) an individual experiences starvation-related medical symptomatology, often, but exclusively, abnormal reproductive hormone but also hypothermia, bradycardia, orthostasis , and severely reduced body fat s tores; and (4) the behaviors ps ychopathology are present for at leas t 3 months . A distorted body image is common but not ess ential or invariable in eating disorders . When patients are asked how other people see them, they almos t always 2310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 45 of 107

acknowledge that they are objectively too thin to others but insis t that they perceive themselves as fat. the initial illness wears on, more ins ightful patients recognize their thinness but persis t in remaining phobically avoidant of healthy weight. T he term atypical anorexia P .2011 nervos a has been applied to patients who recognize thinness , in contras t to thos e with typical anorexia nervos a, who insist that their body image distortions represent objective fact. T hese are not truly atypical only more ins ightful individuals . P rognos tically, thos e recognition of their extreme thinnes s have better res ponses to treatment and more favorable outcomes because they are not cons tantly fighting an inaccurate view of thems elves as heavy. In mos t patients, body weight is tightly tied to s elf-es teem. E ven when patients intellectually appreciate that their weight is within the normal range, the conviction that they weigh more than they desire leads to plummeting s elf-es teem and fears even thin-normal weights as being too fat. Where s elf-induced s tarvation and the core drive for thinness or fear of fatness exis t, a diagnos is of nervos a can be confidently made. Medical disorders be pres ent as consequences of starvation by food res triction and other methods of weight los s (especially purging) or may be incidental or preexisting findings , they are never primary causes when the core ps ychopathology is present and dieting was s elfIn thes e cas es, delaying the diagnosis of eating while waiting for extens ive workups to rule out a 2311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 46 of 107

gastrointestinal, neurological, endocrine, or other suspected underlying medical disorder to account for weight loss or purging behavior is contraindicated. tes ting delays treatment and harms patients. Although the contemporary DS M and IC D approaches ps ychiatric diagnosis, in all of their s erial iterations, represent vas t improvements over previous vague and impres sionistic approaches to diagnosis, they are both works in progres s, with the criteria for various disorders varying from mos tly s cientific in origin to substantially based on minority opinions . Over the years , new and changing opinions have produced different criteria regarding how much weight loss , for example, is for anorexia nervos a to be diagnosed. T he third edition the DS M (DS M-III) required a weight of less than 75 of “normal.” In contras t, DS M-IV -T R requires les s than percent of a healthy weight, achieved either by weight or failure to increase weight along with normal growth. T he DS M-IV -T R requires amenorrhea, thereby excluding men, and ignores studies dis proving the value of amenorrhea. T he s pecific weight-loss of les s than 85 percent of a healthy weight is also problematic at best and uns cientific at wors t. T he decrement from a prior, us ually normal, weight to an unhealthy, s ignificantly lower weight by dieting, and/or purging is the key concept, not the attainment of specific percentage of some population average. weight, like height, is bell shaped in its natural a s elf-induced los s from 120 percent of a population weight, or an “ideal” weight, to 90 percent of that norm can be as indicative of anorexia nervosa as a reduction from a normal 90 percent of ideal weight to 84 percent 2312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 47 of 107

that ideal. P s ychobiologically, anorexia nervosa is whenever a decrement from a s elf-sustaining “set a s ubstantially lower weight caus es s tarvation-related medical symptomatology. R elegating cas es in which final weight is not les s than 85 percent of “expected” weight to the category of eating disorders not otherwise specified is s cientifically disproved and a s ource of the overly large and unneces sary number of eating not otherwis e s pecified diagnos es , which are confusing clinically because of the implied “atypicality,” and often refused reimbursement because of the as sumption that they are not as s erious. T he diagnos tic C riterion A for anorexia nervosa in DS M-IV -T R for amount of weight for a diagnosis of anorexia nervosa gives 85 percent of expected weight as an exemplia gratia, but the number taken as an absolute requirement, not s imply an A young woman who weighed 20 percent above the average weight but was otherwis e healthy, functioning well, and working hard on a rural farm, left home and entered university. S he joined a sorority, started to perceive hers elf as fat compared to her sorority s is ters , started to diet, and reduced weight to 90 percent of the “ideal weight” for her age and gender. At her point of maximum weight los s, s he felt cold, dizzy, apathetic, morbidly afraid of becoming fat. S he started to restrict food choices even more, exercised compuls ively, and herself as s till in need of further weight loss . Her periods became lighter and briefer but did not cease. was not taking oral contraceptives . Although, using s trict DS M-IV -T R criteria, s he would be diagnosed as having an eating dis order not otherwis e specified because she did not reach less than 85 2313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 48 of 107

“expected weight” and had s ome menstrual clinical experts would diagnos e her with incontestable anorexia nervosa. S he meets all of the core clinical ps ychopathological and behavioral criteria for anorexia nervos a. S he responded to standard treatment for anorexia nervosa. Anorexia nervosa has been divided into two the food-res tricting category and the binge-eating or purging category. In the binge-eating or purging little objective binge eating may actually occur. S ome patients purge after only eating s mall amounts of food. Overexercis ing and perfectionistic traits are common in both types . T able 19-2 lists current diagnostic criteria anorexia nervosa according to DS M-IV -T R . T able 19-3 shows the s lightly different, but s ubs tantially similar, criteria of IC D-10.

Table 19-2 DS M-IV-TR Diagnos tic C riteria for Anorexia Nervos a A. R efusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight les s than 85% of that expected).

2314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 49 of 107

B . Intens e fear of gaining weight or becoming fat, even though underweight. C . Dis turbance in the way in which one's body weight or shape is experienced, undue influence body weight or s hape on s elf-evaluation, or denial the seriousness of the current low body weight. D. In pos tmenarcheal women, amenorrhea, i.e., absence of at least three consecutive menstrual cycles . (A woman is cons idered to have if her periods occur only following hormone, e.g., es trogen, administration.) S pe cify type:    R es tric ting type: during the current episode of anorexia nervosa, the pers on has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the mis us e of laxatives , diuretics , or enemas )    B inge-eating or purging type: during the episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., s elf-induced vomiting or the misus e laxatives, diuretics, or enemas)

F rom American P sychiatric As sociation. 2315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 50 of 107

and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 19-3 IC D-10 Diagnos tic C riteria for Anorexia Nervos a Anorexia nervos a A. T here is weight loss or, in children, a lack of gain, leading to a body weight at leas t 15% below the normal or expected weight for age and height. B . T he weight los s is s elf-induced by avoidance “fattening foods .” C . T here is s elf-perception of being too fat, with intrus ive dread of fatnes s, which leads to a selfimpos ed low weight threshold. D. A wides pread endocrine dis order involving the

2316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 51 of 107

hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhea and in men as a los s of interes t and potency. (An apparent exception is persis tence of vaginal bleeds in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill.) E . T he disorder does not meet C riteria A and B bulimia nervosa. C omments T he following features s upport the diagnos is but not es sential elements : s elf-induced vomiting, induced purging, excess ive exercise, and us e of appetite s uppress ants or diuretics . If ons et is prepubertal, the sequence of pubertal events is delayed or even arres ted (growth in girls, the breas ts do not develop and there is a primary amenorrhea; in boys, the genitals remain juvenile). W ith recovery, puberty is often normally, but the menarche is late. Atypic al anorexia nervos a R es earchers studying atypical forms of anorexia nervos a are recommended to make their own decis ions about the number and type of criteria to be fulfilled. 2317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 52 of 107

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

B ulimia nervosa is pres ent when (1) episodes of binge eating occur relatively frequently (twice a week or for at leas t 3 months; (2) compens atory behaviors are practiced after binge eating to prevent weight gain, primarily self-induced vomiting, laxative abus e, or abus e of emetics (80 percent of cas es ), and, less commonly, severe P.2012 dieting and s trenuous exercise (20 percent of cases ); weight is not s everely lowered as in anorexia nervos a; (4) the patient has a morbid fear of fatnes s and/or a relentles s drive for thinnes s and/or a disproportionate amount of self-evaluation depends on body weight and shape. When making a diagnosis of bulimia nervosa, clinicians should explore the poss ibility that the patient has experienced a brief or prolonged prior bout of anorexia nervosa, present in approximately half of nervos a patients . T ables 19-4 and 19-5 list the DS Mand IC D-10 criteria for bulimia nervos a.

2318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 53 of 107

Tables 19-4 DS M-IV-TR C riteria for B ulimia Nervos a A. R ecurrent epis odes of binge eating. An binge eating is characterized by both of the following:    (1) eating, in a discrete period of time (e.g., any 2-hour period), an amount of food that is definitely larger than most people would eat a s imilar period of time and under similar circums tances    (2) a s ense of lack of control over eating during episode (e.g., a feeling that one cannot s top or control what or how much one is eating) B . R ecurrent inappropriate compensatory in order to prevent weight gain, such as s elfvomiting; misuse of laxatives , diuretics, enemas , other medications; fasting; or excess ive exercise. C . T he binge eating and inappropriate behaviors both occur, on average, at least twice a week for 3 months. D. S elf-evaluation is unduly influenced by body shape and weight. 2319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 54 of 107

E . T he disturbance does not occur exclusively episodes of anorexia nervos a. S pe cify type:    Purging type: during the current episode of bulimia nervosa, the person has regularly self-induced vomiting or the misus e of laxatives, diuretics , or enemas    Nonpurging type: during the current episode bulimia nervosa, the person has us ed other inappropriate compensatory behaviors, such as fas ting or exces sive exercis e, but has not engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 19-5 IC D-10 Diagnos tic C riteria for B ulimia Nervos a

2320 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 55 of 107

A. T here are recurrent epis odes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in periods. B . T here is pers istent preoccupation with eating a s trong desire or a sens e of compulsion to eat (craving). C . T he patient attempts to counteract the effects of food by one or more of the following:    (1) self-induced vomiting    (2) self-induced purging    (3) alternating periods of s tarvation    (4) us e of drugs s uch as appetite s uppress ants, thyroid preparations, or diuretics ; when bulimia occurs in diabetic patients, they may choose to neglect their insulin treatment D. T here is s elf-perception of being too fat, with intrus ive dread of fatnes s (usually leading to underweight). Atypic al bulimia nervos a R es earchers studying atypical forms of bulimia 2321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 56 of 107

nervos a, such as those involving normal or body weight, are recommended to make their decis ions about the number and type of criteria to be fulfilled.

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion. T he eating dis orders not otherwise specified category broad and best used where identification of the core ps ychopathology is lacking or where behaviors differ subs tantially from requirements for anorexia nervosa or bulimia nervosa (T able 19-6). F or example, eating not otherwis e s pecified may properly describe patients who show only occasional binges or purges, repeated short epis odes of severe dieting, chewing and s pitting food as the predominant form of disordered eating, or binge eating in a s emi- or unaware s tate during sleepwalking episodes .

Table 19-6 DS M-IV-TR Diagnos tic C riteria for E ating Dis order Not Otherwis e S pec ified

2322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 57 of 107

T he eating dis order not otherwis e s pecified is for dis orders of eating that do not meet the for any s pecific eating disorder. E xamples include 1. F or females , all of the criteria for anorexia are met except that the individual has regular mens es. 2. All of the criteria for anorexia are met except despite s ignificant weight loss , the individual's current weight is in the normal range. 3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compens atory mechanisms occur at a frequency less than twice a week or for a duration of less months. 4. T he regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., selfvomiting after the consumption of two cookies ). 5. R epeatedly chewing and s pitting out, but not swallowing, large amounts of food. 6. B inge-eating dis order: recurrent epis odes of eating in the abs ence of the regular use of inappropriate compens atory behaviors of bulimia nervosa. 2323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 58 of 107

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

E xperts are currently working on sugges ted for the current criteria for future editions of the DS M IC D to better account for current knowledge about such is sues as variability of impairment as sociated with degrees of weight loss , variability of mens trual function, male phys iology, binge-eating dis order, and nightsyndromes, among others . B ecaus e s hame is prominent in eating-disordered symptoms are often concealed, and some diagnos tic detective work may be needed to elicit the diagnosis. Although the bigges t reason for failing to diagnos e an eating disorder is the failure to as k pertinent ques tions, patients s ometimes deny eating disorders , es pecially bulimia nervosa at normal weight, even when clinicians inquire directly about them. C oncealed bulimia nervos a may be s uspected in the presence of loss of dental gastroesophageal reflux disease in a young pers on, abrasions on the knuckles (from s elf-induced vomiting), and puffy cheeks or upper-neck soft tiss ue in otherwis e thin or normal-weight individuals (resulting from parotid and s alivary gland hypertrophy). Others may report the presence of vomitus in the home in the absence of 2324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 59 of 107

gastroenteritis or food poisoning, finding unexpected laxatives or diuretics , or habitual departure to the bathroom immediately after meals. Unexpected tes ts that rais e s us picion include unexplained low potas sium and, occas ionally, bizarre findings , s uch as toothbrush in the s tomach on X -ray. Many young individuals with eating disorders are to or ambivalent about presenting thems elves for diagnostic ass es sment, fearing that they will be forced gain weight agains t their will or that they will be additionally shamed and s corned. C ollateral from parents or other clos e persons is extremely and s hould be sought when an eating disorder is suspected. T he most commonly overlooked categories of patients with eating disorders are men, matrons, and minorities , largely because clinicians rarely think of eating disorder diagnoses when as sess ing thes e populations . Men be as ked about desire for muscularity, fear of being too small, concern with body image from the wais t up (in contrast to women, who are primarily concerned with wais t down), and use of s teroids to enhance weight and desired s hape. Among older patients, especially thos e with ons et in 40s and 50s, mixtures of true eating dis order may coexis t with s eparate medical or psychiatric T he core diagnostic features confirm or reject the diagnosis of an eating dis order. S imilarly, eating should not be excluded from cons ideration in P.2013

2325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 60 of 107

with borderline low or mild mental retardation or in the developmentally impaired. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DIAG NOS T IC C OMO R B IDIT

DIAGNOS TIC P art of "19 - E ating Dis orders " T he diagnostic challenges of eating disorders are only partly addres sed when a s pecific eating disorder is identified, because, in the large majority of cas es, comorbid psychiatric dis orders accompany the eating disorder, with two to four separate additional diagnos es on Axis I or II of DS M-IV -T R commonly seen. In identifying Axis I mood, anxiety, obsess ive-compuls ive, and s ubs tance abus e disorders and Axis II pers onality vulnerabilities and dis orders, the temporal relationship these dis orders to the eating disorder s hould be noted. Mood dis orders that precede eating disorders differ significantly from thos e that first occur after the eating disorder is initiated. Mood dis orders s tarting before disorders usually require separate and s pecific whereas thos e s tarting in the wake of an eating often improve on their own during recovery from the eating disorder. In the s etting of an eating dis order, vulnerable personality traits may be amplified into what appear to be primary personality dis orders but are secondary personality dis turbances. As with Axis I disorders , how personality traits vary in relation to the onset of the eating disorder influences the prognosis of the Axis II component. P remorbid obsess ional traits , for 2326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 61 of 107

example, may appear to be full-blown obsess ivecompuls ive s tates when an individual is malnourished may improve with weight res toration—this differs from conditions in which frank obses sional s ymptoms were present in childhood before the eating dis order. T able 19-7 s hows data from one of several s tudies that have documented the high comorbidity of Axis I in one s tudy of hos pitalized eating-disordered patients. Although the specific percentages vary with studied, the high comorbidity is common.

Table 19-7 Frequenc y of C omorbid Axis I Diagnos es in E ating Dis orde S ubgroups B ingeE ating and R es tricting- P urging T ype T ype Anorexia Anorexia Nervosa Nervosa

B ulimia Nervosa

Any affective disorder

57%

100%

100%

Intermittent

29%

44%

25%

Diagnos is

2327 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 62 of 107

depres sive disorder Major depress ion

57%

66%

100%

Minor depress ion

0

11%

0

Mania/hypomania

0

33%

25%

Any anxiety disorder

57%

67%

50%

P hobic dis order

43%

11%

0

P anic dis order

29%

22%

0

G eneralized anxiety dis order

14%

11%

50%

Obsess ivecompuls ive disorder

14%

56%

50%

Any subs tance 14% abuse/dependence

33%

50%

Drug

14%

22%

0

Alcohol

0

33%

50%

2328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 63 of 107

S chizophrenia

0

0

0

Any codiagnos es

71%

100%

100%

3 or more codiagnoses

71%

100%

100%

No. of (x ± S D)

2.3 ± 2.5

3.8 ±

3.2 ± 1.5

F emale

100%

89%

100%

S ingle

71%

89%

100%

Age (x ± S D)

23.6 ±

25.0 ± 6.4

19.8 ± 5.6

S D, s tandard deviation. Well-diagnosed s chizophrenia is rarely s een together a typical eating disorder, although, in rare cas es , it may cooccur as a statis tical coincidence. T he phras e “perceptual distortion of delusional proportion,” us ed in older literature to describe body image dis tortions in eating-disordered patients, is a reminder that borders between delusional perceptions and s trongly held body image distortions, P.2014 2329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 64 of 107

obses sional beliefs, and uns hakable overvalued ideas not been definitively clarified and that additional is neces sary to further illuminate thes e dis tinctions. F or example, there is a high comorbidity of anorexia with body dys morphic disorder—es timated at 20 percent—in which patients additionally have preoccupations regarding specific body parts not to weight or s hape in particular. B ody dys morphic occurs in delus ional and nondelusional forms , on the extent to which the obs ess ions are ego-alien recognized as unrealis tic or the extent to which the individual firmly believes that the obses sional concerns realis tically jus tified. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > LAB OR AT OR Y E X AMINAT ION AND P AT HOLO G Y

LAB OR ATOR Y AND C L INIC AL P art of "19 - E ating Dis orders " P athophys iology in eating dis orders res ults from (1) the amount and rate of starvation, (2) the means used to produce weight los s (dieting alone, with or without over exercising, self-induced vomiting, laxatives , diet pills, diuretics ), and (3) binge eating. E ating dis order die from either the medical consequences of starvation (cardiac mus cle loss and arrhythmia, s ometimes hypokalemia) or suicide. T he phys ical examination include height; pos tvoiding weight in a simple hospital 2330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 65 of 107

gown obs erved for hidden weights ; vital signs , with particular attention to pulse rate and orthostatic blood press ure changes ; a complete examination of skin, and s ubcutaneous fat (noting the degree of starvation); neurological examination (which is , in general, normal); and a photograph of the patient if notably thin. Laboratory tes ts are helpful for as sess ing the s everity eating disorders and their medical consequences, but for chasing after obscure nonps ychiatric etiologies. It should be remembered that anorexia nervosa patients may die with completely normal laboratory tes t res ults . Abnormal laboratory findings document the presence pathophys iological proces ses and may als o be helpful enhancing motivation. P hys iological meas ures can be divided into thos e that reflect nons pecific cons equences of s tarvation and that are generally selfameliorating, such as mild bradycardia, and thos e that require urgent medical intervention, such as a QT interval on electrocardiogram (E G G ) or marked hypokalemia. Medical specialist consultation s hould be regularly used in the comanagement of thes e patients . T able 19-8 lists s uggested laboratory tes ts for patients anorexia nervosa or bulimia nervos a, with judgment regarding the full extent of workup for individual based on weight loss , severity of illness , s ubtype, and comorbidity. F or example, laboratory s tudies in nervos a binge-eating and purging type and bulimia nervos a often include determination of electrolytes and serum amylase, which are more likely to be abnormal these disorders than in the res tricting type of anorexia nervos a. T he elevated levels of amylase derive from salivary gland rather than pancreatic s ources , unles s 2331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 66 of 107

alcoholism is comorbidly present. W here abnormal amylase is found, fractionation can identify the origin salivary, although this is us ually unneces sary in clinical practice.

Table 19-8 S ugges ted Laboratory S tudies for Patients with E ating Dis orders All    C omplete blood count (anemia is frequent)    E lectrolytes    B lood urea nitrogen, creatinine    T hyroid-stimulating hormone, free thyroxine    E lectrocardiogram    T otal protein and prealbumin    F asting glucos e    Amylas e if purging occurs    S erum phosphate 2332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 67 of 107

B ulimic s yndromes    In addition to above, amylas e (fractionated if abnormal to determine parotid/salivary gland vs . pancreatic origin) If amenorrhea > 3 mos    B one mineral density (dual energy X -ray absorptiometry) In men with weight loss    T estosterone

P atients who have been abus ing diuretics require renal function tests . Many malnouris hed patients with nervos a develop a euthyroid sick s yndrome, in which decreased levels of thyroid-stimulating hormone (T S H), total thyroxine (T 4 ), and total triiodothyronine (T 3 ) may seen, free T 4 and free T 3 are us ually unchanged, and revers e T 3 (rT 3 ) is elevated. G enerally, thes e endocrine abnormalities repres ent energy-cons erving of starvation that improve spontaneously with T hey do not require immediate treatment but are to be followed with a repeat determination in approximately 3 weeks to determine if improvement occurs with Low estrogen and proges terone levels in anorexia are as sociated with the energy-cons erving role of 2333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 68 of 107

hypothalamic hypogonadis m; low levels of luteinizing hormone and follicle-stimulating hormone are als o contrast to elevated luteinizing hormone and folliclestimulating levels resulting from failing ovaries , as in postmenopaus al patients. In men, tes tos terone levels decrease in proportion to weight loss . A man with anorexia nervos a is not fully res tored to a normal weight until testosterone is in the normal range, provided no other causes, such as congenital testicular insufficiency, exis t. T he res toration normal testosterone is a neces sary but not s ufficient criterion to as sess adequate weight improvement in When drug abus e is s uspected, urine and blood are indicated. A fair number of teenage girls using stimulant drugs, such as methamphetamine, do s o to control appetite and promote weight los s in addition to seeking excitement. S tool tests for the pres ence of phenolphthalein may reveal occult, nondisclosed abuse. B one mineral dens ity should be regularly ass ess ed in initial workup of patients with anorexia nervos a or nervos a with a his tory of amenorrhea in women or loss with low testosterone in men. B ecaus e has been ass ociated with negative calcium balance, loss of s keletal calcium in the range of 4 percent per many eating dis order patients have s ignificant bone mineral deficiency—us ually osteopenia but severe as os teoporos is —by their late teens and early twenties , with bones similar to those of elderly women. Osteopenia occurs when bone dens ity is one standard deviation below mean age-adjus ted scores ; occurs when bone dens ity is at least two and a half 2334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 69 of 107

standard deviations below these scores . T hes e cannot be as ses sed by phys ical examination. DualX-ray absorptiometry (DE XA) s cans entail very low radiation, are relatively inexpensive, and are helpful in alerting patients to the realis tic medical consequences their disorders and in guiding clinicians ' concerning nutrition and participation in high-impact activities. T he mechanis ms of osteopenia/osteoporos is anorexia nervosa are more complex than in postmenopaus al os teoporos is , and treatments us eful in postmenopaus al women do not neces sarily help in anorexia nervosa. E strogen s upplementation in nervos a has been shown to offer no benefit in bone mineral dens ity while the patient is still low in weight. P.2015 Ovarian sonograms , preferably trans vaginal, can be particularly us eful in as sess ing individuals who have adopted (and for whom early growth charts are unavailable) or have grown substantially and when a healthy target weight is uncertain. Ovarian changes in a dose–res ponse relationship to the degree of starvation. Multiple small follicles are present when an individual is extremely starved; several s mall cys ts polycys tic, not abnormal polycys tic) are seen with weight restoration. W hen a woman is clos e to normal mens truation, a s ingle dominant cys t is pres ent. T hus, status of the ovarian follicles may be a useful guide to amount of weight res toration indicated. Healthy targe t weight, defined as the weight at which ovulation can spontaneously occur, is achieved when weight is approximately 5 lb greater than the weight at which a 2335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 70 of 107

single dominant cys t can be present. On the average, weight at which mens es reoccur is approximately 92 percent of healthy weight for an individual woman. T he structural and functional neuropathology of nervos a is increasingly well documented by magnetic res onance imaging (MR I), computed tomography (C T ), functional MR I (fMR I), pos itron emis sion tomography and s ingle photon emis sion C T (S P E C T ) scans . total brain volume and s ulcal complexity and increas es brain ventricular size are us ually seen, but normal brain structural studies may als o be s een in s ome very malnouris hed patients. T he neuropathology of anorexia nervos a revers es substantially with refeeding and gain. However, although white matter deficits recover, gray matter changes resulting from s tarvation may not completely return to normal, even many months after weight restoration. T hes e abnormalities are often in corresponding deficits s een in neurops ychological tes ting. Approximately 40 percent of typical anorexia nervos a patients score in an abnormal range on two or more neuropsychological tests in standard batteries , suggesting that thes e patients may have difficulties cognitive-behavioral therapies and other in these s tates. T he extent to which long-term improvement in neuropsychological abnormalities may occur in proportion to weight restoration and ces sation binge–purge activity over a prolonged period of stability not yet clear. F unctional imaging s tudies have unusual degrees of temporal lobe vascular flow in adoles cent anorexia nervos a patients, with abnormalities after weight res toration in some patients , but these studies await extension, replication, and 2336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 71 of 107

confirmation. In usual clinical practice, neuroimaging is neces sary, but, in patients with atypical features, if other findings sugges t that a brain lesion may be present, imaging studies may be of value. Laboratory tes ts s hould not be us ed to frighten However, many individuals with anorexia nervosa, es pecially those who minimize or deny its s erious nes s, benefit from frank dis cus sions of laboratory S ympathetically shared res ults from bone mineral and other laboratory examinations may help patients reass ess and take their dis orders more serious ly. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "19 - E ating Dis orders " Differential diagnos is per se is not generally difficult a full his tory and mental state examination indicate findings of an eating disorder and the core ps ychopathology is present. It has been s ugges ted that eating dis orders primarily repres ent indirect manifestations of mood dis orders, but this hypothesis been robus tly rejected by s everal sources of evidence, including family s tudies . On their own, mood dis orders lack a drive for thinnes s and a morbid fear of fat, but depres sion may produce significant weight loss , lack of appetite, and many of the nonspecific symptoms of loss , s uch as irritability, apathy, and fatigue. B ecause disorders commonly cooccur within eating disorders, 2337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 72 of 107

starting either before, coincident with, or after their their presence needs to be carefully delineated, and time cours e and temporal sequence relating thes e disorders must be noted. Most commonly, depress ive symptoms emerge gradually after the eating disorder started and almos t never have melancholic or features. S ome s tudies sugges t a higher-than-expected of type II bipolar illness in both anorexia nervosa in and bulimia nervosa. P atients with bulimia nervos a who concurrent seasonal affective dis order and patterns of atypical depres sion (with overeating and oversleeping low-light months ) may manifes t seasonal worsening of both bulimia nervos a and depres sive features . In these cases, binges are typically much more severe during months. B right light therapy (10,000 lux for 30 minutes , early AM, at 18 to 22 inches from the eyes ) may be a component of comprehens ive treatment of an eating disorder with seas onal affective dis order. S imilarly, anxiety dis orders may be pres ent before or accentuated during the emergence of eating disorders . E ating dis orders thems elves do not conform either to generalized anxiety or to panic dis order diagnostic although thes e are frequent comorbid syndromes . In instances, a case might be made that anorexia nervos a subs tantially results from a phobic anxiety disorder fear of fatness as the core of the psychopathology). confusion may occur in which previously unrecognized choking episodes and food avoidance result in weight loss due to fear of recurrent choking, a form of specific phobia. C areful his tories may elicit previous episodes of choking on food, often in childhood, that 2338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 73 of 107

not previously recalled and may be confirmed by a A s mall number of patients, usually s ocially phobic, sens itive personalities, fear vomiting in public, based on previous experiences . S uch fear of los ing in public may lead to s ubstantial food inhibition, but individuals manifest the core ps ychopathology of anxiously anticipating uncontrolled vomiting rather than primarily des iring thinness or fearing fatnes s. actual vomiting episodes , in the form of ps ychophys iological reactions , often do occur in the context of specific types of social phobias, such as fright and performance anxieties . E ating dis orders have been identified primarily as Although OC D as an Axis I comorbidity may occur in 25 percent of patients with anorexia nervos a, eating disorders are s eparate dis orders. B y definition, OC Ds involve ego-alien thoughts or behavioral urges that are res is ted, but the process of resis ting generates anxiety. S elf-starvation in anorexia nervosa is us ually, at least initially, ego-syntonic and based on overvalued beliefs the benefits of weight los s rather than on ego-alien thoughts and behaviors, such as excess ive handor checking behaviors. More likely to be pres ent in anorexia nervosa than Axis I OC D as a state are compuls ive traits and obsess ive-compuls ive disorder, marked by perseverance, perfectionis m, inflexibility, and emotional hypersens itivity in the face of failure or disappointment with performance. In body dysmorphic dis order, obsess ions focus on specific parts, not on the body as a whole or on weight or S ubstance abuse, es pecially of s timulants , can subs tantial weight los s. T he use of s timulants by eating 2339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 74 of 107

disorder patients may be us efully divided into cases in which the s timulants are used primarily to promote loss and those in which substances are used for experiences or mood improvement. Alcohol abus e is more common in bulimia nervosa than in res trictinganorexia nervosa. When present, it may dis inhibit and allow the individual to eat s ome otherwis e impermis sible calories or releas e underlying hunger dysphoria, res ulting in binge behavior followed by purging. P.2016 Among bulimia nervos a patients , a substantial perhaps 15 percent—have multiple comorbid impulsive behaviors , including s ubs tance abus e, and lack of control thems elves in such diverse areas as money management (resulting in impulse buying and shopping) and sexual relations hips (often resulting in pass ionate attachments and promiscuity). T hey exhibit self-mutilation, chaotic emotions , and chaotic s leeping patterns. T hey often meet criteria for borderline personality dis order and other mixed pers onality and, not infrequently, bipolar II disorder. Occasionally, delus ional dis orders or other ps ychotic conditions as sociated with fear that food is being poisoned may result in food avoidance, but the diagnosis is usually not difficult. Although clinicians who are not familiar with eating disorders often confus e eating dis orders with primary gastrointestinal or endocrine medical diagnoses , s uch confusion almost always disappears when core 2340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 75 of 107

ps ychopathology is ass ess ed. In more than 60 cas es National Ins titutes of Health, where extens ive medical laboratory examinations were made, not a s ingle individual was later found to have a primary medical for his or her weight los s when core eating disorder ps ychopathology was present. T his principle has been confirmed in several thous and additional cas es . coincidental medical dis orders may be pres ent—for example, a higher-than-expected incidence of irritable bowel s yndrome occurs in patients with anorexia F urthermore, eating dis orders may certainly produce profound medical consequences in many cases , s uch compress ion of the superior mesenteric arteries in emaciated patients resulting in s ignificant intermittent abdominal pain and s ymptoms of small-bowel (W ilkie's s yndrome) or the s uperior mes enteric artery syndrome (T able 19-9). However, the medical symptomatology is never the cause of the eating In occas ional cas e reports about brain tumors misdiagnos ed as anorexia nervos a, the nonspecific loss , amenorrhea, and apathy seen in s uch cases are accompanied by self-induced s tarvation or a morbid of fatness .

Table 19-9 Potential Medic al C ons equenc es of E ating Dis order and S ys tem Affected

C ons equence 2341

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 76 of 107

Anorexia nervos a

 

   V ital signs

B radycardia, hypotens ion marked orthos tatic changes , hypothermia, poikilothermia

   G eneral

Muscle atrophy, los s of body

   C entral system

G eneralized brain atrophy enlarged ventricles, cortical mas s, seizures, abnormal electroencephalogram

   C ardiovas cular

P eripheral (s tarvation) decreased cardiac diameter, narrowed left ventricular wall, decreased res ponse to demand, s uperior mes enteric artery s yndrome

   R enal

P rerenal azotemia

   Hematologic

Anemia of s tarvation, leukopenia, hypocellular bone marrow

   G as trointes tinal Delayed gastric emptying, 2342 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 77 of 107

gastric dilatation, decreased intes tinal lipas e and lactase    Metabolic

Hypercholesterolemia, nonsymptomatic hypoglycemia, elevated liver enzymes , decreased bone mineral dens ity

   E ndocrine

Low luteinizing hormone, low follicle-stimulating hormone, low estrogen or testosterone, low/normal thyroxine, low triiodothyronine, increas ed revers e triiodothyronine, elevated cortis ol, elevated growth hormone, partial diabetes ins ipidus , increased prolactin

B ulimia nervos a and binge-eating and type anorexia nervos a    Metabolic

Hypokalemic alkalosis or acidosis, hypochloremia, dehydration

   R enal

P rerenal azotemia, acute and chronic renal failure

2343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 78 of 107

   C ardiovas cular

Arrhythmias , myocardial toxicity from emetine (ipecac)

   Dental

Lingual s urface enamel los s, multiple caries

   G as trointes tinal S wollen parotid glands, elevated serum amylas e gastric distention, irritable bowel s yndrome, melanos is coli from laxative abus e    Mus culos keletal C ramps, tetany E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > C O UR S E AND P R O G NO

C OUR S E AND PR OGNOS IS P art of "19 - E ating Dis orders " T he cours e of eating dis orders is extremely varied in duration and s everity. T hey are truly spectrum es pecially bulimia nervosa. S ome broad pers pectives concerning the natural history of the eating dis orders as follows . Outcome reports des cribing the natural of eating dis orders depend greatly on how the are defined. Using a fairly rigorous definition of nervos a that includes a his tory of hos pital care, high mortality rates have been reported, with studies 2344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 79 of 107

up to 19 percent death rates in patients who received relatively little posthospital care on 20-year follow-up. Other studies , from centers using very structured treatment programs to full weight res toration and with intens ive group and family psychotherapy, document premature deaths on 10- to 15-year follow-up. Although this s tudy excluded dropouts from treatment it represents the best results publis hed in patients than 18 years . S ome s tudies s uggest that death rates among young women with anorexia nervosa may be as much as 12 times higher than age-matched community comparis on groups and up to twice as high as other female ps ychiatric populations. Death in chronically ill relaps ed patients occurs in a s teady progress ion, in proportion to the number of years out of hos pital. Most recent outcome studies involve follow-up after form of treatment. No data currently exist on which treatment methods res ult in the lowest morbidity and highes t rates of global improvement. T he best cons isting of no deaths and complete abs ence of disorder s ymptoms in 70 percent of patients on followwere found in adoles cents initially treated with inpatient acute treatment in a multidis ciplinary program followed by 4 years of intens ive relaps e prevention emphasizing carefully conducted, evidence-based, informed psychotherapy. F ollow-up studies of anorexia nervos a patients that encompas s a broad range of initial s everity, and s ubs equent chronicity reveal that, overall, approximately 30 percent are well, 30 percent partially improved, 30 percent are chronically ill, and 10 percent have died. Many continue to have chronic anxiety, and pers onality disorders . 2345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 80 of 107

Long-term s tudies show higher-than-expected subs equent rates of an as sortment of medical among those with adolescent eating dis orders. Of increasing concern and only recently documented is fact that long-term os teopenia and osteoporosis are commonly found even in young anorectic patients. T he sobering implication is that thes e female patients will enter the postmenopausal P.2017 phase, even if they return to normal gonadal function, amounts in the “bone bank” insufficient for the additional decline after menstrual function ceas es. Of concern is the demonstration that es trogen is res toring bone density in s tarved patients . T he wors t outcome of any eating disorder involves a combination anorexia nervosa and type I diabetes mellitus , with this group accounting for a dis proportionately high number deaths on follow-up. Mortality for patients with type I diabetes and anorexia nervos a is 34.8 percent compared to 6.5 percent for type I diabetes alone and percent for anorexia nervosa alone. A common finding on follow-up is the trans ition from anorexia nervosa to bulimia nervos a—seen in 50 of bulimia nervosa cas es —but the oppos ite transition occur, and many patients move in and out of complete partial syndromes of these dis orders. An encouraging finding s uggests that, on long-term follow-up, it is completely pos sible for many intens ively treated adoles cents to show complete cure with the absence of any diagnos able eating disorder on follow-up years T hese findings are cons is tent with other s tudies , 2346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 81 of 107

suggesting that, in general, young age of onset and treatment intervention to attain and maintain full weight res toration are ass ociated with better prognos is. T he best prognostic s igns in anorexia nervos a for excellence in outcome are completely normal weight at discharge from acute treatment, intensive follow-up by experienced teams, les s rather than more ps ychiatric comorbidity, les s severe decreas e in weight at shorter duration of illness , and average age of ons et in early to mid-teens rather than very young age or ons et later than 25 years . Malenes s by itself confers no ris k for poor outcome. Men with some degree of sexual fantas y or activity before anorexia nervosa have a outcome. B ulimia nervosa is a more variable dis order than nervos a in its s everity, comorbidity, and treatment outcome. Although much more recently described than anorexia nervosa, it has been better studied because higher prevalence, its lack of severe weight loss hospitalization, and the relative eas e of completing outpatient treatment s tudies comparing and contrasting ps ychotherapeutic and pharmacological interventions. general, bulimia nervos a is characterized by higher partial and full recovery compared to anorexia nervos a. noted in the treatment section, treated cases fare much better than untreated cases . Untreated cases tend to remain chronic or may show small but generally unimpres sive degrees of improvement with time. In a year follow-up study of patients who had previous ly participated in treatment programs, the number of who continued to meet full criteria for bulimia nervosa declined as the duration of follow-up increas ed. 2347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 82 of 107

Approximately 30 percent continued to engage in recurrent binge-eating or purging behaviors. A history subs tance use problems and a longer duration of the disorder at presentation predicted wors e outcome. Depending on definitions, 38 to 47 percent of women were fully recovered at follow-up. Often, the type of ps ychiatric comorbidity defines the outcome of treatment more than the illnes s its elf. clus ter analysis s tudies have s uggested three coherent prototypes based on eating disorder symptoms and personality profiles : a high-functioning or perfectionistic group with reasonably good prognos is , a cons tricted or overcontrolled group for which the condition is us ually chronic, and an emotionally dysregulated or undercontrolled group leas t likely to recover. F or among patients with bulimia nervos a, those with impulsive behaviors and borderline personality have much less likelihood of s ticking with treatment recovering than those with no s ignificant comorbidity or only mild depres sive symptoms . Malenes s has not proved to be a predictor of advers e outcome in either anorexia nervosa or bulimia nervosa. Among men, as in women, the best outcomes occur in adoles cents with good sexual adjustment for their age before the onset of illness , with s upportive families , have had les s initial weight loss and less ps ychiatric comorbidity. B inge-eating dis order, s till in a process of definition, appears to have les s mortality on follow-up than nervos a. Long-term outcome s tudies related to s pecific methods of treatment are lacking, but early studies are encouraging. S evere obesity augurs worse health 2348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 83 of 107

outcomes , es pecially clas s II obesity (body mass index and clas s III obesity (body mass index of more than E ven less well-defined in outcome is reverse anorexia, which overlaps with the newly defined s pectrum of dysmorphic dis orders in men. T he outcome of ps ychiatric comorbidity in eating disorders is variable. T he res pons iveness or of comorbid Axis I mood and anxiety dis orders and depends largely on whether thes e s yndromes the ons et of eating disorders or occurred in their wake. S evere mood and anxiety disorders and OC Ds exis ting before the eating disorders generally remain long-term problems requiring s pecific additional treatment, but, even without s pecific treatments for them, obsess ive depres sive s ymptoms often improve s ubs tantially when weight is restored to normal in anorexia nervosa and when bulimia nervosa abates . T he most common outcome after weight recovery and behavioral improvement for vulnerable pers onality traits worsened starvation, s uch as perfectionism, perseverance, and avoidance, is the return to preillnes s levels. F or all disorders , the greates t ris k of relaps e occurs in the first months after s ucces sful treatment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > T R E AT ME NT O F E AT ING DIS OR

TR E ATME NT OF E ATING DIS OR DE R S P art of "19 - E ating Dis orders " 2349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 84 of 107

T he four es sential components of treatment are s ound principles, evidence-based practices (to the extent that studies have been published), a s pectrum of care appropriate to the intensity of illnes s, and a s killed multidis ciplinary team for serious cas es. T he core treatment goals for all eating disorders are and transdiagnos tic: (1) attaining and maintaining a normal, healthy, individualized, stable body weight; (2) stopping all abnormal eating behaviors, such as food res tricting, binge eating, or purging, and ass ociated abnormal behaviors, especially compulsive exercis e; dismantling the core overvalued beliefs and unhealthy cognitive “schemas ” of automatic cognitive distortions, replacing them with healthy, balanced views of s elf (not primarily dependent on body weight or shape) and the capacity for emotional and behavioral s elf-regulation; treating the comorbid conditions , ps ychiatric and and (5) planning for ongoing relaps e prevention for approximately 5 years after acute improvement. T he methods of treatment include medical, nutritional, ps ychotherapeutic, behavioral, and pharmacological components. T reatment planning requires matching the intens ity of treatment to the s everity of illnes s. After outpatient comprehens ive ass ess ment, patients will be referred to appropriate levels of intens ity of care, from medical/pediatric intensive care units for the medically uns table; s pecialty eating disorder inpatient units for the majority of serious cases of eating step-down or s tep-up to partial hospital (full-day) programs —to long-term res idential community where needed or to outpatient treatment for les s cases; or relaps e prevention. T reatment of s evere disorders usually requires trans itions between several 2350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 85 of 107

steps in the s pectrum, with steps up and s teps down according to respons e to the initial location of Outreach and prevention programs in school and community s ettings round out res ources . P.2018 S tudies s how that outcomes are generally better for patients treated in specialty eating dis order units than general ps ychiatry units that lack specialty programs are considerably better for anorexia nervosa cas es to full normal weight.

Treatment of A norexia Nervos a Inpatient care is indicated not only for physiological abnormalities , but also to provide 24-hour treatment, management, and containment for the intensively ingrained behavioral abnormalities , such as s tarving, compuls ive exercising, and purging, which often have failed to respond to even full-day programs. At weights below 20 percent less than healthy, except under circums tances , most patients require inpatient care; es pecially if the eating disorder is recurrent or with significant psychological or medical comorbidity. E ven full day or partial hospital programs may not adequate containment to produce recovery but are increasingly us ed in the s pectrum of care. C ontroversy exists concerning the propriety and us e of treating treatment-reluctant patients on an involuntary basis through legal commitment. Approximately 10 to percent of cas es in large treatment programs require involuntary treatment. In life-threatening cases , involuntary treatment is appropriate when pers uas ion 2351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 86 of 107

alone fails to get the patient to agree to accept S tudies s how that involuntarily committed patients approximately the s ame outcomes as voluntarily committed patients during acute hospitalization, almost always subsequently appreciate the intervention, and rarely pers is t in feeling angry or litigious . R eluctance of some third-party payers to authorize ongoing care for s everely ill anorexia nervos a patients presents a formidable challenge to patients, families , clinicians . As lengths of stay have decreas ed for nervos a due to insurance res trictions, relapse rates increased. E ffective state and federal parity laws , as judicial decis ions, may help. A federal dis trict court– decis ion ruling that medical benefits s hould be made available to patients with anorexia nervosa until they 85 percent of healthy weight has been underutilized as precedent for access ing medical benefits for the as sociated with anorexia nervos a. T he judge reasoned malnutrition is a medical diagnos is and that medical benefits, regardless of the cause of a medical dis order, legally mandated. T ypical anorexia nervos a patients can transition to hospital from inpatient care at 85 percent of healthy weight, but exceptions occur. T hose with chronic and repeated bouts of illness , comorbid diabetes, or s evere comorbidities on Axis I and Axis II may require higher weights and more prolonged inpatient s tays. T he difference between partial hospital and inpatient care is the length of treatment during the 24-hour day, not the intens ity of treatment or the adequacy of a multidis ciplinary staff. S hort-term s ucces sful treatment appears directly related to the number of hours per day 2352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 87 of 107

and number of days per week of containment and treatment. G oing from 5 to 4 days per week in day programs has resulted in approximately 25 percent effectivenes s. R egarding exceptions to hospital care, research is under way to examine the effectivenes s of s upervis ed family-based outpatient treatment, in which highly motivated, involved, carefully instructed, and clos ely supervis ed parents may supervis e the refeeding of adoles cent patients—the so-called Maudsley model, protocolized and often s ucces sful. Data from these may influence treatment practices in the future.

Weight R es toration T he initial s hort-term goal is to res tore patients fully, and promptly to the ideal healthy range as s pecified in population weights for age, height, and gender or the weight at which there is a 50 percent chance of return mens es for adolescent girls. T he ultimate goal, not achieved during initial inpatient or partial hospital treatment, is to res tore each person to biological for women, the weights at which they will menstruate ovulate without artificial inducements and, for men, the weights at which normal s exual physiology and returns . Accordingly, some patients will not achieve normal biological function until they reach higher than they desire. T he concept of a bell-shaped of heights is widely accepted, but s imilar acceptance is lacking by many clinicians and mos t eating-disordered patients for body weights. Methods of achieving weight res toration vary, but available evidence s uggests that nursing-supervis ed 2353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 88 of 107

refeeding of normal food in appropriate amounts and composition as directed by a dietitian promptly and res tores weight. F or women receiving inpatient care, approximately 3 lb per week are res tored and, for men, to 4 lb per week; up to 2 lb per week are res tored in hospital programs . In outpatient treatment, a minimum weight res toration of 1 lb per week is readily achievable with motivated patients. Although nasogas tric feedings are not ordinarily recommended or endorsed, s ome adoles cent medicine and pediatric programs use overnight gas tric gavage to supplement, but not oral feedings in an effort to achieve desired weights efficiently. Hyperalimentation by central venous lines is us ually contraindicated and often fraught with s evere medical complications. F ailure to fully restore weight adversely affects future outcome. Hunger, even in mildly underweight patients, often s erves to trigger binge-eating episodes . In patients above 70 percent of healthy weight can s tart at 1,500 calories per day, which can be increas ed 500 per day every 4 days during inpatient or partial hos pital treatment or each week in outpatient care. T ypically, women require a maximum of 3,500 calories per day, men may need 4,000 calories or more. T hese levels of energy intake are varied according to individual and medical complications, the mos t common of which are refeeding edema, gastric bloating, and, invariably, cons tipation. Any goal of less -than-fully-normal weight subs tandard. R efeeding hypophosphatemia is an occasional finding even in purely food-res tricting nervos a patients during treatment and requires

2354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 89 of 107

Other Treatment G oals and T he treatment challenge of eating dis orders is enabling patients to s tart eating normally and s top compulsive exercise, binge eating, purging, and other behaviors . E vidence sugges ts that the most effective to change abnormal behaviors , whenever pos sible, is completely interrupt them from the beginning of treatment and replace them with healthy alternatives .

Medic ation When experienced eating dis order inpatient units comprehensive care for anorexia nervos a, adding ps ychotropic medications —specifically, selective serotonin reuptake inhibitors (S S R Is) or atypical antips ychotics —appears to offer no added advantage typical cas es . F urthermore, low-weight patients are likely to experience medication side effects, particularly from tricyclic antidepress ants (T C As ). S everal contribute to the s ens itivity of malnouris hed patients to medications —for example, depletion of body protein, particularly albumin, can increas e the percentage of unbound or free drug in blood, and depletion of body can decrease the volume distribution of fat-soluble medications , leading to increases in s teady-state levels. T he use of thes e medications in other s ettings more treatment-res is tant cases has not been fully explored. W hen s evere major depres sion, anxiety disorders , or OC D precede the ons et of anorexia P.2019 nervos a, concurrent pharmacological treatment of conditions may be helpful. On occasion, antianxiety 2355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 90 of 107

medications may enable patients to deal with the anticipatory anxiety of confronting meals. T wo studies have demons trated that S S R Is are not more effective placebo in decreasing depress ive symptomatology or improving weight restoration in s tarved anorexia patients during nutritional rehabilitation. It is not clear whether the atypical neuroleptics play any role in treatment of eating dis orders, or whether they provoke ego-dystonic appetite and the metabolic syndrome. (50 to 100 mg elemental zinc) has been s hown to more rapidly improve weight res toration in anorexia nervos a. Once weight has been res tored, fluoxetine (P rozac) been s hown to reduce relapse in anorexia nervos a, compared to placebo, all other factors being equal. Of caution, one outpatient s tudy found that adoles cents anorexia nervosa los t weight on citalopram (C elexa) ps ychotherapy vers us ps ychotherapy alone.

Ps yc hotherapies In addition to restoring weight and interrupting eating and exercis e behaviors , treatment requires addres sing the core psychopathology of the eating disorders . P sychotherapies aimed at modifying and altering core pathological beliefs and other contributing ps ychopathological iss ues are key elements of Available evidence strongly favors treatments based on cognitive-behavioral therapies , similar to those robustly demonstrated to be effective in bulimia nervosa, but well proven in anorexia nervos a becaus e of the status of starved patients and the ethical of random as signment to no ps ychological treatment. Additional alternative ps ychotherapeutic interventions 2356 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 91 of 107

based on interpers onal therapies , family therapies , or ps ychodynamically informed ps ychotherapies — particularly thos e us ing s elf-ps ychology and “focal analytical” approaches —may als o be beneficial. S imply changing the abnormal behaviors through behavioral contingencies of reward and punis hment has been disproved as being effective for more than the s hort as it ess entially lets patients “eat their way out of without change in the overvalued beliefs and distorted cognitions. T he core of ps ychotherapeutic treatment is succes sfully engaging and relating to patients , their own self-awarenes s and motivation for change persuading and helping them to recognize, challenge, replace their overvalued beliefs regarding the of weight loss and their phobic fear of fatness with acceptance of healthy, normal, individualized body weights and the skills for s elf-regulation. F or patients with anorexia nervos a, s tudies show that involvement is es sential for good outcomes , with elements of family education, counseling, instruction, therapy incorporated into treatment. Individual, group, and family contexts for ps ychotherapy are all effective, the blend of these contexts is decided on a or age-appropriate bas is .

Treatment of B ulimia Nervos a P sychiatric hos pitalization is only occasionally the treatment of normal-weight patients with bulimia nervos a. E xceptions are the presence of intractable symptoms producing s ignificant physiological repeated failure to respond to competent outpatient treatment, suicidality, and the presence of complicating comorbidities, especially borderline personality 2357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 92 of 107

subs tance abus e, and mood dis orders. F ifteen percent recent and less severe cases of bulimia nervosa have res ponded to four s es sions of ps ychoeducation emphasizing healthy nutrition with relief of bulimic symptoms and behaviors . Up to 20 percent res pond to guided self-help programs us ing profes sionally manuals , ps ychoeducation, and cognitive-behavioral principles. F or the average, moderately severe cas e of bulimia nervosa, cognitive-behavioral therapy has been clearly documented as an effective treatment that is superior to other forms of psychotherapy or ps ychopharmacology alone. Of concern is the fact that relatively few clinicians have currently received training in cognitive-behavioral ps ychotherapy s kills . C ognitive-behavioral therapy has been effective in both individual and group formats, with s hort-term reported by 40 to 50 percent of cas es treated with cognitive-behavioral therapy and s ymptom reduction to less er degree reported in higher percentages. If show little res ponse to cognitive-behavioral therapy approximately eight sess ions, s tudies suggest that an S S R I will improve outcome. At times, other ps ychotherapies , es pecially interpersonal may be mos t us eful. P s ychodynamically informed ps ychotherapies have not yet been well studied for bulimia nervosa, but experienced clinicians value ps ychotherapeutic tactics derived from ps ychodynamic perspectives , particularly relational therapies, s elfps ychology, and focal analytic therapies. E nhancing motivation is a key early treatment element. Antidepress ants have been s hown to be effective for symptom reduction in bulimia nervosa, with 2358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 93 of 107

approximately 60 percent experiencing some s ymptom reduction. However, their use as a s ole therapy is not adequate to effectively treat most patients , as relatively few patients become abstinent of binge eating and purging on medication alone, and most relapse if the medication is discontinued. F luoxetine has been the extensively s tudied, and higher doses —60 to 80 mg day—appear to be more effective than the 20- to 40per-day traditional antidepres sant dose if there are components. In addition, T C As and monoamine inhibitors (MAOIs ) have been effective, although more problematic due to s ide effects and potential for suicide by overdos e. S urpris ingly, res ults using fluvoxamine (Luvox) have not been better than B upropion (W ellbutrin) is relatively contraindicated due an increas ed ris k for seizures in patients with bulimia nervos a. In practice, if results from the initial trials are inadequate, clinicians have found that trying several medications in sequence yields better res ults. If res ults are beneficial, a minimum of 6 months a year on medication is sugges ted, preferably in conjunction with C B T . S tudies in which bulimic patients have been treated both evidence-based ps ychotherapy and conjoint ps ychopharmacology s how small but important over cognitive-behavioral therapy alone and, over pharmacology alone.

C ognitive-B ehavioral Therapy C ognitive-behavioral therapy for bulimia nervosa of s everal phas es . T he firs t focuses on educating about bulimia nervos a, helping them to increas e the 2359 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 94 of 107

regularity of eating and res is t urges to binge or purge, part, through careful self-monitoring and recording. T he second phas e us es various s tructured procedures and homework as signments to help patients broaden their food choices and identify and correct dys functional attitudes, beliefs, and avoidance behaviors . Next, are taught to identify interpersonal stress ors and deal more effectively with them by employing more adaptive coping s tyles. F inally, after s ymptoms have abated, prevention s trategies are us ed to reduce the likelihood relaps es by anticipating and preparing for s tres sful situations and s etbacks likely to be encountered in the future. A lis t of guided self-help cognitive-behavioral therapy–oriented workbooks for patients and clinicians appears in the reference list. P atients with difficult-to-manage multiimpulsive bulimia nervos a are currently being treated with combinations dialectical behavioral P.2020 therapy, intensive psychotherapies, and medications . C ontrolled s tudies are under way to examine the effectivenes s of s uch treatment approaches for these patients.

Treatment of B inge-E ating B ecaus e binge-eating dis order and nonpurging bulimia nervos a clearly overlap, systematic res earch on bingeeating dis order has been des igned based on of bulimia nervosa and non–binge-eating forms of and current treatment recommendations derive from information from all of these fields. G eneral treatment 2360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 95 of 107

principles s ugges t that binge-eating behavior s hould be addres sed before weight reduction for obesity is attempted. T reatment of the binge-eating behaviors is us ually bes t accomplis hed via treatment with cognitivebehavioral therapy, and s ome s tudies show that, for control of binge-eating behaviors , medications add little well-conducted cognitive-behavioral therapy. However, because only approximately 50 percent of patients stop binge eating after cognitive-behavioral therapy and because the addition of antidepres sants has been to increas e weight los s and s ometimes increase rates when added to cognitive-behavioral therapy, the addition of antidepres sant medication is often us eful. In addition to cognitive-behavioral therapy, interpersonal therapy has also shown effectivenes s for binge-eating disorder. A randomized clinical trial s howed that both therapies administered in group settings were similarly effective in achieving binge-eating recovery (73 to 79 percent posttreatment and 62 to 59 percent at 1 year). S ymptoms of binge eating per se appear to benefit medication treatment with s everal different S S R Is, desipramine (Norpramin), imipramine (T ofranil), and, recently, topiramate (T opamax). Open studies s ugges t inositol and sibutramine (Meridia) may be us eful. Most, not all, s tudies s how that medication added to behavioral therapy is much more effective than medication alone. Older s tudies showed that high-dose S S R I treatment (e.g., fluoxetine at 60 to 100 mg) often initially res ulted in weight loss . However, the weight was ordinarily short lived, even when medication was continued, and weight always returned when was stopped. 2361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 96 of 107

T reatment of the obesity ass ociated with binge-eating disorder requires both nutritional modification with reduction and an increas e in aerobic exercis e. F or obesity, especially class III, medical s upervision and, occasion, gastric surgery are required.

S elf-Help G roups E vidence indicates that self-help groups —often laycan be beneficial for those who have a variety of and ps ychiatric disorders. S ome reports s uggest that malnouris hed anorexia nervosa patients may have difficulty participating in groups and that advers e cons equences of group participation may include competition for being the thinnes t patient and learning new maladaptive, “pro-anorexia” techniques. T here is general agreement that groups can be helpful for nervos a. A spectrum of profes sionally mediated to lay-led groups exis ts. Although data are sparse, some reports indicate that a subpopulation of patients with bulimia nervosa and binge-eating dis order find organizations s uch as Overeaters Anonymous (OA) to helpful (with experience varying from group to group individual to individual). F or the treatment of moderate obesity, organizations such as W eight W atchers can extremely helpful and are free of common fads or fixes .”

R elaps e Prevention R is k of relaps e is most common the first several years recovery. Ongoing treatment requires attention both to preventing relaps e and to enhancing the development and adaptability of recovering patients. In 2362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 97 of 107

addition to monitoring for signs of s ymptom return, clinicians attempt to guide patients to work toward developing age-appropriate behaviors and mature skills ; satis fying involvement in s chool, work, and social relations hips ; and an identity bas ed on healthy core rather than on an eating dis order. Major challenges individuals whos e identities have centered around their eating disorders and who cannot imagine life without anorexia nervosa or bulimia nervosa. In relapse work, common cris es can be anticipated, s uch as the return to school, family, holidays involving food, special occasions, complexities in relations hips, moves , and unexpected disappointments. P revention requires building alternative coping skills and methods of stress reduction so that s tres sors do not automatically trigger regress ion to maladaptive, ineffective eating dis order– related modes of reaction. Methods include ongoing ps ychotherapy incorporating basic elements of behavioral therapy, as well as interpersonal and other ps ychotherapies . T he focus remains on continuing weight and eating behaviors and moderate exercis e. weight-res tored anorexia nervos a patients in follow-up, patients receiving fluoxetine—averaging 40 per day—experienced les s weight los s and fewer of depress ion and rehospitalization in the subsequent than those not receiving medication. T he clinicians who are most effective with eatingdisordered patients combine nonposs es sive warmth; freedom from controlling or hierarchical relations hips based on power; a s ound knowledge of technical ps ychotherapeutic s kills , normal human development, family dynamics , and sociocultural influences; an 2363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 98 of 107

unders tanding of the neurobiology of food and weight regulation and the medical symptomatology of eating behaviors ; and the capacity to work as a team member leader. Although objectively not important, the gender the therapist may be subjectively very important to individual patients . S pecific training in eating disorders confers clinical advantages. G enerally well-trained clinicians who lack s pecific training with eatingpatients do not necess arily do well with thes e patients . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > S UG G E S T E D C R OS S -R E F E R

S UGGE S TE D C R OS S R E FE R E NC E S P art of "19 - E ating Dis orders " S ome of the specific syndromes that can be ass ociated with eating disorders are found in C hapter 13 on mood disorders , in C hapter 14 on anxiety dis orders , in on somatoform disorders, in C hapter 11 on s ubs tancerelated dis orders, in C hapter 21 on impulse-control disorders not els ewhere clas sified, in S ection 24.6 on endocrine and metabolic disorders , and in S ection 7.4 typical signs and symptoms of ps ychiatric illnes s. P ers onality disorders are dis cuss ed in C hapter 23, and relations hip between eating disorders and feeding in childhood, rumination, and pica are dis cus sed in 41. Other areas that relate to this chapter include cons ultation-liais on psychiatry (S ection 24.11), problems (C hapter 25), ps ychodynamic therapy 2364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 99 of 107

30.1), and psychiatric treatment of infants, children, adoles cents (C hapter 48). S ections on genetics and ps ychiatry (S ection 1.18), psychopharmacology 31), and family therapy (S ection 30.5) provide more detailed background to unders tanding eating dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > R E F E R E NC

R E FE R E NC E S Agras W S , Apple R F . O ve rcoming E ating Dis orde rs W orkbook: A C ognitive -B ehavioral T reatme nt for Nervos a. New Y ork: Academic P res s; 1999. Agras W S , W alsh B T , F airburn C G , W ilson G T , HC : A multicenter comparis on of cognitivetherapy and interpersonal psychotherapy. Arch G e n P s ychiatry. 2000;54:459–465. P.2021 *American P s ychiatric Ass ociation W ork G roup on E ating Disorders : P ractice guideline for the patients with eating disorders (revision). Am J P s ychiatry. 2000;157(1 S uppl):1–39. Andersen AE , ed.: E ating dis orders. P s ychiatr C lin Am. 2001;24(2). Attia E , Haiman C , W als h B T , F later S R : Does augment the inpatient treatment of anorexia Am J P s ychiatry. 1998;155:548–551. 2365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 100 of 107

B achar E , Latzer Y , K reitler S , B erry E M: E mpirical comparis on of two ps ychological therapies . S elf ps ychology and cognitive orientation in the of anorexia and bulimia. J P s ychothe r P ract R es . 1999;8:115–128. B aran S A, W eltzin T E , K aye W H: Low discharge and outcome in anorexia nervos a. Am J P s ychiatry. 1995;152(7):1070–1072. B ergh C , E riks son M, Lindberg G , S odersten P : serotonin reuptake inhibitors in anorexia nervos a. L ance t. 1997;348(9023):339–340. B irmingham C L, G oldner E M, B akan R : C ontrolled zinc s upplementation in anorexia nervosa. Int J E at Dis ord. 1994;15:251–255. C olantuoni C , R ada P , McC arthy J , P atten C , Avena C hadeayne A, Hoebel B G : E vidence that excess ive sugar intake causes endogenous opioid dependence. O bes R es . 2002;10(6):478–488. Dare C , E is ler I, R us sell G , T reasure J , Dodge L: P sychological therapies for adult patients with nervos a: a randomised controlled trial of outpatient treatments . B r J P s ychiatry. 2001;178:216–221. Devlin B , B acanu S A, K lump K L, B ulik C M, F ichter Halmi K A, K aplan AS , S trober M, T reas ure J , DB , B errettini W H, K aye W H: Linkage analys is of anorexia nervosa incorporating behavioral 2366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 101 of 107

Hum Mol G e net. 2002;11(6): 689–696. de Zwaan M, R oerig J . P harmacological treatment, evidence and experience in ps ychiatry. In: Halmi M, eds . E ating Dis orders . V ol 6. W orld P s ychiatric Ass ociation, J ohn W iley (in pre s s ). E as twood H, B rown K M, Markovic D, P ieri LF : in the E S R 1 and E S R 2 genes and genetic to anorexia nervos a. Mol P s ychiatry. 2002;7(1): 86– *E is ler I, Dare C , R uss ell G F M, S zmukler G I, le Dodge E : F amily and individual therapy in anorexia nervos a. A 5-year follow-up. Arch G e n P s ychiatry. 54:1025–1030. F airburn C . O ve rcoming B inge E ating. New Y ork: G uilford; 1995. F airburn C G , C ooper Z, Doll HA, W elch S L: R is k for anorexia nervosa: three integrated cas e-control comparis ons . Arch G e n P s ychiatry. 1999;56:468– F airburn C G , Norman P A, W elch S L, O'C onnor ME , HA, P eveler R C : A prospective study of outcome in bulimia nervosa and the long-term effects of three ps ychological treatments . Arch G e n P s ychiatry. 1995;52:304–312. F airburn C G , W elch S L, Doll HA, Davies B A, ME : R isk factors for bulimia nervosa: a communitybased case-control s tudy. Arch G e n P s ychiatry. 2367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 102 of 107

1997;54:509–517. G arfinkel P E , Lin E , G oering P , S pegg C , K ennedy S , K aplan AS , Woodside DB : S hould amenorrhoea be neces sary for the diagnos is of nervos a? E vidence from a C anadian community B r J P s ychiatry. 1996;168(4):500–506. G arner DM, G arfinkle P E , eds . Handbook of E ating Dis orde rs . 2nd ed. New Y ork: G uilford; 1977. G ordon I, Las k B , B ryant-Waugh R , C hris tie D, C hildhood-onset anorexia nervosa: towards a biological substrate. Int J E at Dis ord. 1997;22 165. *G rice DE , Halmi K A, F ichter MM, S trober M, DB , T reasure J T , K aplan AS , Magistretti P J , B ulik C M, K aye W H, B errettini WH: E vidence for a susceptibility gene for anorexia nervosa on chromosome 1. Am J Hum G ene t. 2002; 70(3):787– Howard W T , E vans K K , Quintero-Howard C V , WA, Anders en AE : P redictors of s ucces s or failure transition to day hos pital treatment for inpatients anorexia nervosa. Am J P s ychiatry. 1999;156 1702. Hu X, Murphy F , K arwautz A, Li T , F reeman B , G iotakis O, T reasure J , C ollier DA: Analys is of microsatellite markers at the UC P 2/UC P 3 locus on chromosome 11q13 in anorexia nervosa. Mol 2368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 103 of 107

2002;7(3):276–277. J ohns on J G , C ohen P , K asen S , B rook J S : E ating disorders during adolescence and the ris k for and mental disorders during early adulthood. Arch P s ychiatry. 2002;59(6):545–552. K eel P K , Mitchell J E , Miller K B , Davis T L, C row S J : term outcome of bulimia nervosa. Arch G e n 1999;56:63–69. K endler K S , Maclean C , Neale M, K es sler R , Heath L: T he genetic epidemiology of bulimia nervos a. Am P s ychiatry. 1991;148:1627–1637. Lambe E K , K atzman DK , Mikulis DJ , K ennedy S H, Zipurs ky R B : C erebral gray matter volume deficits weight recovery from anorexia nervosa. Arch G e n P s ychiatry. 1997;54(6):537–542. Levitan R D, K aplan AS , Mas ellis M, B asile V S , Lipson N, S iegel G I, Woods ide DB , Macciardi F M, K ennedy S H, K ennedy J L: P olymorphis m of the serotonin 5-HT 1B receptor gene (HT R 1B ) with minimum lifetime body mass index in women bulimia nervosa. B iol P s ychiatry. 2001;50(8):640– Lock J , le G range D, Agras W S , Dare C . T re atme nt for Anore xia N ervos a. New Y ork: G uilford P res s; Mitchell J E , F letcher L, Hans on K , Mus sell MP , C ros by R , Al-B anna M: T he relative efficacy of 2369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 104 of 107

and manual-based self-help in the treatment of outpatients with bulimia nervosa. J C lin P s ychopharmacol. 2001;21:298–304. *P almer R L, B irchall H, McG rain L, S ullivan V : S elffor bulimic disorders : a randomised controlled trial comparing minimal guidance with face-to-face or telephone guidance. B r J P s ychiatry. 2002;181:230– P ierce DW , E pling F W: Activity-based anorexia: a biobehavioral perspective. Int J E at Dis ord. 485. P iran N, K aplan AS , ed. A Day Hos pital G roup P rogram for Anorexia Ne rvos a and B ulimia Ne rvos a. Y ork: B runner/Mazel; 1990. R atnasuriya R H, E is ler I, S zmukler G I, R uss ell G F : Anorexia nervosa: outcome and prognos tic factors 20 years. B r J P s ychiatry. 1991;158:495–502. R obb AS , S ilber T J , Orrell-V alente J K , V aladezE llis N, Dadson MJ , C hatoor I: S upplemental nasogastric refeeding for better s hort-term outcome hospitalized adolescent girls with anorexia nervosa. J P s ychiatry. 2002;159(8):1347–1353. S afer DL, T elch C F , Agras W S : Dialectical behavior therapy for bulimia nervosa. Am J P s ychiatry. 2001;158:632–634. S chmidt U, T reasure J . G e tting B e tter B itE by B itE : 2370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 105 of 107

S urvival K it for S uffere rs of B ulimia Nervos a and E ating Dis orders . London: P s ychology P res s; 1993. S trober M, F reeman R , Lampert C , Diamond J , K ay C ontrolled family s tudy of anorexia nervosa and nervos a: evidence of s hared liability and partial syndromes. Am J P s ychiatry. 2000;157:393– S trober M, F reeman R , Morrell W : Atypical anorexia nervos a: separation from typical cases in cours e outcome in a long-term prospective study. Int J E at Dis ord. 1999;25(2):135–142. S ullivan P F : Mortality in anorexia nervos a. Am J P s ychiatry. 1995;152(7):1073–1074. T reasure J L, Owen J B : Intriguing links between behavior and anorexia nervos a. Int J E at Dis ord. (4):307–311. T reasure J , S chmidt U. Anore xia N ervos a. C linical E vide nce 7. London: B MJ P ublishing G roup; 162. V annatta J B , C agas C R , C ramer R I: S uperior artery (W ilkie's) syndrome: report of three cas es and review of the literature. S outh Me d J . 1976;69 1465. V illapiano M, G oodman LJ . E ating Dis orders : A C hange: P lans , S trategie s , and W orks he ets . New B runner-R outledge; 2001. 2371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 106 of 107

V ink T , Hinney A, van E lburg AA, van G oozen S H, S andkuijl LA, S inke R J , Herpertz-Dahlmann B M, Hebebrand J , R emschmidt H, van E ngeland H, Ass ociation between an agouti-related protein gene polymorphis m and anorexia nervosa. Mol 2001;6(3):325–328. Walsh B T , Agras W S , Devlin MJ , F airburn C G , K ahn C , C hally MK : F luoxetine for bulimia nervosa following poor respons e to psychotherapy. Am J P s ychiatry. 2000;157:1332–1334. Watson T L, B owers W A, Anders en AE : Involuntary treatment of eating disorders . Am J P s ychiatry. (11):1806–1810. Wes tberg L, B ah J , R as tam M, G illberg C , Wentz E , J , Hellstrand M, E rikss on E : Ass ociation between a polymorphis m of the 5-HT 2C receptor and weight in teenage girls. Neurops ychopharmacology. (6):789–793. Wes ten D, Harnden-F ischer J : P ers onality profiles in eating dis orders: rethinking the distinction between axis I and axis II. Am J P s ychiatry. 2001;158 Wilfley DE , W elch R R , S tein R I, S purrell E B , C ohen S aelens B E , Dounchis J Z, F rank MA, Wis eman C V , G E : A randomized comparison of group cognitivebehavioral therapy and group interpers onal ps ychotherapy for the treatment of overweight individuals with binge-eating dis order. Arch G e n 2372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

19

Page 107 of 107

P s ychiatry. 2002;59(8):713–721. *Wolk S L, Devlin MJ . S tage of change as a predictor res ponse to ps ychotherapy for bulimia nervos a. Int J Dis ord. 2001;30:96–100.

2373 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

01/01/2009

20

Page 1 of 65

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > 20 - S leep Dis order

20 S leep Dis orders Wallac e Mendels on M.D. In traditional psychiatric practice, a complaint about the cons equences of the illness often leads to dis covery of underlying disorder. T hus, a patient who comes in to office because of difficulties at the job, or with his or spous e, may be found to have a previously depres sion. In a s imilar manner, the search for sleep dis orders us ually begins with a complaint about cons equences, usually insomnia or daytime J ust as an important as pect of helping the patient problem at first appeared to be job-related is to give a specific treatment for an underlying condition, s o, in treating s leep complaints, one must first recognize and give specific remedies for underlying proces ses. T his chapter reviews the pathophysiologies of s leep, emphasizing those likely to be seen in ps ychiatric B efore beginning, it should be mentioned that, of there are many other fascinating as pects of s leep that only pas sing relevance to the clinical s leep disorders presented here and, hence, are not covered in detail. Among thes e is the continuing mys tery of the ultimate functions of sleep. Like most drive behaviors, sleep probably has multiple functions, jus t as breathing, for instance, facilitates gas exchange but, in addition, 2374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 2 of 65

a mechanism for speech and more complex behaviors, such as playing a mus ical ins trument. S o, too, s leep have originated to serve some bas ic need, on which are additional functions . F rom an evolutionary point of view, the observation that it involves a loss of cons cious nes s, which, at face value, makes an organism vulnerable to the dangers of the environment, suggests that its beneficial functions are important Among thos e that have been propos ed are energy cons ervation, res toration of cellular energy stores , emotional regulation, cons olidation of memory, and preservation of context in which to organize memory of new stimuli. As with the enigma of the functions of sleep, the nature dreaming is beyond the current s cope of this chapter. summary, interes t in s leep and dreaming as aspects of health goes back to the earlies t times . T he E gyptian Imhotep, who may be the earliest recorded physician in history and who was later wors hipped as a god hims elf, incorporated te mple s lee p in his treatment regimen in third millennium B C . B y P tolemaic times , many temples had sanatoria in which patients slept; it was believed that, while they dreamed, they were and healed by the res ident deity. In ancient G reece, Asclepius as ked his patients to sleep on the floor in his temple (although one wonders how comfortable this might be, given the proximity of the native snake population from which his symbol, and, ultimately, the badge of the medical profess ion, was derived). In both cases, patients were encouraged to talk about their dreams , which were likely influenced by the the temple setting and the religious beliefs of patient 2375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 3 of 65

priest. T heories of functions of dreams in modern times are ranging from views that they repres ent manifestations unconscious conflicts or mechanisms for as similating stress ful events or that they represent a delirium-like P os itron emis sion tomography (P E T ) studies of rapid movement (R E M) sleep s ugges t that there is activation the pontine brains tem, as well as limbic and paralimbic cortical structures mediating emotional res ponses, accompanied by a reduction in activity of dors olateral prefrontal cortical structures regulating executive and mnemonic cognitive process es . T wo clinical s leep disorders ass ociated with dreaming, nightmares and terrors, are discuss ed later in this chapter. 

P R IMAR Y AND S E C ONDAR Y S LE E P



P R IMAR Y INS OMNIA



C IR C ADIAN R HY T HM S LE E P DIS T UR B ANC E S



P E R IODIC LIMB MOV E ME NT S Y NDR OME



R E S T LE S S LIMB S S Y NDR OME



S LE E P -DIS OR DE R E D B R E AT HING



NAR C OLE P S Y



IDIOP AT HIC HY P E R S OMNIA



P AR AS OMNIAS



S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P R IMAR Y AND S E C O NDAR Y S LE E P

2376 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 4 of 65

PR IMAR Y AND S L E E P DIS OR DE R S P art of "20 - S leep Dis orders " S leep may, of course, be dis turbed as a consequence some other disorder. In the example us ed previous ly, a patient reported ins omnia as a res ult of depress ion. S imilarly, sleep may be disturbed owing to pain or discomfort from a medical illnes s. In terms of the fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ), s uch cases are be s e condary s lee p dis orders . In contras t, primary dis orders res ult from conditions inherent to the mechanisms by which sleep is regulated. Although this us eful clinical distinction in organizing one's thoughts about a specific patient, ultimately, thes e two are les s clear. In the case of s leep disturbance due to depres sion, for instance, it is pos sible that fundamental alterations in biogenic amine metabolis m that alter states may als o lead to s leep disturbance. T he manifestation of primary sleep dis orders may als o be strongly influenced by nonsleep conditions . in children, for ins tance, often comes out during stress or family disturbance. Although secondary sleep disturbances are not the focus here, sleep in affective disorders is dis cuss ed for the reas ons given previous ly, the increased rate of ins omnia during periods of stress is mentioned in pass ing. Indeed, severe trauma, as that faced by thos e who survived the Holocaust, 2377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 5 of 65

as sociated with reports of altered sleep and dreaming decades. E xternal stimuli can, of course, als o disturb as is reflected by the observation that the rate of prescriptions for sleeping pills (hypnotics) rises in areas surrounding major airports . On the other hand, the frequency of reported insomnia is approximately the in urban and rural areas , reflecting the univers ality of disturbance in basic s leep mechanisms and, perhaps dispelling the fantasy held by city dwellers of bliss ful country life. T he DS M-IV -T R divides primary s leep disorders into dys s omnias and paras omnias . T he dyss omnias, quantity or timing of sleep, are, in turn, divided into ins omnia and hype rs omnia. Insomnia is a perceived disturbance in the quantity or quality of s leep, which, depending on the s pecific condition, may be as sociated with dis turbances in objectively meas ured sleep. F orms insomnia include the primary ins omnias and circadian rhythm sleep dis turbances . P.2023 Hypersomnias represent conditions that are clinically expres sed as excess ive sleepiness . Again, this not as s harp in practice as this class ification s ugges ts. S ome circadian s leep disorders , s uch as delayed phase syndrome, for ins tance, may present as a of ins omnia at night, as well as morning s leepiness . S imilarly, periodic leg movement dis order may pres ent a complaint of insomnia or hypersomnia. P arasomnias abnormal behaviors during s leep or the trans ition between sleep and wakefulness . Often, they reflect the appearance of normal s leep proces ses at inappropriate 2378 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 6 of 65

times . In a s ens e, they are analogous to s exual in which a fundamentally normal, but often minor, in the context of overall s exual behavior comes to dominate and to disturb other as pects of s ex. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P R IMAR Y INS O MN

PR IMAR Y INS OMNIA P art of "20 - S leep Dis orders "

Inadequate S leep Hygiene A common finding is that a patient's lifestyle leads to disturbance. T his is us ually phrased as inade quate hygie ne, referring to a problem in following generally accepted practices to aid sleep. T hese include, for keeping regular hours of bedtime and arous al, avoiding excess ive caffeine, not eating heavy meals before and getting adequate exercis e. F or example, a patient might come to clinic complaining of difficulty getting off to sleep. A closer examination of his history revealed he got home from his commute at 7:00 P M, ate a hasty dinner, kiss ed the kids goodnight, did s ome work for a hours, and then was s urprised to find that he could not sleep. In this case, the problem (or one of them) was his life no longer contained an evening in which to relax and to prepare for s leep. Alternatively, a school teacher might spend the evening grading papers and then find hims elf or herself wide awake at bedtime. In this case, intervention might be to teach him or her better timemanagement s kills to use during the daytime, so that 2379 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 7 of 65

or her evening will be free for relaxation. A patient who complains of awakening after only a few hours might out to be a dis co aficionado, whose extremely irregular bedtimes have disrupted the rhythm of s leep and In this case, guidance in keeping more regular hours be important. A variation on this problem is the patient whos e work and s ocial activities lead him or her to progres sively more sleep deprived as the week he or s he then cras hes and s leeps in on the weekends. Again, education about the importance of keeping relatively regular hours would likely be us eful. T wo caveats are in order when helping to educate a patient about s leep hygiene. T he firs t is that these are general principles and are not applicable to all patients . general, for ins tance, napping is discouraged, except in elderly and debilitated patients , but a s mall group of insomniacs may actually s leep better at night when take brief daytime naps . T he second is that when trying modify a patient's behavior, it is us ually better to focus one or two changes at a time, rather than ass aulting her with a panoply of desired changes , which can acros s as overwhelming. In a way, this is a s pecific general principle: When a tas k s eems so large as to be daunting, it can help to break it down into individual doable pieces.

P s yc hophys iologic al Ins omnia P sychophys iological ins omnia typically presents as a primary complaint of difficulty in going to s leep. A may des cribe this as having gone on for years and denies that it is as sociated with s tres sful periods in his her life. A typical comment is “I don't unders tand it; 2380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 8 of 65

are actually going pretty well for me right now. If I could just get over this problem in going to s leep.” Often, the patient seems to be focused on the sleep disturbance how it is affecting his or her life. While lying in bed sleep, the patient typically ruminates about is sues on her mind, often thinking through the battles of the preceding day or planning s trategies for problems to be faced tomorrow. He or s he typically says that he or s he works at going to s leep and feels frustrated that his or efforts are not rewarded. C haracteris tically, the patient describes s leeping better when away from home. as ked, the patient reports that he or s he can fall as leep when not trying to, for ins tance, when watching A typical story is that the patient is dozing in the living room in front of the television; the s pouse then comes and wakes him or her up, s aying that it is time to go to bed. T hen, when the patient gets into pajamas and into bed, he or she feels wide awake and unable to It is thought that patients with ps ychophys iological insomnia have developed a conditioned s tate of heightened arousal that has become as sociated with act of going to bed or the environment in which s leep typically occurs —the bedroom. T he genes is of this conditioned respons e is not always certain, but, often, after getting to know the patient, one dis covers that the sleep dis turbance began after some emotionally event, which the patient has long since forgotten or he or s he no longer as sociates with the s leep difficulty. typical his tory would be that, s ome years before, the patient had an ups etting breakup with a girlfriend or boyfriend. In the s hort term, of cours e, he or she experienced sleep difficulty as part of a grief or 2381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 9 of 65

reaction. In many individuals , the emotional ups et gradually works its way through in the next few weeks , and, as things s ettle down, s leep returns to normal. In these individuals, however, the emotional ups et but the s leep problem persists and s eems to take on a of its own. T he patient becomes worried about the poor sleep and works hard to overcome it. Over time, the original ass ociation with the traumatic event is One model of ps ychophys iological insomnia s uggests it can be cons idered to have three components —a predis pos ition, a precipitating cause, and factors that maintain the sleep dis turbance. Little is known about these patients may be more vulnerable to sleep disturbance. T he maintaining factors, however, appear include the excess ive worry about poor sleep. It is a bit like F ranklin R oos evelt's remark that “the only thing have to fear is fear itself.” In this case, the worry about sleeping becomes one of the caus es of poor s leep. In effect, the patient as sociates the act of entering the bedroom or going to bed with an uncomfortable condition generating anxiety and heightened arous al, which are incompatible with s leep. (B ecaus e of the res ponse on entering the bedroom, the patient reports that he or s he s leeps better when in a s trange environment—such as a hotel room—than when at home.) Often, he has found that, in most areas of life, working harder leads to rewards, so he tries even sleep; s adly, this is one of the few areas in which trying hard does not work and may, indeed, complicate the problem. When a patient with psychophysiological ins omnia has sleep study, the polys omnogram (P S G ) usually 2382 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 10 of 65

objectively disturbed sleep with a relatively long sleep latency (the time from when the lights are turned out sleep ons et), shortened total sleep time, or frequent awakenings during the night. W hen as ked in the to estimate how long it took him or her to fall asleep how long he or s he s lept, the patient is us ually fairly accurate. T his finding of good concordance between objective and s ubjective meas ures of sleep is crucial to distinction between psychophysiological insomnia and sleep state mis perception. T reatment of ps ychophys iological insomnia is us ually oriented to decathecting the powerful emotional focus that the patient has placed on his s leep problem, reducing the tendency to work hard at going to s leep, and removing conditioned respons e of anxiety and heightened that has become ass ociated with the act of trying to go sleep. P.2024 It s hould be noted that the kind of conditioned seen in these patients is a special cas e of a seen in many different areas of medicine. One example the cancer patient who becomes naus eous while to the chemotherapy clinic. F inally, it s hould be remembered that, although ps ychophysiological may be a dis order in its own right, many patients a conditioned arousal and anxiety res pons e as a complicating factor on top of ins omnia owing to some other reason. A patient whose sleep is dis turbed due to pain or who has the sleep difficulty ass ociated with depres sion, for instance, may begin to worry about his or her s leep and may develop an arousal 2383 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 11 of 65

res ponse when entering the bedroom. T his illustrates a broader problem, which is that, in evaluating patients chronic ins omnia, one often discovers multiple caus es , each of which needs to be treated.

S leep S tate Mis perc eption R ecognition of sleep state misperception (als o known s ubje ctive ins omnia) arose in respons e to a common— often frustrating—clinical phenomenon. A patient would present at the sleep center describing s leeping only for or 2 hours each night and, in colorful terms, would describe the agony of lying in bed awake for endles s hours. S hortly after the lights are turned out in the laboratory, the patient closes his or her eyes and lies with the quiet, regular res pirations of s leep. T he electroencephalogram (E E G ) appears that of a normal sleeper. In the morning, when the doctor enters the bedroom, the patient opens his or her eyes and, with bewildering sincerity, s ays “S ee doctor, I told you I wouldn't s leep a wink.” Later, when the P S G is analyzed, the s tudy indicates a relatively normal night's sleep. In contras t, the patient's morning estimate of the previous sleep des cribes a poor night, which contrasts sharply with these polygraphic res ults . T his is different from the morning report of a patient with conditioned insomnia, a report which s hows good concordance with the sleep recording. S ubjective insomnia, then, is characterized by a diss ociation between the patient's experience of and the objective polygraphic meas ures of sleep. T he ultimate cause of this dis sociation is not yet although it appears to be a specific case of a general 2384 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 12 of 65

phenomenon s een in many areas of medicine. One example is the sensation of dys pnea. On the one hand, can s ee patients with severe chronic obstructive pulmonary disease (C OP D) and markedly poor blood who report no trouble breathing; in contrast, an apparently healthy young man with normal pulmonary function tests can come in reporting a sensation of not being able to get enough air. S imilarly, in the gastrointestinal (G I) literature, there are reports of a variation in the s ubjective recognition of a s ens ation of satiety when the s tomach is distended, and it is thought that at least one aspect of the complex phenomena led to obesity is that s ome obese patients have recognition of this s ens ation of s atiety. One hint at the genes is of s ubjective insomnia comes a landmark study by L. J . Monroe, who reported that, poor s leepers were awakened in early stage II sleep, said that they felt that they had previous ly been awake, contrast to good s leepers , who believed that they had been asleep. T his s eemed to s uggest that some may have a different s ubjective experience of sleep wakefulnes s than good sleepers. T his disturbance appear to be due to being light sleepers, as a group, are no more eas ily arous ed by an auditory stimulus than good sleepers. T his phenomenon has been explored in terms of the way that hypnotic medication may act to improve s leep. T he author and colleagues found that, after receiving a placebo, insomniacs tend to report that they had been awake, as ked after being awakened from nonrapid eye (NR E M) s leep by an auditory tone. After receiving a hypnotic, such as zolpidem (Ambien) or flurazepam 2385 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 13 of 65

(Dalmane), however, the same patients respond like sleepers , s aying that they believed that they had been as leep. T his sugges ts that one as pect of the which hypnotics act may be that they have a cognitive effect; that is , they change a patient's perception of whether he or she is awake or as leep. S uch a cognitive action may help explain why, clinically, many hypnotics seem to offer a great deal of relief to insomniacs (at acutely), whereas drug-induced increas es in E E G such as total s leep time, are often relatively modes t (in review, the mean increase in total sleep induced by a variety of hypnotics was approximately 30 minutes). underlying phys iological bas is for this disorder remains unclear. One promis ing hypothesis is that at least insomniacs are in a s tate of hyperarous al, which is supported by data indicating that they may have metabolic rate. One common mistake in dealing with patients with subjective insomnia is to tell them that (bas ed on the polygraphic data) there is nothing wrong with their T here is always a temptation to do this, with the hope the patient will be relieved to hear this good news. In practice, telling the patient that he or s he is sleeping normally flies in the face of his or her experience, and likely leads to alienating him and losing his is better—although harder—to respect the patient's symptom, explaining that there is a dis parity between what he or she is experiencing and what the polygraph seems to be showing.

Idiopathic Ins omnia Among primary ins omnia patients, there remains a 2386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 14 of 65

that appears to have neither a conditioned s leep disturbance nor a dis sociation between s ubjective experience and polygraphic data. T hey are class ified having idiopathic ins omnia. T ypically, a his tory of going to s leep or of awakening during the night goes to childhood or even infancy, and the patient's is confirmed by the sleep study, which may show an increased s leep latency, decreas ed total s leep, or arousals . T here have been many hypothes es to genes is of this dis turbance, including the poss ibility there may be a dysregulation of biogenic amine metabolism, alterations in basal forebrain function, an altered res ponse to γ-aminobutyric acid type A benzodiazepine receptor activity, or reduced levels of endogenous s leep-promoting substances. theories have s uggested that thes e patients failed to a normal erotization of s leep as infants or that they received conflicting mes sages from their mothers as to safety of sleeping alone. F inally, before examining iss ues of therapy, it s hould mentioned that primary ins omnia is probably not the as light sleep or sleep deprivation. As mentioned previous ly, there is significant evidence that a group, do not awaken in res ponse to an auditory tone more easily than good s leepers . Moreover, they are not excess ively sleepy during the daytime, at leas t as by the Multiple S leep Latency T est (MS LT ); indeed, if anything, they may be hyperaroused. tes ting s tudies s uggest that their pattern of deficits is different from that typically seen in s leep deprivation. Ins omniacs do not s eem to es timate time differently good s leepers . T hus, it appears that the problem of 2387 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 15 of 65

insomnia is more complex than first meets the eye, and solutions for it are probably different from merely increasing the number of minutes of E E G -meas ured

Treatment T reatments for ins omnia include nonpharmacological pharmacological approaches. P.2025

Nonpharmac ologic al Treatments Nonpharmacological treatments include some general recommendations for all patients and more specific behavioral and cognitive approaches. G eneral s lee p hygie ne principles are s ummarized in 20-1. As mentioned previously, it is important to remember that thes e are general guidelines, and they not fit all patients . When presenting these to a patient, us ually better to help him or her focus on only one or of thes e principles at a time and to work s lowly through the entire lis t, rather than making global recommendations that may feel overwhelming. It also be noted that, although it has long since become of the accepted tradition in lectures on sleep dis orders begin with sleep hygiene, there are minimal long-term outcome data to s upport its use.

Table 20-1 S leep Hygiene

2388 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 16 of 65

Maintain regular hours of bedtime and arising. avoid a lifes tyle of progres sive s leep deprivation during the week and then cras hing on the weekends. Do not eat heavy meals near bedtime. A light in contras t, may be helpful. In general, it is best to avoid napping during the daytime. (E xceptions are made for the elderly or debilitated.) E xercise daily. T his is best in the late afternoon early evening. E xercise later in the evening may disturb s leep. Minimize caffeine intake and cigarette s moking within 8 hrs of bedtime. Do not look at the clock during the night. If an clock is needed, put it in a drawer by the bed, s o it can be heard but not s een. If there is something that is worris ome while lying bed, write it down on a piece of paper and to look at the paper in the morning. Let it go until then. Make the bedroom comfortable. In general, it is better to be slightly cool than to be too warm. 2389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 17 of 65

Do not us e alcohol to help in going to sleep.

Among specific behaviorally oriented therapies is control, developed by R ichard B ootzin. It sugges ts that important cause of s leep disturbance is that the patient has come to as sociate behaviors that are incompatible with sleep with the act of trying to go to sleep and the setting in which s leep is to take place. T he goal, then, remove all behaviors from the bedroom, except sleep loving. T hus , the patient is instructed to conduct all activities in another room. F or example, it would not be appropriate to have a s mall des k at which one pays household bills in the bedroom. S ome couples with children retreat to the bedroom as one of the few that they can have a fight behind clos ed doors . if a patient comes to as sociate the bedroom with the having frank dis cuss ions with the spous e, this does not sleep. F inally, it is important that the patient not come think of the bedroom as a place of discomfort. F or this reason, he or s he is told that whenever he or she finds hims elf lying in bed unable to sleep, he or s he s hould up, go in another room, and not to return to bed until he or s he feels ready to sleep. S le e p re s triction therapy, developed by Arthur 2390 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 18 of 65

addres ses the concern that one of the factors that maintains a s leep disturbance is the relatively sleep res ulting from the patient s taying in bed for unnecess arily long periods . In practice, the patient is to keep a sleep diary for, perhaps , 2 weeks and to to the office. T here, the patient and therapis t the average time that the patient is in bed each night the average amount that he or s he estimates is spent as leep. If, for ins tance, the patient estimates that he or is in bed 9 hours nightly but s leeps only 5 hours, he is instructed to stay in bed only 5 hours and to continue to keep the s leep diary. W hen his subsequent es timates sleep time indicate that he has been asleep 85 percent the 5 hours , the duration in bed is increased to 5.5 again, this is increased in 0.5-hour intervals each time es timated s leep ris es to 85 percent of the time in bed. E ventually, the patient's time in bed approaches more conventional amounts, while s leep efficiency is Although s timulus control and s leep res triction addres s different as pects of the factors that maintain poor should be noted that, like most behaviorally oriented therapies, they s hare many qualities. T ypically, they performed with what P eter Hauri and others refer to as co-s cie ntis t mode l. T his approach avoids the s ituation which the therapist is an authority figure who dispens es knowledge or instructions to a patient who is a pass ive recipient. R ather, the therapist s ays , in effect, “We are experts in certain parts of the common problem that we have before us . I am an expert in the principles of regulation but know less about you. Y ou, on the other hand, are the person most knowledgeable about your behavior and habits. Let's work together, then, and 2391 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 19 of 65

bring our own expertis e to this problem that we face together.” T he therapist encourages the patient to take active role in the proces s, rather than pass ively guidance. In part, this is in res ponse to the observation that insomniacs often have a pass ive view of their affliction. F rom the patient's perspective, it can s ound the heavens had inexplicably opened up and s truck her down with this affliction, which, from his or her perspective, has no relationship to events in his or her present or pas t life. One goal of thes e therapies is to encourage the patient to take a much more active and to be actively engaged in the resolution. T his giving well-earned credit to the patient when there is improvement. Another method of encouraging active involvement in previous ly mentioned therapies is to negotiate with the patient what an acceptable outcome would be. B efore beginning treatment, the therapist considers poss ible outcomes . He might ask the patient what he or she to gain from therapy. If the patient gives an high expectation, the therapist might s ay s omething this: “It s ounds like the best thing that could happen would be that you would come here for two or three and, from then, on you would s leep perfectly for the your life. I wis h this would happen, but it doesn't s eem likely to me that s uch a miraculous cure will take place. the other extreme, probably, the wors t thing that might happen would be that you would come weekly for a and improve only, let's s ay, by 5 percent. W e need to balance, somewhere in the middle, that each of us will agree is likely and that would be acceptable.” B y negotiating s uch an outcome, the therapist helps dispel 2392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 20 of 65

unrealistic expectations and helps the patient take a active role in the proces s. C ognitive -be havioral the rapy (C B T ) emphasizes the dysfunctional thoughts in the maintenance of primary insomnia. It sugges ts, for ins tance, that incorrect (e.g., that there is nothing one can do about poor sleep that one night of poor s leep has disastrous may lead to anxiety that perpetuates the disorder and insomniacs tend to have more emotion-oriented coping strategies to s tres sors . It has been reported that as few six weekly s es sions can modify a patient's beliefs and this change correlates s ignificantly with P S G meas ures reduced wakefulnes s and improved s leep efficiency at month follow-up. It has als o been demons trated to aid discontinuation of benzodiazepines in older with benefits evident for up to 1 year. O the r behaviorally orie nted the rapie s have been dealing with insomnia, although, unlike the former, they lack long-term efficacy s tudies. In s ys te matic by reciprocal inhibition, the patient is as ked to cons truct hierarchy of s ituations that, in his or her experience, as sociated P.2026 with poor sleep. T his preliminary part of the treatment often s eems useful in itself, as the ins omniac patient's tendency is often to s tate that the sleep dis turbance is as sociated in any way with events in his or her life. In meantime, the patient is taught a basic relaxation technique, s uch as J acobsonian muscle relaxation. the hierarchy is cons tructed, the patient is asked to visualize the lowes t ranking s ituation as sociated with 2393 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 21 of 65

sleep (e.g., going to bed the night before a trip) and to pair this vis ualization with the relaxation respons e. When this is s ucces sful, he or she moves up the ladder the second leas t stress ful s ituation, and s o on. T he to des ens itize the patient to these experiences , s o that, when they occur, they carry less anxiety. In pas sing, it s hould be mentioned that, when working with the patient to construct the hierarchy and dealing with his or her s tatement that events in his or her life do not seem ass ociated with poor s leep, a technique sometimes used in the ps ychotherapy of pain patients be us eful. In the cas e of pain management, a cancer patient, for ins tance, says , in effect, “My pain comes cancer; what can you, as a ps ychiatris t, do about something like that? ” T he therapist's respons e can be as k the patient whether his or her pain is exactly the every day or whether it is worse some days , and it is some days. T ypically, a patient agrees that the severity vary on different days . T hen the therapis t suggests that “our job, then, is to see what is different about the good days and the bad days.” An analogous process can be when dealing with sleep dis turbance. In paradoxical inte ntion, the patient is as ked to try not sleep. As he or she finds out how difficult it is to s tay intentionally, he or s he comes to recognize the potency homeostatic s leep regulation. T he therapist can then suggest to the patient that his or her body will not allow him or her to mis s too much sleep. Other techniques on breaking up the ruminative thought process es that typically occur while an insomniac lies awake in bed. presumably the mechanism by which the old folk of counting s heep may have s ome benefit. A more 2394 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 22 of 65

way of achieving this end is us ed in cognitive focus ing, which the patient prepares in advance a s eries of reass uring thoughts and images on which he or she is as ked to concentrate, s hould he or s he wake up during night. Other techniques emphas ize s omatic relaxation, including muscle relaxation procedures , and electromyographic (E MG ) biofeedback. In general, efficacy has been minimal.

R E L A TIONS HIP B E TWE E N THE R A P IE S T he relation of nonpharmacological and approaches for chronic insomnia also needs to be cons idered. T he limited number of s tudies comparing two have been inconsistent. T hos e in favor of nonpharmacological therapy report improvement in 70 80 percent of patients and suggest that it takes longer show benefit initially but that the effects are more T hose in favor of medication point to the generally cost and als o emphasize that, in the major s tudies of nonpharmacological therapy, only a s mall number of potential patients s creened for the projects agreed to participate in the fairly rigorous programs and that patients drop out. Indeed, some of the s tudies showing long-term efficacy of nonpharmacological approaches present data only for thos e who completed the trial and appeared for follow-up. S imilarly, studies examining the efficacy of combining pharmacological and nonpharmacological treatments have been inconsis tent, ranging from thos e showing potentiation to at leas t one s uggesting that the use of medication may inhibit the effectivenes s of behavioral 2395 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 23 of 65

therapies. In the absence of conclusive data, the impres sion is that the two are not mutually inconsistent and, indeed, may aid each other. F or example, if a is given a s upply of medicine s ufficient for us e two or times a week, the therapist may inquire on which nights the patient took the medicine and may try to determine what was different about these days that led the patient be concerned that he or s he might not s leep at night. S imilarly, when as ses sing how deeply a patient slept us ing a behavioral technique, the therapis t may use the medicine as a kind of benchmark, as king how the night in comparis on to the medication night. A more answer as to whether combined therapy is more efficacious than either approach alone awaits the performance of appropriate outcome s tudies .

Pharmac ologic al Treatments P harmacological agents for primary ins omnia are cons idered elsewhere in this volume and hence are not discuss ed in detail here. S ome broad comments about their use are in order, however.

US E IN A C UTE VE R S US C HR ONIC INS OMNIA V irtually all pres cription hypnotics are efficacious for insomnias due to upsetting events or change in environment (e.g., a night in the hospital or on a trip). general, s hort-acting agents may be more des irable, because they improve s leep on the firs t night, whereas long-acting agents , s uch as flurazepam, may not show clear benefit until the s econd or third night of adminis tration. Hence, most therapeutic is sues are with 2396 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 24 of 65

the management of chronic primary ins omnia, which is focus here. In pas sing, some therapists believe that the of sedatives or hypnotics after ups etting experiences not be des irable, becaus e they might prevent the from process ing the recent events and working through the problems facing him or her. T he counterargument been that, if a patient gets a good night's sleep, he or may be more alert and effective in dealing with the next day.

L ONG -A C TING VE R S US S HOR THY P NOTIC S T he original benzodiazepine s edative-hypnotics, s uch flurazepam, chlordiazepoxide (Librium), and diazepam (V alium), were relatively long-acting agents , with active metabolites showing half-lives of 50 to 100 hours or F lurazepam, the first benzodiazepine s pecifically for sleep, rapidly replaced the older barbiturates in the 1970s and is representative of the mos t widely us ed for the following decade. It came to be recognized, however, that flurazepam and related compounds had several s ignificant limitations , s pecifically, that they did reach full potency until the second or third night and because of their long half-lives , they als o caus ed sedation. T he later introduction of the short-acting triazolam (Halcion) (half-life of 2 to 5 hours ) seemed to correct both of thes e problems , but concerns arose along with thes e benefits, it might have introduced a difficulty, namely, increased memory disturbance. In addition, it was thought by s ome to lead to more discontinuation sleep dis turbance than the longeragents , which were, in effect, self-tapering. Newer nonbenzodiazepine hypnotics , including zolpidem (half2397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 25 of 65

life of 2.6 hours) and, later, zaleplon (S onata) (half-life hour), appear to be relatively free of daytime sedation, on the first night, and have les s s ignificant memory At the time of this writing, the short-acting zolpidem is far the mos t widely prescribed prescription hypnotic in United S tates . Overall trends for drugs given with the intention of improving s leep, however, s how a 10-year decline in prescription hypnotics and an increas e in the us e of sedating antidepress ants . Unless daytime s edation is s pecifically des ired (as it in s ome cases of ins omnia secondary to anxiety), acting agents are probably the treatments of choice. most significant limitation is the trans ient appearance discontinuation sleep dis turbance with the short-acting benzodiazepines, and even this is ameliorated by half dose for two or three nights before stopping the medication. Another is sue that arises is whether the half-life of zaleplon may make it more des irable, specifically for those cas es of insomnia in which the difficulty is primarily in going to s leep, as it has minimal effects on total s leep time. T his s hort duration of action may als o lead to new methods of administration, it may be us eful to give it during the middle of the night when the patient awakens .

L ONG -TE R M A DMINIS TR A TION Although chronic ins omniacs experience sleep disturbance for months (by definition) and, often, for prescription hypnotics are officially recommended for periods of time, P.2027 2398 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 26 of 65

generally 7 to 10 days. T he main concern about longus e has been that tolerance might develop, a view founded in s tudies of long-acting benzodiazepines in 1970s . More recently, a growing body of s tudies that examine the nonbenzodiazepine zolpidem in nightly for 6 months has shown no evidence of tolerance, as open-label studies of zaleplon for as long as 1 year. E szopiclone, which is under review for approval for us e at the time of this writing, has been reported to maintain efficacy for 6 months. If these studies be borne out, it seems likely that the wides pread view hypnotics are effective only in the s hort term will need be recons idered.

A L TE R NA TIVE A DMINIS TR A TION S TR A TE G IE S T raditionally, most studies of hypnotics have been on nightly adminis tration of medicine, although, in practice, many patients take thes e compounds T he minimal data that are available, which include us e quazepam (Doral) and triazolam every other night or zolpidem in nonnightly us e for 8 weeks , have that these may be viable alternative s trategies. T he half-life of zaleplon (1 hour) has led to a new approach adminis tration as well—the notion that the patient can take the medication when he or she awakens during night, rather than the traditional approach of taking bedtime in anticipation of later sleep difficulty. T he only caveat to this practice is that, even with the s hort halfit is recommended that the patient take zaleplon only if or s he plans to remain in bed for an additional 4 hours.

A L TE R NA TIVE S TO P R E S C R IP TION 2399 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 27 of 65

HY P NOTIC S A number of studies have indicated that, although insomniacs infrequently go to their doctors for help, are a treatment-seeking group. Indeed, as many as 40 percent cons ume alcohol, over-the-counter (OT C ) hypnotics, or both to aid their sleep. T he former is undes irable, becaus e it expos es them to the ris k of abuse, and it is relatively ineffective as an oral hypnotic owing to dis turbed s leep toward the next morning. T he latter, usually antihis tamines , s uch as diphenhydramine (B enadryl), have significant daytime sedative may impair daytime functioning, and are relatively ineffective as nighttime hypnotics. In addition to laboratory s tudies , which are minimal and conflicting, a survey of pers ons in the community by the C ons umer's Union indicated that many fewer considered them “very helpful” compared to thos e who took prescription hypnotics. Many ins omniacs take me latonin and herbal remedies sleep. Although melatonin has clock-res etting that may make it helpful in treating sleep dis turbance to jet lag or irregular s leep cycle dis turbances in the its us efulness in primary ins omnia is a matter of controvers y. Among the few well-controlled laboratorybased studies is one indicating that 1 and 5 mg of melatonin given at 11:30 P M to healthy volunteers had significant effects , whereas dos ing at 6:30 P M, before endogenous s ecretion occurs, did alter sleep. Higher (5 mg) may even dis turb sleep and, when given in the daytime, may impair performance on s uch measures tracking and reaction time. Its safety als o is an is sue, particularly its actions at melatonin receptors in the 2400 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 28 of 65

vasculature of the coronary and cerebral arteries. In melatonin has been reported to caus e vasoconstriction the middle cerebral artery and reduced cerebral blood flow. T he C ons umer's Union s tudy mentioned found that pers ons taking melatonin ranked it “very helpful” much les s frequently than pres cription and gave it the rating “not at all helpful” more frequently than any other treatment. V ale rian derivatives , taken from the root s tock of officinalis , are repres entative of herbal preparations for sleep. It is lis ted in pharmacopoeias in some E uropean countries , although, in practice, it is us ed primarily in medicine. T here is s ome rationale for its us e, as one of components, the lignan hydroxypinores inol, interacts the benzodiazepine receptor. Although its use as a sedative goes back to ancient actual s tudies evaluating its benefits are limited and mixed res ults. S tudies in elderly poor s leepers and ps ychophys iological insomniacs s howed no effects on sleep latency or wake time, although slow wave s leep increased. A s ingle s tudy of a mixture of valerian and hops given to P S G -screened ins omniacs s howed improvement in s leep latency, wake time, and sleep efficiency, as well as improved subjective reports, after weeks. On the pos itive side, there appears to be no daytime residual effects on several tes ts . In the las t 2 years , a combination of valerian and hops has entered the U.S . marketplace as an OT C agent manufactured by a major pharmaceutical hous e, and how it will be received remains to be s een. Antide pre s s ants are often used to aid s leep; the one by far the mos t widely pres cribed for this purpos e is 2401 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 29 of 65

trazodone (Des yrel), the number of pres criptions for are approximately the same as thos e for the leading prescription hypnotic, zolpidem. Des pite this widespread use, there are few s tudies evaluating its poss ible benefits. A multicenter s tudy found that reported that it had some benefits for s leep, although than those of zolpidem. T wo recent sleep laboratory studies found that 100 mg given for one night had no benefits in dys thymic patients complaining of s leep disturbance, although it improved sleep in patients with major depress ion. Its us efulnes s may be limited by its effects, which include aggravation of ventricular arrhythmias, QT interval prolongation, and priapis m. the limited data about its effectivenes s, the reasons its widespread us e are not entirely clear, although, certainly, ease of prescribing (unlike pres cription hypnotics, it is not a clas s IV res tricted agent) may be factor. Mirtazapine (R emeron) is sometimes pres cribed sleep, although its benefits are often offset by daytime sedation. B lood dyscras ias appearing in roughly one in 1,000 patients should also be considered in weighing ris k to benefit ratio of its us e in nondepres sed patients.

NE W HY P NOTIC C OMP OUNDS T he last few years have s een the development of hypnotic compounds that are neither benzodiazepines nonbenzodiazepines acting at the G AB A A receptor. Although none is approved for commercial at the time of this writing, it s eems likely that s ome will appear in the next few years . Among thes e compounds melatonin receptor agonists (the goal of which is to achieve the pos sibly sedative effects of melatonin with more desirable s ide effect profile), neurosteroids, 2402 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 30 of 65

antagonis ts to serotonin receptor s ubtypes, and P antagonis ts . New methods of adminis tration, an intranas al spray of antihistamines , are being cons idered. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > C IR C ADIAN R H Y T HM S LE E P

C IR C ADIAN R HYTHM DIS TUR B ANC E S P art of "20 - S leep Dis orders " T he presence and consis tency of the circadian throughout evolution indicate its vital biological In mammals , many tis sues have the capability of behavior, but the fundamental pacemaker is located in suprachiasmatic nuclei (S C Ns ) in the anterior hypothalamus. As described by C harles C zeisler and others , the S C N pacemaker can be considered to have fundamental characteris tics: phas e, amplitude, period, res etting capacity. T he latter, in which the inherent rhythmicity of S C N cells is coordinated with external cues indicating whether it is day or night, is made by input from a s ubs et of retinal ganglion cells that us e neuromodulator melanops in. T he output ultimately reaches the pineal gland, where it influences the melatonin. T he S C N, in turn, is sensitive to melatonin, which decreases its waking s ignal. Melatonin, previous ly as a pos sible s edative-hypnotic, has been hypothes ized to have two main functions: resetting the S C N pacemaker with information about daylight and 2403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 31 of 65

promoting proces ses as sociated with sleep. V arious as pects of thes e circadian proces ses can go awry, in several clinical s tates that can be manifes ted as insomnia or hypersomnia.

Delayed S leep-P has e S yndrome In delayed s leep-phase syndrome, the circadian operating in a delayed, but stable, relations hip to the night cues of the external world. Hence, a patient complains of being unable to fall asleep until perhaps to 3:00 AM, as it is only then that his circadian s ys tem a point P.2028 reached by the general population at 11:00 P M to midnight. In the morning, the patient has a difficult time getting up until late morning or complains of in the morning, because it is only then that the system reaches a s tate that is expres sed in most individuals at 8:00 or 9:00 AM. A s leep s tudy begun midnight shows a long s leep latency (often as long as 2 3 hours ) but then a relatively normal sleep pattern and total s leep time. T he patient often s ens es that his or sleep is relatively normal, although altered in timing. when taking a history, one can s ay “I know, of cours e, you have many constraints on when you can s leep and up—your job or schoolwork, for ins tance. B ut if you live a life in which you go to bed as late as you like, up when you feel ready, do you think your s leep would okay? ” T he patient us ually says that he or she would just fine under those circumstances. S imilarly, one can if there was ever a time in his or her life in which he or 2404 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 32 of 65

could choos e his or her hours of s leep, and, if s o, how he or s he do? Often, he or she says , yes, when he or was in college, he or s he would stay up late and sleep into the morning and felt well and energetic during that period. Many of these patients are drawn to jobs in they can choos e their own hours of sleep and waking, instance, working from home as freelance computer programmers. F or most, however, the constraints of working world lead to dis tres s. Originally, delayed s leep-phase syndrome was hypothes ized to aris e from a decreas ed ability of the res etting capacity of the pacemaker, s uch that from the retina was only partially success ful in coordinating the daylight–night signal from the external world with the inherent rhythmicity of the S C N. More recently, the pos sibility that thes e are patients with unusually long cycle periods has been sugges ted. focus on the role of the patient's behavior in the this s yndrome. T he firs t major therapy for delayed sleep-phase was chronotherapy, in which the patient is instructed to shift his or her hours of s leep and waking progress ively later each night, until he or s he has moved around the clock to a point at which he or s he has a more bedtime. (It may s eem paradoxical to as k him or her to a progress ive delay in his or her sleep to adjust to the earlier bedtime; this is done because it takes the inherent period of the pacemaker, which is slightly longer than 24 hours.) Once the patient has achieved her new earlier bedtime, one has to emphas ize the importance of faithfully keeping these new hours ; only few nights of going to bed later can dis rupt the newly 2405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 33 of 65

es tablis hed pattern. In practice, it is difficult to keep the patient doing this . Many a therapis t has heard the come in with poor s leep again, giving elaborate explanations as to why he or she had had to stay up the last s everal nights (e.g., “my friend in C alifornia jus t divorced, and she keeps calling me to talk, at all Indeed, one could speculate that the many reas ons patients give for s hifting back to a much later bedtime represent logical rationales for obeying a biological impulse. In any event, the difficulty in having a patient move his or her sleep time around the clock and the difficulty in maintaining the new hours led to the quest new approaches . An alternative approach for managing delayed sleepphase syndrome is bright-light therapy. In this case, the patient is expos ed to bright artificial light in the early morning. V arious commercial fluores cent lights can be us ed for this purpose, and typical treatments might be minutes or more at 3,000 to 10,000 lux. T his res ults in phase advance of the pacemaker, s uch that the s leep– waking signal is res et to more traditional hours . T his is generally benign and effective therapy, although one should be aware of the rare poss ibility of phototoxicity retinal receptors, particularly in the macula, or of s olar retinopathy.

A dvanc ed S leep-P has e S yndrome Advanced sleep-phase syndrome is similar in principle delayed s leep-phase syndrome, except that, in this the rhythm of s leep and waking is advanced relative to traditional hours of bedtime and aris ing. T hus, it is manifest as sleepines s early in the evening and then 2406 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 34 of 65

awakening in the early morning hours with an inability go back to s leep. It is particularly common in the who have a phas e advance of approximately 1 hour in terms of their temperature and melatonin rhythms . T his condition can be treated by adminis tering bright light in the early evening, res ulting in a phase delay of the pacemaker, s uch that the s leep–wake s ignal is in concert with traditional hours for bedtime and aris ing.

Non–24-Hour S leep–Wake C yc le In a non–24-hour s leep–wake cycle, a patient may intermittent insomnia that periodically recurs . It is found in blind individuals and res ults from a complete failure of the resetting mechanis m of the pacemaker. patient then begins to live with a propens ity to have a sleep–wake rhythm with the inherent and uncorrected period of the internal pacemaker, approximately 24.15 hours. In a world in which day and night follow a 24.0cycle, this means that the patient's propensity for sleep cons tantly s hifting forward relative to what would be appropriate to his or her s urroundings . T he res ult is or s he experiences ins omnia, which is periodically exacerbated when his or her internal rhythm is most phase with the environment and which improves as he she moves more in phas e with his s urroundings . adminis tration has been demonstrated to be us eful in regulating sleep in thes e individuals .

S hift Work S hift work can induce s leep disturbances , as well as difficulties , including accidents due to s leepiness during nighttime working hours and, in more extreme cas es, a 2407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 35 of 65

s hift-work s yndrome characterized by G I and disorders . A common experience among night shift workers is to come home in the early morning, to go to bed feeling exhausted, to s leep only 2 to 3 hours, and awaken feeling unrefreshed but unable to continue sleeping. T he treatments for s hift work are complex vary with the type of work schedule (s hift work is , of a general term that can include a wide variety of schedules: fixed work on an evening s hift, cycling shifts from day to evening to night s hifts, and so on). V arious strategies , including napping before going into work in the evening or taking a s cheduled nap nighttime work hours, may be helpful. Us ing bright light night and avoiding light during the day have been propos ed. It may be helpful, for instance, for a nightworker driving home in the morning to wear as not to get a large light exposure immediately before going to bed. It has been demonstrated that us ing circadian principles to design indus trial work schedules can reduce absenteeism and medical difficulties. T reatment with melatonin has been found to be less succes sful than timed bright light expos ure in aiding adjus tment to shift work.

J et L ag J et lag s leep disorder is s imilar to that of s hift work in it repres ents a dys synchrony between one's internal wake rhythm and that of the external world; in this however, the dyss ynchrony results from rapidly one's location to a new environment. After wes tward travel, one is phas e advanced relative to the that is , one wants to go to bed earlier and to get up than what is appropriate for the new location. E as tward 2408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 36 of 65

travel res ults in being phas e delayed relative to one's surroundings—the P.2029 tendency is to s tay up later and to get up later than needed. A number of strategies have been proposed dealing with jet lag. One can, for ins tance, slowly adjust the new hours before leaving on the trip. B efore wes tward, for instance, one can progres sively go to later and get up later while s till at home. S pecial diets been propos ed, but their effects s eem relatively Maximizing light expos ure during the new daytime and minimizing light during the new nighttime are helpful, there is evidence that timed melatonin adminis tration aid adjus tment. In jet lag and s hift work, the use of acting hypnotics can aid s leep at the new bedtime, but there is no evidence that this leads to more rapid adjus tment to the new time schedule. A number of inves tigators and pharmaceutical houses are trying to develop chronobiotics , medications that help res et the pacemaker, although none has yet reached the prescription drug market with this indication.

Irregular S leep–Wake R hythm Irregular sleep–wake rhythm is characterized by shifting hours of s leepiness and wakefulnes s. It is an affliction of dis co aficionados and others who a highly irregular schedule, although it is s ometimes in pers ons who have had tumors or other pathology of hypothalamus. T reatment is organized around altering behavior, encouraging the patient to keep regular bedtime and aris ing and to avoid napping. 2409 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 37 of 65

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P E R IODIC LIMB MOV E ME NT

PE R IODIC L IMB S YNDR OME P art of "20 - S leep Dis orders " P eriodic limb movement syndrome (P LMS ) (als o nocturnal myoclonus ), along with res tles s legs would be cons idered to be in the dys s omnia not s pecifie d category in terms of the DS M-IV -T R . A with P LMS is neurologically normal while awake but, during sleep, manifests periodic s tereotyped of the limbs (usually the legs ). T hese movements extension of the toes , as well as flexion of the ankle knee. T he patient is us ually unaware that thes e movements occur, although the bed partner may be too aware. T he res ult of these events is us ually although hypersomnia may als o appear. P LMS is as sociated with renal dis eas e, as well as iron vitamin B 12 anemia; some investigators believe that it is exacerbated by tricyclic antidepress ants, although are differing views on this is sue. T he disorder tends to problem of middle age in both s exes, with increasing frequency with advancing age. C hildhood cas es have reported, and there is s ome evidence that it is with attention-deficit/hyperactivity disorder (ADHD). It is not clear whether the sleep dis ruption ass ociated with movements leads to s leepiness , manifested in children hyperactivity, or whether both res ult from a common 2410 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 38 of 65

underlying etiology. P eriodic limb movements (P LMs) commonly s een in sleep studies of narcoleptics . One found a P LM index of greater than five in 61 percent of obstructive sleep apnea (OS A) patients; the P LMs and disordered breathing events had different periodicities, however, sugges ting that they have different T he ultimate etiology is uncertain, although it has been hypothes ized that it res ults from hyperactivity in some areas of the s pinal column, particularly in the and cervical segments , triggered by a poorly supras pinal sleep-related mechanis m. Although most authors emphasize the role of the P LMs in disrupting sleep, others speculate that they are, in fact, respons es sleep that is disturbed for s ome other reason. T his view would explain the high frequency of P LMs in narcoleps y, which is characterized by multiple in nocturnal s leep, and in s leep apnea, in which s leep disturbed by arous als res ulting from dis ordered events. Others have questioned whether the frequent appearance of P LMs in end-stage renal disease is as sociated with the sense of dis turbed s leep in these patients. On the P S G , P LMs are 0.5 to 5.0 seconds in duration occur every 20 to 40 s econds (F ig. 20-1) during NR E M s leep. Often, they are accompanied by a K or brief arousal signal in the E E G channels of a P S G . C linicians differ as to whether to count only thos e that accompanied by E E G evidence of arous al or to count P LMs regardles s of E E G cons equences. A diagnosis P LMS requires a P LM index of at least five per hour.

2411 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 39 of 65

FIGUR E 20-1 E xample of periodic leg movements as seen on the polysomnogram. C Z-02, electroencephalogram channel; E C G , E MG , electromyogram; LOC , left electrooculogram; right electrooculogram. T he traditional treatment for P LMS has been (K lonopin) in doses of 0.5 to 2.0 mg per day. this often brings a s ubjective s ens e of improved sleep the patient but is us ually P.2030 not as sociated with decreased numbers of P LMs on P S G . T his has sugges ted to s ome investigators that mechanism of action of clonazepam may be to the arousal res ponse to the movement. E ffectivenes s often limited by the complaint of daytime sedation, has led many clinicians to administer shorter-acting benzodiazepines. Another approach is to adminis ter doses of L-dopa (Larodopa), although others are 2412 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 40 of 65

to do this becaus e of the poss ibility of bringing out movement disorders or dopaminergic psychosis . no specific evidence is known, s ome clinicians believe the need for medications is reduced over time if enter s tres s -management programs or s imilar anxietyrelieving programs. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > R E S T LE S S LIMB S S Y NDR

R E S TL E S S L IMB S P art of "20 - S leep Dis orders " R es tles s limbs syndrome (R LS ) (also known as E kbom s yndrome ) is an uncomfortable subjective s ensation of limbs , usually the legs, sometimes described as a crawly” feeling or as the s ens ation of ants walking on skin. It tends to be worse at night, and (in contrast to claudications) is relieved by walking or moving about. It appears as a cause of s leep initiation insomnia, as the patient may find it difficult to lie still in bed, needing to up to relieve the dis comfort. T he ultimate cause is unknown, but it appears often in pregnancy, iron or vitamin B 12 deficiency anemia, and renal dis eas e. T here are no specific findings on the P S G , although often s ees increased movement artifact on the E MG channel before sleep ons et. Mos t patients with R LS have P LMS , although most patients with P LMS do not R LS . T he firs t s tep in treatment is looking for anemia and treating it, if found. B enzodiazepines are relatively 2413 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 41 of 65

ineffective. T he off-label use of L -dopa and carbidopa (S inemet), bromocriptine (P arlodel), and pergolide (P ermax) is often helpful. In rare patients who are affected, the off-label use of narcotic analges ics can when other treatments have been tried and have failed. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > S LE E P -DIS OR DE R E D B R E AT

S L E E P-DIS OR DE R E D B R E ATHING P art of "20 - S leep Dis orders " S leep-disordered breathing may pres ent as or ins omnia. OS A, the most common and relevant for this chapter, is characterized by periods of obstruction of the upper airway during s leep, resulting decreases in arterial oxygen s aturation and a trans ient arousal, after which res piration (at least briefly) normally. It tends to occur in patients who snore the majority of s norers do not have s leep apnea) and res ults in a s ens ation that sleep has not been Many, although by far not all, patients are overweight, it appears more frequently in patients with s maller jaws true micrognathia, acromegaly, and hypothyroidis m. S tudies of the upper airway sugges t that, as a group, patients have s maller airways than normal s leepers , there is a great deal of overlap. Medical cons equences include cardiac arrhythmias, s ys temic and pulmonary hypertens ion, and decreased s exual drive or function. exact relationship of obesity, OS A, and hypertens ion is 2414 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 42 of 65

matter under inves tigation, s ome arguing that hypertens ion is a consequence of OS A, whereas believe that OS A and hypertens ion can best be viewed difficulties arising from a common etiology, including obesity. It tends to be an illness of middle age, men, but can occur at any age, including children. On the P S G , episodes of OS A in adults are multiple periods of at leas t 10 s econds in duration in nasal and oral airflow ceas es completely (an apnea) or partially (a hypopnea), while the abdominal and ches t expansion leads indicate continuing efforts of the diaphragm and acces sory muscles of res piration to air through the obs truction (F ig. 20-2). T he arterial P.2031 saturation drops, and, often, there is a bradycardia that may be accompanied by other arrhythmias , such as premature ventricular contractions . At the end, an reflex takes place, seen as a waking signal and motor artifact on the E E G channels . At this moment, sometimes called the bre akthrough, the patient can be observed making brief restless movements in bed. T he patient then returns to sleep, with normal respirations . T hese events can occur in NR E M or R E M s leep, the us ually more frequent, the latter usually more s evere. Different laboratories require different numbers of to make a diagnosis , usually five or ten disordered breathing events per hour of s leep. Many laboratories a s cale of the number of dis ordered breathing events hour to class ify OS A as mild, moderate, or severe. clas sification based solely on the frequency of events be les s helpful than firs t s upposed, as the true s everity 2415 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 43 of 65

should include consideration of the degree of arterial oxygen s aturation, the presence or abs ence of cardiac arrhythmias, and other factors .

FIGUR E 20-2 E xample of an obstructive sleep apnea on the polys omnogram. C Z-O2, electroencephalogram channel; E C G , electrocardiogram; E MG , LOC , left electrooculogram; R OC , right C entral s leep apnea (C S A), which tends to occur in the elderly, res ults from periodic failure of central nervous system (C NS ) mechanis ms that s timulate breathing. original teaching was that OS A results in a complaint of excess ive sleepines s, whereas C S A is manifes t as but later case s eries have emphas ized that either may appear in either dis order. T he P S G features of similar to those of OS A, except that, during the periods apnea, a ces sation of res piratory effort is s een in the 2416 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 44 of 65

abdominal and ches t expansion leads. S everal features of OS A and C S A are s ignificant in ps ychiatric practice. T hese include decreased ability to concentrate, decreas ed libido, memory complaints , and deficits in neuropsychological tes ting. Many or even patients have dysthymic features , and, although many patients manifes t OS A and major depress ion, it is not certain that this occurs more often than would be s een chance. One study has indicated that, among OS A patients, thos e with a history of treatment for affective disorder s how greater decrements in ventilatory meas urements . Although s ys tematic data are minimal, many clinicians have the impres sion that, in cases of refractory depress ion, if OS A is found and treated, the depres sive s ymptoms may improve. tes ting indicates that mos t, but not all, deficits can be relieved by treatment. P atients s ometimes awaken from apneas with a of being unable to breathe, and thes e epis odes need to distinguished from nocturnal panic attacks. In taking a history, it s hould be noted that perhaps one-third of patients with daytime panic attacks also have thes e episodes during sleep, but it is rare to have panic purely at night. S imilar awakenings can occur in cases paradoxical vocal cord movement, but, in this s ituation, there is us ually a history of trauma or s urgery of the S leep apnea episodes also need to be dis tinguished nocturnal laryngospasm, in which patients report that are unable to s peak or can only whis per for a few after awakening. Another reas on for awarenes s of s leep-disordered breathing in ps ychiatric practice is that patients who 2417 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 45 of 65

complain of ins omnia and who have unrecognized may develop res piratory depress ion if given mos t traditional hypnotics. T he benzodiazepines have s uch res piratory depres sant qualities that their effects are clinically insignificant in persons with normal on the other hand, they can significantly exacerbate and other ventilatory dis orders. T his appears to be particularly true of the longer-acting agents . S tudies of short-acting agents have been mixed, and one s tudy suggested s light improvement in C S A. T he newer nonbenzodiazepines appear to s hare thes e respiratory depres sant qualities , although in milder form. T he important thought to keep in mind is that, if a patient sleep dis turbance appears overs edated in the daytime after being given a hypnotic, there s hould be at least cons iderations: (1) that this represents daytime sedation as a direct effect of the drug or (2) that the has exacerbated previously unrecognized sleep apnea. When a sedative is needed for patients with s leep one can give low dos es of s edating tricyclic antidepres sants (an off-label use), as they do not res piration and may have mild s timulatory effects . daytime anxiolytic is desired, it s hould be noted that buspirone (B uS par) does not appear to adversely res piration. In addition to OS A and C S A, some patients are found have mixed-type apneas, in which the early part of the disordered breathing event appears central in nature there is an absence of res piratory effort), whereas the part of the event appears obstructive. C linically, there little or no difference between what is s een in this form and what is seen in OS A. Upper airway resistance 2418 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 46 of 65

syndrome (UAR S ) is an interesting condition in which patient manifests the s leepiness , fatigue, and other features of OS A, but the P S G fails to reveal s pecific events. More elaborate testing with meas ures of intraes ophageal pres sure (a s urrogate for intrapleural press ure) reveals that, owing to increas ed upper res is tance, the patient mus t generate much greater negative pres sures to produce airflow. T reatment with continuous positive airway pres sure (C P AP ) has been shown to improve daytime alertness and other T he major treatments for OS A are C P AP and surgical approaches. C P AP is performed by administering room at low press ures (us ually les s than 15 cm of water through a nasal mask or small cus hioned nasal during s leep. It is remarkably effective acutely and has advantage of s paring the patient from a surgical procedure, although it carries the dis advantage that it must be used for long periods of time, or even the of the patient. A B elgian s tudy has indicated that 70 to percent of patients who try C P AP accept it, and 90 of them (us ually those who derive subjective benefit initially) continue to use it in the long term. Devices that automatically titrate and deliver the correct pres sure been developed; initial data indicate that they may be better tolerated, although the degree of improvement in daytime sleepines s is approximately the same as for conventional C P AP . Minor complications of C P AP irritation of the eyes from air leaks around the mask nasal drynes s or congestion. In rare cases , pneumomediastinum or pneumocephalus can occur. Alternative devices for treating OS A include tongueretaining devices or systems for advancing the 2419 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 47 of 65

T heir effectivenes s remains under investigation. T he original s urgical treatment for OS A was chronic tracheotomy, which is extremely effective (and may be gold s tandard of effectiveness ). T he concerns , of are that it is, in s ome s ens es , a disfiguring procedure, it requires maintenance, and that it can have complications , s uch as infection. Later, a modified procedure, the uvulopalatopharyngoplas ty (UP P P ) was developed, in which portions of the uvula and s oft are removed and the upper airway is widened. Its advantage is that (if success ful) it is a one-time (in contras t to the continuing need to us e C P AP ), but disadvantage is that it is a major surgical procedure requiring hospitalization and a certain amount of initial discomfort. More importantly, even in the bes t of hands , the success rate, in the range of 60 to 70 much lower than that of C P AP . R are complications can include changes in the voice and nasal regurgitation of liquids when s wallowing. A number of more surgical approaches , including mandibular or s elective widening of s pecific portions of the airway, performed as well, P.2032 although s election procedures to determine which is likely to benefit from which procedure are still under inves tigation. F or patients with s noring without s leep apnea, an outpatient laser-based technique (las eruvuloplasty [LAUP ]) is available. Medical remedies for s leep apnea are of limited benefit and probably should be considered treatments of choice. P erhaps the best s tudied is off-label use of 2420 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 48 of 65

protriptyline (V ivactil), 5 to 20 mg, which decreases sleep (which is usually as sociated with the more apneas ) and increases geniogloss us muscle tone. Its benefits are often limited by its anticholinergic side Low dos es of medroxyprogesterone acetate (P rovera) (again, an off-label use) may have beneficial effects, although, in rare cases, apneas may be exacerbated to uneven stimulation of the diaphragm and access ory muscles of res piration. Other compounds that have tried experimentally but are les s widely us ed are the label use of fluoxetine (P rozac) and buspirone. Lownasal oxygen has had mixed results ; it is generally of benefit in uncomplicated s leep apnea, although it is indicated in cases of apnea complicating other conditions. In addition to thes e s pecific procedures, a number of general precautions and behavioral interventions be us ed in all patients. C ertainly, weight loss should be encouraged in all obese patients, and, in extreme gastric s urgical procedures can be considered. weight loss can widen the upper airway and can lead to proportionate reduction in required C P AP press ure. patient should be encouraged to learn not to s leep on or her back and to avoid alcohol and drugs that are res piratory depres sants . He or she should be about driving, as OS A patients have been found to higher rate of automobile accidents . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > NAR C OLE P S

NAR C OL E PS Y 2421 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 49 of 65

P art of "20 - S leep Dis orders " Narcolepsy is a condition characterized by excess ive sleepiness , as well as auxiliary s ymptoms that the intrus ion of as pects of R E M sleep into the waking It typically begins in the teens or 20s but can occur or later. Once it appears, it is a lifelong condition. T he attacks of narcoleps y repres ent epis odes of irresistible sleepiness , leading to perhaps 10 to 20 minutes of after which the patient feels refreshed, at leas t briefly. helping s eparate sleep attacks from daytime other caus es , it is helpful to ask about epis odes of that have appeared at unus ual or inappropriate times, instance, during intens e conversations or s ex. In to sleep attacks , patients develop one or more symptoms, usually over the course of the next few after the appearance of the s leepiness . T he most of thes e is cataplexy, the s udden onset of weakness of weight-bearing muscles , lasting for a minute or les s occurring in ass ociation with the express ion of emotion, such as anger or laughter. (C ataplexy should be distinguished from catalepsy, the waxy flexibility of the limbs in catatonic schizophrenia.) C ataplectic episodes may be as mild as a sudden s ens ation of needing to sit down or may be so severe that the patient collaps es helpless ly to the ground. Often, the patient remains during the epis ode, although vis ual hallucinations may appear in longer ones lasting more than 1 minute. symptoms include sleep paralysis or hypnagogic hallucinations . T he former is characterized by a brief period of paralys is that occurs as the patient is drifting to sleep or awakening in the morning. Hypnagogic 2422 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 50 of 65

hallucinations are vivid dream-like experiences that when the patient is drifting off to sleep or is in the of awakening in the morning (hypnopompic hallucinations ). S leep paralysis and hypnagogic hallucinations can be accompanied by a s ens ation of a weight on the ches t and anxiety. T heir appearance in narcoleps y, in combination with sleep attacks and cataplexy, s hould be distinguis hed from occas ional episodes in the abs ence of daytime sleepines s, which occur as is olated events in persons without narcoleps y. S ome patients des cribe epis odes that are s uggestive automatic behavior, in which they have done things , s uch as putting dis hes in the clothes washer, for which they have no memory. T hes e probably represent actions taken during a period of sleepines s, which are later recalled. F inally, and somewhat paradoxically, sleepy individuals typically complain of difficulty with nighttime sleep, which is characterized by frequent awakenings . On the P S G , sleep is indeed dis turbed, with frequent arousals , and, often, there are significant numbers of periodic leg movements . T he diagnosis is made from a specialized daytime sleep recording, the MS LT , in patient is given four or five opportunities to s leep for as long as 20 minutes, at 2-hour intervals acros s the day. mean time to fall as leep is calculated, and it is whether the patient has marked sleepines s (usually defined as a mean s leep latency of less than 5 addition to s leepiness , however, during these naps , the narcoleptic patient typically shows two or more of R E M s leep, a phenomenon that is unlikely in other conditions of excess ive s leepiness . T his obs ervation of 2423 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 51 of 65

ons e t s le ep is diagnostic, as well as sugges tive, of the pathophys iology of narcoleps y, which appears to the intrus ion of as pects of R E M sleep (muscle atonia dreams ) into wakefulness . Hence, cataplexy and sleep paralysis can be s een as repres enting the atonia that occurs in R E M, whereas hypnagogic hallucinations an expres sion of the dreaming that is characteristic of Although there is s ome unders tanding of this dysregulation of R E M s leep in narcoleps y, the pathophys iology is s till being inves tigated. An with certain genetic human leukocyte antigen (HLA) markers has been found, but these can also occur in as ymptomatic individuals. T he child of a narcoleptic is approximately 20 times more likely to have narcoleps y than the general population, but there is no s imple Mendelian mode of trans mis sion. R ecent work that the sleepiness of narcolepsy may result from abnormalities in the function of the neuromodulator orexin/hypocretin in the hypothalamus. Occas ional of a narcoleps y-like condition (secondary narcoleps y) been reported in patients with various C NS including children with s uprasellar tumors and hypothalamic obes ity. T he medical treatment of narcolepsy is oriented to the target s ymptoms. F or the s leepiness , the traditional treatment has been the us e of s timulants , such as amphetamines. T olerance may appear, and s ome believe that the use of weekly drug holidays decreases likelihood. More recently, modafinil (P rovigil) has been found to increase wakefulnes s, while demonstrating a more benign s ide effect profile than the traditional analeptics. C ataplexy is us ually respons ive to the 2424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 52 of 65

antidepres sants. In this off-label use, compounds such imipramine are given in much lower dos es than are for depress ion, for example, 50 mg, and the patient shows improvement within one or two nights. Other tricyclics , s uch as protriptyline, and s elective serotonin reuptake inhibitors (S S R Is ), s uch as fluoxetine, may cataplexy in this off-label use. In addition to medical treatments, a number of and educational interventions are important in narcoleps y. B ecause patients often awaken refreshed brief naps , it is helpful to work with the patient, or both to arrange for periods of s cheduled sleep the day. S ymptoms are us ually exacerbated during deprivation, which should be avoided. T he of narcolepsy are such that patients have often not achieved as much in life as their intelligence and drive might otherwise have produced; often, they have been told by teachers and employers that they are lazy, fact, they are pathologically s leepy. Not s urprisingly, experiences can lead to poor s elf-es teem, which can further inhibit the P.2033 patient's ability to achieve. Hence, education about the disorder and reass urance, for the patient and family, be important. Many patients with narcoleps y are dys thymic. In number of clinicians comment on the s imultaneous occurrence of major depress ion and narcoleps y, but population s tudies indicate that thes e are common illness es, and their coexis tence appears no more often than would be expected by chance. In ps ychiatric 2425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 53 of 65

it is als o important to dis tinguis h between hypnagogic hallucinations and visual hallucinations from other and to consider narcoleps y in the differential diagnos is when hearing about a patient who exhibits episodes are sugges tive of automatic behavior. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > IDIOP AT HIC HY P E R S OM

IDIOPATHIC P art of "20 - S leep Dis orders " Idiopathic hypers omnia is a condition characterized by excess ive s leepiness and naps from which the patient not awaken refres hed. T he MS LT confirms significant sleepiness , without evidence of R E M ons et s leep Nocturnal s leep s tudies show no characteris tic pattern, although s low wave sleep may sometimes be elevated. us ually begins in young adulthood and becomes a condition lasting a lifetime. S ome cases appear to be familial and are as sociated with specific HLA antigens, whereas others begin after viral infections, and a group develops thes e symptoms but has neither family history nor postviral status . T reatment is empirical, involving use of amphetamines or other T here are also re curre nt hype rs omnias that appear in distinct episodes weeks apart. An example of these is K leine-Levin syndrome, us ually found in male and characterized by periods of sleepines s and eating. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P AR AS OMNIA

2426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 54 of 65

PAR AS OMNIAS P art of "20 - S leep Dis orders " P arasomnias, abnormal behaviors during sleep, are divided into forms as sociated with s low wave sleep or sleep. T he former includes s leep terror and disorder, whereas the latter includes nightmare and R E M behavior disorder.

S leep Terrors S leep terrors are epis odes in which a child awakens confused and upset, with marked autonomic seen clinically as rapid pulse and diaphores is . T here is report of dreaming, and, eventually, the s eemingly inconsolable child returns to s leep, with no memory of event in the morning. T he P S G shows that thes e appear out of s low wave s leep, and the overall night have hypersynchronous delta activity. S leep terrors occur in as much as 3 percent of children and tend to away in adoles cence.

S leepwalking Dis order S leepwalking disorder tends to occur between 4 to 8 of age and, like night terrors , tends to dis sipate in adoles cence. E pisodes occur out of slow wave sleep; during them, patients appear confused and disoriented. rare cases , they may become violent if arous ed, but, us ually, they can be guided back to bed. T his benign condition needs to be distinguished from the rarer, but more clinically s ignificant, problem of nocturnal 2427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 55 of 65

Although a clinical E E G is the ultimate way of distinguishing thes e two dis orders, some features of history are of help: (1) P atients with sleepwalking return to bed, whereas those with s eizure dis order may awaken in the morning in another room. (2) Although it good practice to help protect sleepwalkers from harm, they rarely injure thems elves ; in contrast, the with seizure disorder may have a his tory of falling down the stairs or walking into a window. (3) T he sleepwalker can usually be guided back to bed, whereas the patient is not res ponsive to guidance during the If an epis ode is captured on the polygraph, it is s een as awakening and motor artifact appearing during s low sleep. If a patient with night terrors or sleepwalking not have an epis ode during a particular s leep one s uggestive piece of evidence is the presence of arousals out of s low wave s leep, which are fairly uncommon in the abs ence of a paras omnia. Night terrors and sleepwalking are benign conditions, treatment cons is ts primarily of educating and the parents . Although both can be exacerbated by of stress or s leep deprivation, in childhood, neither is as sociated with psychiatric illness . S ome cas es of sleepwalking may be induced by medication. Medical intervention is rarely needed for typical night terrors or sleepwalking. In difficult cas es, some clinicians try the label use of benzodiazepine sedatives, which decreas e slow wave s leep.

Nightmares Nightmares are vivid dreams that become more anxiety producing, ultimately resulting in an 2428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 56 of 65

awakening. T hey can occur occasionally in as much as half of children in the range of 3 to 6 years of age. In contrast to night terrors , the child is not confus ed, does not exhibit the mass ive autonomic s igns, and des cribes having had a scary dream. Nightmares in children are as sociated with psychiatric illness ; in contrast, approximately one-half of the roughly 1 percent of who experience frequent nightmares are found to have disorders , including borderline pers onality and schizophrenia. Nightmares are sometimes brought out R E M-suppress ing drugs, in which cas e, the treatment gradually dis continue the medication, if pos sible. S ome authors s uggest that nightmares occur more frequently persons with certain personality traits, including thos e with thin boundaries and more creative individuals . is no widely accepted medical intervention.

R E M B ehavior Dis order R E M behavior disorder is characterized by episodes of complex, often violent, behavior and is thought to represent a patient acting out his or her dreams . It is common in older men, and there is often a history of a small s troke or other C NS ins ult in the last months or It may also appear as an early event in the evolution of P arkins on's dis ease. If an episode is captured on the polygraph, it shows motor artifact appearing out of sleep. If a patient with R E M behavior dis order does not have an epis ode while in the laboratory, the sleep may s how a failure of the normal hypotonia of the bearing muscles during R E M s leep. In cats, a that is s uggestive of R E M behavior dis order can be induced by les ions of the areas s urrounding the locus ceruleus , a brainstem noradrenergic center. T he initial 2429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 57 of 65

was that the clinical disorder repres ents a malfunction the des cending pathway to the s pinal cord, which produces atonia during R E M; its prevalence in the and in parkinsonian patients has sugges ted that there be a more complex etiology involving alteration of function in pontine areas , including the nucleus pedunculopontine, where integration of sleep–wake regulation with locomotor s ys tems takes place. T he widely us ed treatment for R E M behavior disorder is the label administration of clonazepam.

S leep Dis turbanc es in P s yc hiatric Dis orders S leep disturbances in ps ychiatric disorders are the chapters of this volume devoted to the specific disorders . S everal epidemiological s tudies have the as sociation of ins omnia and ps ychiatric disorder; indeed, one s uggests that if a person with no known complains of insomnia at initial interview and does so again at 1-year follow-up, he or s he is almost 40 times likely as the general population to have a diagnosable ps ychiatric disorder. In the sleep center s etting, approximately one-third of pers ons coming in complaining of ins omnia are found to have a disorder, which is major depress ion in approximately half the cases. T here are als o s everal studies affectively normal insomniacs have a much higher rate subs equently developing major depres sion in the next several years . It is not yet known whether therapeutic interventions for the ins omnia will reduce this increased ris k. P.2034 2430 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 58 of 65

P erhaps 80 percent of patients with major depres sion complain of insomnia. R oughly 10 percent of patients des cribe hypersomnia, and this usually those with atypical or bipolar depres sion. S leep studies major depress ion reveal some combination of sleep latency, s hortened total s leep, and increased arousals during the night. S low wave sleep is us ually reduced. In addition, a number of features of R E M characteristic: (1) T he firs t R E M episode often occurs minutes or less after s leep onset (a s hort R E M subs tantially earlier than the roughly 90- to 110-minute R E M latency s een in asymptomatic normal young (2) ins tead of the normal progres sion in duration of episodes acros s the night, they are all of roughly equal length; and (3) the first R E M episode may have a particularly high number of eye movements . T he s hort R E M latency has been interpreted by s ome to be a biological marker of depres sion. T he underlying pathophys iology behind the short R E M latency is not P os sible interpretations are that it is a consequence of heightened s ens itivity of muscarinic cholinergic that it represents an altered ratio of cholinergic activity adrenergic activity in the brainstem, or that it is a cons equence of a poss ibly phas e-advanced os cillator the circadian regulatory system. A number of inves tigators have s uggested that s leep disturbance is more than an epiphenomenon resulting from depres sion and may instead be involved in its genes is. S upport for this notion comes from the observation that s everal manipulations of s leep (total or partial sleep deprivation or R E M sleep deprivation) 2431 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 59 of 65

represent potent (although time consuming and not always practical) treatments for depress ion. In treating sleep dis turbance in depres sed patients, several therapeutic options are available. One approach is to change to a more sedating antidepres sant, for from imipramine (T ofranil) to amitriptyline (E lavil). the S S R Is and newer mixed-action agents , this could done by changing, for ins tance, from fluoxetine or paroxetine (P axil) to the sedating mirtazapine. (In using the latter, however, one s hould be aware of the rare, potentially s erious , blood dys crasias that can appear.) antidepres sant is of clinical benefit but dis turbs s leep, can happen with fluoxetine, s ome clinicians add low of trazodone, although, in rare cas es , confusional can result. T here are s ome data to sugges t that initially adding the newer nonbenzodiazepine hypnotics to the antidepres sant regimen can give symptomatic relief for the depres sed patient's poor s leep, although this is sue still under investigation.

P os ttraumatic S tres s Dis order P os ttraumatic stress dis order (P T S D) patients typically describe poor s leep, and, indeed, the DS M-IV -T R incorporates two as pects (nightmares and a state manifes ted as ins omnia) in the diagnos tic criteria. study of car accident victims sugges ts that thos e who persis tent insomnia and daytime sleepines s for months after the trauma are more likely to later develop P T S D. Many patients complain of difficulty initiating and maintaining sleep, and s ome have anxiety dreams . Increased R E M dens ity and elevated arous al from R E M have been reported. In general, however, laboratory findings have been inconsistent, and 2432 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 60 of 65

interpretation is complicated by not fully cons idering comorbid psychiatric conditions . C linically, many of patients als o have major depress ion and are receiving various antidepress ants . T here are s ome data to that the off-label use of the anticonvulsant gabapentin (Neurontin) or the α1-adrenergic antagonis t prazos in (Minipres s) may improve their s leep. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > S UG G E S T E D C R OS S -R E F E R

S UGGE S TE D C R OS S R E FE R E NC E S P art of "20 - S leep Dis orders " T he basic s cience of s leep is discus sed in S ection Mood dis orders are covered in C hapter 13, and anxiety disorders are dis cus sed in C hapter 14. Light therapy, deprivation, and s leep delay are discuss ed in S ection and s leep disorders among the elderly are discus sed in S ection 51.3b. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > R E F E R E NC

R E FE R E NC E S Antrobus J . T heories of dreaming. In: K ryger MH, Dement W C , eds. P rinciple s and P ractice of S le e p Me dicine . P hiladelphia: WB S aunders; 2000:472– B aillargeon L, Landreville P , V erreault R , G regoire J P , Morin C M: Discontinuation of 2433 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 61 of 65

benzodiazepines among older ins omniac adults with cognitive-behavioural therapy combined with gradual tapering: A randomized trial. C MAJ . 2003;169:1015–1020. B as siri AG , G uilleminault C . C linical features and evaluation of obs tructive s leep apnea-hypopnea syndrome. In: K ryger MH, R oth T , Dement W C , eds. P rinciple s and P ractice of S le e p Medicine. WB S aunders; 2000:869–878. B ootzin R R : S timulus control treatment for ins omnia. P rocee dings of the 80th Annual C onve ntion of the Ame rican P s ychological As s ociation. 1972;7:395– C aps oni S , S tankov B M, F raschini F : R eduction of regional cerebral blood flow by melatonin in young rats . Neuroreport. 1995;6:1346–1348. C ons umers Union: Overcoming insomnia. R eport. 1997;62:10–13. C zeisler C A, Duffy J F , S hanahan T L, B rown E N, J F , R immer DW , R onda J M, S ilva E J , Allan J S , Dijk D-J , K ronauer R E : S tability, precision, and nearhour period of the human circadian pacemaker. 1999;284:2177–2181. Dawson D, V an Den Heuvel C J : Integrating the of melatonin on human phys iology. Ann Me d. 1998;30:95–102.

2434 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 62 of 65

G illin J C , Dow B M, T hompson P , P arry B , T andon B enca R : S leep in depres sion and other psychiatric disorders . C lin N euros ci. 1993;1:90–96. Hobs on J A, S tickgold R , P ace-S chott E F : T he neurops ychology of R E M s leep dreaming. 1998;9:R 1–R 14. *J ames S P , Mendels on W B : Herbal preparations for sleep. S le e p H ypnos is . (in pre s s ). J ames S P , Mendels on W B : T he us e of trazodone as clinical hypnotic: A critical review. J C lin P s ychiatry. pre s s ). K rys tal A, W alsh J , R oth T , Amato DA: T he efficacy and safety of eszopiclone over s ix months nightly treatment: A placebo-controlled study in patients with chronic ins omnia. S le e p. 2003;26 [S uppl]:A310. Mendels on W B . Human S le ep: R es e arch and New Y ork: P lenum P res s; 1987:1–436. *Mendelson WB . Do studies of s edative/hypnotics suggest the nature of chronic insomnia? In: J , G odbout R , eds. S le e p and B iological R hythms : Me chanis ms and Applications to P s ychiatry. New Oxford Univers ity P res s; 1990: 209–218. Mendels on W B . Drugs which alter s leep and s leeprelated res piration. In: K una S T , ed. S le e p and 2435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 63 of 65

in Aging Adults . New Y ork: E ls evier S cience; *Mendelson W B : E ffects of flurazepam and the perception of s leep in ins omniacs . S le e p. 1995;18:92–96. Mendels on W B : T he relationship of sleepiness and blood pres sure to res piratory variables in obs tructive sleep apnea. C he s t. 1995;108:966–972. Mendels on W B : Are periodic leg movements with clinical s leep disturbance? S le e p. 1996;19:219– Mendels on W B . Hypnotics: B asic mechanisms and pharmacology. In: K ryger MH, R oth T , Dement W C , P rinciple s and P ractice of S le e p Medicine . WB S aunders; 2000:407–413. Mendels on W B . Ins omnia. In: C onn's C urre nt P hiladelphia: W B S aunders ; 2001:31–34. Mendels on W B , C arus o C . P harmacology in sleep medicine. In: P oceta J S , Mitler MM, eds . S le e p Diagnos is and T re atme nt. T otowa, NJ : Humana 1998:137–160. Mendels on W B , G arnett D, G illin J C , W eingartner H: experience of insomnia and daytime and nighttime functioning. P s ychiatr R es . 1984;12:235–250. *Mendelson W B , J ames S P , G arnett D, S ack D, NE : A ps ychophysiological s tudy of ins omnia. 2436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 64 of 65

R es . 1986;19:267–284. Monroe LJ : P sychological and physiological between good and poor s leepers . J Abnorm 1967;72:255–264. *Morin C M, C ulbert J P , S chwartz S M: Nonpharmacological interventions for ins omnia: A meta-analysis of treatment efficacy. Am J 1994;151:1172–1180. Morin C M, R odrigue S , Ivers H: R ole of stress , and coping s kills in primary ins omnia. P s ychos om 2003;65:259–267. P elayo R , G uilleminault C . Narcolepsy and daytime sleepines s. In: P oceta J S , Mitler MM, eds. Dis orde rs : Diagnos is and T re atme nt. T otowa, NJ : P res s; 1998:95–116. P rovini F , V etrugno R , Meletti S , P lazzi G , S olieri L, Lugares i E , C occagna G : Motor pattern of periodic movements during s leep. Neurology. 2001;57:300– R ay J D. C ults. In: R edford DB , ed. T he Ancie nt Oxford, UK : Oxford University P ress ; 2002:61–91. S chweitzer P K , W als h J K : T en-year trends in the pharmacologic treatment of insomnia. S le e p. 1998;21:247(abst). S pielman AJ , S askin P , T horpy MJ : T reatment of 2437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

20

Page 65 of 65

insomnia by res triction of time in bed. S le e p. 1987;10:45–56. S tone B M, T urner C , Mills S L, Nicholson AN: activity of melatonin. S le e p. 2000;23:663–669. T urek F W , Dugovic C , Zee P C : C urrent the circadian clock and the clinical implications for neurological dis orders. Arch Neurol. 2001;58:1781–

2438 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

01/01/2009

21

Page 1 of 102

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > 21 C ontrol Dis orders Not E ls ewhere C las s ified

21 Impuls e-C ontrol Dis orders Not E ls ewhere C las s ified Harvey R oy Greenberg M.D. T he category of impuls e -control dis orders , not s pecifie d, includes impulse-related conditions that are subs umed under other diagnos tic categories in the fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ). T he expansion of this chapter over earlier discuss ions in K aplan and C omprehe ns ive T e xtbook of P s ychiatry reflects an awarenes s that thes e disorders , taken together, for a s ubs tantial proportion of ps ychiatric illnes ses. T he feature common to this group is the repeated to res is t an intens e impulse, drive, or temptation to perform a particular act that is obvious ly harmful to s elf others , or both. B efore the event, the individual usually experiences mounting tens ion and arousal, but not cons is tently—mingled with cons cious pleas ure. C ompleting the action brings immediate gratification relief. W ithin a variable time afterward, the individual experiences a conflation of remors e, guilt, s elfand dread. T hes e feelings may s tem from obscure unconscious conflicts or awarenes s of the deed's 2439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 2 of 102

on others (including the poss ibility of serious legal cons equences in s yndromes such as kleptomania). S hameful s ecretiveness about the repeated impuls ive activity frequently expands to pervade the individual's entire life, often s ignificantly delaying treatment. S igmund F reud declared that artists discovered the Oedipus complex long before ps ychoanalys is. Analogous ly, powerful portraits of impuls e-ridden personalities were drawn by S ophocles and W illiam S hakes peare, long before 19th century F rench J ean-E tienne E squirol described patients whose impulsiveness demonstrated “all the features of elevated to the point of delirium.” S ince E squirol, of impuls e control have eluded definitive let alone effective means of treatment. In contemporary nosology, the category of impuls e dis orders not e ls ewhe re clas s ified entered the third of the DS M (DS M-III) in 1980. B y DS M-IV -T R , this syndromes has been expanded to encompass gambling, trichotillomania, kleptomania, intermittent explosive dis order, pyromania, and impulse-control disorders not otherwise specified. T he latter address es syndromes waiting in the wings for definitive inclusion exclusion. T he category of habit and impuls e dis order in the 1992 tenth edition of the Inte rnational S tatis tical Dis e as es and R e late d H ealth P roble ms (IC D-10) is analogous to the DS M-IV -T R 's impuls e -control not els e whe re s pecifie d. Intermittent explos ive dis order not mentioned per se in the IC D-10 schema. Habitual of alcohol or drugs , as well as addictive or otherwis e pathological sexual and eating disorders , is specifically 2440 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 3 of 102

excluded.

Table 21-1 IC D-10 Diagnos tic C riteria for Habit and Impuls e Dis orders Pathologic al gambling    A. T wo or more episodes of gambling occur period of at least 1 year.    B . T hese epis odes do not have a profitable outcome for the individual but are continued despite personal dis tres s and interference with personal functioning in daily living.    C . T he individual describes an intense urge to gamble which is difficult to control and reports he or s he is unable to s top gambling by an effort will.    D. T he individual is preoccupied with thoughts mental images of the act of gambling or the circums tances surrounding the act. Pathologic al fire s etting (pyromania)    A. T here are two or more acts of fire s etting

2441 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 4 of 102

apparent motive.    B . T he individual describes an intense urge to fire to objects , with a feeling of tens ion before the act and a feeling of relief afterward.    C . T he individual is preoccupied with thoughts mental images of fire s etting or of the surrounding the act (e.g., abnormal interes t in fire engines or in calling out the fire s ervice). Pathologic al s tealing (kleptomania)    A. T here are two or more thefts in which the individual s teals without any apparent motive of personal gain or gain for another pers on.    B . T he individual describes an intense urge to with a feeling of tension before the act and a of relief afterward. Tric hotillomania    A. Noticeable hair los s is caused by the persis tent and recurrent failure to resist impulses pull out hairs .    B . T he individual describes an intense urge to out hairs, with mounting tension before the act a s ense of relief afterward. 2442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 5 of 102

   C . T here is no preexis ting inflammation of the and the hair pulling is not in res ponse to a or hallucination. Other habit and impuls e dis orders    T his category s hould be used for other kinds of persis tently repeated maladaptive behaviors that not secondary to a recognized psychiatric and for which it appears that there is repeated to resist impuls es to carry out the behavior. T here a prodromal period of tension with a feeling of releas e at the time of the act. Habit and impuls e dis order, uns pec ified

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion. T he IC D-10's habit and impuls e disorders are by repeated acts with no clear rational motive that be controlled by the patient and are us ually harmful to interes ts of s elf and others. IC D-10 s tates the caus es these conditions are unknown, further ass erting that are only grouped together because of broad des criptive similarities , “not because they are known to share any other important features .” 2443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 6 of 102

Over the pas t several decades , numerous studies have probed the complex phenomenology and etiology of impulse-control disorders . C onsiderable progress has made in conceptualization and treatment. Divers e, apparently disparate, conditions are now widely to have common epidemiological, genetic, neurobiological, and therapeutic features. T hes e are shared not only within the group, but often with other serious psychiatric illness es (notably depres sive and addictive disease) as well. Interconnections are and vary enormous ly from one impulse-ridden patient another. T he blurring of diagnos tic boundaries between control disorders and other Axis I and Axis II conditions often cited in the literature and regularly challenges the clinician. S tudies sugges t that a s ignificantly high comorbidity exists between the impuls e-control subs tance abus e disorders , affective dis orders, compuls ive disorder (OC D), and obs es sive-compuls ive personality dis order. Other important comorbid include borderline personality, antisocial personality, narcis sistic pers onality disorders; one or another type pathological aggres sion; attention-deficit disorder; disorders ; and paraphilias. F rom a genetic perspective, family histories of with impulse-control problems are replete with depres sion, bipolarity, substance abus e, and disorders . Mutatis mutandis , the family trees of patients with the latter problems often reveal a s tatistically meaningful presence of one or another impulse-control disorders . Neurobiological res earch sugges ts that compromis ed 2444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 7 of 102

frontal lobe function may contribute to the dis inhibition some impulse-disordered patients. S imilarities in serotoninergic and other neurotrans mitter have als o been dis covered across the entire spectrum impulse disorders . Improvement with s elective reuptake inhibitors (S S R Is ), mood regulators, and antagonis ts points to common neurobiological between the impuls e-control s yndromes, which are variably dis played in their comorbid illness es. F rom a behavioral and cognitive viewpoint, whatever other origins of impulse-control disorders may be, the frequent repetition of impulsive behavior s ui ge ne ris is regarded as a major caus e of its installation within the ps yche. B ehavioral s trategies useful in treating abuse dis orders and obs ess ional states have been to a gamut of impuls ive behaviors with reas onable succes s. G iven this intricate web of intersections in etiology and treatment, researchers have attempted to ascertain “figure in the P.2036 carpet,” a central organizing schema for the impulse disorders that may also explain the link between them their comorbid conditions. One theory pos tulates a cons tellation of obs e s s ive -compuls ive s pectrum with varying degrees of overlapping features in each between three subgroups : (l) impulse-control disorders , disorders of phys ical appearance and sensation (e.g., dysmorphic dis order and hypochondriasis ), and (3) neurological disorders hallmarked by repetitive bursts tics, spasms, or other pathological movements (e.g., 2445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 8 of 102

T ourette's s yndrome and S ydenham's chorea) (F ig. 21-

FIGUR E 21-1 Obs ess ive-compuls ive-related dis orders. (F rom Hollander E , K won J H, S tein DJ , et al.: compuls ive and s pectrum dis orders: Overview and of life is sues. J C lin P s ychiatry. 1996;57[S uppl]:3, with permis sion.) It has been further s ugges ted that the s yndromes the obsess ive-compuls ive s pectrum could notionally be located along an axis according to the approximate that each dis order is driven by risk avers ivenes s on the hand (compulsive s yndromes ), or risk seeking syndromes) on the other (F ig. 21-2). P s ychological contributing factors aside, the amplitude of ris k seeking ris k avoidance may be mediated by s erotonin, with neurotransmitters playing a les ser part.

2446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 9 of 102

FIGUR E 21-2 C ompulsivity-impulsivity dimens ion. Hollander E : T reatment of obsess ive-compuls ive with S S R Is. B r J P s ychiatry. 1998;25[S uppl]:7, with permis sion.) Another important line of inquiry s tems from the cons picuous comorbidity of impuls e-control disorders with unipolar and—most notably—with bipolar illness 2447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 10 of 102

(common features of bipolarity and impuls e-control difficulties include pleasurable and dangerous onset in adolescence or early adulthood, episodic chronic cours e, similar abnormalities in and improvement with mood s tabilizers and S S R Is) 21-3).

2448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 11 of 102

FIGUR E 21-3 Hypothesized relations hip between compuls ivity, impulsivity, unipolarity, and bipolarity a s ingle dimens ion. T he compuls ivity-unipolarity end of spectrum is characterized by harm-avoidant behaviors, inhibited thinking and behavior, ins ight into of symptoms , resis tance to impulses and behaviors , absence of pleas ure. T he impulsivity-bipolarity end of spectrum is characterized by harmful behaviors , disinhibited or s pontaneous thinking and behavior, little insight into dangerousness of symptoms , little impulses and behaviors , and pleasurable feelings. IC D, impulse-control disorder; OC D, obsess ive-compuls ive disorder. (F rom McE lroy S , et al. Are impulse control disorders related to bipolar disorder? C ompr P s ychol. 1996;37:229, with permis sion.) P.2037 On this bas is, a clas s of affe ctive s pe ctrum dis orders been hypothes ized that embraces affective, obs ess ive, impulsive dis orders. T hes e conditions are notionally 2449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 12 of 102

located on an inferred axis according to their different degrees or combinations of compulsivity and or impuls ivity and bipolarity. T he schema elegantly accounts for patients pres enting a perplexing mixture impulsivity and obsess ion (these liminal cases would be situated at the midpoint of the axis ). S uch formulations are neither definitive nor mutually exclusive. T hey are best contemplated as touchs tones, signifying that the truth about the deep s tructures of the impulse-control disorders is finally being glimpsed, as through a glas s darkly. T he increas ing volume and sophistication of research will s urely s hed more light on these intriguing maladies. F reud famously predicted that ps ychiatry's future would manifest a s wing of the pendulum between ps ychodynamically and somatically oriented theories about mental illnes s. C urrent research into impulsedisorders overwhelmingly explores their materiality— neurobiology, heredity, and ps ychopharmacology. In context of this lates t oscillation, the astute clinician will neglect psyche for s oma. One's attentivenes s to loading and s erotonin fluctuations should not preclude receptivenes s to the impulsive patient's inner world, to past trauma, and to dysfunctional family and s ocial circums tances . T here is, after all, a s earch for and meaning embedded within the molecules of human beings . 

P AT HOLOG IC AL G AMB LING



T R IC HOT ILLOMANIA 2450

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 13 of 102



K LE P T OMANIA



P Y R OMANIA



INT E R MIT T E NT E XP LOS IV E DIS OR DE R





IMP ULS E -C ONT R OL DIS OR DE R S NOT S P E C IF IE D S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified P AT HOLO G IC AL G AMB LING

PATHOL OGIC AL P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified" P athological gambling is the mos t common impuls e disorder in this category. It afflicts several million Americans , cons tituting a major, increasing public problem; hence, s ignificant space is devoted to it here.

His tory Archeological and anthropological research bear tes timony to the ubiquity of gambling, normative and pathological, in every time and place. G ambling may well have had religious origin: P erhaps attempts to divine the will of the G ods or F ates gave way to betting on more tangible outcomes. Wagering on the speed and strength of man or beas t arguably dates back to human prehis tory. Dice have found in the tombs of E gypt. E ncamped soldiers of 2451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 14 of 102

upended chariots and bet on the turn of their wheels . ancient C hines e are s aid to have staked digits or limbs games of chance, the American Mojave Indians risked wives, and the G ermanic barbarians of J ulius C aesar's wagered life or freedom. P redeces sors of modern card games , craps , and gaming machines go back several hundred years to s everal thousand years . E very gambling was wildly popular in R enais sance and E nlightenment E urope. Des pite the P uritan ethic, the gamut of E uropean gambling quickly found favor the firs t American colonists , es pecially horse racing. As the American frontier expanded, gamblers followed farmer, the rancher, and the entrepreneur. G ambling flouris hed in the marginal milieus of cattle towns and mining camps, on Mis siss ippi riverboats , and in the and s alons of major cities . B y the mid-19th century, gambling had es tablis hed an increasingly ominous as sociation with criminal elements in wes tern towns eastern cities. C orruption of law enforcement officials politicians inevitably accompanied the consolidation of gambling interes ts. A powerful gangs ter and gambler coalition was forged by the 1930s and 1950s , with gangland muscle and cash backing illegal gambling legitimate busines ses behind the s cenes . In the las t two decades , major entertainment in Las V egas , Atlantic C ity, and Native American have reaped vaster profit from legitimate gaming than from their mob antecedents. C orporate s trategies are increasingly—and s ucces sfully—aimed at low-stake, family gambling. T he new wave of gaming is further by states and churches with straitened budgets . gambling Web sites are plentiful: T his global casino 2452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 15 of 102

well prove to be the greates t source of gaming revenue history. T he current total take of legal and illegal es timated to be at least 0.5 trillion dollars yearly. T he chaotic life and times of the pathological gambler have proven perennially fertile ground for artis ts . One the most powerful and clinically accurate depictions of disorder is found in F yodor Dos toevs ky's novella, T he G amble r, based on the author's own descent into hell.

Nos ology P athological gambling was first des ignated as a diagnostic entity in DS M-III. P arameters were revis ed revis ed DS M-III (DS M-III-R ), redefined yet again for and es sentially retained in DS M-IV -T R . T he current definition emphasizes the afflicted individual's overwhelming preoccupation and obsess ion with gambling, tolerance and withdrawal in the progres s of condition, difficulty in controlling gambling activity and chas ing behavior, the us e of gambling to alleviate dysphoric emotional s tates, and the devas tating impact gambling on vocation, social, and family life. IC D-10 delineates pathological gambling as a “disorder frequent, repeated epis odes of gambling that dominate the patient's life, to the detriment of s ocial, material, and family values and commitments .” Like IV -T R , IC D-10 notes the patient's obs ess ive with and inability to control gambling P.2038 behavior, as well as the emergence of pathological gambling under s tres s. An alternate term, compuls ive 2453 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 16 of 102

gambling, is mentioned but is dismis sed, “because the behavior is not compulsive in the technical s ens e, nor the disorder related to obs ess ive-compuls ive neuros is .” S pecifically excluded from the IC D-10 category are gambling epis odes ; gambling for excitement or profit by those “likely to curb their habit when confronted with heavy loss es, or other adverse effects ”; and gambling sociopathic personalities .

E pidemiology Although comprehensive worldwide s tatistics have yet be compiled, excellent local s tudies all point to a 3 to 5 percent rate of problem gamblers in the general population and an approximate 1 percent rate of individuals meeting the requirements for pathological gambling. In the United S tates, the combined population of and pathological gamblers is es timated at 5 million. combined loss es run into the billions , with an average individual indebtednes s of $30,000. W ealthy gamblers with the means to s ustain a huge habit may hundreds of thous ands or even millions of dollars. C ollateral loss es due to time away from work, total unemployability, and eros ion of s avings as a result of gambling are s taggering. T he typical patient in treatment studies is a white man from a comfortable economic background, 35 to 50 of age. However, s urveys of more extensive populations indicate that pathological gambling cuts acros s every ethnic, clas s, age, and occupational (according to anonymous casino pers onnel, physicians 2454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 17 of 102

amongst their most cons is tent heavy players and As every type of gambling has become increasingly access ible over the past few decades, the rate of and pathological gambling has ris en s pectacularly, es pecially in locales with legalized gaming. E scalation been noted in the poor, notably poor minorities; adoles cents ; elderly retirees; and women. One out of pathological gamblers is now female: It has been suggested that women are gambling more becaus e an increased presence in the workplace gives them more cash. T hese groups are all s till greatly unders erved regard to res earch and treatment. F amily histories of pathological gamblers s how an increased rate of s ubs tance abus e (particularly and depres sive dis orders. A parent or influential the patient often has been a problem or pathological gambler. T he family circle is likely to be competitively materialistically oriented, evincing intense admiration money and as sociated symbols of s ucces s. In this compuls ive gambling has been called the dark side of American dream.

C omorbidity S ignificant comorbidity occurs between pathological gambling and mood dis orders (especially major depres sion and bipolarity) and s ubs tance abus e (notably alcohol and cocaine abus e and caffeine and nicotine dependence). C omorbidity als o exis ts with attention-deficit/hyperactivity disorder (ADHD) (particularly in childhood), various personality dis orders (notably narciss is tic, antis ocial, and borderline disorders ), and other impuls e-control disorders . 2455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 18 of 102

many pathological gamblers have obsess ive traits, full-blown obsess ive-compuls ive disorder is uncommon.

E tiology C ons iderable differences in precipitating factors are discovered from one patient to another and within the pathological gambler's lifetime as well. T he disorder— others in its class —is best conceptualized not as a monolithic entity, but as a condition encompas sing subs ets of dys functional behavior with diverse of divers e etiologies. F or decades, E dmund B ergler's compuls ive los e r dominated ps ychoanalytic res earch. B ergler as serted the pathological gambler is a pathological narciss is t, res ents the loss of childhood megalomania and bears a profound grudge agains t parents and other authority figures for reining in inflated infantile omnipotence. Aggress ion directed against sundry agents of occasions guilt and an intens e need for punis hment. pleas ures of gambling are related to the joy of rebellion; the pain of gambling is related to the certain expectation of punishment. E ventually, the anguis h of is eroticized and elaborated into a chronic masochistic stance, wherein the patient savors victimhood, relishes injus tice collecting, and revels in self-pity and s purious righteous indignation. B ergler's views have largely been s uperseded by more nuanced formulations , notably by R alph G reens on and succes sors . G reenson believed that pathological gratified multiple pregenital and genital conflicts, rooted in oral-receptive, anal-sadis tic, and, especially, oedipal 2456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 19 of 102

strivings . G reenson was one of the first clinicians to speculate that gambling might defend against affect. Hearkening back to the pos sible theological origins of gambling, the pathological gamblers' relentles s to play compris es a kind of s pilt religion, betokened by host of s upers titions and rituals pitched at beating the odds. Analytical therapy often reveals a covert, fear of death, s uggesting that thes e patients may be courting the erratic favors of Lady Luck in aid of the ultimate score—winning over mortality its elf. Many studies indicate that the makeup of most pathological gamblers does not conform to tidy ps ychoanalytic paradigms. R esearch efforts have been directed at elucidating other causes —none of which neces sarily negates the importance of ps ychological factors . T he family history of problem gambling in pathological gamblers has already been mentioned. T win studies further s ugges t that the dysfunctional gambler, bes ides identifying with a gambling relative, may have inherited genetic potential for the illnes s. B ehavioral-cognitive s tudies conceptualize pathological gambling as a learned, dis as trous habit. Many pathological gamblers exhibit exquis ite sensitivity a gamut of reinforcers directly or indirectly related to wagering. An example of direct or primary the slot-machine jackpot's lure of high magnitude of return for a low-re s pons e , s upposedly small, (ignoring cumulative loss ). An example of indirect or secondary reinforcement would be the “comps ” offered 2457 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 20 of 102

casinos , s uch as s pecial room rates and free drinks. casino design and management s uggest an elegantly sinis ter deployment of virtually every behavioral to encourage betting over one's head. C ognitive s tudies indicate that many pathological gamblers are prone to characteristic cognitive biases distortions. T hes e include discounting the sum of many small bets made at great cost toward achieving a big such as a jackpot; magnifying one's own s kills while minimizing the talents of others ; los ing s ight of the amount of gambling time neces sary to make up loss es; selectively privileging memories of wins over los ses; the absolute conviction that a chain of los ses heralds impending win (the s o-called gambler's fallacy). P romis ing recent research has probed the the pathological gambler, although more questions been raised than answered. P atients with lesions in a neural system whose pathways involve the (V M) prefrontal cortex, amygdala, and other s tructures show denial or unawarenes s of various problems for common-sens e judgments . T his type of injury also seems to predis pos e patients to pursue actions with term rewards but long-term negative consequences. T he V M regulatory s ys tem is believed to activate somatic markers, which then provide covert or overt signals heralding the P.2039 need for appropriate decis ion making. Inves tigators speculate that s ubs tance abus ers and, poss ibly, pathological gamblers , who have analogous problems 2458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 21 of 102

seeking short-term gratification over long-term pain, have a lack of warning makers due to dysfunction of V M regulating apparatus. V arious studies s ugges t that complex, articulating neurotransmitter dysregulation may exist in gamblers , similar to abnormalities in s ubs tance and patients with other behavioral and impuls ive problems . Imbalances in serotoninergic, noradrenergic, and dopaminergic mediation have all been pos tulated subvert the mechanisms underpinning appropriate behavioral arous al, initiation, dis inhibition, and reward reinforcement. In normal subjects exposed to high-ris k and low-ris k gambling experiments , individuals who preferred stimulus -rich environments cons is tently s ought long wagering more to win more. One conjectures that— the presence of other predisposing factors —such might eas ily be attracted to social and even gambling. Much has been written about one or another culture's supposed gambling predilections —the E nglis h, for sports ; T exans, for high-stakes poker. T hese notions largely anecdotal and, often, frankly prejudicial. As the entire United S tates is experiencing an unparalleled explosion of legal and illegal gambling, regardles s of bettor's race, creed, or national origin. A connection has definitely been establis hed between arrival of a cas ino and the ris e of pathological gambling the surrounding area, with a lag of approximately 3 to 5 years before the increase occurs . At leas t mos t casinos situated s ome distance away from mos t American 2459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 22 of 102

or cities . S adly, the greater access ibility of other betting opportunities , such as bingo games, lotteries , and offparlors where none exis ted before, may well activate a legion of problem gamblers who never knew they had a problem. T he destructive potential of ever more Internet gambling looms es pecially ominous .

Diagnos is , C ours e, and P rognos is T he typical individual meeting the DS M-IV -T R criteria pathological gambling (T able 21-2) is in his or her midto 40s , married or divorced, and vocationally strong gambling interes t has frequently paralleled his her ordinary life s ince adolescence or young adulthood. C ontrary to B ergler's theories , the potential s ufferer has excellent gaming knowledge and s kills and may be reasonably cons is tent winner.

Table 21-2 DS M-IV-TR Diagnos tic C riteria for Pathologic al A. P ersis tent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:    (1) T he patient is preoccupied with gambling preoccupied with reliving pas t gambling experiences , handicapping or planning the next venture, or thinking of ways to get money with which to gamble). 2460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 23 of 102

   (2) T he patient needs to gamble with increasing amounts of money to achieve the desired excitement.    (3) T he patient has had repeated unsuccess ful efforts to control, to cut back, or to s top gambling.    (4) T he patient is res tles s or irritable when attempting to cut down or to stop gambling.    (5) T he patient gambles as a way of es caping problems or of relieving a dysphoric mood (e.g., feelings of helples sness , guilt, anxiety, and depres sion).    (6) After los ing money gambling, the patient returns another day to get even (“chas ing” one's loss es).    (7) T he patient lies to family members , others to conceal extent of involvement with gambling.    (8) T he patient has committed illegal acts , s uch forgery, fraud, theft, or embezzlement, to finance gambling.    (9) T he patient has jeopardized or lost a relations hip, job, or educational or career opportunity because of gambling. 2461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 24 of 102

   (10) T he patient relies on others to provide to relieve a desperate financial situation caused gambling. B . T he gambling behavior is not better accounted by a manic epis ode.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. In the setting of life stress or a big win or without caus e, the previous ly success ful gambler begins to fall behind. Instead of s topping and cutting loss es, he or begins to chas e — spending ever more time and expanding his or her wagering repertoire to include multiple gaming opportunities. Over s everal months to years of chas ing loss es, he or she becomes embroiled es calating, tightening, and frightening s piral of options , which inevitably extend outside gambling its elf. and family resources are raided, loan s harks are us ed, criminal enterprises are undertaken, although us ually last recourse. Male gamblers commonly turn to embezzlement, scams , and credit card fraud; women be drawn into pros titution. When every option is exhaus ted, the pathological is exposed, often to the horrified s urpris e of s ignificant others . T he experience is devastating: B ankruptcy, 2462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 25 of 102

imprisonment, and even suicide may follow. However, expos ure can have a pos itive outcome through the out, s uch as a rescue by family or friends paying off or remiss ion of indebtednes s by bank, bookmaker, or shark. Once expos ed, some pathological gamblers get help quit betting. Unfortunately, the patient more often bored and restless , begins as sociating with other gamblers , commences wagering, and soon is engaged chas ing anew. Many pathological gamblers undergo repeated episodes of spiraling, exposure, bail-out, and relaps e, with gradual deterioration of personal relations hips and career until, at the end stages of the illness , their lives lie in utter ruin. Morris C hafetz's class ification of re active and addictive alcoholism us efully applies to many pathological gamblers . T he re active gambling type has a s table, productive s ocial and vocational life. His or her normal gambling behavior typically involves one or two modalities but periodically s hades over into binges of compuls ive play, often precipitated by obvious external stress ors . T he patient keeps recovering his or her us ually without treatment, until he or she los es control definitively. T he addicted pathological gambler, on the other hand, intens ely involved with every aspect of gambling and out of control much earlier. B y his or her 20s, gambling pervades every aspect of an idios yncratic, marginal lifes tyle, hallmarked by chronic instability in work and social relations hips. One emphasizes that prolonged spirals of pathological gambling by a healthier reactive type eventually produce a deteriorated end-stage 2463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 26 of 102

picture that is indis tinguishable from that of the type. R egardless of typology, a craving for action is central behavior of most pathological gamblers. Although they may ascribe their driven modus vivendi to an obvious need for cash, the arousal afforded by action its elf them ever deeper into the gaming vortex, or, once up, action s ustains them as an independent attraction. Action may s pin out of a gaming situation's peculiar ambiance—for example, the steamy milieu of the race track, polluted by rumor and fals e report, or the eternal glittering daylight of the casino with the seductive click P.2040 of a roulette wheel and the jingle of slot machines. T he action high can be found far from ordinary gambling locales , in bowling alleys , bars, and legal and illegal parlors in which any form of play can be ins tantly arranged. In time, the harried search for ever more sources of financing itself becomes part of the action. R egardless of s ocial background, ethnicity, or many pathological gamblers exhibit s trikingly similar personality traits . T hey tend to be intelligent (although deeply intellectual) and overconfident to the point of abrasivenes s. T hey are perennial optimis ts, deniers , rationalizers . B y turns, they are touchingly loyal or insensitive—notably when chas ing. T hey poss es s an gallows wit and appear s uperficially quite gregarious are often inwardly beset by profound feelings of lonelines s. T hey do not eas ily express their feelings ; indeed, they may be so unable to get in touch with an 2464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 27 of 102

inner life as to be cons idered alexithymic (a feature of patients with other impulse-control disorders ). B oth pathological and success ful profess ional typically evince a curious grandios e elitism. T hey are absolutely certain that they “know the s core” about gambling, as well as life in the wider world—for which gambling is held as a dog-eat-dog metaphor. T he pride pathological gamblers in their idios yncratic vocation, at its dis as trous end s tage, is es pecially poignant, the enormous suffering entailed. T he cours e of the pathological gambler is often for the wors e by comorbid conditions, notably abuse and affective illnes s. T he easy acces sibility of and alcohol in gambling environments often disinhibits the pathological gambler, res ulting in wilder play, or the heavy burden of indebtednes s precipitates depres sion, which, in turn, triggers off more gambling binges. Many pathological gamblers are paradoxically hypochondriacal and dreadfully neglectful of their well-being. T hey eat poorly and often excess ively, are sleep deprived and underexercis ed, and are exces sive cons umers of caffeine and nicotine. Hard statis tics are lacking, but anecdotal evidence s uggests that they may more vulnerable than general populations to hypercholes terolemia, cardiopulmonary disease, and peptic ulcer.

Differential Diagnos is P athological gambling s hould be distinguis hed from the social gambling practiced in one form or another by a majority of the population (es timated at approximately 2465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 28 of 102

percent). Normative gambling is based on the desire relaxation and profit, the inherent pleasure in variety of ego functions , ris k taking in a controlled and the satis faction of other obscure, pos sibly conflictrelated, drives . Unpathological gamblers us ually play designated occasions , with a notion of predetermined acceptable loss es . T heir pleas ure is highly predicated the companionable s ocial milieu that gambling offers. F or profess ional gamblers , play is bus iness —often one many busines ses . C ontrary to the conception of the glamorous high roller, profes sionals usually avoid the limelight to avoid taxes. T hey know s pecific games thoroughly, are prepared to take requis ite risks, coolly acknowledge the losing s treaks that come with the territory, and are prepared to weather them without control. However, reactive profes sional gamblers— a les ser extent, s ocial gamblers —may s lip into pathological gambling, often in the context of s ome environmental s tres sor. Acute s ubs tance abuse, notably acute alcoholis m, may precipitate a gambling bout in an individual without signatures of pathological gambling. G ambling binges are occasionally seen in the context schizophrenic's delusional s ys tem (e.g., being that G od has told one to wager one's life's s avings in saving mankind). E xces sive wagering may occur manic phase of bipolarity, in patients not otherwis e inclined to gamble. T he relationship between bouts of gambling and viciss itudes of mood is more problematic in 2466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 29 of 102

gamblers with comorbid affective illness —es pecially hypomania and mania. T he latter often s eem wired to universe, like the manic, and fairly crackle with tension they purs ue their dizzy dance over the abyss . Y et, they return quickly to a more temperate state of mood once play has ceased, may be reactively elated after a win, appropriately depress ed after a loss . In any case, most pathological gamblers wager chronically whether high, low, or relatively euthymic, with or without obvious precipitating cause. It is moot whether mood swings precipitated by biological dys function per s e can gambling. T he antis ocial pers onality frequently pres ents with collateral gambling behavior that reflects the inherent criminality and lack of empathy. He (or, les s she) does anything poss ible to win and is often a cheater. Loss stimulates blame rather than remorse may precipitate violent retaliation. Unlike antis ocial gamblers , the majority of pathological gamblers have a better work record, a more stable family life, and a moral set before the disruptions caused by chronic begin. When they commit crimes or s cams , it is out of desperation, with a humiliating loss of pride, in a lasteffort to get money to cover loss es or to keep on gambling. Unlike the morbid ego-alien preoccupations the obs es sive-compuls ive patient, the pathological gambler's overweening preoccupation with play is, in cases, completely ego-syntonic.

Treatment V irtually every mental health modality has been the pathological gambler. F or decades, the res ults 2467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 30 of 102

ungratifying, and relapse rates were high. B etter unders tanding of the patient's psychology and neurobiology now contributes to improved outcomes . C hances for success hinge on careful individualizing of treatment for each cas e. C ombined approaches are us eful. Mos t pathological gamblers make difficult regardless of the type of therapy. Like adoles cents — they much res emble—they rarely s eek help on their and, indeed, may bitterly oppos e treatment. T hey are us ually forced into cons ultation after many years of gambling, after expos ure precipitates an ultimatum that the gambler gets help or s uffers divorce or prosecution, example. T he pathological gambler's enormous pride, formidable denial, lack of introspection, impatience, and incurable optimism all militate agains t the formation of a working alliance in psychoanalytically oriented therapy (as well other therapies ). B es ides their gambling, patients often present a hos t of s erious problems and s ymptoms — depers onalization, hypochondrias is, obesity, panic and profound depres sion—that do not yield readily to talking therapies . P athological gamblers expect magical interventions are likely to leave when miracles are not forthcoming. may go through the motions of patienthood and yet remain inwardly convinced that a turn in luck and adequate funding will provide the s olution to their problems . T hey are notably contemptuous about gambling inexpertis e. T he therapis t who is a gambling can occasionally us e ignorance to good advantage by having the client teach him or her the ropes . P sychotherapy with a pathological gambler is likely to 2468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 31 of 102

stormy—marked by miss ed ses sions , relaps es , and financial crises leading to disruption or ces sation of treatment. T hes e patients especially require a tolerant, noncritical attitude. With their testy pride and razorintuition of rejection, they do not remain long in an atmos phere with the smalles t tincture of moralizing or contempt. F irm but kind limit s etting, which may include payment at each ses sion, is often neces sary. G reater res ponsibility in handling fees can be an important of improvement. T he attractivenes s of group techniques for pathological gamblers is not s urprising, given their extravers ion. family, and couples P.2041 therapy have all been helpful. T he distress ing impact of gambling on significant others often becomes clearer registers more potently on the patient in family than in individual therapy alone. G amblers Anonymous (G A) is an international s elf-help organization adminis tered by abs tinent pathological gamblers , with branches in nearly every large city and many small towns acros s the world. G A is run along step lines analogous to Alcoholics Anonymous (AA), similar collateral groups for relatives , which are worthwhile when a pathological gambler refuses help. C lients are encouraged to confront their problems in company of others thoroughly acquainted with every and twis t of chasing. S pons ors can be provided; financial res titution is a crucial as pect of treatment. Unfortunately, the G A drop-out rate is high, especially first-time clients and when G A (or individual therapy, 2469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 32 of 102

that matter) is the sole s ource of help. Once deemed ineffective, medication now figures regularly in the treatment of many pathological S tudies indicate stabilization of affect and modification aberrant gambling behavior with mood s tabilizers lithium [E skalith]) and antidepress ants (notably S S R Is clomipramine [Anafranil]). Improvement is mos t likely in dual diagnos is patients with s ignificant comorbid illness . T he close relationship of pathological gambling drug and alcohol addiction has led to treatment trials the opioid antagonis t naltrexone (R eV ia) to specifically block gambling urges, with a measure of success . E ducational, behavioral, and cognitive strategies the pathological gambler's inherent pragmatism— particularly in patients who are highly resistive to analytically oriented treatment. S imple instruction about their condition by an instruction manual and class work has enabled many patients to s top or to reduce gambling. More intricate cognitive-behavioral aim at undoing the habituating impact of s pecific gambling milieus and decreas ing or redirecting the for action. P atients are instructed in relaxation decrease tens ion, to identify s pecific gambling triggers , and to substitute gambling with competing rewards , for example. G ambling programs are especially us eful in as saying coordinating multiple modalities ; these are s teadily increasing acros s the United S tates . T reatment of the pathological gambler us ually takes place in an setting. However, it may be necess ary to break a debilitating gambling cycle by hospitalization, using a of several days to weeks to organize an effective 2470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 33 of 102

outpatient treatment plan. Intriguingly, hospitalized pathological gamblers may s how s igns of physiological, well as emotional, distress analogous to hos pitalized addicts undergoing detoxification. G iven the gambler's chronically poor health habits , many patients need a complete phys ical examination, appropriate laboratory studies, and thorough evaluation of and exercise status .

G ambling and the L aw S tate and federal legal systems are still primarily concerned with the punis hment of pathological rather than their rehabilitation. S ome 60 percent of pathological gamblers commit illegal acts over their careers . T hese crimes are overwhelmingly bouncing checks, financial scams , and prostitution. It is generally appreciated that incarceration can become a dis guised bail-out, forestalling or eliminating requirements for res titution. P rison life itself is often with gambling, for cigarettes , drugs, and other items services . E xperts believe that rather than jailing mos t gamblers outright—particularly the majority without antis ocial pathology—the offender s hould be offered option to dis continue gambling, to make restitution, and to undergo some form of treatment as a condition of probation. T o date, a few states have actually s et up agencies programs to deal with pathological gambling—even as most states have been quick to allow lotteries , race and casinos to replenis h their coffers . It is the height of hypocris y for powerful gaming interes ts, backed by the 2471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 34 of 102

powers that be, to tell the pathological gambler to “bet with your head, not over it,” while failing to redress the ps ychological disas ters that they are facilitating. F rank was a 32-year-old busines sman whose uncle compuls ive horse player. His maternal grandmother committed s uicide with sleeping pills. He was an avid player and sports bettor s ince his early teens , taking in being a s mall but s teady winner. F rank found formal education boring and dropped out of college in his fres hman year to take over his father's appliance store. expanded the bus iness to a chain of electronic outlets. Over the next decade, he pros pered, married happily, had three children, and lived in s ubs tantial During the s ame time, F rank's inveterate gambling increased. B es ides his weekly poker game and sports betting, he enjoyed occasional S aturday outings with his poker buddies to a casino that had opened at a nearby Indian res ervation. He mos tly broke even or sustained s mall loss es , but he was immens ely by several big s cores at blackjack and craps , games had not played much before. After his father's sudden death from a stroke, F rank traveling more often to the casino and s tarted playing higher stakes . S oon, he found himself betting then thous ands, of dollars on the turn of a card or the throw of the dice. T he size of s ports betting s imilarly increased. He vis ited the casino mos t weekends and weekday nights, lying about his whereabouts to colleagues and family. Within 2 years , F rank accumulated several million gambling debts. Now, he gambled not to win but to 2472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 35 of 102

up—still fervently believing that “one s treak would put straight.” He invaded bus iness and personal finances, juggled accounts, charged his credit cards beyond the maximum limit, and borrowed money from loan s harks exorbitant rates. He had always s hielded his wife and family from his problem. P rofoundly depress ed, he cons idered killing himself in a car accident, so that “everyone would be taken care of.” He used cocaine to alleviate his despair. T he grim reality of F rank's indebtednes s and its cause unmas ked when his wife discovered that he had plundered the children's college funds to pay off a loan shark who had threatened to have his family killed. At she wanted to divorce him, but then her wealthy father intervened and bailed F rank out. He swore that he never gamble again, entered G A, and, within a few months, was back at the cas ino. S everal more epis odes of recovery and relapse did divorce and left F rank penniless . He finally entered a program for pathological gamblers , where he was diagnosed as also having atypical bipolar dis order. T reatment has included individual and group medication with an antidepres sant and mood regulator, family therapy (his wife is now willing to s ee him, but to live with him), and a program of restitution. He works a delicatess en clerk, has been abstinent for 6 months , says that “not a day goes by that I don't miss the E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified T R IC HOT ILL OMANIA

2473 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 36 of 102

TR IC HOTIL LOMANIA P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified"

His tory and Des c ription T richotillomania is a chronic dis order characterized by repetitive hair pulling, driven by escalating tension and caus ing variable hair loss that is us ually—but not visible to others . T he disorder was known at leas t as back as the 12th century. F ormation of trichobezoars — hairballs accumulating in the alimentary tract from hair pulling and s wallowing—was des cribed in the late 18th century. T he term trichotillomania was coined by a dermatologis t, F rancois Hallopeau, in 1889. P.2042 T richotillomania was once deemed rare, and little about was described beyond phenomenology. T he condition now regarded as more common. W ith a substantial increase in research, treatment has greatly improved the 1980s .

Nos ology T richotillomania was firs t recognized in the DS M-III-R . DS M-III-R clas sified trichotillomania as an impuls edisorder, chiefly because of the typical cycle of tension, the inability to res is t the urge to pull hair, and releas e and gratification afterwards . DS M-IV then specifically excluded hair pulling secondary to medical 2474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 37 of 102

conditions or other ps ychiatric disorders from the diagnosis. T he criterion of s ignificant distress or impairment in s ocial, occupational, or other important of functioning was added and was s ubs equently maintained in DS M-IV -T R . IC D-10 class ifies trichotillomania under habit and dis orders , as a condition “characterized by noticeable loss due to a recurrent failure to resist impuls es to pull hairs, preceded by mounting tens ion and… followed by sens e of relief or gratification.” T he diagnosis s hould be made if “pre-exis ting inflammation of the s kin” exis ts if hair pulling occurs “in res pons e to a delusion or hallucination.” “S tereotyped movement dis order with plucking (F 98.4)” is also specifically excluded.

E pidemiology T he prevalence of trichotillomania may be because of accompanying shame and secretivenes s. diagnosis encompass es at leas t two categories of hair pullers differing in incidence, severity, age of and gender ratio. Other subsets may exist. T he potentially mos t s erious, chronic form of the us ually begins in early to mid-adoles cence, with a prevalence ranging from 0.6 percent to as high as 3.4 percent in general populations and with a female to ratio as high as 9 to 1. T he number of men may higher, becaus e men are even more likely than women conceal hair pulling. A chronic trichotillomania patient is likely to be the only or oldest child in the family. A childhood type of trichotillomania occurs equally in girls and boys. It is s aid to be more common 2475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 38 of 102

than the adolescent or young adult syndrome and is generally far les s s erious dermatologically and ps ychologically. T he family history of trichotillomania patients is toward OC D and obs es sive-compuls ive personality disorder, anxiety and affective disorders (notably depres sive), and tics. Although a s trong his tory of trichotillomania has not been dis covered in family members, one study demonstrated a 25 percent rate of unspecified alopecia in relatives of childhood hair An estimated 33 to 40 percent of trichotillomania chew or s wallow the hair that they pull out at one time another. Of this group, approximately 37.5 percent develop potentially hazardous bezoars .

C omorbidity S ignificant comorbidity is found between and OC D (as well as other anxiety dis orders); syndrome; affective illnes s, es pecially depres sive conditions; eating dis orders ; and various pers onality disorders —particularly obs ess ive-compuls ive, and narcis sistic personality dis orders. C omorbid abuse dis order is not encountered as frequently as it is pathological gambling, kleptomania, and other

E tiology T he precis e caus es of trichotillomania are s till P sychoanalytically oriented theories cite childhood loss separation as precipitants . T he child-like appearance of some adoles cent patients resulting from hair pulling supposedly betokens the wish to regres s to an infantile state and to avoid the burgeoning pres sure of 2476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 39 of 102

sexuality. E rotic, s adomas ochis tic, and s ymbolic masturbatory aspects of hair pulling have been in the analytical literature. T he frequent hair twis ting and hair patting of infants young children (often combined with thumb sucking) said to repres ent attempts to recuperate the abs ent mother's presence via the child's own body. Intriguing analogies may be drawn between human hair manipulation and various animal and avian grooming behaviors that appear to facilitate homeostasis, when alone, and s ocial bonding via mutual grooming. Under rubric, trichotillomania has a distinctively tactile, s elfsoothing quality for many patients . A s pecific family constellation has been described in a predominantly female cohort of adolescent and young adult patients with chronic trichotillomania. Although found in other psychiatric disorders , these family are peculiarly inflected by the role played by early experiences centered around hair and, later, by hair its elf. One parent, us ually the mother, is dominating and intrus ive. Her aggres sive facade conceals considerable and needines s. Often, her child has s hown anxious since infancy, pos sibly on a cons titutional bas is. and child become increas ingly embroiled in an intens e, hostile-dependent relations hip that interferes with the child's healthy s eparation. An uncanny mutual preoccupation with the beauty of the daughter's hair— styling and grooming—develops early on and may other family members . With the onset of trichotillomania during puberty, the 2477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 40 of 102

mother's attempts to make her daughter stop pulling hair are countered by the youngster's s tubborn T his tangled partnership has been deemed a hairs ymbios is : T he s ymptom becomes a battleground for acting out conflicts over individuation. On tactful adult patients may reveal an earlier hair-pulling One emphas izes that the cons tellation is not in every cas e—or may exis t in a more benign version. C hronic trichotillomania may s hare biological features, well as comorbidity with obs es sional and affective T richotillomania and obsess ive-affective illnes s serotoninergic drugs. B ecaus e many chronic hair do not respond as robustly or at all to s erotoninergic agents , other neurobiological dysregulation could be implicated. F rom a cognitive-behavioral perspective, chronic hair pulling is an intensely s elf-reinforcing activity, acquiring an intense, habitual life of its own.

Diagnos is , C linic al F eatures , and C ours e C hronic trichotillomania is hallmarked by complex behaviors before, during, and after epilation (T able 21T he urge to pull customarily develops during solitary activity—relaxing, reading, and watching televis ion, for example. Alternately, it aris es in the context of anxiety frus tration related to external s tres s. S ome patients that antecedent tingling or burning s ens ations in the compel them to s eek relief by pulling.

Table 21-3 DS M-IV-TR Diagnos tic 2478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 41 of 102

C riteria for Tric hotillomania A. R ecurrent pulling out of one's hair resulting in noticeable hair loss . B . An increas ing s ens e of tens ion immediately pulling out the hair or when attempting to res is t behavior. C . P leas ure, gratification, or relief when pulling the hair. D. T he disturbance is not better accounted for by another mental dis order and is not due to a medical condition (e.g., a dermatological E . T he disturbance causes clinically s ignificant distress or impairment in s ocial, occupational, or other important areas of functioning.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. A favorite private location is often used for hair pulling, es pecially the patient's bedroom or bathroom (the masturbatory connotation of these locales is obvious). 2479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 42 of 102

prodromal period may las t for a few moments, but, commonly, tens ion builds over a longer time, until it cons umes the patient's thoughts , and epilation begins . T ension may be experienced as pleas urable or painful, meld of both. T he hair-pulling epis ode las ts minutes to several hours . Most patients pluck at a particular site—typically the crown or s ide of the s calp, with variable spread into adjacent areas in time (F ig. 21-4). B esides —or ins tead the scalp, hair may be pulled from the eyebrows, and pubic region (denuding the latter is a notable embarrass ment) (F ig. 21-5). Men pull hair from beards mous taches or from arm and leg hair growth.

2480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 43 of 102

FIGUR E 21-4 E xample of plucking of the hair of the scalp due to trichotillomania. (S ee C olor P late.)

FIGUR E 21-5 E xample of plucking of the pubic hair due trichotillomania. T he hair root is a favored target of hair-pulling. P atients describe an idiosyncratic pleas ure in getting the root, particularly in s tripping P.2043 it away from a plucked hair. S ome state that they hear special popping sound or otherwis e know that the root has been extracted. T he hair is often nibbled and 2481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 44 of 102

swallowed while pulling or after a s ufficient quantity of hair has been collated. T he root may be conspicuous ly savored. When the bout ends , pleas ure is s ucceeded by shame, remors e, and disgust—particularly over hair S hame and frus tration are es pecially intense when an is denuded that had been left alone for awhile, so that growth could take place. Hair los s from trichotillomania can be concealed from family and friends for a cons iderable time, as long as epilation is confined to a s mall area. C oncealment is maintained by careful combing, us e of hair extensions, wearing hats or kerchiefs on one pretext or another. Inevitably, los s becomes obvious to others , although patient does not easily admit its cause at home or in a doctor's office. T reatment for other alopecias is undertaken with a profus ion of remedies and healers, a firm diagnos is is finally made—us ually by a knowledgeable dermatologist. P ermanent ces sation of s evere trichotillomania after expos ure is the exception rather than the rule. T he is sometimes marked by little change in hair loss or gradual improvement, but, more often, frequent remis sions and serious exacerbations occur over many years . Using a wig is common; occas ionally, hair is from it, too. C hronic trichotillomania can be as sociated with permanent follicular damage and baldnes s. T he long-term ps ychological outcome of does not s imply hinge on the s eriousness of hair los s se. T he prognosis often depends on the extent to hair pulling is conflated with comorbid 2482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 45 of 102

On its own, trichotillomania spins off abundant despair and diminis hed s elf-es teem. T hes e problems can with major depress ion, borderline or narciss istic personality problems, or eating dis orders to create a malignant feedback loop, with s ubs tantial deterioration quality of life. T he progres sion of childhood trichotillomania is us ually benign compared to the adolescent and young adult variety. A hair-pulling s ymbiosis is notably lacking in cases. E pilation is more akin to a transient habit, in duration and limited impact to the brief epis odes of phobic or compuls ive s ymptoms common in childhood. T he formation of a trichobezoar is always a potential complication in trichotillomania. Impacted hair can anemia due to nutritional deficiencies, intestinal obstruction, pancreatitis , peritonitis, small or large perforation, and, rarely, acute appendicitis. S ymptoms appear ins idious ly or acutely, depending on the and extent of the trichobezoar. P res enting problems include epigastric dis comfort as sociated with meals, altered bowel habits, weakness , weight los s, anorexia, nausea, and vomiting, with or without hematemesis. Weight preoccupation without a full-fledged eating disorder is commonly ass ociated with trichotillomania, particularly during adolescence.

Differential Diagnos is T rue trichotillomania should be dis tinguished from childhood or adolescent hair twirling and twisting actual hair plucking, which is found more frequently in girls than boys. 2483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 46 of 102

Hair pulling can develop ex nihilo during an acute ps ychotic illness —schizophrenic or affective—as a res ponse to command hallucinations or a s pecific delus ional s ys tem or as a tangible express ion of the hyperbolic despair and s elf-loathing of ps ychotic depres sion. E pilation us ually ceases with remis sion of acute psychos is, although it may occasionally be noted chronic psychosis. P.2044 With its many ritualistic aspects, trichotillomania may difficult to differentiate from the ritualis tic behavior of OC D—particularly because one patient may harbor conditions. T richotillomania is driven by at leas t a modicum of pleasure seeking, whereas compulsive are chiefly directed at relieving intolerable anxiety and dread. T he us ually planned epilation of trichotillomania s hould distinguished from spasmodic mus cular and verbal tics T ourette's s yndrome. However, as noted, these may afflict the s ame patient. T richotillomania should be dis tinguished from factitious hair pulling in aid of receiving medical attention and sympathy. Alopecia due to other medical caus es mus t always be out when trichotillomania is s uspected. It is rare to find trichotillomania precipitated by or coexisting with alopecia.

L aboratory S tudies If necess ary, the clinical diagnosis of trichotillomania 2484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 47 of 102

be confirmed by punch biopsy of the scalp. In patients with a trichobezoar, blood count may reveal a mild leukocytos is and hypochromic anemia due to blood Appropriate chemis tries and radiological s tudies should also be performed, depending on the bezoar's location and impact on the gas trointes tinal (G I) tract.

Treatment Most cas es of childhood trichotillomania respond well brief therapy, using s upport, s imple behavioral and is sue-focus ed s tres s management for family and patient, when neces sary. B y contras t, the treatment of s evere adolescent or trichotillomania is likely to be prolonged and arduous requires a combination of modalities . C linicians s hould aware that patients are deeply as hamed of their hair pulling, eas ily frightened, and intens ely denial prone. Many have avoided help for years. In teenagers with trichotillomania, res is tances are compounded by native oppos ition to adult intervention. An unpress ured, unintrusive s tance is especially helpful during the initial workup. Much comfort derives from simple education, from discovering that hair pulling does not make one weird or crazy and that others share the problem and s ucces sfully deal with it. P sychoanalytically oriented psychotherapy yields res ults. Improved understanding and esteem may lead improved relationships and educational and vocational succes s, although hair pulling itself persists s tubbornly. Individual therapy is especially problematic with embroiled in the tangled web of a hair-pulling E ffective work cannot proceed in the office when a 2485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 48 of 102

is cons tantly being cajoled, bribed, or criticized vis à vis hair pulling at home. T he predictable repercuss ion of parental pers uas ion, however well intended, is what one youngs ter called “screw-you” hair pulling, further hair loss and reinforcement of a negative s elf-image. S ome s ort of intervention is needed in this setting by the primary therapist or a collateral therapist, if forging an effective working alliance with the patient precludes intensive contact with family members . Healthier families may require couns eling and s upport to weather the s tres s impos ed by a youngster's trichotillomania per s e. V irtually every clas s of ps ychotropic medication has directed at chronic hair pulling. S erotoninergic agents, particularly S S R Is and clomipramine, have figured prominently in recent years , reflecting inves tigation of relations hip between trichotillomania and OC D or disorder. C as e s tudies and anecdotal reports over controlled large-scale outcome s tudies . S ome patients do well and cons is tently maintain Others do not res pond at all, or an early robust fades over time. T ricyclics , lithium, and bus pirone (B uS par) have been along with or for augmentation of S S R Is . Improvement been occasionally reported with clonazepam (K lonopin) and monoamine oxidas e inhibitors (MAOI). P reliminary work indicates that the opioid antagonis t naltrexone be helpful in disrupting the rus h that is experienced in hair-pulling attacks . C ognitive-behavioral therapy has s hown increas ing promis e. F or instance, in habit reversal training (HR T ), 2486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 49 of 102

therapist ass embles a package of individualized to address hair pulling, such as fostering awarenes s of specific affective and situational triggers, ins truction in relaxation and s topping techniques , development of competing res ponses, and the use of journals to progres s. Individual HR T is combined with HR T group meetings for teaching, as well as social s upport. As other modalities , relaps e after initial s ucces s is patients s hould be counseled to s ee pas t a temporary defeat. Anecdotal reports indicate some effectivenes s of on a s hort-term basis. Ignorance and shame about trichotillomania continue prevent patients from getting help. Awarenes s of the problem has been enhanced by local and national groups . K athy was a 24-year-old editor who had s uffered from trichotillomania since 17 years of age. T ypical hairbehavior began during junior year at a highly private high s chool in the s etting of increasing torment ruminations about not getting into the “right” college. plucked, chewed, and swallowed hair from the top and sides of her s calp, as well as her eyebrows . S he hair pulling from her family and friends , because she thought “I was going nuts.” S he finally blurted out her symptoms to a trus ted pediatrician during a routine visit. K athy's parents were profes sionals who made intense academic demands on all of their children; family life otherwis e not notably problematic. As a child, she was extremely critical of herself and afraid of failure. Her 2487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 50 of 102

experienced mild periodic depress ion since college. brother developed obs ess ions and compulsions during late teens . B oth res ponded well to fluoxetine (P rozac). K athy had received analytic ps ychotherapy, behavioral therapy, and medication (recently fluoxetine and clomipramine) elsewhere. Although she made good progress psychologically, she was never able to pulling her hair long enough for it to grow back. S he wide circle of friends but still kept romance at arm's fearing that a potential lover would be frightened off if found out her “secret.” S he could not bring hers elf to replace the “ratty” wig that she had been wearing since late teens . “It makes me look dowdy,” she s aid, “but a new one would be like telling myself I'll never get K athy s ought treatment chiefly for regulation of her medication but quickly proved amenable to weekly ps ychotherapy s es sions . Her clomipramine was while s he explored the sense of damage and that made her fend off men who liked her. S he was helped by weekly meetings at a trichotillomania s upport group. After 6 months , her self-es teem had improved, had fewer bouts of hair pulling and had begun dating hesitantly. S he arrived at her las t sess ion dis playing an attractive new wig, s tating ironically: “It is n't my real yet, but at least it's better than my old rug.” E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified >

K L E PTOMANIA P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere 2488 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 51 of 102

C las sified"

Definition and His tory T he defining behavior of kleptomania is the repetitive theft of items that are us ually of little monetary value are not realistically needed. Increasing tens ion is experienced before s tealing. F eelings of relief and gratification during and after the act eventually give to guilt, remors e, and s elf-loathing, compounded by the fear of arres t. K leptomania is profoundly repugnant P.2045 to many s ufferers , inconsis tent with their otherwis e behavior and beliefs (T able 21-4).

Table 21-4 DS M-IV-TR Diagnos tic C riteria for K leptomania A. R ecurrent failure to resist impuls es to s teal that are not needed for personal us e or for their monetary value. B . Increasing s ense of tension immediately committing the theft. C . P leas ure, gratification, or relief at the time of committing the theft.

2489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 52 of 102

D. T he s tealing is not committed to express anger vengeance and is not in res ponse to a delusion hallucination. E . T he s tealing is not better accounted for by conduct dis order, a manic epis ode, or antisocial personality disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he diagnosis of kleptomania was first coined in 1838 E squirol and C harles -C hretien-Henri Marc and was grounded on P hillipe P inel's earlier concept of a manie s ans de lire —insanity without delus ion or clouding of cons ciousnes s. E s quirol subsumed kleptomania under ins tinctive monomanias — conditions in which a s ingle, irre s is tible impulse was acted out. S ubsequent inves tigation during the 19th century was largely descriptive. P sychoanalytic exploration of single few cas es of kleptomania throughout the 20th century yielded valuable insights and s ome headway in S ince the 1980s, interest in kleptomania has increas ed, paralleling res earch into the psychobiology of other impulse-control disorders , as well as affective and obses sive illnes s. Nevertheless , no large cohort of 2490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 53 of 102

kleptomania patients has been s tudied to date.

Nos ology K leptomania was mentioned pas s im in the first edition the DS M (DS M-I). It was omitted from the s econd the DS M (DS M-II), arguably because it was viewed as cons tituent s ymptom of other conditions, rather than a separate disorder. It was listed as a viable diagnos is in DS M-III and, subsequently, in DS M-III-R , DS M-IV , and IV -T R , with s everal changes along the way. DS M-III-R emphasizes that the stolen object is not for personal use. As sociated tens ion specifically occurs “immediately before committing the theft.” C riterion D DS M-III-R newly s tipulates that stealing “is not to expres s anger or vengeance” and is not a respons e delus ion or hallucination.” T he absence of planning and collaboration in connection with theft as a qualifier is dropped in DS M-III-R . C riterion D—“the s tealing is not to conduct disorder or anti-social pers onality thus reframed in DS M-IV : “T he stealing is not better accounted for by C onduct disorders , a Manic epis ode, Antisocial P ers onality Disorder.” DS M-IV -T R continues these exclusions . IC D-10 des ignates kleptomania as “pathological hallmarked by “repeated failure to resist impuls es to objects that are not acquired for pers onal use or gain. T he objects may be discarded, given away, or hoarded.” T he typical cycle of tens ion before s tealing, sens e of gratification during and immediately after, the act,” and the solitary nature of thefts are noted. despondency, and guilt” between episodes of s tealing “not prevent repetition.” E xcluded from the diagnos is 2491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 54 of 102

recurrent acts of carefully planned s hoplifting for gain; organic mental dis order, in which payment for is overlooked “as a cons equence of poor memory and other kinds of intellectual deterioration”; and disorder with stealing.”

E pidemiology K leptomania was once thought to be extremely rare: instance, in a 1947 study of arres ted s hoplifters , less percent s howed evidence of the disorder. Many the field now believe that kleptomania is s ubs tantially underreported owing to the reluctance of ashamed patients to s eek help, as well as their not-unwarranted of pros ecution. F ailure to document kleptomania may als o s tem from of education or prejudice about the condition by law enforcement officials and health profes sionals. When kleptomania is seen as a criminal, rather than a is sue, many patients are s ure to be misdiagnos ed— written off—as antis ocial pers onalities , to be sanctioned. Although it is widely held that kleptomania is predominantly a disorder of women, the high female to male ratio (approximately 3 to 1) may reflect the fact more women seek or are compelled to use ps ychiatric services than men. F or ins tance, once under court supervis ion, a female s hoplifter is likely to be sent for a ps ychiatric evaluation, whereas a male offender is dispatched to jail. S everal of the kleptomaniacs described by Marc and E squirol were royals, s uch as K ing V ictor of S ardinia 2492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 55 of 102

K ing Henry IV of F rance. A lion's s hare of interest in disorder is commanded by patients from favored backgrounds becaus e of the dis crepancy, absurd or poignant, between their wealth and power and the objects that they filch. Nevertheles s, there is no that kleptomania is a s pecial affliction of the rich. Limited data sugges t that higher rates of affective and obsess ive-compuls ive traits occur in first-degree relatives of kleptomania patients. F amilies als o may be pervaded by the s ame preoccupation with financial succes s and material acquis ition encountered in the relatives of pathological gamblers .

C omorbidity P atients with kleptomania are s aid to have a high comorbidity of major affective illnes s (usually, but not exclusively, depres sive) and various anxiety dis orders. Ass ociated conditions als o include other impuls edisorders (notably pathological gambling and shopping), eating dis orders, and substance abuse disorders , alcoholism in particular.

E tiology P sychoanalytic speculation about kleptomania has abundant relative to the s mall number of patients Analys ts conceptualize compuls ive s tealing as a highly overdetermined act, exquis itely balanced between gratification and punishment. S tealing is intended to res tore intraps ychic equilibrium and to redres s s undry childhood traumata, intrapsychic dis tortions , or both. syndrome has been interpreted as an attempt to rectify actual or perceived neglect and narciss is tic injuries of 2493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 56 of 102

childhood via vengeful attack, to s tave off formidable feelings of low self-es teem through aggres sive and to gratify forbidden infantile sexual wis hes and masturbatory fantasies. W ith the omnipres ent threat of retaliation, s tealing often comes to poss ess a peculiar masochistic s izzle. T he stolen object has been construed as a talisman of recuperated loss acros s the s tages of child oral, anal, and genital. According to the developmental level of the patient's fixation, it may s ymbolize milk, breast, penis , or child. In some patients , compuls ive s tealing is strongly by the familial superego lacunae des cribed in and adolescent conduct disturbances by Adelaide and S amuel S zurek: An apparently upright, ethical projects uncons cious delinquent wishes on the child, proceeds to act out the dis avowed parental behavior. S ince the 1980s, analytical theories have been by s peculation on the neurobiology of kleptomania. T he significant comorbidity of the condition with affective disorders and obs es sive-compuls ive P.2046 pathology has been emphas ized, as well as the occurrence of affective dis order and OC D in clos e Although s ubs tantive confirmation is yet to come, kleptomania has been theorized as an obs es sivecompuls ive s pectrum dis turbance and affective disturbance. F rom a behavioral and cognitive perspective, stealing—like other impulse-control disorders —is 2494 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 57 of 102

powerfully self-reinforcing by virtue of its repetitive and highly ritualistic aspects.

C linic al F eatures and C ours e Most episodes of kleptomania seem to occur spontaneously and s uddenly, with little, if any, premeditation. However, deeper probing often reveals that theft ensued in the s etting of a recent s tres s —an argument with a busines s colleague or a lover's accompanied by frus tration, anger, and an ambiguous sens e of neediness . P atients report a mixture of dread and pleas ure before stealing. S ome feel agonizingly caught between the to relieve intolerable tension versus moral s cruples and fear of capture. Others plunge directly into action a moment's hes itation, es pecially when a well-defined pattern of s tealing has developed over repeated Most bouts of kleptomania take place in public, at supermarkets , and malls, for example. S tealing at parties or social events is less common. S tolen objects us ually have negligible value; in any case, they are not needed or could be easily afforded. T he items vary, or same object is stolen each time (es pecially undergarments ). S ome patients hoard and examine pilfered goods : T heir kleptomania poss es ses a fetishis tic as pect. More frequently, stolen material is hidden without s ubsequent attention; given away, out, or donated to charity by way of res titution; surreptitiously replaced at the point of origin; or with a jury-rigged explanation or with an admis sion of guilt and a plea for forgiveness . 2495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 58 of 102

P atients are intens ely as hamed of s tealing and s trive mightily to keep it s ecret and under control. T hey avoid stores pilfered in the pas t; they even warn s tores in advance or ceas e s hopping altogether. P atients feel ps ychologically and morally when they are able to free thems elves of s tealing for a while; they feel devastated despairing when they backslide. K leptomania clas sically begins in late adoles cence to mid-20s, often emerges in the context of compulsive shopping, and can remain undetected for years (in one study, first involvement with the legal system occurred 35 years of age for women and at 50 years of age for S tealing bouts may occur s poradically, with quies cent periods, or may relentles sly escalate until the patient's inevitable arrest and pros ecution. E xpos ure precipitates crushing humiliation, akin to the trauma experienced by pathological gamblers when loss es are revealed. Although exposure us ually the individual to seek help, it may als o—as in the gamblers —provide an unhelpful bail-out, through deals struck with compas sionate store owners , res titution by patient or relatives, or adjudication for les ser offenses condition of treatment, and s o forth. K leptomania is likely to be a chronic illnes s, hallmarked repeated relaps es over decades. S tatistics on outcome lacking. B y anecdotal report, some patients find relief through therapeutic or s piritual intervention, or both; others simply burn out or continue s tealing indefinitely. Impris onment and s uicide to avoid incarceration are meaningful poss ibilities . T he cours e of kleptomania is decisively influenced by 2496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 59 of 102

serious comorbid conditions. Individuals with shopping dis order often begin compuls ive s tealing the former condition easily shading over into the latter. E pisodes of kleptomania are als o precipitated by the disinhibiting influence of substance abuse. Although there is no cons istent kleptomania personality type, many patients manifest obsess ive-compuls ive narcis sistic tendencies . Lacunae in judgment about stealing may extend into other life areas. P atients experience genuine contrition and deeply fear arrest; they can als o appear strangely incapable of gras ping actual legal consequences of their actions and feel obscurely unempathic, wronged, and entitled vis à vis victims ' injured feelings : A woman pilfered her bes t friend's favorite paperweight during a party and then returned it the next day and revealed her kleptomania. S he was offended and angry because her friend did not immediately expres s what cons idered to be the proper degree of s ympathy and forgivenes s about her problem.

Differential Diagnos is E pisodes of theft occas ionally occur during psychotic illness , for example, acute mania, major depress ion ps ychotic features , or s chizophrenia. P sychotic stealing obviously a product of pathological elevation or depres sion of mood or command hallucinations or delus ions. T heft in individuals with antisocial personality dis order deliberately undertaken for personal gain, with some degree of premeditation and planning, often executed 2497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 60 of 102

with others. Antis ocial stealing regularly involves the threat of harm or actual violence, particularly to elude capture. G uilt and remors e are distinctively lacking, or patients are patently ins incere. In contrast, kleptomania a s olitary activity, directed at property rather than and s tealing occas ions s hows of genuine remorse after event. S hoplifting has become a national epidemic. F ew shoplifters have true kleptomania; the majority are teenagers and young adults who “boost” in pairs or groups for “kicks,” as well as goods , and do not have a major ps ychiatric disorder. Acute intoxication with drugs or alcohol may precipitate theft in an individual with another ps ychiatric dis order without significant ps ychopathology. P atients with Alzheimer's dis ease or other dementing organic illness may leave a store without paying owing forgetfulness , rather than larcenous intent. Malingering kleptomania is common in apprehended antis ocial types, as well as nonantisocial youthful shoplifters. G iven a s ufficiently intelligent perpetrator, fictive vers ion can be quite difficult to dis tinguish from genuine disorder. E pisodes of s tealing are commonplace in childhood, for example, taking change from a parent's purs e or T he overwhelming majority of these are trans ient and reflect no serious ps ychological disturbance.

Treatment T he majority of patients avoid help until they become involved with the law, and some form of psychological 2498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 61 of 102

as sistance is made a condition of remaining free. B y time, the dis order is likely to be entrenched, and corres pondingly difficult. C omplex therapeutic is sues often raised by the implied threat of pros ecution if treatment is not s ought or maintained. No controlled treatment studies of kleptomania have undertaken. Multiple modalities are common. S ucces s been reported on an anecdotal basis with various outpatient talking approaches, including group, and family work. Individual ps ychotherapy alone often insufficient to control acting out. Indeed, stealing may actually be precipitated by the trans ferential viciss itudes of insight-oriented treatment. P.2047 A panoply of behavioral and cognitive s trategies and medications have address ed kleptomania, with the anecdotal reports of s ucces s. Antidepres sants and stabilizers may be particularly helpful in cas es in which kleptomania clearly occurs against a background of affective illness . Naltrexone has shown s ome promis e specifically blocking the impuls e to steal. V ery few 12-step programs exist for kleptomania per arguably owing to tremendous s hame combined with unwillingness to go public, becaus e of fear of legal cons equences. Individuals with comorbid substance or gambling difficulties indicate that stealing is often remediated by AA and G A participation, even when choos e not to reveal their thieving. S ome nonabusing kleptomania patients claim that they have obtained simply by attending 12-step meetings without direct 2499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 62 of 102

participation or s elf-revelation. Uncontrollable kleptomania can occas ionally be broken brief hospitalization, although securing insurance coverage pres ents a formidable problem. in a dual-diagnosis program that accepts patients with kleptomania is particularly helpful, if one can be found. An unwary therapis t can eas ily become overinvolved in the patient's attempts to avoid legal action. One does to remember that relaps es are common and must be with realis tically, while making authorities duly aware of the pathological nature of the problem. T he proces s of adjudication that is s o desperately feared by patients occasionally turn out to be an unexpected adjuvant to treatment. R egular check-ins with a competent, compass ionate probation officer can help s trengthen patient's impaired superego function. J ane was a 42-year-old, highly s uccess ful, single from a wealthy background. S he called herself a “shopyou-drop type” and had always been able to afford the expensive des igner clothing that she loved. S ince her “legit” shopping had been paralleled by “boosting” cheap panties and brass ieres from dis count s tores. not wear the s tolen items; indeed, s he cons idered them “sleazy.” S he could never bring hers elf to get rid of either and kept boxes filled with pilfered lingerie in a storage facility. J ane talked or bought her way out of trouble until her when s he was arrested while s tealing pantyhos e from same K -Mart for the third time in as many months. As a condition of probation, s he was ordered to s ee a ps ychiatris t. Her attendance was s poradic, and s everal 2500 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 63 of 102

more thefts occurred over the next 2 years . S he als o experienced substantial depres sion, which she tried to alleviate by heavy drinking. J ane finally began taking her problem serious ly after another arrest precipitated a s uicidal ges ture. S he keeping appointments regularly and cons ented to citalopram (C elexa) and naltrexone. S he believes that participation in an AA group for high-press ured has been at leas t as effective—if not more so—in controlling her s tealing. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified >

PYR OMANIA P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified"

Definition and His tory P yromania is defined as recurrent, deliberate fire (T able 21-5). C ontrovers y continues over whether the condition should be class ified under the impulsedisorders or, indeed, whether it compris es a s eparate entity at all.

Table 21-5 DS M-IV-TR Diagnos tic C riteria for Pyromania

2501 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 64 of 102

A. Deliberate and purposeful fire setting on more than one occasion. B . T ens ion or affective arousal before the act. C . F ascination with, interes t in, curios ity about, or attraction to fire and its s ituational contexts (e.g., paraphernalia, uses, and consequences ). D. P leas ure, gratification, or relief when s etting or when witnes sing or participating in their aftermath. E . T he fire s etting is not done for monetary gain, an expres sion of sociopolitical ideology, to criminal activity, to expres s anger or vengeance, improve one's living circums tances , in res ponse delus ion or hallucination, or as a res ult of judgment (e.g., in dementia, mental retardation, subs tance intoxication). F . T he fire s etting is not better accounted for by conduct dis order, a manic epis ode, or antisocial personality disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. 2502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 65 of 102

Like kleptomania, pyromania evolved out of P inel's concept of la manie s ans de lire — madness without delus ion or clouding of the sensorium, with substantive preservation of reasoning power. E arly 18th century F rench ps ychiatrists Marc and E squirol categorized pyromania as a monomanie ince ndiare — another of ins tinctive monomanias in which a patient acts out one irresistible impuls e.

Nos ology P yromania was mentioned pas s im in DS M-I and was omitted altogether in DS M-II, under the tacit that it did not merit consideration as a new diagnos is . It was so acknowledged for the firs t time in DS M-III; was categorized under impulse-control disorders , not elsewhere s pecified; and was described as a recurrent failure to resist to set fires, intense fascination with the setting of fires , and seeing fires burn. P rior to s etting the fire, there is a build-up of tension. Once the fire is under way, the individual experiences intens e pleasure or releas e. Although the fire-setting res ults from a failure to res is t an there may be considerable advance preparation. DS M-III-R redefined and otherwise modified s everal of DS M-III parameters . T he phrase “recurrent failures to 2503 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 66 of 102

impulses to set fires” was eliminated and was replaced “deliberate and purposeful fire setting on more than occasion.” C riterion C (“fas cination with”) elaborates further on ps ychological preoccupations related to fire setting. T he exclus ions of DS M-III's C riterion E were augmented to indicate that pyromania cannot be diagnosed if fire setting is clearly a res pons e to delus ions or hallucinations . T he revis ed C riterion F states that the diagnosis cannot be made when fire occurs in the setting of a manic epis ode, conduct or antisocial personality dis order. All DS M-III-R criteria pyromania are maintained in DS M-IV and DS M-IV -T R . T he IC D-10 characterizes pyromania as “multiple acts attempts at s etting fire to property or other objects, without apparent motive.” Incendiary activity is s aid to accompanied by tension and excitement over its Als o noted are pers istent preoccupations with firesubjects , fire-fighting equipment, and calling out the fire service. E xcluded from the diagnosis are fire s etting for obvious reas ons and fire setting by “a young person conduct dis order,” by “an adult with ‘sociopathic personality disorder,’” and by individuals with schizophrenia or organic ps ychiatric disorders .

E pidemiology No major study of pyromania has been conducted Nolan D. Lewis and Helen Y arnell's 1951 examination nonprofit incendiary cas es from the files of the National B oard of F ire Underwriters and since J . L. G eller's overview of adult pathological fire s etting. Only 3 to 4 percent—some 50 of the 1,594 fire setters —of the and Y arnell population fit DS M-IV -T R criteria 2504 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 67 of 102

P.2048 for pyromania. G iven the persis tent paucity of literature, as sertions about epidemiology and, indeed, any other as pects of pyromania are tentative. T he condition is supposedly rare. Mos t patients are with a male to female ratio of approximately 8 to 1. F ire setting by children and adoles cents continues to enormous problems , res ulting in s ubstantial damage to property and danger to life. More than 40 percent of arrested ars onists are younger than 18 years of age. stress es that few meet formal criteria for pyromania, although differential diagnosis is often difficult. B y anecdotal report, the families of pyromania patients show increased ps ychiatric problems , similar to the derangements of other impulse-control disordered patients, such as affective illness es ; substance abus e, particularly alcoholis m; and various personality

C omorbidity P yromania is significantly as sociated with substance disorder (es pecially alcoholism); affective disorders, depres sive or bipolar; other impulse control disorders, as kleptomania in female fire setters; and various personality dis turbances, such as inadequate and borderline pers onality disorders . Attention-deficit and learning disabilities may be cons picuously with childhood pyromania; this constellation frequently persis ts into adulthood.

E tiology 2505 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 68 of 102

T he few in-depth explorations of pyromania have been conducted by ps ychoanalys ts. F reud famously inferred articulation between fire, ambition, and ure thral he als o theorized that pyromania repres ented a masturbatory equivalent. S ubs equent inves tigators describe fire setting and its related preoccupations as highly overdetermined activities expres sing repres sed childhood s exual or aggres sive drives, or both, aimed redress ing a panoply of real or perceived early the context of a dys functional, chaotic early family life. P yromania has been variously interpreted as a s triving exact revenge against rejecting, abus ive parents or adult figures, to acquire power in the context of chronic feelings of helples sness and inadequacy, or to master traumatic memories of the primal s cene. S ome young pyromania patients are s aid to act out projected, disavowed incendiary impulses of a parent or other member with superego lacunae. T here has been little research on the biological and cognitive-behavioral features of pyromania. T he lack reflects not only the disorder's inherent rareness , but an unwillingness to be identified that is even more formidable than the res is tance of trichotillomania and kleptomania patients. P reliminary studies hint at serotoninergic and other neurotrans mitter dysfunction, well as disordered glucos e regulation with the of a hypoglycemic trigger. Abundant clinical and phenomenological similarities between pyromania and other impuls e-control de s ire warrant the cons ideration of pathological fire as an affective s pectrum dis turbance or an obsess ive2506 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 69 of 102

compuls ive s pectrum dis turbance.

C linic al F eatures and C ours e A typical episode of pyromania begins with ris ing linked to thoughts of fire s etting. T ens ion often a dis tinctly erotic quality and may be accompanied by res tless nes s, headaches , palpitations, and tinnitus. Dis sociated feelings and alcohol intoxication before fire setting have been reported. In some cas es , preparation setting a fire is painstaking; in others , it is perfunctory. incendiary's pleasure over the conflagration derives several s ources : watching the flames themselves, may engender s exual arous al that is so intens e (pyrolagnia) as to lead to mas turbation, and watching activities connected with the fire, including the conflagration's es calating material devas tation, its on others, and, es pecially, the firemen's activities as go about extinguishing the blaze. P yromania patients often strongly identify with the firefighter's s trength and competence. In addition to lighting fires , they may undertake volunteer duties at firehouses or may become volunteer firefighters thems elves , then taking delight in putting out the that they have lit. W omen are les s likely to become involved with the firefighting community. Many patients prolong their idiosyncratic enjoyment by lingering in the vicinity of a fire that they have s et. It is the context of a perennial return to the scene or leave it that they are frequently apprehended by police or arson s quad detectives. T hey then regularly display striking denial, even after being pres ented with most damning evidence (unlike individuals with 2507 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 70 of 102

kleptomania, who readily confes s when caught). T ension drops after a fire-setting epis ode, and the may fall into a deep, relaxed sleep. T he overwhelming and remors e of individuals with kleptomania or trichotillomania do not seem to plague pyromania patients as consis tently. S ome even seem eerily toward the destruction that they have wrought. E pisodes of pyromania may occur s poradically, with prolonged impulse-free intervals . Other patients are afflicted by daily urges to set fire over many years . clinical impress ion is that a majority of fire-setting episodes occur at night—a time that offers greater poss ibilities for concealment and that may als o potent sexual and aggres sive ass ociations . A 28-year-old fire s etter said that he was tremendous ly aroused by the s ight of flames agains t the background black night sky. He remembered being awakened at 6 years of age by ominous noises coming from his sister's bedroom. He peeked through her open door was profoundly shocked—and arous ed—by the stark vision of her and a boyfriend, lit by a pool of bright lamplight, having pass ionate sex. P yromania usually begins in mid- to late adoles cence, earlier onset is not unusual. T he typical patient is said intellectually limited; comes from an underprivileged social background and a dysfunctional, violence-prone family; and often has s ignificant learning and handicaps in childhood. C hild or adoles cent fire s etting and preoccupations with fire may be unaccompanied other s ymptoms . P yromaniac behavior is more likely to 2508 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 71 of 102

part of a clus ter of petty delinquent behaviors that includes running away, truancy, and thieving, making primary diagnosis uncertain (vide infra). F ire setting at home frequently occurs in the youngster's room or the parental bedroom. If behavioral problems are s erious enough to require institutionalization, incendiary is likely to carry over to residential treatment centers , training s chools , and other in-patient settings , causing enormous problems. T he typical adult patient with pyromania suppos edly is vocational underachiever, has difficulty in s us taining relations hips , and may lead a marginal existence. this notionally average patient may compris e only one subtype, if the mos t common, of the condition. Other patients come from more s table families and exhibit achievement levels vocationally and socially. T heir life of fire setting remains a shameful secret. No definitive data about the cours e of pyromania exist. anecdotal evidence, some patients continually s et fires throughout their lives , despite repeated incarcerations , end up permanently imprisoned. Others persist in their setting P.2049 indefinitely, keeping it s urreptitious and limited enough avoid arres t. F or s till others , a gradual burnout of the disorder takes place in later decades. One s urmises the progres sion of pyromania is cons iderably inflected comorbid conditions , especially s ubs tance abus e and affective illnes s. Most self-immolations are obviously a function of 2509 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 72 of 102

ps ychos is or nonps ychotic social protes t. However, it seems reasonable to as sume that some pyromaniacs terminate their lives by setting fire to themselves, accidentally (particularly when intoxicated) or in the context of profound depres sion.

Differential Diagnos is Des pite the DS M-IV -T R 's exclus ionary criteria, it is extremely difficult to differentiate true pyromania from fire setting of other s yndromes , es pecially adoles cent conduct dis turbances. F ire setting in schizophrenia or manic-depres sive is clearly a function of flagrant thought disturbance, precipitated by command hallucinations or delusions. P yromania should not be diagnos ed if fire s etting is by acute intoxication with alcohol or other substances, lacking other parameters of the disorder. F ire setting in severe mental retardation or organic dementia clearly stems from impaired judgment based cerebral deficit: An 80-year-old man with Alzheimer's disease forgot he had left a cigarette burning on the edge of a night while looking for an as htray. T he cigarette fell into a was tebasket filled with combustible material, causing a major conflagration. F ire setting by individuals with antisocial dis order their criminal, unempathic, and remorseles s natures. Incendiary acts are clearly aimed at revenge, profit, or concealing a crime. T he triad of violence to animals , setting, and bedwetting in childhood is widely held to 2510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 73 of 102

marker for particularly violent antis ocial behavior in adoles cence and adulthood. P yromania should be dis tinguis hed from s etting fires as means of political protes t or sabotage, of bringing attention to s ome pers onal wis h or need, or of gaining some other recognition in a nonpsychotic context. C hildren with no psychiatric disturbance may s et fires inadvertently as a function of ordinary experimentation. P laying with matches or lighters in this context is occasionally catastrophic but nevertheles s does not warrant a diagnos is of pyromania or other ps ychiatric disorder. Little is known about the profess ional arsonist or torch. Law enforcement sources s ugges t that career overwhelmingly male, pride themselves on their highly specialized expertis e, and—if only to avoid more prosecution—go to great lengths to ens ure that their does not cause physical harm. T he torch's criminality is usually confined to fire s etting, and he or she may not always fit the tidy paradigms of antis ocial pers onality disorder. One speculates that torches embody yet another s ubset of pyromania, in pathological incendiary impulses are rationalized and acted out under the aegis of doing a job for hire.

Treatment T reatment of pyromania continues to be problematic owing to a lack of a willing clientele, even when fire are incarcerated. Des pite anecdotal reports of s ucces s ps ychoanalytic methods , most pyromania patients are hardly apt candidates for ins ight-oriented therapy 2511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 74 of 102

to their profound denial, heavy drinking, and an alexithymic inability to identify and to work through feelings. With s o little data available on any s ort of therapy, and definitive cure in s ight, one can only advocate the multimodal approach that is characteristic of treatment other impulse-control disorders : flexible deployment of various psychotherapies, cognitive and behavioral and drug intervention according to the unique presentation of each patient. C hildhood fire s etting mus t always be taken serious ly, es pecially when episodes are repeated, damage is subs tantial, the family structure notably is and the patient is substantially inarticulate. Under these circums tances , family therapy combined with individual treatment may be particularly helpful. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > E X P LOS IV E DIS OR DE R

INTE R MITTE NT E XPL OS IVE DIS OR DE R P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified"

Definition Intermittent explosive dis order is characterized by repeated failure to resist aggress ive impulses, resulting punctate explos ions of aggres sion that cause serious 2512 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 75 of 102

phys ical harm or damage, or both, to property. T he eruption of violence is typically far out of proportion to precipitating s tres s (T able 21-6).

Table 21-6 DS M-IV-TR Diagnos tic C riteria for Intermittent Dis order A. S everal discrete episodes of failure to res ist aggres sive impuls es that res ult in s erious acts or destruction of property. B . T he degree of aggress ivenes s express ed the epis odes is gross ly out of proportion to any precipitating ps ychosocial stress ors . C . T he aggres sive epis odes are not better for by another mental dis order (e.g., antisocial personality disorder, borderline personality a psychotic disorder, a manic epis ode, conduct disorder, or attention-deficit/hyperactivity and are not due to the direct phys iological effects a s ubs tance (e.g., a drug of abuse or a a general medical condition (e.g., head trauma or Alzheimer's disease).

F rom American P sychiatric As sociation. 2513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 76 of 102

and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

C omparative Nos ology Intermittent explosive dis order arguably is the most controvers ial entity of this group. T he diagnos is out of several decades of debate about whether a syndrome consisting of repeated explosive episodes should be clas sified as a psychiatric illness in the firs t and, as suming this s yndrome exis ts, about where to it nos ologically. Investigators have particularly over whether a disorder s uch as this could be some kind of neurophys iological dysfunction, although still being s eparated diagnostically from other with obvious organically induced aggress ion. A patient meeting current DS M-IV -T R criteria for intermittent explosive dis order would have been diagnosed in DS M-I as a pas s ive -aggres s ive aggres s ive type . DS M-II replaced the latter with pe rs onality, which, in turn, was eliminated by DS M-III in favor of intermitte nt e xplos ive dis orde r. T he new diagnos is was advanced to account for with s o-called epis odic dyscontrol syndrome, in which sudden epis odes of violent behavior erupted without 2514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 77 of 102

notable intervening psychopathology. A diagnosis of is olated e xplos ive dis order was also added to the salient feature was a P.2050 single epis ode of violent behavior with catas trophic cons equences. T he DS M-III vers ion of intermittent explosive disorder allowed for but did not require an organic etiology to s upport the diagnosis. It was noted that, in s ome cases , “features s uggesting an organic disturbance may be pres ent such as nons pecific E E G [electroencephalogram] abnormalities or minor neurological signs and symptoms thought to reflect subcortical or limbic system dys function.” T he was implicit, however, that psychosocial factors alone could cause the dis order. During the fashioning of DS M-III-R , intermittent disorder was , at firs t, deleted and then restored. T hose favoring elimination believed that repetitive violent outburs ts should not be s ubsumed within a dis crete ps ychiatric entity or thought that, when a substantive neurophys iological etiology could be proven, explos ive episodes would be bes t clas sified under the rubric of organic mental disorder. C oncern was voiced at that time—and s till exis ts today—about s tandardizing a nonorganic ps ychiatric diagnosis that could then be as a legal defens e in cases of violent crime. T he res tored DS M-III-R diagnosis reflected the final conclus ion of evaluators that psychosocial and environmental factors played a conclusive role in some cases of intermittent violent behavior. However, exclusionary category was created—organic 2515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 78 of 102

syndrome, explosive type—to account for intermittent explosive cas es with a definitive history of central system (C NS ) dysfunction. DS M-IV and DS M-IV -T R retain the DS M-III-R 's explos ive dis orde r; eliminate organic pe rs onality explos ive type ; and redefine the exclusionary criteria: diagnosis now should not be made in the pres ence of manic epis ode, ADHD, and any “general medical (e.g. head trauma, Alzheimer's disease).” Intermittent explosive dis order is not recognized as a distinct diagnosis in IC D-10. It is mentioned under habit and impuls e dis orde rs (F 63.8), without s pelling specific parameters .

E pidemiology Intermittent explosive dis order is believed to be rare, although the condition may be underreported. T he few s tudies available indicate a male preponderance high as 80 percent. F amily his tories, particularly in firstdegree relatives, show a high rate of one or more comorbid mood disorders , anxiety dis orders, substance abuse dis orders, and impuls e-control disorders — intermittent explosive dis order its elf.

C omorbidity A major as sociation has been noted between explosive disorder and mood disturbances — bipolar disorder (more than 50 percent in one study). Meaningful comorbidity is also des cribed with anxiety disorders , substance abuse disorders, eating personality dis orders, attention-deficit disorder, and 2516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 79 of 102

impulse-control disorders .

E tiology Although res earch has been limited, it is generally as sumed that intermittent explos ive dis order—like impulse-control disturbances —is caus ed by a varying confluence of ps ychos ocial and neurobiological factors. P atients regularly des cribe chaotic family backgrounds , with explosive behavior and verbal and phys ical abus e, often in the context of acute alcohol intoxication. Ide ntification with the aggre s s or is a common defense mechanism, in which the explosive violence of a parent clos e relative is internalized. T his sinis ter coping replicates the acts of s tormy violence to which patients have been expos ed during their formative years. S ituations that realis tically or symbolically evoke of early oppress ion and trauma may s park explosive episodes . T ypically, an acute s ens e of narcis sistic lowered self-es teem, and profound feelings of s hame humiliation are evoked: A 28-year-old man had been repeatedly brutalized by alcoholic mother throughout childhood and early adoles cence. He felt particularly humiliated when s he would s lap his face during frequent bouts of uncontrollable anger. One evening, while they were drinking at a local tavern, a friend playfully s lapped his cheek. T he patient s uddenly “saw red,” broke a beer over the man's head, and then mauled him severely. Modes t neurobiological studies point to pos sible deranged s erotonin neurotrans mis sion in patients 2517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 80 of 102

identified with intermittent explosive dis order; low cerebrospinal fluid (C S F ) levels of 5acid (5-HIAA) in s ome impulsive, temper-prone and lowered levels of platelet s erotonin reuptake in patients with epis odic rage. A connection has also inferred between elevated C S F testosterone levels and aggres sive or openly violent behavior. P atients may show s oft neurological signs (e.g., of reflexes) and nons pecific E E G findings (e.g., diffus e activity). An element of genetic loading is s uggested by the fact that blood relatives are more likely to have characteristic outbursts of explos ive behavior adoptive relatives. In an overview of 27 cases, S usan L. McE lroy and colleagues concluded that intermittent explos ive could be class ified as an affective s pectrum based on the s trong comorbidity of bipolar disorder, a high familial rate of mood disturbances , disturbed circadian rhythms, and res pons iveness to thymoleptics .

C linic al F eatures , Diagnos tic C ons iderations , and C ours e An explos ive episode may be preceded by a period of es calating tension and aggress ive feelings or may a flas h with little or no inciting cause. T he attack itself is often accompanied by irritability, rage, mood elevation, increased energy, and racing thoughts. F eelings of diss ociation and depers onalization, without later for the event, are described. P hys ical s ymptoms may antedate or may occur during the outburst—for tingling, tremor, palpitations , ches t tightness , tinnitus , head press ure or headaches. After the episode, relief 2518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 81 of 102

quickly followed by remors e, fatigue, and depress ion. A migraine-type headache may be carried over from the attack or may develop de novo. E xplos ive eruptions us ually las t approximately 10 to 20 minutes ; they may occur frequently, in clusters; or weeks to months may intervene before another episode. S ome patients no aggress ive tendencies between outburs ts, but the majority exhibit some type of chronic impulsive or aggres sive behavior. P atients are often perceived by others —and view thems elves —as perennially angry. experience s ubthre s hold s tates, in which serious aggres sion is headed off by exercising s haky control or engaging in less dangerous behavior—screaming, pounding a table, or punching a wall. Against the background of severe family dysfunction, the childhood individuals with intermittent explosive dis order is hallmarked by temper tantrums and s undry behavioral difficulties —stealing or fire s etting. T he youngs ter's problems are often compounded by defective attention, concentration, and hyperactivity. Intermittent explosive dis order characteris tically begins during late childhood to the early 20s , with a mean age onset of 18.3 years of age. C ourse is dependent on the frequency and severity of explosive episodes. S evere show poor s chool performance, employment problems , and s tormy interpersonal relationships . Divorce, injury self or others from fights and accidents (e.g., during of road rage), and sundry financial and legal problems (including incarceration) are common. Narcis sistic, obses sive, paranoid, or s chizoid personality traits may es pecially predis pos e patients to aggres sive outbursts. P.2051 2519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 82 of 102

Although there is no extensive s tudy of outcome, the term history of the disorder may be epis odic or chronic. prolonged course with markedly deteriorated quality of life is likely when explos ive behavior occurs regularly, serious cons equences , in the pres ence of severe conditions—es pecially substance abuse disorders, disorders , and substantive character pathology. When intermittent explos ive disorder is s uspected, the patient must be pains takingly evaluated to rule out one the many medical or neurological conditions that can caus e aggres sive epis odes. A bas ic workup includes thorough neurological examination; blood chemis tries as say the poss ibility of diabetes , liver dis eas e, kidney disease, thyroid dis ease, syphilis , alcohol, and lead or poisoning; urinalys is with toxicology s creen; and s kull rays. F urther study may us e E E G , magnetic res onance imaging (MR I), computed tomography (C T ), and emis sion tomography (P E T ) scanning.

Differential Diagnos is DS M-IV -T R s tres ses that intermittent explos ive can only be diagnosed after all other medical and ps ychiatric caus es of intemperate aggress ion are absolutely ruled out. When it can be proven definitively that the aggres sive behavior is directly caused by a medical or organic condition (e.g., pos tconcuss ion syndrome), a diagnos is of pe rs onality change due to a ge neral me dical condition, aggre s s ive type , is made, than intermitte nt e xplos ive dis order. Aggress ive outburs ts are common in delirium and when the underlying caus e has been res olved. 2520 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 83 of 102

explosions are rarely s een in epilepsy, notably in and temporal lobe seizures. Aggress ion due to substance intoxication or withdrawal diagnosed by a his tory of abus e (not always easy to obtain), as well as by appropriate blood and urine Alcohol remains the mos t common cause of intoxicated aggres sive behavior. Amongs t s treet drugs, (P C P ) is es pecially known to precipitate extreme, behavior. Intermittent explos ive disorder can only be diagnosed in a violence-prone s ubs tance abus er if criteria of the former dis order are completely met. Aggress ive outburs ts as sociated with various disorders us ually have a more planned, premeditated quality. However, antisocial personality dis order and borderline pers onality disorder occasionally present serious, deliberate aggres sive acts, as well as unpremeditated violence. G iven the fulfillment of other criteria, intermittent explos ive disorder can then be diagnosed together with the requisite personality Attacks of anger as sociated with autonomic arousal tachycardia and flushing), related to terrifying feelings being out of control, can occur in major depress ive disorder and panic disorder. DS M-IV -T R allows the additional diagnosis of intermittent explosive dis order when aggres sive and destructive outbursts clearly do take place during periods of depress ion or a panic and other criteria are s atis fied. Aggress ive outburs ts as sociated with s chizophrenic or a manic psychotic state are obvious ly related to ps ychotic phenomena, such as command delus ions of pers ecution. 2521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 84 of 102

Individuals with violent antis ocial tendencies may malinger s ymptoms of intermittent explos ive disorder to es cape punishment. Intentional violent behavior without any mental dis order distinguished by obvious motivation and hope for gain through aggress ive action. Dis play of anger in the context of frus trating life events , standard environmental press ures, or pos ttraumatic disorder (P T S D), precipitated by extraordinary stress , shows a res ponse appropriate to the cause of unlike the rage on little provocation that is intermittent explosive dis order. Amok is a culturally inflected eruption of exhibitionis tic violence. T he perpetrator, typically a man with no pattern of violence, s lashes or shoots at random often in a crowded public place, until he is subdued or killed. He appears to be in a dis sociated s tate; if he survives , he is amnes ic for the epis ode. T he practice of running amok is traditionally attributed to various southeas t Asian countries but has been reported elsewhere.

Treatment Most individuals with intermittent explos ive disorder do not seek treatment. Ins tead, they are compelled to get help by family pres sure or legal circums tances . P sychoanalytic ps ychotherapy is not likely to be undertaken and is problematic becaus e of the average patient's limited capacity for insight, brittlenes s of defens es , and alexithymia. A long-term s upportive relations hip combined with other modalities is generally 2522 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 85 of 102

more helpful. S imply knowing that one can call a concerned therapist when destructive impulses can greatly help a patient exert s uccess ful control. rage manageme nt s ess ions specifically directed at control are als o us eful. T he ps ychopharmacological treatment of intemperate aggres sion is s till in its infancy, and is largely single or small case studies . Improvement has been reported with divers e medications ; us ing drugs from than one clas s has become increasingly common. include anticonvulsants (e.g., carbamazepine phenytoin [Dilantin], gabapentin [Neurontin], [Lamictal]); antianxiety agents (e.g., benzodiazepines); mood regulators (e.g., lithium); β-adrenergic receptor antagonis ts (e.g., propranolol [Inderal]); and antidepres sants. S everal studies indicate that S S R Is reduce anger and irritability, with improvement rates as high as 60 percent. S olid res earch is clearly needed in area. When prescribing drugs of the benzodiazepine family buffer anxiety related to explosive behavior, the should be aware of their potential for caus ing and cons equent escalation of aggress ion in s ome (notably with clonazepam at higher doses). V arious cognitive-behavioral s trategies can help bring aggres sive impuls es under control. F or instance, deep relaxation is used in s ys tematic flooding of explosive s ituations to decreas e angry res ponses. After mastery of imaginal flooding, the patient uses neutralize anger in carefully graded real-life E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

2523 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 86 of 102

> T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > C ONT R OL DIS OR DE R S NOT OT HE R W IS E S P E C I

IMPUL S E -C ONTR OL DIS OR DE R S NOT S PE C IFIE D P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified" T he conditions within the category of impuls e -control dis orders not othe rwis e s pe cifie d do not s atis fy the for any of the previous ly mentioned impulse-control disorders or do not fit the paradigm of any other ps ychiatric disorder involving impulse-control problems described in the DS M-IV -T R (e.g., paraphilias and abuse dis orders) (T able 21-7).

Table 21-7 DS M-IV-TR Diagnos tic C riteria for Impuls e-C ontrol Dis order not Otherwis e S pec ified T his category is for dis orders of impulse control skin picking) that do not meet the criteria for any specific impulse-control disorder or for another mental disorder having features involving impuls e control described elsewhere in the manual (e.g., 2524 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 87 of 102

subs tance dependence or a paraphilia).

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T his heterogenous group includes compuls ive s exual behavior that is unclass ifiable elsewhere, compulsive and cuticle biting (onychotillomania), face picking, self-cutting and other P.2052 forms of s elf-mutilation, and compulsive buying. T he two s yndromes warrant further discus sion, becaus e compuls ive s hopping is now considered to be a major mental health problem, and delicate s elf-cutting to be on the ris e. A future DS M will pos sibly recognize or both as viable diagnostic entities to be listed with impuls e control dis orde rs not e ls e where s pe cifie d. IC D-10 contains two categories analogous to the DS MT R 's impuls e control dis orde rs not othe rwis e s pe cified. first—other habit and impuls e dis orde rs — disorders of “persis tently maladaptive behavior” that clearly not ass ociated with “a recognized psychiatric syndrome,” characterized by “repeated failure to res is t impulses to carry out the behavior,” prodromal tens ion, and “a feeling of releas e at the time of the act.” Intermittent explosive (behavior) disorder is the only 2525 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 88 of 102

listed in this group without comment. No criteria are and no examples are given for the s econd category— and impuls e dis orde rs , uns pe cified.

C ompuls ive B uying T he irresis tible compulsion to buy was well known to ancients . P etronius' S atyricon ironically delineates the insensate greed for acquisition that gripped wealthy R omans . Nineteenth century nosology termed the condition oniomania; it was als o clas sified as one of impuls ive ins anitie s . T he inordinate buying habits of wealthy addicts —like wealthy kleptomaniacs—has commanded public attention. However, like gambling, compuls ive buying cuts acros s the entire spectrum and is ominously on the rise. E stimates of prevalence range from 1 percent to as high as 5 the general population. Most patients —80 to 90 are female. C ompulsive buyers feel ris ing tens ion and excitement during a variable prodromal period and experience and s atis faction during a s hopping binge, followed by depres sive deflation. G uilty des pair may s eem related to ruinous overspending. Y et, many well-to-do excess ive buyers s till report agonizing postshopping remors e, s elf-loathing, and a terrible sens e of Most patients s hop alone, for thems elves . B uying vary in frequency, length, and duration. A typical bout several hours ; however, s ome patients describe s prees cons ume a day or s everal days . During intervening thinking is often invaded by fantasies about shopping, patients wrestle frantically for control. T hey may deliberately confine thems elves outside to store-free 2526 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 89 of 102

or may stay at home to quell their buying—where they tempted by catalogues and televis ion s hopping Items purchas ed are often related to personal clothes, perfume, makeup, and shoes . C lothing may be worn a few times or never at all and is hoarded. Male patients favor electronic and automobile equipment, hardware, or tools. However, es sentially any object for may be s ought obsess ively. Impulse purchas ing is common. C ompulsive buying gradually cons umes ever more of individual's time and money, with calamitous impact on vocational performance and social life: After several years of increas ing shopping binges , 35-year-old attorney, began attending weekend At first, she only bid on jewelry but soon became s o up in the action that she found herself impulsively bids on objects that she neither needed nor wanted. ran up more than $200,000 of debt and invaded res ources . Her marriage and friendships deteriorated. was hounded by loan s harks and considered killing yet s till kept attending auctions until s he was barred for failure to make good on her purchas es . S he sought only when threatened with bankruptcy, and her said that he wanted a divorce. T he similarity of compuls ive buying to the driven of pathological gambling and kleptomania is obvious. C omorbidity for kleptomania is es pecially high— frequently, but not exclusively, related to financial difficulties . Other significant comorbid conditions mood dis orders, s ubs tance abus e disorder, eating 2527 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 90 of 102

(bulimia in particular), OC D, attention-deficit disorder, various personality dis turbances . F amily histories are positive for mood, s ubs tance abus e, and impuls edisorders . C ompulsive buying usually begins in late adolescence develops insidiously, until it is unmas ked in the late 20s early 30s . T he cours e thereafter is epis odic and more favorable or chronic and severe, with attendant job bankruptcy, family dysfunction, divorce, and even or imprisonment. S erious comorbid pathology— related to bulimia, mood disorder, and drug abus e— militates for a poorer prognos is. T he etiology of the condition is multifaceted. P sychoanalysts s peculate that compulsive buying represents a complex s ymbolic restitution, variously redress ing low self-es teem, female cas tration anxiety (purchase equals penis ), fear of death, and depress ive emptines s, for example. B ehavioris t theory similarities between compulsive buying and other addictions regarding the intense reinforcement of repeated s hopping binges and the development of tolerance with the need for more purchas es to obtain relief, to name a few. Neurobiologists conjecture that compulsive buying may be yet another affective spectrum dis order or spectrum dis order by virtue of its phenomenology, its familiar comorbidity pattern, and its family his tory. Analogous dys regulation within the s erotoninergic and other neurotrans mitter s ys tems has been pos tulated not yet proven. It is commonplace that Wes tern society is intensely 2528 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 91 of 102

cons umeris t. E normous advances in the technology of cons umption, ever more sophis ticated advertis ing, and ubiquity of Internet marketplaces all combine to compuls ive buying in the afflicted and even, perhaps, create a legion of new s hopping addicts in those predis pos ed by chemis try, conflict, and character. With regard to differential diagnos is, compulsive and noncompuls ive s hoppers feel energized and happy buying. T his transitory well-being s hould not be with the prolonged elation propelling the febrile purchasing of bipolarity, accompanied by other manic stigmata. Devotees of unpathological so-called s hopyou-drop s prees occasionally overspend but do not as frequently and are not obs ess ed with s hopping, nor does purchas ing have the pervasive des tructive impact characteristic of the compuls ive buyer. However, shopping may insidiously escalate into compulsive S us picions on this score warrant the clinician's deeper exploration of shopping behavior and shopping-related preoccupations. T here have been no large-scale treatment s tudies of compuls ive buying. C ase reports s uggest that a combination of therapies is favored and more effective than a single modality. S ucces s has been achieved ps ychoanalytically oriented and supportive therapy, as well as cognitive techniques, for example relaxation imaginal work. T he res ults of pharmacotherapy are ambiguous; variable improvement has been reported antidepres sants, mood s tabilizers , anxiolytics, and antips ychotics , and combinations thereof. Debtors Anonymous (DA) meetings or other self-help groups proven effective in controlling buying impulses, alone 2529 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 92 of 102

combined with other therapies .

Delic ate S elf-C utting T he term de licate s e lf-cutting was coined by P aul P ao 1969 to delineate a s yndrome of precis e self-mutilation, predominantly afflicting adolescent and young adult women, which exhibits the hallmarks of other impuls econtrol disorders . Its prevalence has not been but many clinicians P.2053 believe that the s yndrome is not rare and has been increasing s ignificantly. T he condition is characterized by shallow, meticulous cutting into the s kin, us ing a razor blade or sharp knife, often in a series of s lices . T he most favored locations the wris t and lower arms. C utting elsewhere, such as breasts, abdomen, pubic area, is s aid to be as sociated even more s erious psychopathology. C utting is not a suicidal act but is connected with the releas e of tens ion and anger, with or without the attempt to stabilize frightening feelings, such as fragmentation. B orderline personality dis order is arguably ass ociated more cons is tently with delicate self-cutting than is the case with any other impulse-control disorders . significant comorbid conditions include OC D, affective disorder, diss ociative or depersonalization dis order, dysmorphic dis order, and eating disorders. F amilies extraordinarily dysfunctional, with high rates of affective and anxiety dis orders. Most theories about etiology derive from 2530 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 93 of 102

work. A s ubs tantial number of patients have illness , injury, or abus e by family members in Analytical investigators describe difficulties in affective regulation, with early failure to internalize appropriate soothing mechanis ms ; chronic anxiety about ego disintegration, loss of control, and maintaining ego boundaries ; disturbances in body image; and intense of sexual arousal and vaginal sensations. B izarre and frightening as s elf-cutting appears, to the patients thems elves , it is a profoundly reparative means for res toring psychic equilibrium. Little is written about the neurobiological and behavioral features of delicate s elfcutting. T he condition may qualify as an obs es sive spectrum dis order or affective s pectrum disorder (es pecially the former), with poss ible dysregulation of several neurotrans mitter s ys tems. B ehaviorists s tres s formidable reinforcing potential of the s ymptom, based the immense relief it provides . Delicate s elf-cutting typically begins in early around menarche. P atients may hide the disorder for adroitly concealing their wounds with long-sleeved clothing. T he condition is episodic in s ome patients , away with time. T he outcome is far more problematic behavior is firmly entrenched as a coping strategy, particularly when delicate s elf-cutting is as sociated with severe borderline pers onality disorder and mood disorders . In chronic cas es , dysfunction and marginalization of life is extens ive, with multiple hospitalizations and s uicidal tendency. R egarding differential diagnos is, single or multiple attempts in major depres sive dis order may be with delicate s elf-cutting; the former diagnosis is made 2531 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 94 of 102

the bas is of the obvious guilt-ridden intention to kill or, least, to injure ones elf, as well as obvious ly depress ed mood and vegetative symptoms. S elf-mutilation in schizophrenia is often bizarre (e.g., castration and enucleation) and is res ponsive to command or delusions . Malingered cutting, notably encountered in prisoners or psychiatric inpatients with no previous (es pecially adoles cents ), has an obvious, manipulative purpos e or can occur during an epidemic of copy-cat acting out. T he wris t cutting and other s elf-mutilations mentally retarded or autis tic institutionalized patients the complex intraps ychic symbolic meanings of self-cutting. Lesch-Nyhan s yndrome is a rare X-linked reces sive disorder that usually presents with the hallmark of severe, involuntary s elf-mutilation, occasionally including s elf-cutting. As sociated with the disease are cognitive impairment, choreoathetosis, and hyperuricemia. Mos t patients are male. S uccess has been reported in treating delicate selfwith ps ychoanalys is . Ins ight-oriented therapy is not to undertaken lightly with these patients and is often prolonged and stormy, with a s ubs tantial ris k of transferential dis tortions . Anecdotal reports note improvement with S S R Is , mood regulators , and various cognitive-behavioral techniques. Whatever treatments are us ed, delicate s elf-cutters make enormous emotional demands on the therapist because of their uns hakable need for attention, even they push help away. T oo much involvement may be 2532 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 95 of 102

perceived as a frightening intrusion by a patient whos e sens ibility is also finely tuned to the least hint of and who is prone to act out in either case. B alanced compass ion is requis ite. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > C R OS S -R E F E R E NC E S

S UGGE S TE D C R OS S R E FE R E NC E S P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified" As abundantly des cribed, many other disorders are comorbid with the impulse-control disorders , may with impulsive features, and may be contemplated as alternatives during differential diagnos is . T he reader is therefore directed to discuss ions of OC D (C hapter 14); mood dis orders, notably bipolar dis order (C hapter 13); anxiety dis orders (C hapter 14); and s ubs tance abuse dependency dis orders (C hapter 11; also, s ee S ection for a discus sion of conditions as sociated with eating dis orders, notably bulimia (C hapter 19); disorders , notably fugue states (C hapter 17); disorders , notably antis ocial and borderline personality disorders (C hapter 23); paraphilias , compuls ive sexual behavior, and sexual addiction (C hapter 18); and neurological and medical conditions as sociated with impulsivity (dementias, S ection 10.3). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

2533 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 96 of 102

> T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified >

R E FE R E NC E S B audamant M: Description de deux mass es de trouvee dans l'es tomac et les intestines d'un jeune garcon age de 16 ans. His t S oc R oy Me d. B lack DW : C ompulsive buying: a review. J C lin P s ychiatry. 1996;57[S uppl]:50. B laszcynski A. O ve rcoming C ompuls ive G ambling: Help G uide Us ing C ognitive -B ehavioral T echnique s . London: R obins on; 1998. B rady K T , Myrick H, McE lroy S : T he relationship subs tance use disorders , impulse control dis orders, pathological aggres sion. Am J Addict. 1998;7:221. B rower C , S tein DJ : T richobezoars in case report and literature overview. P s ychos om 1998;60:658. C hambers R O, P otenza MN: Neurodevelopment, impulsivity, and adolescent gambling. J G ambl S tud. 2003;19:53. *C hris tenson G A, C row S J : T he characterization treatment of trichotillomania. J C lin P s ychiatry. [S uppl]:42. C hris tenson G A, F aber R J , de Zwaan M, R aymond S pecker S M, E kern MD, Mackenzie T B , C ros by R D, S J , E ckert E D, Mus sel MP , Mitchell J F : C ompulsive 2534 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 97 of 102

buying: descriptive characteristics and ps ychiatric comorbidity. J C lin P s ychiatry. 1994;55:5. C ohen IJ , S tein DJ , S imeon D, S padaccini E , R osen Aronowitz B , Hollander E : C linical profile, and treatment his tory in 123 hairpullers: a survey J C lin P s ychiatry. 1995;56:319. *C rockford DN, el-G uebaly N: P athological critical review. C an J P s ychiatry. 1998;43:43. C unningham-Williams R M, C ottler LB : T he epidemiology of pathological gambling. S emin C lin Neurops ychiatry. 2001;6:155. Dannon P N: T opirmate for the treatment of kleptomania: a cas e s eries and review of the C lin Neuropharmacol. 2003;26:1. Dickers on MG , Hinchy J , E ngland S : Minimal and problem gamblers : a preliminary inves tigation. J G ambling S tudie s . 1990;6:87. Doctors S . T he s ymptom of delicate s elf-cutting in adoles cent females : a developmental view. In: S C , Looney J G , S chwartzberg AZ, S oros ky AD, eds. Adoles ce nt P s ychiatry: De ve lopmental and C linical S tudie s . V ol 9. C hicago: University of C hicago 1981:443. *Durst R , K atz G , T eitelbaum A, Zis lin J , Dannon K leptomania: Diagnos is and treatment options . C NS 2535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 98 of 102

Drugs . 2001;15:185. E squirol E . Me ntal Maladie s : A T re atis e on Ins anity. P hiladelphia: Lea and B lanchard; 1845. F elthous AR , B ryant S G , W ingerter C B : T he intermittent explosive dis order in violent men. B ull Acad P s ychiatry L aw. 1991;19:7l. *G eller J L: P athological fires etting in adults. Intl J P s ychol. 1992;15:283. G eller J L, B ertsch G : F ire-setting behavior in the histories of a s tate hos pital population. Am J 1985;142:465. G rant J E , K im S W , P otenza MN: Advances in the pharmacological treatment of pathological gambling. G ambl S tud. 2003;19:85. *G reenberg HR , S arner C A: T richotillomania: and s yndrome. Arch G e n P s ychiatry. 1985;12:482. P.2054 Hollander E , B egaz T , DeC aria C : P harmacologic approaches in the treatment of pathological C NS S pe ctrums . 1998;3:72. Hollander E , K won J H, S tein DJ , B roatch J , Himelein C A: Obs es sive-compuls ive and s pectrum disorders : overview and quality of life iss ues . J C lin 2536 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 99 of 102

P s ychiatry. 1996;57[S uppl]:3. K ammerer T , S inger L, Michel D: T he incendiaries : criminological, clinical and psychological s tudy of 72 cases. Ann Me d P s ychol. 1967;1:687. K euthen NJ , O'S ullivan R L, S prich-B uckmins ter S : T richotillomania: current is sues in conceptualization and treatment. P s ychothe r P s ychos om. K im S W, G rant J E : T he ps ychopharmacology of pathological gambling. S emin C lin Ne urops ychiatry. 2001;3:184. Lejoyeux MJ , Ades J , T ass ain V , S olomon J : P henomenology and ps ychopathology of buying. Am J P s ychiatry. 1996;153:1524. Leong G B : A psychiatric study of persons charged ars on. J F ore ns ic S ci. 1995;37:1319. Lesieur HR , R os enthal R J : P athological gambling: a review of the literature. J G ambling S tudies . Lewis ND, Y arnell H: P athological firesetting (pyromania). Nerv Me nt Dis Mon. 1951;82:8. Lion J R : T he intermittent explosive dis order. Ann. 1992;22:64. Mans ueto C A, T ownsley-S ternberger R M, T homas A, G oldfinger-G olomb R : T richotillomania: a 2537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 100 of 102

comprehensive behavioral model. C lin P s ychol R e v. 1997;17:567. Marc H: C ons iderations medico-legales s ur la monomanie et particularement incendiare. Ann Hyg P ubl Me d L e g. 1833;10:367. McE lroy S L, Huds on J I, P ope HL J r, K eck P E J r, T he DS M-III-R impulse control dis orders not clas sified: clinical characteristics and relations to ps ychiatric disorders. Am J P s ychiatry. McE lroy S L, K eck P E J r, P hillips K A: K leptomania, compuls ive buying, and binge-eating dis order. J C lin P s ychiatry. 1995;56:14. McE lroy S L, P ope HG J r, K eck P E J r: Are impuls e disorders related to bipolar dis order? C ompr 1996;37:229. McE lroy S L, S outullo C A, DeAnna B A, T aylor P J r, P E : DS M-IV intermittent explos ive dis order: a report 27 cases . J C lin P s ychiatry. 1998;59:203. P ao P : T he syndrome of delicate s elf-cutting. B r J P s ychol. 1969;42:195. P etry NM, Armentano C : P revalence, ass ess ment, treatment of pathological gambling: a review. S erv. 1999;50:1021. P etry NM, R oll J M: A behavioral approach to 2538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 101 of 102

unders tanding and treating pathological gambling. S emin C lin Ne urops ychiatry. 2001;6:177. P otenza MN: T he neurobiology of pathological gambling. S emin C lin Ne urops ychiatry. 2001;3:217. R eis t C , Nakamura K , S agart E , S okolski K N, Impulsive aggres sive behavior: open-label treatment with citalopram. J C lin P s ychiatry. 2003;64:81. S punt B , DuP ont I, Lesieur H, Liberty HJ , Hunt D: P athological gambling and subs tance mis use: a of the literature. S ubs t Us e Mis us e . 1998;33:2535. S tein DJ , Hollander E , Liebowitz MR : Neurobiology impulsive behavior and the impuls e control Neurops ychiatry C lin N euros ci. 1993;5:9. S tein DJ , S imeon D, C ohen LJ , Hollander E : T richotillomania and obses sive-compuls ive disorder. C lin P s ychiatry. 1995;56[S uppl]:28. S ylvan C , Ladouceur R , B oisvert J M: C ognitive and behavioral treatment of pathological gambling: A controlled study. J C ons ult C lin P s ychol. T avares H, Zilberman ML, el-G uebaly N: Are there cognitive and behavioural approaches s pecific to the treatment of pathological gambling? C an J 2003; 48:22. T oneatto T : C ognitive pathology of problem 2539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

21

Page 102 of 102

S ubs t Us e Mis us e . 1999;34: 1593. Winchell R M: T richotillomania: pres entation and treatment. P s ychiatr Ann. 1992; 22:84.

2540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

01/01/2009

Page 1 of 40

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > 22 - Adjus tment Dis orders

22 Adjus tment Dis orders J effrey William K atzman M.D. Oladapo Tomori M.D. T he diagnostic category of adjustment dis orders is us ed among clinicians in practice. It is one of a few diagnostic entities in which an external stres sful event linked to the development of s ymptoms. T he event involves financial, legal, or relationship difficulties or a medical diagnosis. T he adjustment dis order cons truct often criticized for a lack of s cientific support, and there few controlled s tudies of the adjustment disorders in literature to date. T he diagnosis of adjus tment disorder s trays from the general phenomenological approach of the revised edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ). T he diagnos is provides little in way of observable symptom criteria. Instead, it etiological model linking a s tres sor to s ymptom T his model is unique to adjus tment disorder, posttraumatic s tres s disorder (P T S D), and most other cases , the focus of the DS M-IV -T R is on symptom sets to es tablis h a diagnosis , not on linkages . T he linkage of an environmental stress or and symptom formation is cons is tent with paradigms used many clinicians, and this may account for some appeal 2541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 2 of 40

this diagnos tic category. T he development of s ymptoms as a res ult of difficult events is widely considered part of the general human experience. F or this reas on, the diagnosis is often seen far les s s tigmatizing than other ps ychiatric disorders as symptoms develop in respons e to an event and are short-lived. T his idea was validated with a study of adoles cent and child psychiatrists through a s urvey the DS M-IV -T R work groups . F ifty-five percent of those who res ponded to the s urvey indicated that they us ed adjus tment disorder diagnosis to avoid stigmatization patients. F urthermore, the diagnos is is not viewed by medical ins urance carriers as a preexisting illnes s in same way that other diagnos es are. C linicians often diagnosis to protect patients for future applications for medical, life, and disability insurance. Des pite the clinical appeal of this category of adjus tment disorders have been seen as problematic number of reas ons . T he diagnostic criteria des cribe a syndrome in which a stres sful event leads to the development of a symptom complex. However, within diagnostic construct, there are no criteria to qualify the stress or for an adjus tment disorder in any way. the symptom complex that develops has been criticized lacking s pecificity. T he temporal course between the stress or and the development of s ymptoms lacks scientific evidence. F urthermore, it is difficult in clinical practice to link an event to the development of a complex. T hese is sues have raised questions with the diagnosis in general and have, no doubt, contributed to the lack of academic investigation. P erhaps the dilemma in considering this diagnos tic category 2542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 3 of 40

the question as to why s ome individuals develop symptoms in response to a stress ful event, whereas do not. When clinicians us e this diagnosis to avoid or to attempt to link environmental experiences with symptom development, the potential for erroneous treatment decisions is quite real. One notable s tudy in area examined the concordance rate of diagnoses from medical house staff officers with later psychiatric cons ultations. In fact, 50 percent of inpatients with adjustment disorder by medical house staff were diagnosed with delirium by a ps ychiatric consultant. 

DE F INIT ION



HIS T OR Y



C omparative Nos ology



E P IDE MIOLOG Y



E T IOLOG Y



DIAG NOS IS AND C LINIC AL F E AT UR E S



DIF F E R E NT IAL DIAG NOS IS



C OUR S E AND P R OG NOS IS



T R E AT ME NT



F UT UR E DIR E C T IONS



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > DE F INIT ION

2543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 4 of 40

DE FINITION P art of "22 - Adjustment Dis orders " T he adjus tment disorders are a diagnostic category characterized by an emotional res ponse to a stress ful event. T ypically, the s tres sor involves financial is sues , medical illnes s, or a relationship problem. However, event may qualify by current diagnos tic criteria. T he symptom complex that develops may involve anxious depres sive affect or may present with a disturbance of conduct. T here is little specificity to qualify thes e symptoms other than an excess of what would be expected from the particular stress or or a s ignificant or occupational impairment. B y definition, the must begin within 3 months of the s tres sor and must within 6 months of removal of the stress or. If the complex is less than 6 months in duration, it is deemed acute. S ymptoms las ting beyond 6 months of the initial event are coded as a chronic adjus tment disorder. T he symptom complex must not qualify for another Axis I condition. A variety of s ubtypes of adjustment disorder identified in the DS M-IV -T R , varying on the particular predominant affective presentation. T hese include adjus tment disorder with depres sed mood, anxious mixed anxiety and depress ed mood, disturbance of conduct, mixed dis turbance of emotions and conduct, unspecified type. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > HIS T O R Y

2544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 5 of 40

HIS TOR Y P art of "22 - Adjustment Dis orders " His torically, the DS M has held a place for a diagnostic category involving an acute ps ychological res ponse to environmental s tres sor. T he initial impetus for this through documentation of severe wartime s tres s s een World W ar II, as well as through the evolution of crisis intervention theory and practice. T he firs t edition of the DS M (DS M-I) in 1952 des cribed the category of s ituational pers onality dis order. W ithin this category the subtypes of gros s s tres s reaction, adult s ituational reaction, adjustment reaction of infancy, adjustment reaction of childhood, adjus tment reaction of and adjus tment reaction of late life. T he diagnosis was modified somewhat in the second edition of the DS M (DS M-II), which changed the to trans ie nt s ituational dis orde r. T his category was for “more or les s transient dis orders of any s everity (including those of psychotic proportions ) that occur in individuals without any apparent underlying mental disorders and that repres ent an acute reaction to overwhelming environmental stres s.” T he DS M-II similar P.2056 developmental s ubtypes to the DS M-I; however, the subtypes of gros s s tres s reaction and adult s ituational reaction were eliminated. T he s tipulation that this 2545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 6 of 40

diagnosis not be us ed in the presence of another major ps ychiatric diagnosis was often ignored, with the of obscuring treatment recommendations. A large body literature also emerged ques tioning the use of this diagnosis in youth, which many argued was a time of inevitable turmoil and s ituational stress es . Anna F reud, example, stated that “upholding of a steady equilibrium during the adoles cent proces s is, in itself, abnormal.” C ritics als o pointed to the danger of using this adoles cence rather than noting more severe ps ychopathology, s uch as s chizophrenia or personality disorders . T he third edition of the DS M (DS M-III) introduced the diagnosis of adjus tme nt dis orde r. T he developmental periods of the earlier diagnostic s ys tems were Ins tead, the s ubtypes of adjus tment disorder were categorized based on the predominant affective experience. T hes e included adjus tment disorder with depres sed mood, anxious mood, mixed emotional features, disturbance of conduct, mixed disturbance of emotions and conduct, work inhibition, withdrawal, and atypical features . T he revis ed third edition of the DS M (DS M-III-R ) retained these diagnostic s ubtypes and an additional one involving physical complaints. T he III-R also specified that symptoms of an adjus tment disorder could not exceed 6 months . T he fourth edition of the DS M (DS M-IV ) modified the diagnosis of adjus tment dis order in s everal ways . T he subtypes of mixed emotional features , work inhibition, withdrawal, and phys ical complaints were eliminated. stress or was allowed to pers is t for an indefinite period time. A des criptor of chronicity was specified, whereby 2546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 7 of 40

symptoms pers isting for longer than 6 months were deemed chronic. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > C omparative Nosology

C omparative Nos ology P art of "22 - Adjustment Dis orders "

DS M T he diagnosis of adjus tment disorder has been problematic on multiple levels and, at times , has been termed a was tebas ke t diagnos is . T he diagnos is that a s tres sor precede the development of a s ymptom complex. T he stress or criteria and the description of symptomatology are criticized in the literature. T he of the stres sor lacks s pecificity. T he time course to the development of s ymptoms is, in some s ens e, arbitrary has changed his torically. T he duration of the stress or is also highly variable from one clinical setting to the next. is extremely difficult in clinical practice to infer caus ality from the s tres sor to the development of s ymptoms . A clinician mus t then as sess whether an individual's symptoms are above and beyond what would be cons idered normal for that particular stress or. T he literature points to the potential subjective nature of this evaluation. Multiple authors have als o ques tioned the validity and reliability of the diagnosis and the overlap with other diagnostic categories. G iven the enduring nature of the diagnosis within the psychiatric diagnostic system, however, one mus t cons ider the function that 2547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 8 of 40

entity s erves.

S tres s or C riteria T he DS M-IV -T R criteria for adjus tment disorder rely and foremost on the presence of a stress or. T he nature the stress or, however, is decidedly vague. T he DS Mstates only that the stress or is identifiable but makes mention as to what would qualify as a stress or. T his is contrast to other DS M-IV -T R diagnoses involving the presence of a stress or in which the nature of the event made more explicit. B ereavement, for example, death. P T S D requires a s tres sor involving a threat of a s erious injury to s elf or others , or a res ponse intens e fear, helples sness , or horror. F or an disorder, however, the only requirement is that a can be identified. T his leaves the clinician to determine whether any particular s tres sor could lead to the development of a stress res ponse. T he range in the and intens ity of stress ors is quite large, and one would reasonably believe that a divergent group of human experiences would lead to a s imilar ps ychological experience. S imilarly, the implication of the current criteria is that is an expectable reaction to a particular s tres sor. are left to determine what respons e might be to any identifiable event. A clinician can only have a subjective idea regarding an appropriate reaction to a given stress or. T his would s tem from the pers onal and culture of the individual examiner. F or example, a clinician whose wife died as a result of breas t cancer have quite a different idea of what an expectable ps ychological res ponse to the diagnosis is than a 2548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 9 of 40

who has no pers onal experience with this particular disease entity. P erhaps most problematic is the notion of linear implied in the diagnosis of adjustment disorder. T he diagnosis implies a rather s implis tic model of cause effect. C ritics of this model, however, point to the complexity of interactions involved in the development a s ubjective experience. One author address es this eloquently when presenting different models of He ass erts that an event rarely involves mere linear caus ality. T he event can provide further feedback to elaboration of the original cause. More complex models caus ality mus t also be cons idered in the generation modification of symptoms . As a result of this complex interaction, an individual is frequently left with a set of symptoms and coping abilities that is different than the starting point.

Temporal C ours e DS M-IV -T R describes the onset of symptoms of disorder within 3 months of a s tres sor and the of symptoms within 6 months of the termination of the stress or. T here is some evidence to s upport the idea of symptom development closely following the time of the stress or. T wo s tudies have demonstrated the close temporal relations hip of stress or and s ymptom In one study of children with a new diagnos is of ins ulindependent diabetes, nearly one-third developed adjus tment disorders . T he highest risk period was in first month after diagnosis, and 31 of 33 children had developed s ymptoms within the firs t 3 months after the diagnosis of diabetes. In another s tudy of patients 2549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 10 of 40

undergoing cardiac s urgery, patients developed symptoms immediately before surgery or within the firs t month after surgery. However, one could imagine that symptom formation in some individuals might come with considerable time T his idea is considered in the diagnosis of P T S D, be termed with de laye d ons e t, if symptoms pres ent 6 months or more from the time of the s tres sor. One anticipate that s uch a s imilar delay could occur for the stress of an adjustment dis order. T he literature the potential temporal variation in symptom formation from the onset of the s tres sor. One s tudy examined the timing and number of life events occurring in the year before the onset of emotional dis orders in school-aged children in an outpatient clinic. T hirty percent of cas es not develop s ymptoms until 6 months to 1 year after undes irable event. C hildren who experienced multiple negative life events were more likely to have les s time between stress or and s ymptom formation. T he diagnosis of adjus tment disorder s pecifies that the symptoms do not persist for more than 6 months once stress or—or its consequences —have terminated. It is extremely difficult for a clinician to gauge when a is no longer a stress or. In many cases , s tres sors this diagnos is do not go away. R ather, the meaning of stress or to the individual may change over time. Y et, it difficult to determine when a particular meaning changes for an P.2057 individual. T he literature supports the notion that emotional symptoms can linger for quite some time. 2550 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 11 of 40

study compared the long-term mental health effects in adults of two different community stress ors (the T hree Mile Island accident and wides pread unemployment to layoff). S ymptoms remained elevated for as long as months afterwards. In another study, 35 percent of and 66 percent of adolescents had enduring s ymptoms longer than 6 months from the time of the stress or. It is unclear, however, whether thes e data s how that an can lead to lingering res ponses or whether the event lingers and continues to impact an individual, therefore engendering ongoing emotional s ymptoms . T he DS M-IV -T R does make s ome allowance for this the designation of acute versus chronic adjustment disorders . T he des ignation of chronic is reserved for with symptoms lasting longer than 6 months in the context of ongoing s tres sors .

R eliability T he literature contains mixed information about the reliability of the adjus tment disorder construct. S tudies speak to the poor reliability of the diagnosis, given the vague diagnostic criteria. One study showed an agreement for adjus tment dis orders to be 0.05 (P = not significant) in a survey of ps ychiatris ts and us ing 27 child and adolescent cas e histories. T he the U.K . W orld Health Organization (W HO) s tudy of reliability of the ninth revision of the Inte rnational C las s ification of Dis e as e s (IC D-9) categories in adoles cents were consis tent with this. T he interrater reliability for adjus tment disorders was 0.23, lower than many other categories.

2551 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 12 of 40

Validity Des pite the poor reliability of the diagnosis , however, another body of literature des cribes the predictive and the discriminative us efulness of the diagnos is. T he predictive validity of the diagnos is of adjus tment was demons trated in a large study of adult inpatients . inves tigators s ought to determine whether patients with adjus tment disorder s hared a s imilar prognos is at 5 S eventy-nine percent of adults in the s tudy were well at year follow-up. T he diagnosis was not as predictive for adoles cents , with 57 percent well at 5 years. T he suggest that the good prognosis s hared by the adult cohort implies s pecific characteris tics of the group diagnosed with adjus tment disorder and that the diagnosis carries with it a prediction of recovery at 5 T his predictive validity, however, is not s hared by the cohort of children in the sample. F urther work has delineated other features that are to adjus tment dis order, when compared to major depres sion, s ugges ting des criptive validity. P atients diagnosed with adjus tment disorder had a lower of illness rating, a greater likelihood to improve in the hospital, a greater s everity of stress ors, better recent functioning, and more likelihood to be rated as at follow-up. A further s tudy found adjus tment disorder be a specific psychiatric dis order manifested mainly through depress ive s ymptoms as sociated with marital family problems . T he patients tended to display instability in the form of a pers onality disorder or interpersonal problems and tended to be in the age group. T heir problems were more rapidly s olved in the majority of specific ps ychiatric affective 2552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 13 of 40

T his is consis tent with an earlier s tudy involving a 2,078 male Navy-enlis ted pers onnel diagnos ed with transient situational disturbance. T his proved to be a disabling diagnosis than any other ps ychiatric condition terms of chronicity, length of hospitalization, and ability return to a previous job.

C ultural P ers pec tives An interesting dis cus sion is pos ited regarding the us efulnes s of the adjus tment disorder diagnos is the lens of cultural anthropology. T his pers pective cons iders the evidence that most cultures have an named for a process whereby an individual is stress ed the point of s ymptom development. T his parallels the concept of a ne rvous bre akdown within a particular setting. In this s ens e, the adjus tment dis orders s hare features with other culture-bound syndromes , s uch as s us to, koro, and Arctic hysteria in that they all describe development of a set of s ymptoms after a particular stress or. T he particular cultural variety of adjustment disorder is affected by (1) the nature, intensity, and meaning of the stress or in ques tion; (2) the nature of modal pers onality configuration of the people which includes s tyle or rules, or both, about behavior emotional express ion; (3) idiosyncratic features of the in question; and (4) the meaning that adjustment has in the culture. T he individual is firs t treated within family and other social support networks . W hen this the event is inevitably medicalized in s ome fas hion. preservation of a diagnostic category of adjustment disorders in the DS M-IV -T R may point to this process . In W es tern cultures , clinicians often use the diagnos is 2553 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 14 of 40

adjus tment disorder as a means of communication to patients and third parties that the individual in ques tion res ponding to an outs ide event. T hird parties, including health and life insurance carriers, often look at this diagnosis as a nonrecurring phenomenon with a good outcome.

IC D-10 T he tenth edition of the IC D (IC D-10) als o contains a category of adjus tment dis orders . T he diagnos is is to the DS M-IV -T R entity in outlining the development of ps ychological symptoms following a s tres sor. However, IC D-10, the symptoms mus t appear within 1 month of stress or, instead of the 3-month temporal cours e of IV -T R . T he IC D-10 criteria share with DS M-IV -T R the requirement that s ymptoms mus t not persis t for longer than 6 months after the removal of the s tres sor. T he and DS M-IV -T R differ in their consideration of Whereas the DS M-IV -T R requires the s pecification of or chronic for all subtypes of adjus tment dis order, the 10 only refers to chronicity if the primary experience involved is a depress ed s tate. In this case, the prolonged depress ive reaction is used to des cribe symptoms las ting for as long as 2 years. T he IC D-10 states that symptoms of an adjustment disorder may be any of those found in the major neurotic, stres s-related, s omatoform, or conduct provided that the s ymptoms are not sufficient to qualify for the particular diagnos tic entity. It goes on to s pecify specific diagnostic s ubtypes of adjustment disorder on the nature, degree, and temporal course of involved. T hese subtypes track the DS M-IV -T R 2554 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 15 of 40

fairly well, in that they involve s ymptoms of depres sion, anxiety, and conduct. However, there are s ome is sues are unique to the s ubtypes of IC D-10. F or example, the IC D-10 subtype of adjus tment disorder with disturbance of other emotions is s omewhat s imilar to DS M-IV -T R category of mixed emotional features. However, this IC D-10 category is also us ed to code childhood regres sive reactions, including bedwetting thumb s ucking. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > E P IDE MIOLO G

E PIDE MIOL OGY P art of "22 - Adjustment Dis orders " F ew s tudies have examined the prevalence of disorder in community samples. One s tudy conducted two treatment sites sought to determine the frequency various Axis I diagnoses. Of 164 patients s een at a urban clinic, 88 percent met S tructured C linical for DS M-IV -T R (S C ID) criteria for an Axis I diagnos is , percent met criteria for two or more diagnoses. T here general concordance between clinical diagnoses and diagnoses from a S C ID. T he notable exception was in area of adjus tment dis orders . T he diagnos is of disorder far surpas sed any other diagnos is in the T he category of adjus tment disorders accounted for 54 P.2058 percent of all diagnoses made by a clinical interview. 2555 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 16 of 40

However, it accounted for les s than 4 percent of made by S C ID. A much larger s tudy of patients on entry to the Wes tern P sychiatric Institute clinical services involved a as sess ment of more than 11,000 individuals of all ages us ing a s emistructured ass es sment form and DS M-III criteria s heets. T en percent of the sample was found to have adjustment disorders , making it the second diagnostic category. In children and adolescents than 18 years of age, more than16 percent had disorders . In adults, the female to male ratio was approximately two to one. In children, there was only a slight preponderance of girls with the diagnosis. A further study examined the prevalence of adjus tment disorder among adults and children admitted to an inpatient psychiatric hos pital. T he particular hos pital served a predominantly middle-clas s white community approximately 900,000 individuals. Of the adults, 7.1 percent were admitted with an adjus tment disorder diagnosis, and 34.4 percent of the adolescents were admitted with an adjus tment disorder diagnos is . S tudies of patients in the medical setting point to the prevalence of adjustment disorders in the context of a medical illnes s. In a study of 107 patients with head neck cancers, 14 (12.1 percent) had a diagnosis of adjus tment disorder. In another s tudy of 55 women first recurrence of breas t cancer, 19 (35 percent) were diagnosed with adjus tment disorder. In a s tudy of 92 children diagnos ed with new-onset ins ulin-dependent diabetes mellitus , 33 (36 percent) of the children developed an adjustment disorder within 6 months of 2556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 17 of 40

time of medical diagnosis . T he literature also dis cuss es the development of ps ychiatric s ymptoms after natural dis asters. In a multiple dis as ter s tudies us ing metaanalytical disas ter exposure was as sociated with a 17 percent increase in psychopathology. T his included s ymptoms depres sion, anxiety, s tres s, phobia, somatization, and drug us e, and global dis tres s. One prospective inves tigation coded victims ' res pons e to the 1993 floods in the United S tates . V ictims reported more depres sive symptoms after the events compared their counterparts who were not affected. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > E T IO LOG Y

E TIOL OGY P art of "22 - Adjustment Dis orders " C urrent knowledge regarding the relationship between stress ful life experience and the development of symptoms remains complex. Unres olved ques tions in the literature regarding the etiology of adjustment disorder. Many authors in the field of adjustment disorders the idea of linking a s ingle s tres sor with a s ymptom complex. T he model of a single s tres s exposure symptoms does not account for the complex array of symptoms that are s een in clinical practice. Although studies have as signed relative values to specific the methodology of s uch studies is controversial. Axis 2557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 18 of 40

DS M-IV -T R , allowing a clinician to cons ider the a s tres sor in a multiaxial formulation, has been shown have poor reliability. As discus sed previous ly, if a does impact an individual, the model of linear caus ality less us efulnes s than other complex models of Another ques tion involves the interplay of temperament and environmental responsivenes s. C urrent ps ychoanalytic theory places tremendous importance the context in which an event occurs in cons idering the development of s ymptoms . T he lack of an attuned res ponse from others to s tres sors typically involved in adjus tment disorders may contribute to the disruption experienced. C urrent literature points to the importance of childhood experiences in the vulnerability to s ymptom formation res ponse to later life s tres s. E vidence from a variety of sources sugges ts that early experience with diminis hed control may foster a cognitive style characterized by an increased probability of interpreting or process ing subs equent events as out of one's control. T his may represent a ps ychological vulnerability to the development of anxiety. One s tudy examined 54 men experiencing an disorder as a res ult of conscription. S ubjects were adminis tered a S ymptom C hecklist 90 for a rating of ps ychological, behavioral, and s omatic complaints the last month. T hey were also given a self-report instrument that es timated the perception of parenting received in childhood during the first 16 years of life separate instrument that meas ured early separation anxiety. T he study concluded that abus ive and overprotective parenting received in childhood, as well 2558 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 19 of 40

early separation anxiety, were important factors for the development of adjus tment dis order in s oldiers. S tudies also demons trate that individuals with ongoing ps ychiatric s ymptomatology at the time of the stress or may be more prone to develop symptoms as a result of stress ful life event. In individuals after cardiac s urgery, prolonged adjustment dis order was correlated with preexisting mood s ymptomatology. In another study involving Is raeli children who suffered the loss of their fathers in war, preexisting conduct s ymptoms were correlated with poor adjustment. T he literature s uggests that the degree of exposure to stress ful life events may, to some extent, be influenced familial and genetic factors. T win studies have the degree to which thes e factors predispose one to expos ure to s tres s over the lifetime. One study of 2,000 twin pairs s howed a modest concordance for the likelihood of s tres s exposure. T his correlated more for monozygotic than dizygotic pairs . G enetic and factors each accounted for 20 percent of the variance stress exposure. A further s tudy demonstrated a role of genetics in the likelihood of developing P T S D after expos ure to traumatic events. T he s tudy s uggested symptom formation in res ponse to a stress may be some genetic control. T hes e s tudies point, to s ome to the role of temperament or biological predisposition the development of adjustment dis orders. T here is little in the literature regarding known changes in individuals with an adjus tment disorder. However, one important recent study examined neurochemical changes in individuals with an disorder after a suicide attempt. P latelet monoamine 2559 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 20 of 40

oxidase (MAO) activity was found to be significantly in patients compared to controls . Urinary 3-methoxy-4hydroxyphenylglycol (MHP G ) was higher in the patient group. P las ma levels of cortisol were s ignificantly the patient group as well. T he findings of higher urinary MHP G output and higher cortisol plas ma levels point to poss ible parallel activations of the noradrenergic and the hypothalamic-pituitary-adrenal axis at the time the attempt. T his is of particular interes t in a s uicide attempt in adjus tment disorders , which, by definition, stress -related conditions. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > DIAG NO S IS AND C LINIC AL

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "22 - Adjus tment Dis orders " P sychiatric taxonomy, for the mos t part, relies on the difficult task of ass ess ing qualitative and quantitative changes in behavior as principal illness criteria. T his difficulty is particularly apparent in the subthres hold disorders , such as adjustment dis orders. S ubthres hold disorders are often poorly defined and overlap with diagnostic categories. C riticis m of the adjus tment diagnosis has been around the inference and value judgment that may be required to make the diagnos is , well as problems with validity and reliability. B ecaus e diagnosis of adjus tment disorder is widely us ed in practice, it appears that iss ues of diagnostic rigor and 2560 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 21 of 40

clinical us efulness are at odds . A precipitating experience in the form of a s tres sful or life s ituation is the sine qua non for the diagnosis of adjus tment disorder. P.2059 It is characterized by the development of emotional or behavioral s ymptoms in the context of an identified ps ychos ocial s tres sor. T he symptoms vary widely in and s everity, and the pers on may not be aware of the stress or as being s ignificant. In contras t to other DS Mdisorders , the adjustment disorder criteria have no and s pecific s ymptom profile that defines the condition. T he premis e of an adjustment disorder is a res ponse to an identifiable s tres sor that results in the development of clinically s ignificant emotional or behavioral s ymptoms. T he implication is that, without precipitating event or situation, the adjus tment (or perhaps maladjus tment) res ponse might not have occurred. T he nature and severity of the s tres sor are specified. S uch a res ponse is viewed as pertinent if it occurs within 3 months of the ons et of an identifiable stress or. It is deemed clinically s ignificant if by marked distress in exces s of what would be given the nature of the stress or, or significant in social and occupational functioning. T he challenge the clinician, in these s ituations, is to differentiate a reasonable and expected res ponse to ps ychosocial stress ors from that which might indicate a diagnos is of adjus tment disorder. T he diagnos tic criteria for disorders define the contextual and temporal characteristics of a subthreshold respons e to a 2561 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 22 of 40

ps ychos ocial s tres sor; they do not apply if the s tres s related dis turbance meets the threshold for another specific Axis I diagnosis or is thought to be an of a preexisting Axis I or II disorder. Adjustment disorders may occur in any age group. studies have identified s chool problems as the most frequent precipitant in adoles cents , whereas marital problems are common in adults . S tres sors may be multiple, recurrent, or enduring events . As a result, temporal and caus al relations hips with s ymptoms are often uncertain. S everal studies have des cribed pres enting features of adjus tment disorders in clinical samples. In mos t depres sive s ymptoms have been most prominent. T wo studies from a mixed child and adult population depres sive mood in more than one-half of the study sample. Other s ymptoms noted in patients with adjus tment disorder were insomnia (53 percent), other vegetative s ymptoms and social withdrawal (29 and s uicidal indicators (29 percent). Depress ive s ymptoms appear to be characteris tic of adjus tment disorders in children and adults, although behavioral s ymptoms and mixed presentations are more frequently in children and adolescents. T hes e findings have been replicated in a number of s tudies following the University of Iowa study, which reported 87 percent of adults with adjus tment dis order had depres sive s ymptoms , compared to 63 percent of adoles cents . In contras t, 77 percent of adoles cents had behavioral s ymptoms, whereas 25 percent of adults C ommon symptoms of adjus tment disorders identified 2562 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 23 of 40

Wes tern P s ychiatric Ins titute s tudy included depres sed mood, low s elf-es teem, s uicidal behavior, increased activity, hypervigilance, impulsivity, and s ubstance us e. T hese symptoms may be ass ociated with other subthreshold mood and anxiety disorders that are not stress related, and it is unclear whether they are in the context of stress . In an attempt to better the symptom profile for adjustment disorders , two of youth who developed adjus tment disorders after the diagnosis of diabetes mellitus reported an average of symptoms: feeling sad, s uicidal ideation, pes simism, anhedonia, irritability or anger, and fatigue. S tudies of adjustment disorders using s tructured diagnostic instruments have reported high levels of comorbidity. In a mixed group of children and adults , approximately 70 percent of patients with adjus tment disorders had at leas t one additional Axis I diagnosis. However, comorbidity of adjus tment dis orders with Axis I dis orders was less than in dysthymic disorder or major depress ive disorder. T he degree of comorbidity be an important determinant of the level of impairment and ris k for poor outcomes in persons diagnos ed with adjus tment disorders . A recent study demons trates the potential efficacy of a screening instrument to identify patients with disorders . T his one-question instrument was applied to population of patients with a new diagnosis of cancer. study suggests that this brief screening ins trument is a valid tool to identify patients with potential adjus tment disorders and other diagnoses of depres sion. S everal studies have reported a s ignificant as sociation adjus tment disorders with suicidal ideation, particularly 2563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 24 of 40

youth. In an urban hospital setting, 56 percent of all admis sions for suicidal behavior were clas sified as transient situational disorders using DS M-II criteria. age range was 15 to 24 years of age, with the majority cases being women. T hese findings underscore the s eriousnes s of disorders in a s ubs et of individuals ; s ubthres hold conditions may carry high morbidity, including the risk serious s elf-harm and death.

S ubtypes S ix subtypes of adjustment dis orders have been based on the predominant s ymptom presentation. IV -T R does not identify s pecific s ymptom profiles for of the subtypes; however, attempts have been made to more accurately des cribe them. Notable symptoms for individual adjustment disorder s ubtypes include the following: (1) in depress ed mood, depress ion, low self-es teem, and s uicidal indicators; (2) in anxiety, generalized anxiety, increased motor activity, and situational anxiety; (3) in disturbance of conduct, impulsivity, lack of ins ight, and violent behavior; and (4) mixed disturbance of emotions and conduct, exces sive alcohol ingestion, s uspicious ness , hos tility, defrauding behavior, and homicidal ideation. A recent publication s ugges ted a further potential of adjus tment dis order bas ed on a unique emotional res ponse to the s tres sor. T his concept, termed pos ttraumatic embitterme nt dis orde r, is characterized emotional res ponse of embitterment and feelings of injus tice after an exceptional, negative life event. T his be accompanied by thoughts of revenge and repeated 2564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 25 of 40

intrus ive memories of the event. T he diagnosis of adjus tment disorders requires the cons ideration of the pers on's coping style, the details of the situation within which symptoms emerged, and s elfperception of the s tres sor's impact. T he clinician als o needs to appreciate the relations hip between the event and the onset, cours e, and expected outcome of symptoms. T he diagnos is of adjustment disorder less on well-circums cribed symptom clusters than the totality of the clinical picture as perceived by the T here are certainly patients for whom this category appropriate, for ins tance, high-functioning individuals experience mood or anxiety symptoms in res ponse to change of occupational status , loss of loved ones , and newly diagnos ed or ongoing medical conditions. In practice, however, the adjustment dis order category serves a nonclinical function and may not reflect the as sess ment of the clinician. A 48-year-old married woman, in good health, with no previous ps ychiatric difficulties , presented to the emergency room reporting that she had overdosed on handful of antihis tamines s hortly before s he arrived. described her problems as having started 2 months soon after her husband unexpectedly requested a S he felt betrayed after having devoted much of her 20year marriage to being a wife, mother, and S he was sad and tearful at times, and she occasionally difficulty s leeping. Otherwise, s he had no vegetative symptoms and enjoyed time with family and friends. felt desperate and suicidal after she realized that “he longer loved me.” After crisis intervention in the 2565 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 26 of 40

emergency s etting, she res ponded well to individual ps ychotherapy over a 3-month period. S he required benzodiazepines for anxiety during the period treatment. B y the time of discharge, s he had returned her bas eline function. S he came to terms with the poss ibility of life after divorce and was exploring her options under the circums tances . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "22 - Adjustment Dis orders " P.2060 A wide range of ps ychiatric disorders frequently occur the context of s tres sful life events. E tiological linkage of specific s tres sor to s ymptom formation, however, is a cons ideration only in the cas e of adjustment disorder, posttraumatic syndromes, and bereavement. T ypically, DS M-IV -T R phenomenological approach es tablis hes diagnostic thres hold us ing a combination of quality, quantity, and duration of s ymptoms . T he adjus tment disorder category is one of the few whose definition not include a specific profile of s ymptoms and signs . S ubsyndromal symptoms coupled with an identified ps ychos ocial s tres sor dis tinguis h adjustment dis order other Axis I disorders in DS M-IV -T R . T he adjus tment disorders have been des cribed by s ome authors as a transitional diagnos tic category, becaus e the level of 2566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 27 of 40

symptomatology and impairment in adjus tment was found to be intermediate between a comparis on group of patients with a DS M-III problem-level and s pecific, above-threshold diagnos es . Other Axis I conditions are s tres s related but have an established diagnostic thres hold or have s ubthreshold symptoms are not neces sarily linked to s tres s. It is not clear that stress or criterion is specific enough to adequately discriminate between adjustment disorders and other subthreshold dis orders that are not linked to stress . R egardless of the s tres sor, a more specific Axis I as sumes precedence when appropriate criteria are satis fied. T he upper thres hold is thus established by criteria for the major s yndromes, whereas the lower threshold between adjus tment dis orders and other subthreshold dis orders is les s clear. T he presence of a stress or is a requirement in the of adjus tment dis order, P T S D, and acute stress P T S D and acute stress disorder have the nature of the stress or better characterized and are accompanied by defined cons tellation of affective and autonomic symptoms. In contrast, the stress or in adjus tment can be of any severity, with a wide range of poss ible symptoms. W hen the res pons e to an extreme stress or not meet the acute stress or pos ttraumatic dis order threshold, the adjustment disorder diagnos is would be appropriate. T he adjus tment disorder s ubtypes need to be distinguished from s ubthres hold types of the major mental disorders , the so-called not otherwis e s pecified (NOS ) categories . T he presence of an identifiable sets adjus tment dis orders apart from the NOS 2567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 28 of 40

DS M-IV -T R . Interestingly, if the symptoms of disorder persist for more than 6 months after the or its consequences have resolved, the diagnos is have to change to the appropriate NOS category, if symptoms remain s ubthres hold, or a more s pecific Axis diagnosis. T he differentiation of adjustment dis order from a mood disorder due to a general medical condition is complex. Although the medical condition may be the obvious stress or, affective s ymptoms may aris e as a direct phys iological cons equence of some medical medical and other settings, care must be taken to distinguish between the reasonable and expected res ponse to ps ychosocial stress ors , which s ome have described as nonpathological reactions to stress , and inordinate res pons e that may suggest an adjus tment disorder. S ome authors have propos ed the concept of de moralization as a normal respons e to advers ity. Normative data on s tres sor respons e patterns are not available in any rigorous fashion; thus, inference and judgment continue to play a significant role in the diagnosis of adjus tment disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > C O UR S E AND P R OG NO

C OUR S E AND PR OGNOS IS P art of "22 - Adjus tment Dis orders " His torically, adjustment disorder has been viewed as a transitional diagnostic category and, by definition, is not 2568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 29 of 40

an enduring diagnosis. It is presumed that, without the occurrence of the stress or, the condition would not and that s ymptoms do not persist beyond 6 months the stress or or its cons equences have terminated. T he symptoms resolve or progress to a more s erious T he importance of age, pers onality type, social s upport systems , and comorbid conditions in modulating the cours e of adjustment disorders has been described by some authors . T here is s ome suggestion that persons unusually s evere s ymptoms may repres ent a previous ly compromis ed group. Attempts have been made by a number of investigators addres s the ques tion of whether an initial episode of adjus tment disorder predicts the s ubs equent development of more specific and severe pathology. Multiple studies have shown a fairly benign cours e for adults , with a lower likelihood of recovery in 5-year follow-up study at the Univers ity of Iowa s howed recovery rate of 71 percent in adults vers us 44 percent adoles cents . An additional 8 percent of adults were follow-up but had intervening problems , compared to percent of the adoles cent group. Almost 70 percent of adoles cent group was ill during the 5-year follow-up period, whereas les s than 30 percent of the adult group experienced psychiatric dis orders in the s tudy period. Although most of the adults developed major disorder and alcohol abuse, the adoles cents developed wider range of major psychiatric disorders , including schizophrenia, bipolar dis order, antis ocial pers onality disorder, drug abus e, and major depres sive dis order. C hronicity of s ymptoms and behavioral s ymptoms were the bes t predictor of poor outcome. T he adjus tment 2569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 30 of 40

disorder s ubtype alone did not predict the follow-up diagnosis. Another study that s urveyed all adolescents receiving mental health treatment in a geographical found that 52 percent of those originally diagnosed as having DS M-II trans ient situational dis order continued ps ychiatric treatment at 10-year follow-up. One s tudy that looked at the cours e and prognosis of depres sive disorders in children and adolescents that adjus tment disorder with depres sed mood was not characterized by an increas ed risk for major depress ive disorder. It was not determined whether some of the children later developed disorders other than thos e in mood spectrum. A related s tudy of children diagnosed with adjustment disorder found that this diagnos is did increase the ris k for poor outcome when compared to a control group without an adjustment disorder diagnos is, but the two groups matched for comorbidity. T hese findings s uggest that some of the ris k for poor outcome reported in children and adolescents might be related comorbidity with other dis orders. T ypically, the diagnos es of major depres sion, schizophrenia, bipolar disorder, and substance us e are as sociated with a significant s uicide risk. However, individuals with adjustment disorder may als o carry a significant risk of s uicide. A recent s tudy of 119 with adjustment disorder indicated that 60 percent had documented s uicide attempts in the past, and 96 had been s uicidal during their P.2061 admis sion to the hospital. F ifty percent had attempted suicide immediately before hospital admis sion. 2570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 31 of 40

diagnoses of substance abuse and pers onality disorder contributed to the suicide risk profile. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > T R E AT ME N

TR E ATME NT P art of "22 - Adjustment Dis orders " T he adjus tment disorders may present with symptomatology acros s multiple s ymptom domains ; there is no single treatment intervention approach for heterogeneous clinical manifestation of the disorder. T here has been little systematic study of the treatment individuals with adjustment disorder and other subthreshold conditions . Nonetheles s, adjustment dis orders are common in clinical practice, and attention to this and other subthreshold conditions may potentially fores tall the development of more severe psychiatric morbidity. T he clinician is often faced with the question of whether there is s ufficient psychiatric morbidity to warrant treatment intervention. T he treatment of individuals adjus tment disorder requires the careful as sess ment of nature and severity of symptoms, with cons ideration of ris k factors ass ociated with poor outcome, such as premorbid functioning and persistent s tres sors . It is es sential to understand the meaning of the s tres sor to patient and why it is ass ociated with the pres enting symptoms. T he primary goals of treatment are the relief of 2571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 32 of 40

and the achievement of a level of adaptive functioning that is comparable to or, in s ome s ituations, better than the level of premorbid functioning. It is important to unders tand and to facilitate thos e factors that mitigate pathological res ponse to s tres s, as well as the patient's level of vulnerability and capacity for adaptation. T reatment interventions s hould be designed to the impact of the stress ors on day-to-day function and mobilize adaptive s tres s -coping mechanisms. S pecific treatment interventions that may be individuals with adjustment disorder include supportive ps ychological approaches and cognitive-behavioral ps ychodynamic interventions. C oncrete guidance with res olution of stress ors is often helpful. S hort-term treatment may be adequate for many patients; more extended treatment may be appropriate in in which individual characteris tics predispose the to s tres s intolerance. Depending on the level of acuity exis ting supports, cris is intervention and case management may be necess ary on a s hort-term basis preclude rapid progres sion and perhaps to avoid hospitalization. Individual ps ychotherapy tends to be supportive in nature, rather than exploratory. It is important to help the patient better understand the meaning of the stress or and why it may have overwhelmed his or her coping mechanis ms . F amily, couples, and group therapies may have us efulness , depending on the pres enting circumstances. A recent publication sugges ts the validity of a new form of ps ychotherapy, mirror therapy, for the treatment of patients with adjus tment dis order with depres sed mood a result of myocardial infarction. 2572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 33 of 40

T here are hardly any s ys tematic clinical trials efficacy of pharmacological interventions in individuals with adjustment disorders . T here is plenty of less evidence from cons ultation-liais on and clinical s ettings suggesting that it is reasonable to consider the us e of medications to treat specific symptoms with adjustment disorders . T ypically, thes e are antidepres sants and anxiolytics . S elective s erotonin reuptake inhibitors (S S R Is ) have been found to be treating s ome subthreshold depress ive s yndromes and may benefit certain subtypes of adjus tment dis orders . number of s urveys looking at prescribing practices office-based physicians since the 1980s show a increase in the prescription of antidepress ants . It however, be emphas ized that ps ychosocial strategies remain the mains tay of treatment, with pharmacological intervention being a complementary treatment E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "22 - Adjustment Dis orders " C reating an interactive model that takes into account stress and res iliency factors that are respons ive to individual and cultural differences remains challenging. Ques tions abound regarding the adjustment dis orders; instance, what is the relationship between adjus tment disorder and other s tres s -related dis orders, such as and acute stress dis order? S hould s tres s -related be grouped together in the DS M, as in IC D-10? Are 2573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 34 of 40

subtypes of adjustment disorders more appropriately conceptualized as minor disorders of mood, anxiety, behavior? S ome authors have sugges ted that a better of the adjus tment dis orders might require a radical T he choice may be that the diagnosis of adjus tment disorder is not based on a definition that lends its elf to rigorous investigation and thus should be recons idered that its pragmatic us efulness , despite methodological problems , should be recognized as a reas on for further study, particularly from the epidemiological and therapeutic viewpoints . T he latter option would require continued efforts to improve the s pecificity and of the diagnos tic category. F urther res earch mus t be be directed toward optimal treatment approaches us ing systematic clinical trials and rigorous cost–benefit analyses . Ultimately, the usefulness of a diagnostic category is largely dependent on the s trength of its prognos tic and therapeutic implications. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "22 - Adjustment Dis orders " Anxiety disorders , including P T S D, are discus sed in 14, and mood disorders are discus sed in C hapter 13. S uicide is presented in S ection 29.1 and C hapter 45. S eparation and divorce are covered in S ection 30.5 on 2574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 35 of 40

couples therapy, S ection 24.9 on stress , and C hapter relational problems. B ereavement is dis cuss ed in 28.5, and phys ical abus e and s exual abuse are S ection 28.6. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > R E F E R E NC

R E FE R E NC E S Akizuki N, Akechi T , Nakanishi T , Y oshikawa E , M, Nakano T , Murakami Y , Uchitomi Y : a brief screening interview for adjus tment dis orders major depress ion in patients with cancer. C ancer. 2003;97:2605. *Andreasen NC , Hoenck P R : T he predictive value of adjus tment disorders : A follow-up study. Am J P s ychiatry. 1982;139:584. Andreas en NC , Wasek P : Adjustment dis orders in adoles cents and adults . Arch G e n P s ychiatry. 1980;37:1166. B onelli R M, B ugram R : Additional A-criterion for adjus tment disorders ? C an J P s ychiatry. C as ey P , Dowrick C , W ilins on G : Adjus tment F ault line in the ps ychiatric gloss ary. B r J P s ychiatry. 2001;179:479. C horpita B F , B arlow DH: T he development of T he role of control in the early environment. P s ychol B ull. 1998;124:3. 2575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 36 of 40

*Despland J N, Monod L, F errero F : C linical adjus tment disorder in DS M-III-R and DS M-IV . P s ychiatry. 1995;36:454. F abrega H, Mezzich J : Adjustment disorder and ps ychiatric practice: C ultural and historical as pects . P s ychiatry. 1987;50:31. F abrega H, Mezzich J , Mezzich A, C offman C : validity of the DS M-III depress ions. J Ne rv Ment Dis . 1986;174:573. G inexi E M, W eighs K , S immens S , Hoyt DR : Natural disas ter and depres sion: A pros pective investigation reactions to the 1993 Midwest floods . Am J P s ychol. 2000;28:495. G iotakos O, K onstantakopoulos G : P arenting childhood and early separation anxiety in male cons cripts with adjustment dis order. Mil Med. 2002;167:28. G onzalez-J aimes E I, T urbull-P laza B : S election of ps ychotherapeutic treatment for adjus tment dis order with depress ive mood due to acute myocardial infarction. Arch Me d R e s . 2003;34:298. G reenberg W M, R osenfeld DN, Ortega E A: disorder as an admiss ion diagnos is . Am J 1995;152:459. J ones R , Y ates W R , Williams S , Zhou M, Hardman 2576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 37 of 40

Outcome for adjus tment dis order with depress ed mood: C omparis on with other mood disorders . J Dis . 1999;55:55. P.2062 J udd LJ , R apaport MH, P aulus MP , B rown J L: S ubsyndromal symptomatic depres sion: A new disorder? J C lin P s ychiatry. 1994;55[S uppl]:18. K endler K S , Neale M, K es sler R , Heath A, E aves L: study of recent life events and difficulties. Arch G e n P s ychiatry. 1993;50:789. K im K J , C onger R D, E lder G H J r, Lorenz F O: influences between stress ful life events and internalizing and externalizing problems . C hild De v. 2003;74:127. K ovacs M, G ats onis C , P ollock M, P arrone P L: A controlled prospective s tudy of DS M-III adjustment disorder in childhood. Arch G e n P s ychiatry. K ovacs M, Ho V , P ollock MH: C riterion and validity of the diagnosis of adjus tment disorder: A prospective study of youths with new-onset insulindependent diabetes mellitus. Am J P s ychiatry. 1995;152:523. K ryzhanovskaya L, C anterbury R : S uicidal behavior patients with adjus tment dis orders . C ris is .

2577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 38 of 40

K ugaya A, Akachi T , K ouyama T , Nakano T , Mikami Okamura H, Uchitomi Y : P revalence, predictive and s creening for psychological dis tres s in patients newly diagnos ed head and neck cancer. C ancer. 2000;88:2817. Lewins ohn P M, R ohde P , K lein D, S eeley J R : into adulthood. J Am Acad C hild Adole s c P s ychiatry. 1999;38:56. Linden M: P os ttraumatic embitterment disorder. P s ychothe r P s ychos om. 2003;72:195. Looney J G , G unders on E K : T ransient s ituational disturbances : C ourse and outcome. Am J 1978;135:660–663. Margolis R L: Nonpsychiatric hous e s taff frequently misdiagnos e ps ychiatric disorders in general inpatients . P s ychos omatics . 1994;35:485. Okamura H, Watanabe T , Narabayas hi M, Ando M, Adachi I, Akechi T , Uchitomi Y : distress following first recurrence of disease in with breast cancer: P revalence and ris k factors. C ancer R e s T re at. 2000;61:131. S hear MK , G reeno C , K ang J , Ludewig D, F rank E , HA, Hanekamp M: Diagnos is of nonpsychotic community clinics. Am J P s ychiatry. 2000;157:581. S lavney P R : Diagnosing demoralization in 2578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 39 of 40

ps ychiatry. P s ychos omatics . 1999;40:325. S naith R P : T he concepts of mild depress ion. B r J P s ychiatry. 1987;150:387. *S nyder S , S train J , W olf D: Differentiating major depres sion from adjus tment dis order with depress ed mood in the medical setting. G e n Hos p P s ychiatry. 1990;12:159. S palletta G , T roisi A, S aracco M, C iani N, P asini A: S ymptom profile, Axis II comorbidity and s uicidal behavior in young males with DS M-III-R depres sive illness es. J Affect Dis ord. 1996;39;141. S tolorow R D, Atwood G E . C onte xts of B eing: T he Inte rs ubje ctive F oundations of P s ychological L ife . T he Analytic P ress ; 1992:54. *S train J J , Newcorn J , W olf D, F ulop G . Adjustment disorder. In: Hales R E , Y udofsky S C , T albott J A, Ame rican P s ychiatric P res s T e xtbook of P s ychiatry. Was hington, DC : American P sychiatric As sociation P res s; 1994. S train J J , S mith G C , Hammer J S , McK enzie DP , B lumenfield M, Muskin P , Newstadt G , W allack J , A, S chleifer S S : Adjustment disorder: A multis ite of its utilization and interventions in the liais on psychiatry s etting. G e n Hos p P s ychiatry. 1998;20;139.

2579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 40 of 40

T ripodianakis J , Markianos M, S arantidis D, Neurochemical variables in subjects with adjustment disorder after s uicide attempts. E ur P s ychiatry. 2000;15:190. V an der K link J J , van Dijk F J : Dutch practice for managing adjus tment dis orders in occupational primary health care. S cand J W ork E nviron He alth. 2003;29:478. *Woolston J L: T heoretical considerations of the adjus tment disorders . J Am Acad C hild Adole s c P s ychiatry. 1988;27:280.

2580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

01/01/2009

Page 1 of 220

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > 23 - P ers onality Disorde

23 Pers onality Dis orders Dragan M. S vrakic M.D., Ph.D. C . R obert C loninger M.D. P ers onality disorder is a common and chronic dis order. prevalence is estimated between 10 and 20 percent in general population, and its duration is express ed in decades. T his means that at least one in every five to individuals in the community has pers onality disorder. Als o, many instances of violent and nonviolent crime large percentage of the pris on population are with underlying pers onality disorder. T hes e individuals have chronic impairments in their ability to work and to love; tend to be les s educated, drug dependent, single, and unemployed; and tend to have marital difficulties . T hey consume a large portion of community s ervices, social welfare benefits , and public health resources . Approximately one-half of all ps ychiatric patients have personality disorder, which is frequently comorbid with Axis I conditions. P ersonality disorder is also a predis pos ing factor for other psychiatric disorders (e.g., subs tance use, suicide, affective dis orders , impuls edisorders , eating disorders , and anxiety dis orders) in it interferes with treatment outcomes of Axis I and increases personal incapacitation, morbidity, and mortality of thes e patients. 2581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 2 of 220

P ers ons with pers onality disorder are frequently aggravating, de manding, or paras itic and are generally cons idered to have poor prognosis . Alternatively, they be seductive or dependent and may elicit inappropriate blurring of profess ional boundaries, such as s exual or the urge to res cue. T hese patients challenge the of the physician's theoretical knowledge, clinical s kills , even pers onal maturity. In general, practitioners with narcis sism, high energy, and high tolerance are optimal treating patients with personality dis order. Many patients in s omatic medicine and neurology have personality disorder comorbid with their phys ical P ers onality factors have been as sociated with ris k for coronary artery disease, angina pectoris, contraction of human immunodeficiency virus (HIV ), ps oriasis, ulcerative colitis , and many other so-called ps ychos omatic diseases. On the other hand, many with pers onality problems who seek medical help frequently have negative workups and no medical explanation for their complaints . During the last several decades there has been a increase in clinical and res earch interest in pers onality disorder. After the introduction of explicit diagnostic criteria and the multiaxial diagnos tic s ys tem in the third edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-III) in 1980, personality dis order has diagnosed more frequently and more s ys tematically. DS M criteria have been revised and standardized in subs equent editions of the DS M—the revis ed third of the DS M (DS M-III-R ) (1987) and the fourth edition of DS M (DS M-IV ) (1994). In addition, in 2000, the revis ed fourth edition of the DS M (DS M-IV -T R ) was published. 2582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 3 of 220

multiaxial diagnos tic s ys tem means that personality disorder and mental retardation are class ified on Axis whereas all other mental dis orders are clas sified on T he availability of thes e two axes facilitates the of pers onality disorders , as it ens ures that personality disorder is not diagnostically overlooked even when it cooccurs with a clinically more prominent Axis I T he increased clinical recognition of pers onality probably reflects its increas ed pres ence in the general population. At the turn of the 20th century, when F reud was pioneering his unders tanding of human neuros es and neurotic problems were the dominant ps ychopathology of eve ryday life . At the time, the ps ychological tas k people were facing was to find acceptable ways to express their as ocial impulses, predominantly aggres sion and s exuality. Obvious ly, behavior codes of present s ociety differ s ubs tantially the ethical cons ervativis m at the turn of the century. Aggress ion and sexuality have become much easier to expres s in an ethically more liberal s ociety. Instead of struggling with morality, people of the 1990s are faced with questions of identity, meaning, and choice. Nowadays , one frequently encounters patients who help but cannot precisely des cribe their problems , who more disappointed than anxious , who struggle with questions of purpose rather than guilt, who are rather than inhibited; who feel empty rather than sad, who manifes t a peculiar inability to learn from as they tend to repeat maladaptive behaviors over and over again. Another pos sible explanation for the increas ed interest personality dis order is its pos ition s omewhere in 2583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 4 of 220

minor and major ps ychiatric problems (e.g., adjus tment disorder vs. schizophrenia), which makes it interes ting wide variety of experts and s chools , ranging from sociodynamic to purely biological. As noted previous ly, pers onality disorder underlies susceptibility to many other ps ychiatric and medical problems . Accordingly, diagnos is and treatment of any ps ychiatric patient, as well as patients with problems , and prevention planning in many medical syndromes are inadequate without a s ys tematic to ass es sing and clas sifying pers onality. F inally, the development of ps ychiatry as a whole has generated an increased interest in personality dis order. E very s cience in its initial stages has a tendency to its s ubject as clearly as poss ible. Once s ufficiently developed, it naturally begins to recognize various and transitional forms . It is now clear that pers onality disorder repres ents a more or less s evere variation of normal personality, which ps ychiatry, owing to its own development, has begun to recognize. 

B AS IC DE F INIT IONS AND T E R MINOLOG Y



C ONC E P T UAL AND P S Y C HOME T R IC IS S UE S



P E R S ONALIT Y DE V E LOP ME NT : S E LF -OR G ANIZING P S Y C HOB IOLOG IC AL



P E R S ONALIT Y DIS OR DE R



INDIV IDUAL P E R S ONALIT Y DIS OR DE R S



C LINIC AL AND P S Y C HOME T R IC IS S UE S



E T IOP AT HOG E NE S IS OF P E R S ONALIT Y 2584

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 5 of 220



T R E AT ME NT



S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > B AS IC DE F INIT IO NS AND

B AS IC DE FINITIONS AND TE R MINOLOGY P art of "23 - P ers onality Dis orders " T he terms pe rs onality, temperame nt, motivation, and ps yche are often used interchangeably. T his is misleading and unjustified. T hes e concepts are to dis tinguis h them with more clarity.

P ers onality P ers onality is complex and unique: on the one hand, people differ greatly from one another in multiple components of behavior, P.2064 and, on the other hand, each person express es only their many potential lifestyles. T he common of all existing definitions of pers onality is that they are functional, that is, they focus on ques tions related to motivation and mental adaptation of the organism. S pecifically, G ordon Allport defined pe rs onality as the “dynamic organization within the individual of those ps ychophys ical systems that determine his /her unique 2585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 6 of 220

adjus tment to his/her environment.” Allport elaborated on this definition by explaining that expres sion “dynamic organization” emphasizes that personality is an organized s ys tem (unitas multiple x) cons tantly evolving and changing. T he s yntax “within individual” means that personality is what lies behind specific individual's acts. T he term “ps ychophys ical” that personality is neither exclus ively mental nor exclusively neural, but a combination of the two. T he “determine” indicates that personality traits are determining tendencies that guide express ive and adaptive behaviors. T he express ion “unique the environment” has functional and evolutionary significance pointing to personality as a mode of and, more generally, adaptation, which is unique to individual. It has been widely accepted that pers onality develops through the interaction of hereditary dis pos itions and environmental influences. W addington's notion of canalization (or epige netic lands cape ) has been include the reciprocal necess ity of genetic endowment and environmental s timulation in the development of behaviors . G enetic differences account for one-half of the variance in mos t normally distributed temperament traits . Of the remaining 50 percent of the variance, 30 to 35 percent is explained by nonshared environmental effects (i.e., experiences that are unique the individual), and 10 to 15 percent is explained by meas urement error and nontrait s core fluctuations . C ontrary to the common belief, environmental that are shared by siblings (such as having the s ame parents , living in the s ame neighborhood, and going to 2586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 7 of 220

the same s chools ) have little or no influence on differences in personality. Of note, adoption studies suggest s omewhat lower heritability of approximately percent for pers onality traits . T his reflects nonadditive genetic variance (e.g., higher-order interaction among alleles at each locus or among loci), which is the s ame monozygotic twins but contributes little to the res emblance of first-degree relatives. F rom the s tructural standpoint, personality can be decompos ed into temperament, character, and psyche. R oughly speaking, temperament involves bas ic character involves rational concepts about s elf and interpersonal relations , and the ps yche involves self-awarenes s and intelligence. S elf-awarenes s and intelligence influence pers onality development subs tantially, s o meas ures of temperament and provide an incomplete understanding of personality development. B as ic functions of personality are to feel, think, and to perceive, and to incorporate these into purpos eful behaviors .

Temperament T e mpe rame nt refers to the body's biases in the of conditioned behavioral responses to prescriptive phys ical s timuli. B ehavioral conditioning (that is , procedural learning) involves presemantic sensations elicit basic emotions , s uch as fear or anger, cons cious recognition, descriptive obs ervation, or reasoning. P ioneering work by Alexander T homas S tella C hess conceptualized temperament as the component (how) of behavior, as differentiated from motivation (why) and content (what) of behavior. 2587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 8 of 220

concepts of temperament, however, emphas ize its emotional, motivational, and adaptive as pects . four major temperament traits have been identified: avoidance, novelty seeking, reward dependence, and persis tence. It is remarkable that this four-factor model temperament can, in retros pect, be s een as a modern interpretation of the ancient four temperaments : Individuals differ in the degree to which they are melancholic (harm avoidance), choleric (novelty sanguine (reward dependence), and phlegmatic (persis tence). However, the four temperaments are unders tood to be genetically independent dimensions that occur in all factorial combinations, rather than mutually exclus ive categories .

Ps yc hobiology of Temperament T emperament traits of harm avoidance , novelty re ward de pende nce , and pe rs is te nce are defined as heritable differences underlying one's automatic to danger, novelty, and various types of reward, res pectively. T hes e four temperament traits are closely as sociated with the four basic emotions of fear (harm avoidance), anger (novelty s eeking), attachment dependence), and ambition (pers is tence). Individual differences in temperament and bas ic modify the process ing of s ens ory information and early learning characteristics , es pecially as sociative conditioning of uncons cious behavior res ponses. T emperament is conceptualized as heritable bias es in emotionality and learning that underlie the acquis ition emotion-based, automatic behavioral traits and habits are obs ervable early in life and are relatively stable 2588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 9 of 220

one's life s pan. E ach of the four major dimens ions is a normally quantitative trait, which is moderately heritable, observable early in childhood, relatively stable in time, moderately predictive of adoles cent and adult behavior. T he four dimensions have been shown to be homogeneous and independently inherited from one another in large, independent twin studies in the United S tates and Australia. T emperamental differences, are not stable initially, tend to stabilize during the and third year of life. Accordingly, ratings of these four temperament traits at 10 to 11 years of age were predictive of pers onality traits at 15, 18, and 27 years age in a large sample of S wedis h children. T he four dimensions have been repeatedly s hown to universal acros s different cultures , ethnic groups, and political s ys tems on every inhabited continent. In summary, these aspects of personality are called te mpe rame nt, because they are heritable, manifest life, are developmentally s table, and are cons is tent in different cultures . T able 23-1 s ummarizes contrasting of behaviors that distinguish extreme s corers on the dimensions of temperament. Note that each extreme of these dimens ions has specific adaptive advantages disadvantages, so neither high nor low s cores mean better adaptation.

Table 23-1 Des c riptors of Individuals Who S c ore High and Low on the Four Temperament Dimens ions 2589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 10 of 220

 

Des c riptors of E xtreme Variants

Temperament Dimens ion

High

Low

Harm avoidance

P es simis tic

Optimis tic

 

F earful

Daring

 

S hy

Outgoing

 

F atigable

E nergetic

Novelty s eeking

E xploratory

R es erved

 

Impulsive

Deliberate

 

E xtravagant

T hrifty

 

Irritable

S toical

R eward dependence

S entimental

Detached

 

Open

Aloof

2590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 11 of 220

 

Warm

C old

 

Affectionate

Independent

P ers is tence

Indus trious

Lazy

 

Determined

S poiled

 

E nthus ias tic

Underachiever

 

P erfectionist

P ragmatist

T he component traits (facets ) for each of the four temperament dimens ion have distinct learning characteristics and correlate more strongly with one another than with other components of temperament. T hey s hare a common s ource of covariation that is and invariant regardless of changes in the environment and past experience. E ach of the four temperament dimensions has unique genetic determinants according family and twin s tudies, as well as studies of genetic as sociations with s pecific deoxyribonucleic acid (DNA) markers. T he four dimensions of human temperament clos ely to those obs erved in other mammals. Multiple levels in the phylogeny of learning abilities in animals invertebrates to man indicate that learning has multiple component proces ses that are hierarchically organized and interact extensively throughout development (F ig. 2591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 12 of 220

1).

FIGUR E 23-1 A hierarchical model of learning. In F ig. 23-1, temperament corresponds to the sens ation, ass ociation, and motivation that underlie the integration of skills and habits based on emotion. F igure 23-1 is us eful to specify the hierarchical phylogenetic and ontogenetic organization of learning and its relevance to the concepts P.2065 of temperament and character, not to compare learning 2592 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 13 of 220

humans at a particular age to learning in lower animals. S pecifically, temperament and character are conceptualized on the bas is of two types of memory learning, which have been des cribed in humans and primates. T hese are called proce dural me mory (i.e., behavioral conditioning) and s e mantic me mory (i.e., term propos itional or declarative memory). (the emotional core of pers onality) involves procedural memory regulated by complex dis tributed circuits in the corticos triatolimbic s ys tem, primarily the sensory areas, the amygdala, and the caudate and putamen. P rocedural memory underlies ass ociative learning and involves presemantic perceptual proces sing of information and affective valence that can operate independently of abs tract conceptual or volitional proces ses. In contrast, semantic learning involves cognitive functions of abs traction and s ymbolization. T hese two s ys tems of learning and memory can be diss ociated functionally from one another and also from third memory system that is unique to human beings . Neurobiological s tudies of animals have been highly informative about the functional organization of brain systems underlying procedural learning and E xplicit animal models have been described based on extensive work in rodents and other nonprimates, providing hypotheses that are now being tested in humans P.2066 us ing modern techniques of brain imaging, neurochemis try, and neurogenetics. T he most comprehensive neurobiological model of learning in 2593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 14 of 220

animals that has been s ys tematically related to the structure of human temperament is s ummarized in 23-2. T his model distinguishes four dis sociable brain systems for behavioral activation (novelty s eeking), behavioral inhibition (harm avoidance), social (reward dependence), and partial reinforcement (persis tence).

Table 23-2 Four Dis s oc iable B rain Influenc ing S timulus -R es pons e P Underlying Temperament B rain (R elated Pers onality Dimens ion)

Princ ipal R elevant Neuromodulators S timuli

B R

B ehavioral activation (novelty seeking)

Dopamine

Novelty

Ex pu

 

 

C S of reward

A ap

 

 

C S or UC S of relief of

Ac av

2594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 15 of 220

monotony or punis hment  

 

 

Es

B ehavioral inhibition (harm avoidance)

γ-Aminobutyric acid

Aversive conditioning (pairing C S and UC S )

Fo of C

 

S erotonin (dorsal raphe)

C onditioned signals for punis hment, novelty, and frus trative nonreward

Pa av ex

S ocial attachment (reward dependence)

Norepinephrine

R eward conditioning (pairing C S and UC S )

Fo of ap C

 

S erotonin raphe)

 

 

P artial reinforcement (persis tence)

G lutamate

Intermittent

R to ex

 

S erotonin (dorsal

R einforcement  

2595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 16 of 220

raphe)

C S , conditioned stimulus ; UC S , unconditioned s timulus . Adapted from C loninger C R : A s ys tematic method for cl description and class ification of personality variables. Ar P s ychiatry. 1987;44:573–588. T he ps ychobiology of harm avoidance, novelty reward dependence, and pers is tence is briefly the following s ections.

HA R M A VOIDA NC E Harm avoidance involves a heritable bias in the of behavior in respons e to signals of punis hment and frus trative nonreward. It is observed as fear of shyness , s ocial inhibition, pas sive avoidance of or danger, rapid fatigability, and pes simis tic worry in anticipation of problems even in situations that do not worry other people. Adaptive advantages of high harm avoidance are cautious nes s and careful planning when hazard is likely. T he dis advantages occur when hazard unlikely but still is anticipated, which leads to inhibition and anxiety. P eople low in harm avoidance carefree, courageous, energetic, outgoing, and even in s ituations that worry mos t people. T he of low harm avoidance are confidence in the face of danger and uncertainty, leading to optimistic and energetic efforts with little or no distress . T he 2596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 17 of 220

disadvantages are related to unres pons iveness to or unrealis tic optimism, with potentially severe cons equences when hazard is likely. T he ps ychobiology of harm avoidance is complex. In animal s tudies , as cending s erotoninergic projections the dorsal raphe nuclei to the s ubs tantia nigra inhibit nigros triatal dopaminergic neurons and are ess ential conditioned inhibition of activity by s ignals of and frustrative nonreward. B enzodiazepines disinhibit pass ive avoidance conditioning by γ-aminobutyric acid (G AB A)–ergic inhibition of s erotoninergic neurons originating in the dors al raphe nuclei. T he anterior serotoninergic cells in the dorsal raphe nucleus intermingle with the dopaminergic cells of the ventral tegmental area, and both groups innervate the same structures (e.g., basal ganglia, accumbens, and providing opposing dopaminergic-serotoninergic influences in the modulation of approach and behavior. T he anterior s erotoninergic projections from dorsal raphe to s triatum, accumbens, amygdala, and frontal cortex are usually as sociated with serotonin (5-HT 2 ) receptors . Individuals who are high in harm avoidance and novelty seeking are expected to have frequent approach-avoidance conflicts, as seen in binging and purging in bulimia. More generally, behavioral inhibition (i.e., high harm avoidance) predis pos es individuals to anxiety, depres sion, and low self-es teem. E ffective antidepress ant treatment lowers scores in harm avoidance, but higher s cores in harm avoidance predict poorer respons es to including tricyclics and s elective s erotonin reuptake inhibitors (S S R Is). 2597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 18 of 220

R ecent neuropsychological studies confirm that harm avoidance is as sociated with individual differences in clas sical aversive conditioning, whereas other of pers onality are uncorrelated (T able 23-3). Harm avoidance, not other dimens ions of temperament, is replicably ass ociated with potentiation of startle res ponses . Neurops ychological tests also confirm that harm avoidance is ass ociated with behavioral F or example, harm avoidance is as sociated with the validity effect (the P os ner tas k uses a detection time paradigm with dis crete presentation of simple stimuli in the periphery). C ues that correctly direct attention to the spatial location at which the target stimulus will appear are called valid cue s , whereas that direct attention to incorrect locations are called invalid cue s . In three large samples of healthy college students, those higher in harm avoidance have greater slowing of their reactions after invalid cues or les s from valid cues than others .

Table 23-3 R eported Ps yc hobiologic al C orrelates of Harm Avoidanc e Variable

E ffec t

Neuroanatomy (positron emiss ion tomography) 2598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 19 of 220

   Medial prefrontal (left)

Increased activity (behavioral inhibition)

   Anterior (right)

Increased activity (s ens itivity to threat)

Neurops ychology

 

   Avers ive conditioning

G reater as sociative with punishment (r = .4)

   E ye-blink startle reflex

P otentiation of respons e avers ive stimulus (effect size = 1.9)

   P osner validity effect

G reater slowing of res ponses after invalid (r ≥.3)

   S patial delayed res ponse

B etter ability to delay res ponses after inges ting amphetamines (r = .5)

Neurochemistry

 

   P latelet s erotonin type 2 receptor

F ewer receptors (r = -.6)

   P las ma γaminobutyric acid

Lower level (r = -.5)

2599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 20 of 220

Neurogenetics

 

   S erotonin transporter

G reater reuptake activity

R ecent functional magnetic resonance imaging (fMR I) studies found that healthy human volunteers who are in harm avoidance tend to have a greater volume of right anterior cingulate gyrus . T he correlation was 0.49 with the right, but not the left, anterior cingulate. individual differences in harm avoidance have been observed to be significantly negatively correlated with functional differences in activity in the medial prefrontal network at res t. T his includes significant negative correlations between regional blood flow and the score harm avoidance in paralimbic regions , s uch as the left parahippocampal gyrus and the left orbitoinsular and various neocortical regions in the frontal, parietal, temporal cortex. P os itron emis sion tomography (P E T ) the National Ins titute of Mental Health (NIMH) with 18 F deoxyglucose (F DG ) in 31 healthy adult volunteers a s imple continuous performance task s howed that avoidance was as sociated with P.2067 increased activity in the anterior paralimbic circuit, specifically the right amygdala and ins ula, the right 2600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 21 of 220

orbitofrontal cortex, and the left medial prefrontal T his activation pattern corresponds well to the 5-HT 2 terminal projections of the dorsal raphe. However, 5has been measured only in platelets (T able 23-3). Higher plas ma G AB A levels have also been correlated low harm avoidance. P las ma G AB A has als o been correlated with other measures of anxiety proneness has been highly correlated with brain G AB A levels . a gene on chromosome 17q12 that regulates the expres sion of the serotonin trans porter has been found account for 4 to 9 percent of the total variance in harm avoidance in most, but not all, of the tests of this relations hip. T hese findings support a role for G AB A serotoninergic projections from the dors al raphe underlying individual differences in behavioral inhibition as meas ured by the trait of harm avoidance.

NOVE L TY S E E K ING Novelty s eeking reflects a heritable bias in the initiation activation of appetitive approach in response to approach to s ignals of reward, active avoidance of conditioned signals of punis hment, and escape from unconditioned punis hment (all of which are to covary as part of one heritable system of learning). Novelty s eeking is obs erved as exploratory activity in res ponse to novelty, impulsiveness , extravagance in approach to cues of reward, and active avoidance of frus tration. Individuals high in novelty s eeking are quick tempered, curious , easily bored, impulsive, and disorderly. Adaptive advantages of high novelty seeking are enthusiastic exploration of new and stimuli, potentially leading to originality, discoveries, 2601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 22 of 220

reward. T he disadvantages are frequent and easy boredom, impulsivity, angry outburs ts , potential in relationships , and impress ionism in efforts. P ers ons in novelty s eeking are slow tempered, uninquiring, reflective, frugal, res erved, tolerant of monotony, and orderly. T heir reflectiveness , res ilience, systematic and meticulous approach are clearly advantageous these features are adaptively needed. T he reflect tolerance of monotony and lack of enthusiasm, potentially leading to prosaic routinization of activities. Mesolimbic and mesofrontal dopaminergic projections have been shown to have a crucial role in incentive activation of each aspect of novelty seeking in animals . example, dopamine-depleting les ions in the nucleus accumbens or the ventral tegmentum lead to neglect of novel environmental stimuli and reduce s pontaneous activity and inves tigative behavior. B ehavioral by dopaminergic agonists is dependent on integrity of nucleus accumbens but not the caudate nucleus . In human studies, individuals at ris k for P arkinson's have low premorbid scores in novelty s eeking but not other dimensions of pers onality, s upporting the importance of dopamine in incentive activation of pleas urable behavior. T he initiation and frequency of hyperactivity, binge eating, s exual hedonis m, drinking, smoking, and other s ubs tance abus e, es pecially are each ass ociated with high s cores in novelty T he ps ychobiological correlates reported for novelty seeking are s ummarized in T able 23-4. High s cores correlate with increased metabolic activity on P E T in cingulate cortex and left caudate. In addition, high seeking is ass ociated with decreased activity of the left 2602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 23 of 220

medial prefrontal cortex, which is exactly the same as sociated with increased activity in individuals scoring high in harm avoidance. T his s uggests that medial prefrontal cortex may be an important site in the proces sing of approach-avoidance conflicts. In recent fMR I study found that high novelty seeking was correlated with increas ed volume of the left, but not the right, pos terior cingulate gyrus in healthy human volunteers .

Table 23-4 R eported Ps yc hobiologic al C orrelates of Novelty S eeking Variable

E ffec t

Neuroanatomy (positron emiss ion tomography)    Medial prefrontal (left)

Decreas ed activity (behavioral disinhibition)

   P osterior cingulate

Increased activity (behavioral activation)

   C audate (left)

Increased activity (behavioral activation)

2603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 24 of 220

Neurops ychology    R eaction time

S lower to respond if not reinforced (neutral stimuli, = -.4)

   S timulus intens ity res ponses (N1/P 2 event-related potential)

Augmentation of intens ity of cortical to novel stimuli (r = .5)

   S edation

More easily sedated by diazepam (V alium) (lower threshold, r = -.3)

   R ey word list memory

Deterioration of verbal memory when excited (after inges ting amphetamine, r = .6)

Neurochemistry    Dopamine transporter

Higher dens ity obs erved striatum

   P latelet oxidase type B

Lower activity (as sociated with cigarette s moking)

Neurogenetics

2604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 25 of 220

   Dopamine type 4 receptor

Ass ociation with exon 3 variant

   Dopamine transporter

G reater reuptake activity

E voked potential studies of stimulus intens ity confirm that novelty seeking is ass ociated with augmentation of s timulus intensity, particularly with stimuli. Novelty seekers are also sensitive to sedatives stimulants: T hey are eas ily overs edated by benzodiazepines and overs timulated by leading to deterioration in their information process ing. T heir reaction times are s low to neutral stimuli. T he as sociation of increas ed s triatal activity with high novelty s eeking is more s pecifically ass ociated with density of the dopamine transporter, P.2068 suggesting that novelty seeking involves increased reuptake of dopamine at presynaptic terminals , thereby requiring frequent s timulation to maintain optimal levels of pos tsynaptic dopaminergic s timulation. Novelty leads to various pleas ure-seeking behaviors, including cigarette smoking, which may explain the frequent observation of low platelet monoamine oxidas e type B (MAO B ) activity, because cigarette s moking has the 2605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 26 of 220

of inhibiting MAO B activity in platelets and in brain. S tudies of candidate genes involved in dopamine neurotransmis sion (e.g., dopamine transporter and locus ) have provided evidence of as sociation with seeking and no other dimens ion of temperament. T he dopamine transporter, which is res ponsible for reuptake of dopamine and a major s ite of action of including s timulants like methylphenidate (R italin), is encoded by a gene locus on chromosome 5p. P olymorphisms at this gene locus are ass ociated with attention-deficit disorder and other dis orders related to variation in novelty seeking. Likewis e, polymorphisms the DR D4 locus have been as sociated with attentiondeficit disorder, opioid dependence, and other traits related to novelty seeking.

R E WA R D DE P E NDE NC E R eward dependence reflects a heritable bias in the maintenance of behavior in respons e to cues of s ocial reward. R eward dependence is characterized by sentimentality, social s ens itivity, attachment, and dependence on approval by others . Individuals high in reward dependence are tender hearted, s ens itive, dedicated, dependent, and sociable. One of the major adaptive advantages of high reward dependence is the sens itivity to social cues that facilitates affectionate relations and genuine care for others. T he related to s ugges tibility and loss of objectivity encountered with people who are excess ively socially dependent. Individuals low in reward dependence are practical, tough-minded, cold, s ocially insens itive, irresolute, and indifferent if alone. T he advantages of 2606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 27 of 220

reward dependence are personal independence and objectivity that is not corrupted by efforts to pleas e Its adaptive dis advantage is related to s ocial detachment, and coldnes s in s ocial attitudes. Noradrenergic projections from the locus ceruleus and serotoninergic projections from the median raphe are propos ed to influence such reward conditioning (T able 2). In animals , s timulation of the noradrenergic locus ceruleus or its dorsal bundle or direct application of norepinephrine decreas es the firing rate of terminal neurons and increases their sensitivity to other so that targeted s timuli can s tand out from nontargeted stimuli. In humans , short-term reduction of norepinephrine release by acute infusion of the α2 presynaptic agonist clonidine (C atapres) s electively impairs paired-as sociate learning, particularly the acquisition of novel ass ociations . T he noradrenergic ceruleus is located at the same posterior level of the brains tem as the s erotoninergic median raphe, and these pos terior monoamine cells innervate structures are important to formation of paired as sociations, s uch the thalamus , neocortex, and hippocampus . Neurophysiological s tudies s how that the anterior temporal lobe decodes s ocial signals, such as facial and s ocial ges tures . C onsequently, individuals high in reward dependence are expected to be particularly sens itive in their s ocial communication, whereas those in reward dependence are expected to be socially T he ps ychobiological correlates reported about reward dependence are summarized in T able 23-5. As reward dependence is ass ociated with individual differences in formation of conditioned s ignals of 2607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 28 of 220

T his is als o s upported by its as sociation with individual differences in paired as sociate learning.

Table 23-5 R eported Ps yc hobiologic al C orrelates of R eward Dependenc e Variable

E ffec t

Neuroanatomy (positron emiss ion tomography)    T halamus

Increased activity (facilitates sensory proces sing)

Neurops ychology    R eward conditioning

Increased as sociative pairing with rewards (r = .3)

   P aired as sociates

B etter learning of novel as sociations (r = .5)

   P osner validity effect

F as ter respons es after valid cues (r = -.4)

2608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 29 of 220

Neurochemistry    Urinary 3-methoxyhydroxyphenylglycol

Less excretion of norepinephrine metabolite (r = -.4)

   P las ma cortisol

Higher morning cortisol when depres sed (r = .3)

   Urinary Harman

G reater excretion of indoleamine product in alcoholics high in dependence (r = .7)

Neurogenetics    S erotonin type 2C receptor

Allelic ass ociation size = 2)

High reward dependence is as sociated with increas ed activity in the thalamus , which is consis tent with about the importance of s erotoninergic projections to thalamus from the median raphe in modulation of communication. T his is further supported by the finding low levels of urinary 3-methoxy-4-hydroxyphenylglycol (MHP G ) with high reward dependence. High reward dependence is also as sociated with hypercortisolemia patients with melancholia but not in individuals who are not depres sed. 2609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 30 of 220

P E R S IS TE NC E P ers is tence reflects a heritable bias in the maintenance behavior des pite frus tration, fatigue, and intermittent reinforcement. It is observed as industriousness , determination, ambitious nes s, and perfectionism. persis tent people are hard working, pers evering, and ambitious overachievers who tend to intens ify their in res pons e to anticipated reward and perceive and fatigue as a pers onal challenge. High persistence adaptive behavioral strategy when rewards are intermittent but contingencies remain stable. W hen the contingencies change rapidly, perseveration becomes maladaptive. Individuals low in persistence are inactive, unstable, and erratic; they tend to give up when faced with frustration, rarely strive for higher accomplis hments , and manifest a low level of perseverance even in res ponse to intermittent reward. Accordingly, low persistence is an adaptive s trategy reward contingencies change rapidly and may be maladaptive when rewards are infrequent but occur in long run. P ers is tence can be objectively meas ured by the partial reinforcement extinction effect in which pers is tent individuals are more res is tant to the extinction of previous ly intermittently rewarded behavior than other individuals who have been continuous ly reinforced. work in rodents s howed that the integrity of the partial reinforcement extinction effect depends on projections from the hippocampal subiculum to the nucleus accumbens. T his glutaminergic projection may be cons idered as a short circuit from the behavioral system to the behavioral activation system, thereby 2610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 31 of 220

converting a conditioned s ignal of punis hment into a conditioned signal of anticipated reward. T his is probably dis rupted in humans by lesions of the orbitomedial cortex that may have a s pecific antipersistence effect of therapeutic benefit to some severely obs es sive-compuls ive patients. B ilateral cingulotomy, which reduces harm avoidance only, is effective in reducing persistent compuls ive behavior cingulotomy combined with orbitomedial lesions . P.2069 T hese findings in animals suggested that the regulation persis tence involved the ventral striatum, which the nucleus accumbens. T his has recently been tes ted humans and has been confirmed. Individual differences persis tence are s trongly correlated (r = .8) with meas ured by fMR I in a circuit involving the ventral striatum, orbitofrontal cortex and ros tral insula, and prefrontal and cingulate cortex (B rodmann's area [B A] S ubjects low in persis tence exhibited relative activity within this circuit, whereas those high in persis tence exhibited relative increases. P ersistence also correlated with apparent s election bias , such that subjects with high persistence scores made relatively pleas ant judgments at the expens e of neutral when viewing pictures from the International Affective P icture S ys tem (T able 23-6).

Table 23-6 R eported Ps yc hobiologic al C orrelates of Pers is tenc e 2611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 32 of 220

Variable

E ffec t

Neuroanatomy    Orbitomedial cortex

Dis connection reduces perseveration

Neurops ychology    G ambling style

P ers everation in bet s ize despite continuing loss es

   R ey word list learning

Learning without reinforcement (r = .5)

Neurochemistry    G lutaminergic connection

E ss ential for partial reinforcement extinction effecta

   S ubiculum to nucleus accumbens

 

Neurogenetics    S erotonin type 2C

Allelic ass ociation (effect 2612

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 33 of 220

receptor

size = 2)

aP artial

reinforcement extinction effect is or increas ed res is tance to extinction after intermittent reinforcement.

Motivation S urvival and reproduction, the bas ic drives for all species , are expres sed in humans primarily through experiential derivatives, that is , affects and emotions. contrast to the limited motivational s pectrum of the drives , emotions have an independent motivational that makes them not only the primary motivational for many people, but als o the personality proces ses give meaning, at least to rational materialists, who up most of contemporary society. T emperament traits of harm avoidance, novelty reward dependence, and pers is tence, with their primary emotions of fear, anger, attachment, and ambition, are obs ervable early in development. in children has demons trated that, during the firs t months of life, fear and anger differentiate from the disposition to dis tress (a tendency to be become ups et autonomically arous ed eas ily and intensely). During period, which is characterized by active regres sive in the organization of neuronal circuits and density of synapses, especially in frontal, temporal, and limbic 2613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 34 of 220

cortical areas , many other complex and s ocial human behavior emerge. T hes e new functions , are organized around an early s et of enduring and emotional dispositions referred to in this work as te mpe rame nt traits . A relatively limited s pectrum of emotions is as sociated with the four temperament traits (T able 23-7). Depending on whether a particular temperament trait is high or low, certain emotions tend dominate one's motivation, perception, and behavior.

Table 23-7 E ffec ts of Pos itive (+) an (-) R einforc ement on E motional S ta Temperaments  

Low S

High S c orers

Temperament Dimens ion +

-

Harm avoidance

Anxious (agitated)

Depress ed C heerful (retarded)

Novelty seeking

E uphoric

Angry

P lacid

R eward

S ympathetic

Dis gus ted

Aloof

+

2614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 35 of 220

dependence P ers is tence

E nthus ias tic

S teadfas t

Uns table

As can be inferred from T able 23-7, the s ame external stimulus is likely to elicit responses via activation of multiple temperament dimens ions. F or example, novel unfamiliar s timuli elicit interes t in approach in to novelty s eeking, as well as inhibition of approach in proportion to harm avoidance. E ach temperament trait clearly involves an integration of multiple emotional that may be conflicting (competitive) or facilitatory (s ynergis tic). S uch s hared environmental effects mean the genetic and phenotypic structure of personality cannot be as sumed to be the s ame. T emperament involves a relatively s mall s et of as sociated with one's basic needs , for example, safety called primary motives ). E xces sive fear and anger, as sociated with temperament, are motivationally monopolistic and take over the personality by altering perception, learning, and behavior in a biased way. However, under normal circumstances, after survival are met, the goals of normally developing pers onality change to include not only the integrity of the physical self, but als o the integrity of the mental s elf (e.g., selfes teem). Normal pers onality development also adapts 2615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 36 of 220

numerous social goals (e.g., education, occupation, family) and a rich s pectrum of secondary (social) (s uch as shame, pride, empathy, and compas sion). s e condary, s ocial, or growth motives are closely related to character development. S pecifically, basic emotions of fear, anger, and excitement are into more complex s econdary emotions, such as carefulnes s, as sertiveness , and joy, through the with increasingly more complex internalized concepts as sociated with character. E ven though s ome bas ic character components develop early in life, s uch as and confidence, it is the completion of s elf-object differentiation (“me” vs . “not me”) between 18 months 3 years of age that sets the s tage for the development character traits and secondary emotions , such as T he secondary emotions take over as primary of further character development and maturation. Of they are not as monopolistic as the basic emotions and thus motivate development of more flexible and adaptable personality traits. As s hown in T able 23-8, of the three character traits is ass ociated with a typical pattern of s econdary emotions .

Table 23-8 E ffec ts of Pos itive (+) Negative (-) R einforc ement on S tate of Three C harac ters  

High S c orers

Low S c ore

2616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 37 of 220

C harac ter Dimens ion

+

-

S elf-directed

Hopeful

R es ourceful V ain

S ham

C ooperative

Loving

F orgiving

S cornful

R eve

P eaceful

G reedy

Mise

T ranscendent J oyful

+

-

P.2070 In conclusion, abnormal (deviant, immature) motivation derives from two or three dominant, monopolistic elementary emotional needs as sociated with s urvival. contrast, mature motivation develops after bas ic needs met, and the person is freed to experience numerous secondary motives for growth in character and in selfawarenes s. T his explains the motivational inflexibility poverty of deviant personality and accounts for all the motivational diversity and flexibility of mature

C harac ter C haracte r refers to the mind, that is , the conceptual personality. It involves individual differences in s elfconcepts and object relations that reflect pers onal and values. In other words, character is what a person makes of hims elf or herself intentionally. C haracter is 2617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 38 of 220

rational and volitional. W hereas temperament involves basic emotions , s uch as fear and anger, character secondary emotions , s uch as purpos eful moderation, empathy, patience, and, in even more mature hope, love, and faith. As a res ult, character can be described as mental self-government, which involves executive, legislative, and judicial functions . In the discuss ion that follows , the concept of character is outlined bas ed on the seven-factor psychobiological model of pers onality. T he ps ychodynamic concept of character, which has contributed many illuminating clinical and theoretical formulations on the subject, is discuss ed in s ome detail as well.

Ps yc hobiology of C harac ter C haracter (or the conce ptual core of personality) higher cognitive functions , which include abs traction, symbolic interpretation, and reasoning. T hese higher cognitive functions are instantiated in complex networks in the brain, which involve encoding of schemas by the hippocampus with long-term s torage semantic memories in neocortex. S uch symbolic functions interact with temperament through cognitive proces sing of emotionally ridden sensory percepts regulated by temperament. T his temperament– interaction leads to the development of mature, realistic internalized concepts about the self and the external world. T he executive, legislative, and judicial functions mental s elf-government can be meas ured as three character traits, which are called s e lf-dire cte dne s s , coope rativene s s , and s e lf-trans cende nce , respectively. character traits are adaptive, but their low ends are advantageous because of a limited s pectrum of 2618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 39 of 220

circums tances in which immaturity, especially low selfdirectedness and cooperativeness , means better adaptation than maturity. S elf-directedness quantifies differences in the competence of individuals . A highly self-directed self-sufficient, res ponsible, reliable, resourceful, goal oriented, and s elf-accepted. T he most advantageous summary feature of s elf-directed individuals is that they are realis tic and effective, that is, they are able to adapt their behavior in accord with individually chos en, voluntary goals . Individuals low in s elf-directedness are blaming, helpless , irresponsible, unreliable, reactive, unable to define, to s et, and to pursue meaningful goals . S uch poor executive function, manifes t as behavior and lack of internal guidance, is rarely advantageous to the individual. C ooperativenes s quantifies differences in the functions of individuals . Highly cooperative people conceptualize themselves as integral parts of human society. S uch highly cooperative pers ons are des cribed empathetic, tolerant, compass ionate, s upportive, and principled. T hes e features are advantageous in and s ocial groups but not in individuals who mus t live solitary manner. P eople who are low in are s elf-absorbed, intolerant, critical, unhelpful, and opportunis tic. T hey primarily look out for and tend to be incons iderate of other people's rights or feelings. S elf-transcendence quantifies individual differences in judicial functions of people. S elf-transcendence reflects the extent to which people conceptualize themselves an integral part of the univers e as a whole. S elf2619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 40 of 220

transcendent individuals are described as judicious, insightful, s piritual, unpretentious , and humble. T hes e traits are adaptively advantageous when people are confronted with suffering, illness , or death, which is inevitable with advancing age. T hey may appear disadvantageous in most modern s ocieties in which idealism, modesty, and a meditative search for might interfere with the acquisition of wealth and P eople low in s elf-transcendence tend to be pragmatic, objective, materialistic, controlling, and pretentious. individuals appear to fit in well in mos t W estern because of their rational objectivity and materialistic succes s. However, they cons is tently have difficulty accepting s uffering, failures , personal and material and death, which leads to lack of s erenity and problems , particularly with advancing age. C ontras ting sets of descriptors that dis tinguis h the three character are s ummarized in T able 23-9.

Table 23-9 Des c riptors of Individuals Who S c ore High and Low on the Three C harac ter Dimens ions  

C harac ter

Des c riptors of E xtreme Variants High

Low

2620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 41 of 220

Dimens ion

S elf-directed

R es pons ible

B laming

 

P urposeful

G oalles s

 

R es ourceful

P as sive

 

S elf-accepting

Wishful

 

Dis ciplined

Undisciplined

C ooperative

T olerant

Intolerant

 

E mpathic

Ins ensitive

 

Helpful

S elfis h

 

C ompas sionate R evengeful

 

P rincipled

Opportunistic

S elftranscendent

J udicious

P ragmatic

 

Ins ightful

Objective

 

Acquiescent

S keptical

2621 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 42 of 220

 

S piritual

Materialistic

 

Idealistic

R elativis tic

As shown in T able 23-9, high and low s corers in each character dimens ion are dis tinguis hed by behavior that arise from differences in concepts that are each internally cons istent but not logically falsifiable. F or example, people low in s elf-transcendence live in the material world, s keptical of whatever they cannot prove objectively and us e practically. In contras t, for highly transcendent individuals, the meaning of life goes material things and includes intuitive awareness of beautiful, true, and good, to which materialis ts may be insensitive. E ach s et of beliefs appears to be internally cons istent to those who hold them, who also regard approach to life as realistic. F urthermore, s piritual cannot prove a materialis t is wrong (at leas t not to the satis faction of the materialis t!), or vice vers a, becaus e has different intuitions of reality on which they base concepts . C haracter matures in a s tepwise manner in incremental shifts from infancy through late adulthood. T he timing rate of trans itions between levels of maturity are functions of antecedent temperament configurations, systematic cultural bias es , and experiences unique to 2622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 43 of 220

individual, which depend on individual differences in episodic memory or intuitive P.2071 self-awarenes s that enables human beings to past experiences . T he developing character traits (i.e., newly internalized concepts about one's s elf and the external world) optimize adaptation of temperament early emotionality) to the environment by reducing discrepancies between one's emotional needs and favoring s ocial press ures . In F ig. 23-1, character corresponds to the process es of logic, cons truction, and evaluation of abs tract s ymbols that are based on conceptual repres entation of information and that are well developed only in some mature humans . T hes e proces ses are related to functions (predominantly logic), legislative functions (predominantly cons truction), and judicial functions (predominantly evaluation). R ecent fMR I res earch in healthy human volunteers by Debra G usnard and Marc R aichle has demonstrated strong correlation between directedness and a cortical circuit involving the medial prefrontal cortex, which is known to regulate executive function. E arlier work has s hown that markers of neocortical process ing, s uch as the P 300 related potential and contingent negative variation, are correlated with measures of character but not with temperament. Namely, s elf-directedness , but not temperament traits , correlates moderately with the evoked potential P 300 (r = .4; P T able of C ontents > V olume II > 23 - P ers onality Disorders > P E R S ONALIT Y DE V E LO P M F UNDAME NT ALS O F A S E LF -OR G ANIZING P S Y C H OB IO LOG IC AL C O M

PE R S ONAL ITY DE VE L OPME NT: FUNDAME NTAL S OF A OR GANIZING PS YC HOB IOL OGIC AL C OMPL E X P art of "23 - P ers onality Dis orders " Dragan M. S vrakic and colleagues formulated a quantitative model of normal and deviant pers onality development as a complex dynamic system that is s elforganizing and partly molded by familial and 2644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 65 of 220

influences. T he model allows for nonlinear interactions among etiologically distinct components of pers onality. also accounts for the frequent, but not invariant, development of s tage-like periods of moderately stable personality configurations (s imilar to pers onality types ) punctuated by abrupt trans itions in which there are structural reorganization and emergence of new features. T he model is based on a s ophis ticated mathematical framework that can be implemented and tes ted with readily acces sible data. More recently, the developmental interactions among temperament, character, and ps yche have been able to be interpreted terms of interactions among procedural, semantic, and episodic systems of learning and memory. T he central ideas behind this model are the following: P ers onality is as a dynamic multidimensional comprised of more elementary operating (traits) that are organized in an interdependent way that is critical to carrying out a particular function. S uch a system is characterized by particular rules operation, for example, the principles of as sociative learning within the temperament function, long-term semantic learning within the character function, and episodic intuitive awarenes s within the ps yche function. T he satisfaction of s uch multiple res ults in nonlinear dynamics , which are of all systems involving growth and development in biology, neuroscience, ps ychology, and s ociology. S uch multidimensional dynamic systems are called complex adaptive s ys te ms . T he correlations observed among multiple 2645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 66 of 220

traits can be us ed to explain the s pontaneous organization of s table multidimensional configurations (i.e., pers onality types ); these types develop in a stage-like fashion with s ucces sive of prolonged s tability punctuated by rapid However, the progres sion of each individual is because differences in intuitive awarenes s result in subs tantial variability that is unique to each T he model accounts for functional interactions multiple types of influence, including genetic family environment, s ociocultural norms, and experiences that are unique to each individual. B as ed on the s pecified basic differences between temperament and character (T able 23-10), plus variation in level of intuitive awarenes s, this model takes into account all as pects of information proces sing from ass ociative conditioning of habits skills to enculturation about goals and values within unique ps ychological context. P ers onality development is pres ented as a walk on an adaptive (or fitnes s) landscape with two or more hills (representing high adaptive values) s eparated by (representing low adaptive values ). F itnes s is defined ability to produce change in personality. In general, a complex system subjected to cons traints res ponds to these constraints by optimizing fitness , that is, by changes in personality. As change in personality is motivated by optimization of fitness , people most likely and most rapidly move in the direction of the greatest increase in adaptive value (i.e., the neares t hill). Once have reached the peak of the hill, they s tay there for a 2646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 67 of 220

relatively long time, because they would first have to decrease fitness (i.e., descend into the valley) to find a with a higher peak (i.e., better adaptation). S uch development is called U s hape d. As noted, temperament and character traits are etiologically distinct but functionally related. S uch an interactive s ys tem has the property of being s elforganizing as a result of the collective dynamics among multiple components. In other words, the organism is spontaneously driven to find patterns of behavior that res ult in coherence of all information about the external and the internal milieu. F or example, harm avoidance interacts with novelty seeking and P.2076 reward dependence, inhibiting approach to novel and inhibiting s ocial attachments by increasing fear of unfamiliar and s ens itivity to social criticis m. cons istent negative correlations of harm avoidance novelty seeking and reward dependence have been In contras t, novelty seeking and reward dependence positively s ynergis tic, facilitating sociability and seeking social approval. S uch interactions influence the stability each of the eight pos sible multidimensional or profile s of temperament traits (F ig. 23-3), making more s table than others .

2647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 68 of 220

FIGUR E 23-3 C haracter configurations. In the fitness lands cape, the valleys (or the adaptive minima) are unstable, because even s mall such as random events , drive the s ys tem away from points of the lowes t fitnes s. In contrast, hills (i.e., maxima) are s table, becaus e they act as attractors for lower points in the neighborhood. C onsequently, personality interactions tend to self-organize into such attractor s tate and to remain in that configuration in the absence of external press ure or maturational F or the understanding of the chronicity and treatment res is tance of personality dis orders , it is of critical importance to realize that a particular pers onality configuration may be highly s table, even though it may not be the mos t adaptive behavior poss ible for that 2648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 69 of 220

individual. T his chapter is mainly concerned with patterns of of character traits as a function of relatively s table temperament traits and variation in the level of s elfawarenes s, as dis cus sed in the following s ections. T he three character traits interact to produce eight pos sible character configurations or profiles (F ig. 23-4).

FIGUR E 23-4 P ers onality: an integrated schema. Any change in these character configurations can be predicted from the initial temperament configuration, taking into account temperament–character and the effects of sociocultural norms , random events unique to the individual, social learning within the and genetic factors. However, whether there is change depends on s elf-awarenes s, which is unique to each 2649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 70 of 220

individual and unpredictable, that is, underdetermined free. All these s ources of individual differences the likelihood for different s table character in the outcome. T he s ociocultural P.2077 norms can be additionally accounted for as the bias in development as sociated with demographic variables , s uch as s ubculture, gender, race, age, and occupation. T hes e norms and s ocial education in the family create environments that are supportive or oppres sive of s pecific character development. W ith all taken into account, it turns out that a single initial temperament configuration may lead to s everal stable character configurations ; this aspect of development is referred to as multifinality. T hes e are graphically repres ented in F igures 23-5, 23-6, and with four different initial temperament configurations their poss ible character outcomes .

2650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 71 of 220

FIGUR E 23-5 Most probable character outcomes for adventurous antecedent temperament traits. C O, cooperativeness ; S D, s elf-directedness ; S T , s elftranscendence.

2651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 72 of 220

FIGUR E 23-6 Most probable character outcomes for explosive (borderline) antecedent temperament traits . cooperativeness ; S D, s elf-directedness ; S T , s elftranscendence.

2652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 73 of 220

FIGUR E 23-7 Most probable character outcomes for sens itive antecedent temperament traits. C O, cooperativeness ; S D, s elf-directedness ; S T , s elftranscendence. T hree dimensions of character (s elf-directedness , cooperativeness , and s elf-transcendence) are drawn three orthogonal axes, and each character represented by a point in this abstract s pace. E ight poss ible high–low combinations of three character dimensions are repres ented by the corners of the cube. 2653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 74 of 220

Observe that certain temperament types may and do ris e to several poss ible s table character outcomes , with a certain probability, a feature characteris tic of nonlinear systems . T he size of the bulging at a character configuration is proportional to the probability of that outcome. F igures 23-5, 23-6, 23-7 illus trate this adventurous (high novelty s eeking, low harm low reward dependence), explosive (high novelty high harm avoidance, low reward dependence), and sens itive (high novelty s eeking, high harm avoidance, reward dependence) temperament types. S imilar can be obtained for the remaining five temperament configurations. Individuals are born with one temperament profile with several poss ible character outcomes . T his multifinality reflects the fact that the lands cape in personality development has objective subjective components. F eelings and internalized concepts that are unique to the individual do influence evaluation of the objectively worthwhile goals and T he observed dis crepancies between the natural directions influenced by antecedent temperament traits and actually achieved character configurations point to the importance of external events, s uch as s ocial and random fluctuations in the final character outcome. As a res ult of the presence of points of high and low adaptive values in the fitnes s landscape, personality development is characterized by periods of relative stability alternating with more rapid trans itions to new adaptive levels . T he s ubs cale s tructure of the T emperament and C haracter Inventory (T C I) was formulated to s pecify character in terms of 15 steps of its development, as s hown in T able 23-11. 2654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 75 of 220

Table 23-11 S piral Movement of 15 S teps in Pers onality Development S teps

SD

CO

ST

T olerant vs. suspicious (trus tful vs. mistrustful)

—

TC I Tier 1    [1] C O1

—

   [2] S D1

R es pons ible — vs . blaming (res pectful vs . shameful)

—

   [3] S T1

—

—

Hopeful vs . demanding (moderate vs. indulgent)

—

—

TC I Tier 2    [4]

P urposeful

2655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 76 of 220

S D2

vs . aimles s (nonviolent vs . aggres sive)

   [5] C O2

—

E mpathic vs . cruel (prudent vs . s cornful)

—

   [6] S T2

—

—

C ons cientious vs . unjust (fairnes s vs . defiant)

TC I Tier 3    [7] S D3

R es ourceful — vs . inept (benevolent vs .

—

   [8] C O3

—

G enerous vs . disagreeable (kind vs . hostile)

—

   [9] S T3

—

—

S piritual vs. materialistic (contemplative vs . greedy)

2656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 77 of 220

TC I Tier 4 [10] S D4

S elfaccepting vs . vain (humble proud)

—

—

[11] C O4

—

— F orgiving vs . revengeful (compass ionate vs . callous )

[12] S T4

—

—

E nlightened vs . objective (patient vs. controlling)

TC I Tier 5 [13] S D5

C reative struggling (authentic vs .

—

—

[14] C O5

—

Integrity vs. unprincipled (well-being vs . unfulfilled)

—

2657 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 78 of 220

[15] S T5

—

—

C oherent vs . dualistic (virtuous vs . practical)

C O, cooperativeness ; S D, s elf-directedness ; S T , selftranscendence; T C I, T emperament and C haracter Inventory. T he 15 steps in character development are a ideal, corres ponding to the modal pathway that leads to full character development with high scores on all three character dimens ions, which is not optimal for Observe that success ive s teps in character form a s piral pattern, where each revolution around the spiral (presented as each of the five T C I tiers in T able introduces a new s et of developmental iss ues with the new s et of component facets of the three character traits. F urthermore, each revolution of the depends on different levels in a hierarchy of intuitive awarenes s. F or example, in early character during the firs t revolution around the s piral, a person encounters problems of trust versus mistrust, selfversus s hame, and moderation versus indulgence; are as sociated with s ocial acce ptance (first facet for cooperativeness ), re s pons ibility (first facet for selfdirectedness ), and s e lf-forgetfulne s s (first facet for s elftranscendence). T his depends s ubs tantially on a intuitive sense of being, whereas later developmental 2658 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 79 of 220

depend on the intuitive s ens es of freedom, and s till developmental tasks depend on beauty, truth, and goodness . As can be inferred from T able 23-11, as move along the s piral, people s ucces sively face new developmental tasks as sociated with new component facets in self-directedness , cooperativeness , and s elftranscendence. T his spiral pattern of character development provides P.2078 P.2079 an opportunity to correct de ve lopmental flaws that were made at any of the previous s teps within the s ame trait. F or example, as character develops around the s piral reach a new step of cooperativenes s (e.g., one gets in line historically with iss ues of and res ponsibility (als o s teps of cooperativeness , but encountered during earlier revolutions ) (T able 23-11). alignment facilitates retros pective revis ions of errors at these earlier developmental levels. T he poss ibility of re tros pe ctive he aling of old character errors is planning the psychotherapy of patients with pers onality disorders . Namely, when addres sing problems related certain developmental s tep, these patients are more susceptible to changes related to previous s teps within same character traits. T his 15-step developmental sequence is consistent prior qualitative des criptions of developmental stages J ean P iaget, F reud, and E rik E rikson (T able 23-12) but allows for the actual nonlinearity in development that depends uniquely in each individual on intuitive 2659 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 80 of 220

awarenes s.

Table 23-12 C omparis on of Diffe Des c riptions of Pers onality Develo Temperament and C harac ter Inventory Developmental S tep

J ean Piaget

   [1] C O1—trus t in reality

S igmund Freud

E ri E ri

S ensorimotor (reflexive)

Oral

T ru

   [2] S D1—selfres pect

S ensorimotor (enactive)

Anal (negativistic)

Au

   [3] S T 1—hope

S elf–object differentiation

E arly phallic

—

   [4] S D2— purpos efulnes s

Intuitive

Late phallic (exploratory)

Init

   [5] C O2— empathy

Operational (concrete)

Latency (conforming)

—

   [6] S T 2—

Operational

E arly genital

Ide

2660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 81 of 220

cons cientious nes s (abstract)

(cons cientious work)

   [7] S D3— res ourcefulness

—

—

—

   [8] C O3— mutual helpfulness

—

Later genital (s ocial maturity)

Inti

   [9] S T 3— spirituality

—

—

—

[10] S D4—selfacceptance

—

—

—

[11] C O4— compass ion

—

—

Ge

[12] S T 4— patience

—

—

—

[13] S D5— authenticity

—

—

—

[14] C O5— integrity

—

—

Inte

[15] S T 5— coherence

—

—

—

2661 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 82 of 220

C O, cooperativeness ; S D, s elf-directedness ; S T , s elf-

C omputer simulations of the s elf-organized of character have been carried out beginning with initial temperament traits and taking into account all of previous ly mentioned contributing factors . T hese simulations found that children first increas e in selftranscendence (i.e., become imaginative and enjoy fantas y), then increas e in cooperativenes s (i.e., conforming and rule based), and only later increase in directedness (i.e., behavior becomes increas ingly selfreliant and autonomous). T his prediction is cons is tent the des cription of the stages of ego-development by Loevinger and her colleagues . T his early s equence not exclude the s ubs equent further development of character dimens ions in res ponse to demands of social roles with age or changes in self-awarenes s, or It is this subs equent development in res pons e to social pres sures that may explain adult selfand moral development, as des cribed by E rikson, Lawrence K ohlberg, and others . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > P E R S ONALIT Y DIS OR

2662 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 83 of 220

PE R S ONAL ITY DIS OR DE R P art of "23 - P ers onality Dis orders "

Normal vers us Deviant Normal pers onality is us ually defined (1) directly, us ing criteria of health ideals ; (2) indirectly, as the opposite to deviant personality; or, mos t frequently, (3) statis tically, behaviors that are most common in the given environment. T he dis tinction between normal and abnormal personality is inherently relative, as it relies arbitrary cut-off points on the continuum between two extremes (low and high) of any behavior. T his also context dependent, as the s ame behavior, in different situations, could be viewed as normal or maladaptive (e.g., invariant cautiousness , when danger unlikely, and the s ame trait, when danger is likely). However, relying s olely on the s ocial or s ituational to establish the diagnos is is problematic, becaus e personality dis order involves many noninterpers onal as well (e.g., narciss istic pers ons satis fy many aspects their grandios ity in fantas y). Here, pers onal deviance also does not reliably dis tinguis h between normal behavior and pers onality disorder (e.g., s ome are s ocially withdrawn without impairment in functioning or signs of personal suffering and distress ). other words, pers onal P.2080 and s ocial aspects are needed to fully account for the 2663 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 84 of 220

symptoms of personality dis order.

C las s ific ation of P ers onality T he leading clas sifications of personality dis order are Inte rnational C las s ification of Dis eas e s (IC D) of the Health Organization and the DS M of the American P sychiatric Ass ociation. T he clas sification of disorder in the ninth edition of the IC D relied on S chneider's book P s ychopathic P e rs onalities and his description of ten discrete socially deviant personality types . T he lates t edition of the IC D, IC D-10, publis hed 1987, corresponds more clos ely to the DS M system, however. Anglo-American concepts of personality originate in J ames P ritchard's des cription of moral which was later termed s ociopathy and which finally became antis ocial pers onality dis orde r in the second of the DS M (DS M-II) in 1968. However, other class ified personality dis orders in the DS M s ys tem can be traced the work of S chneider. T his chapter describes the T R clas sification of pers onality disorder. It is , however, descriptively s imilar to IC D-10, and, for practical much of the following section on DS M-IV -T R holds for 10 as well. A noteworthy exception is that IC D-10 schizotypal personality dis order on Axis I, among schizophrenic disorders , whereas DS M-IV -T R keeps disorder on Axis II, among personality disorders .

DS M-IV-TR C las s ific ation According to DS M-IV -T R , the critical criterion for distinguishing deviant pers onality traits is the pres ence (evidence) of long-term maladaptation and inflexibility that are manifested as s ubjective dis tres s or 2664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 85 of 220

sociooccupational functional impairment, or both. DS MT R defines pe rs onality dis orde rs as An enduring pattern of inner experience and behavior deviates markedly from the expectations of the individual's culture. T he pattern is manifes ted in two (or more) of the following areas : cognition (i.e., ways of perceiving and interpreting other people, and events) affe ctivity (i.e., the range, intensity, lability and appropriatenes s of emotional res ponse) interpersonal functioning impulse control T he pattern is stable and of long duration and its onset be traced back at leas t to adoles cence or early It is inflexible and pervasive acros s a broad range of personal and s ocial situations and leads to clinically significant dis tres s or impairment in social, or other important areas of functioning. P ers onality disorder s ubtypes clas sified in DS M-IV -T R s chizotypal, s chizoid, and paranoid (C luster A); borderline , antis ocial, and his trionic (C luster B ); and obs e s s ive -compuls ive , de pe ndent, and avoidant In addition to thes e ten s tandard disorders , the DS Mclas sifies two disorders , pas s ive -aggres s ive and among crite ria s e ts and axe s provide d for furthe r s tudy Appendix B . T he DS M-IV -T R arranges categorical personality disorders into three clus ters , each sharing some clinical features : C luster A includes three with odd, aloof features , such as paranoid, schizoid, 2665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 86 of 220

schizotypal. C luster B includes four disorders with dramatic, impulsive, and erratic features , s uch as borderline, antisocial, narciss is tic, and histrionic. includes three disorders sharing anxious and fearful features, s uch as avoidant, dependent, and obs es sivecompuls ive. S everal s tudies have s upported the validity of thes e clus ters , except that the s ymptoms for compuls ive disorder tend to form a separate, fourth clus ter. Note that the three dimensions underlying A, B , and C (i.e., detachment, impuls ivity, and corres pond clos ely to normal temperament traits (i.e., reward dependence, high novelty s eeking, and high avoidance, respectively), s uggesting that variation in temperament traits might be s ignificant in among the three clus ters of disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > INDIV IDUAL P E R S ONAL IT Y

INDIVIDUAL PE R S ONAL ITY DIS OR DE R S P art of "23 - P ers onality Dis orders "

G eneral Diagnos tic G uidelines DS M-IV -T R introduces the following general guidelines the diagnosis of personality dis order. P.2081 Many of the features of various pers onality disorders may be s een during an epis ode of another mental 2666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 87 of 220

disorder. T he diagnos is of personality disorder is made only made only when the features are typical of longfunctioning and are not limited to a dis crete epis ode of another mental disorder. Likewis e, when maladaptive behavior features are due to the direct ps ychological effects of a s ubs tance (e.g., various ps ychoactive subs tances , including medication) or a general medical condition, diagnosis of personality disorder is not warranted. J udgments about pers onality functioning mus t take into account one's ethnical, s ocial, and cultural background. P ers onality disorder s hould not be confus ed with acculturation after immigration or with the expres sion of customs and religious and political values that are characteristic of one's culture of origin. Diagnos is of s pecific pers onality disorder may be made children or adoles cents when observed maladaptive personality traits are pervas ive, persistent, and unlikely be limited to a particular developmental s tage or an episode of an Axis I dis order. T o diagnos e a disorder in an individual who is younger than 18 years age, the features mus t be pres ent for more than 1 year. T he only exception to this is antisocial personality which cannot be diagnosed in individuals who are younger than 18 years of age. C linical experience points to a potential s ex-bias in diagnosing personality dis orders. C ertain pers onality disorders are diagnos ed more frequently in men (e.g., antis ocial and schizoid), whereas some disorders are frequently diagnosed in women (e.g., borderline, histrionic, and dependent). E ven though it is likely that there exis t real gender differences in the prevalence of 2667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 88 of 220

these dis orders, clinicians are cautioned not to certain personality dis orders in men and women of social s tereotypes about typical gender roles and behaviors . Observed maladaptive behavior traits must be that is , manifes t in a wide range of personal and s ocial contexts (i.e., at home, at work, and with family and friends ), not is olated as pects of the person's life. T he collection of data from collateral informants is thus cons idered critical to ensuring the high-quality as sess ment, diagnostic reliability, and validity. In addition to official diagnos tic criteria, DS M-IV -T R specifies a group of as s ociated features . T hes e not given in the form of explicit criteria (as their official counterparts) but rather as loos e descriptions of but fairly frequent, behaviors intended to help clinicians cases in which the diagnos is is not certain.

C lus ter A P ers onality Dis orders Paranoid Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of paranoid personality dis order are excess ive s uspicious ness and dis trus t of others as a pervasive tendency to interpret actions of others deliberately demeaning, malevolent, threatening, exploiting, or deceiving. Diagnostic features als o least four of the following: [black right-pointing arrowhead]Hypers ens itivity to and unforgivenes s of insults, slights, and rebuffs 2668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 89 of 220

[black right-pointing arrowhead]Unwarranted tendency to ques tion the loyalty of friends or the fidelity of s pouse or sexual partners [black right-pointing arrowhead]R eluctance to in others because of unwarranted fear that the information will be us ed against them [black right-pointing arrowhead]P reoccupation with cons pirational explanations of and hidden or threatening meanings into benign events or remarks [black right-pointing arrowhead]Unwarranted tendency to perceive attacks on their character or reputation with angry reactions or counterattacks S ome of the as sociated features include [black right-pointing arrowhead]E xces sive need to self-sufficient and s trong sens e of autonomy [black right-pointing arrowhead]P ervas ive inability relax and to compromise [black right-pointing arrowhead]F requent involvement in legal disputes [black right-pointing arrowhead]F requently impress others as fanatics [black right-pointing arrowhead]T endency to form clos ed groups or cults cons is ting of people with beliefs [black right-pointing arrowhead]P eculiar ability to generate fear in others 2669 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 90 of 220

C OMP L IC A TIONS C omplications include brief reactive psychosis, in res ponse to s tres s.

C OMOR B IDITY T hese patients are at increas ed risk for major obses sive-compuls ive disorder (OC D), agoraphobia, subs tance abus e or dependence. T he mos t common cooccurring pers onality disorders are s chizotypal, narcis sistic, avoidant, and borderline. P aranoid personality dis order has been postulated to premorbid antecedent of delusional disorder, paranoid type.

IMP A IR ME NT Impairment is frequently only mild and typically occupational and s ocial difficulties.

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in men.

E P IDE MIOL OG Y P revalence rates of 0.5 to 2.5 percent in the general population, 10 to 30 percent for ps ychiatric inpatients , 2 to 10 percent for psychiatric outpatients are reported DS M-IV -T R .

F A MIL IA L P A TTE R N A ND G E NE TIC S S ome s tudies have demonstrated increased this personality dis order among relatives of probands 2670 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 91 of 220

chronic s chizophrenia and delus ional dis order, type.

DIF F E R E NTIA L DIA G NOS IS P aranoid personality dis order is dis tinguis hed from schizophrenia (es pecially paranoid type); delus ional disorder, paranoid type; and affective disorder with ps ychotic features bas ed on periods with positive ps ychotic s ymptoms, such as delusions and When a brief reactive psychosis with delus ions the clinical picture of paranoid personality disorder, this distinction is far more difficult. T he duration of the latter and its frequent ass ociation with s tress are us ually sufficient for differential diagnosis. P aranoid personality dis order is sometimes difficult to distinguish from the following pers onality disorders : [black right-pointing arrowhead]S chizotypal (which includes magical thinking, unusual perceptual experiences , oddities in s peech, appearance, and thought proces ses) [black right-pointing arrowhead]Obs ess ivecompuls ive, s chizoid, borderline, and histrionic (all with no prominent paranoid ideation) [black right-pointing arrowhead]Avoidant (which includes fear of embarrass ment) [black right-pointing arrowhead]Antisocial (which includes personal gains in antis ocial behavior) [black right-pointing arrowhead]Narcis sistic (which includes fear of having hidden imperfections and 2671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 92 of 220

revealed)

S c hizoid Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of schizoid personality dis order are a pervas ive pattern of s ocial detachment and a restricted range of expres sed emotions in interpersonal settings beginning by early adulthood and present in a variety contexts , as indicated by four or more of the following: [black right-pointing arrowhead]Indifference to and criticis m [black right-pointing arrowhead]P reference for activities and fantasy (so-called loners ) [black right-pointing arrowhead]Lack of interest in sexual interactions P.2082 [black right-pointing arrowhead]Lack of des ire or pleas ure in clos e relations hips [black right-pointing arrowhead]E motional detachment, or flattened affectivity [black right-pointing arrowhead]No close friends or confidants other than family members [black right-pointing arrowhead]P leas ure in few, if any, activities S ome of the as sociated features include 2672 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 93 of 220

[black right-pointing arrowhead]Difficulty in expres sing anger, even in respons e to direct provocation, which contributes to the following features [black right-pointing arrowhead]Impress ion of flattened affect [black right-pointing arrowhead]P as sivity in adverse circums tances [black right-pointing arrowhead]S evere lack of skills

C OMP L IC A TIONS C omplications include very brief reactive ps ychos is , particularly in res ponse to s tres s.

C OMOR B IDITY T his pers onality disorder s ometimes appears as the premorbid antecedent of delusional disorder, schizophrenia, or, rarely, major depress ion. T he most common cooccurring personality dis orders are schizotypal, and avoidant.

IMP A IR ME NT Impairment includes frequently severe problems in relations . Occupational problems develop when interpersonal involvement is required; s olitary work sometimes favorably affects overall performance.

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in men and may caus e more impairment in 2673 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 94 of 220

them.

E P IDE MIOL OG Y P revalence rates varying from uncommon (DS M-IV 7.5 percent in the general population.

F A MIL IA L P A TTE R N A ND G E NE TIC S An increas ed prevalence among the relatives of with s chizophrenia or s chizotypal personality dis order been reported.

DIF F E R E NTIA L DIA G NOS IS S chizoid pers onality disorder is distinguis hed from schizophrenia, delus ional dis order, and affective with ps ychotic features bas ed on periods with positive ps ychotic symptoms , s uch as delus ions and in the latter. W hen a brief reactive ps ychos is the clinical picture of schizoid personality dis order, this distinction is far more difficult. T he duration of the latter and its frequent as sociation with stress are us ually sufficient for differential diagnosis. S chizoid pers onality disorder is distinguis hed from disorder and As perger's s yndrome by more s everely impaired social interactions and s tereotypical behaviors and interes ts in the latter two disorders . S chizoid is distinguished from the following pers onality [black right-pointing arrowhead]S chizotypal (which includes magical thinking, unusual perceptual experiences , oddities in s peech, appearance, and thought proces ses) [black right-pointing arrowhead]Avoidant (adequate 2674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 95 of 220

emotionality in the latter, als o s ocial isolation due to the fear of embarras sment, not indifference) [black right-pointing arrowhead]Obs ess ivecompuls ive (adequate capacity for intimacy, sometimes exces sive isolation due to perfectionis m and workaholic attitudes) [black right-pointing arrowhead]P aranoid (which includes s uspicious ness , ideas of reference, and guarded facade)

S c hizotypal Pers onality Dis order C L INIC A L C R ITE R IA S chizotypal pers onality disorder is characterized by and interpersonal deficits as indicated by pervasive discomfort with reduced capacity for close well as cognitive and perceptual distortions and behavior (not s evere enough to meet criteria for schizophrenia). Diagnostic features als o include at five of the following: [black right-pointing arrowhead]Ideas of reference (not delus ions) [black right-pointing arrowhead]Odd beliefs and magical thinking (s uperstitiousness ; beliefs in clairvoyance; telepathy, als o known as s ixth s e ns e ; in children and adolescents, bizarre fantas ies or preoccupation) [black right-pointing arrowhead]Unusual perceptual disturbances (illus ions, including bodily illus ions 2675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 96 of 220

sens ing a presence of a pers on nearby) [black right-pointing arrowhead]P aranoid ideation suspicious nes s [black right-pointing arrowhead]Odd, eccentric, peculiar behavior [black right-pointing arrowhead]Lack of close except family members [black right-pointing arrowhead]Odd thinking and speech without incoherence (e.g., vague, metaphorical, overelaborated, and s tereotypical) [black right-pointing arrowhead]Inappropriate or cons tricted affect [black right-pointing arrowhead]S ocial anxiety that does not diminis h with familiarity and that is as sociated with paranoid fears

P R E DIS P OS ING F A C TOR S E mpirical findings about this disorder are difficult to interpret, as there appear to be s everal clinical this dis order, with potentially differential relationships to the schizophrenic s pectrum. Adoption, family, and twin studies demons trate an increas ed prevalence of schizotypal features in the families of schizophrenic patients, especially when s chizotypal features were not as sociated with comorbid affective symptoms. S mall, anticipatory saccades that disrupt s mooth pursuit eye movement, hypothes ized to be a marker of genetic vulnerability to schizophrenia, have been also detected schizotypal and introverted personalities . T he nature of relations hip of this pers onality disorder and 2676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 97 of 220

is still controvers ial, with some genetic s tudies not the relationship, and with s ome s tudies finding a of gradation in multifactorial liability from s chizotypal personality (mild), to broad schizophrenia (moderate), narrow schizophrenia (s evere).

C OMP L IC A TIONS C omplications include trans ient ps ychotic episodes, particularly in res ponse to s tres s. S ymptoms become s o s ignificant that they meet criteria for schizophreniform disorder, delusional dis order, and ps ychotic disorder.

C OMOR B IDITY More than one-half of these patients have had at leas t episode of major depress ion, and 30 to 50 percent major depress ion concurrent with this pers onality disorder. T he mos t common cooccurring personality disorders are s chizoid, paranoid, avoidant, and

IMP A IR ME NT Impairment typically includes occupational and social difficulties .

S E X R A TIO T he sex ratio is unknown; this disorder is frequently diagnosed in women with fragile X s yndrome.

E P IDE MIOL OG Y A prevalence rate of 3 percent in the general reported in DS M-IV -T R . E arlier reports sugges ted a between 2 and 6 percent. 2677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 98 of 220

F A MIL IA L P A TTE R N A ND G E NE TIC S T here is an increased prevalence of this personality disorder among the first-degree relatives of probands schizophrenia. Also, there is an increased prevalence schizophrenia and other psychoses in the relatives of probands with s chizotypal personality dis order. T he disorder itself tends to aggregate in families (DS M-IV -

DIF F E R E NTIA L DIA G NOS IS S chizotypal pers onality disorder is distinguis hed from schizophrenia, delusional disorder, and affective with ps ychotic features based on periods with pos itive ps ychotic symptoms , s uch as delus ions and in the latter. W hen a brief reactive ps ychos is with complicates the clinical picture of schizotypal this dis tinction is far more difficult. P.2083 S chizotypal pers onality disorder is difficult to from the heterogeneous group of solitary, odd children whos e behavior is characterized by s ocial isolation, eccentricity, and peculiarities in language s een in disorder, As perger's s yndrome, and express ive and receptive-expres sive language disorder. disorders might be distinguished by the primacy and severity of the disorder in language accompanied by compens atory efforts of the child to communicate by other means and also by specialized language Autistic dis order and Asperger's s yndrome are distinguished based on more s everely impaired social interactions and s tereotypical behaviors and interests 2678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 99 of 220

the latter two dis orders. S chizotypal dis order is distinguished from the following pers onality disorders : [black right-pointing arrowhead]S chizoid and paranoid (which rarely have magical thinking, perceptual experiences , or oddities in s peech, appearance, and thought process es) [black right-pointing arrowhead]Narcis sistic (with predominant s ens e of grandiosity, fragile s elfand fear of having hidden imperfections or flaws revealed) [black right-pointing arrowhead]Avoidant (which rarely has oddities in appearance and behavior; fear of embarras sment, not disinterest and detachment, caus es social avoidance and isolation) [black right-pointing arrowhead]B orderline (characterized by affective instability and stormy relations hips , as well as impulsive and manipulative behavior)

C lus ter B P ers onality Dis orders Antis oc ial Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of antisocial personality dis order are pervas ive disregard for and violation of rights of others occurring since 15 years of age and continuing into adulthood. A person has to be 18 years of age or older, there has to be evidence of conduct dis order before 15 years of age (conduct disorder involves a repetitive and 2679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 100 of 220

persis tent pattern of behavior in which the basic rights others or major age-appropriate social rules are the examples include aggres sion to people or animals , both; destruction of property; deceitfulness or theft; and serious violation of rules). Diagnos tic features also at least three of the following: [black right-pointing arrowhead]F ailure to conform social norms (res ulting in frequent arres ts) [black right-pointing arrowhead]Deceitfulnes s, including lying and conning others for personal or pleasure [black right-pointing arrowhead]Impulsivity or failure to plan ahead [black right-pointing arrowhead]Irritability and aggres siveness , including repeated phys ical fights as saults [black right-pointing arrowhead]R eckless ness , with disregard for s afety of self and others [black right-pointing arrowhead]Irrespons ibility, indicated by the failure to honor financial or to s ustain consistent work behavior [black right-pointing arrowhead]Lack of remorse, indicated by indifference or rationalization of having hurt, mistreated, or stolen from others S ome of the as sociated features include [black right-pointing arrowhead]P romis cuity and inability to s ustain a monogamous relationship 2680 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 101 of 220

[black right-pointing arrowhead]Lack of empathy, cynicis m, and contempt for feelings , rights , or of others [black right-pointing arrowhead]Inflated and self-appraisal [black right-pointing arrowhead]Abusiveness and irrespons ibility toward children

C OMP L IC A TIONS C omplications include dys phoria, tension, low for boredom, depress ed mood, and premature, violent death.

C OMOR B IDITY T hese patients are at increas ed risk for impuls e control disorders , major depress ion, s ubs tance abus e or dependence, pathological gambling, anxiety disorders , and s omatization disorder. T he mos t common personality disorders are narcis sis tic, borderline, and histrionic.

IMP A IR ME NT Impairment is extremely variable and typically includes social difficulties .

S E X R A TIO According to DS M-IV -T R , this dis order is more (by a ratio of 3 to 1) diagnos ed in men.

E P IDE MIOL OG Y P revalence rates of 3 percent for men and 1 percent 2681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 102 of 220

women in the general population and 3 to 30 percent in clinical s ettings , with even higher rates for forensic samples and substance abus ers, have been reported. noted in DS M-IV -T R , there has been s ome concern disorder may be underdiagnos ed in women, given the emphasis on aggres sive items in diagnosing conduct disorder. A high frequency of antisocial pers onality dis order is as sociated with low socioeconomic status and urban settings .

C OUR S E After 30 years of age, the most flagrant antisocial behaviors (promiscuity and crime) and the less severe behaviors and subs tance use tend to decrease.

F A MIL IA L P A TTE R N A ND G E NE TIC S Antisocial personality dis order is more frequent among first-degree biological relatives of probands with this disorder. B iological relatives of women with antisocial personality dis order are at increased ris k for the same disorder compared to biological relatives of men with antis ocial personality dis order. G enetic studies have suggested familial transmiss ion of antis ocial disorder, s ubs tance use, and s omatization disorder, former two being characteris tic of men, and the latter being characteris tic of women in the s ame family. Adoption s tudies have s hown that genetic and environmental factors contribute to the risk for this disorder. Adopted and biological children of parents with 2682 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 103 of 220

personality dis order are at increased ris k for this C onduct dis order (before 10 years of age) and accompanying attention-deficit/hyperactivity disorder (ADHD) increas e the likelihood of developing antisocial personality in adult life. C onduct disorder is more likely develop into antisocial disorder with erratic parenting, neglect, or inconsis tent parental discipline.

DIF F E R E NTIA L DIA G NOS IS Antisocial personality dis order is dis tinguished from bipolar disorder, manic, on the bas is of epis odic cours e and euphoric mood of the latter. Antisocial disorder is distinguished from the following pers onality disorders : [black right-pointing arrowhead]Narcis sistic (which rarely manifes ts s erious criminality, aggress ion, deceit and is characterized by excess ive need for admiration and envy of others ). [black right-pointing arrowhead]His trionic (which includes s eductiveness , attention seeking, superficiality, and rarely s erious criminality and aggres siveness ). [black right-pointing arrowhead]B orderline (which includes manipulativeness to gain nurturance and affective ins tability). C ontrary to the common belief that borderline pers onalities rarely commit crime, individuals with explos ive or borderline (high harm avoidance, high novelty s eeking, and reward dependence) frequently manifest antis ocial behaviors (s e condary ps ychopathy). S econdary ps ychopathy is distinguished from antisocial personality proper (or primary ps ychopathy), as the 2683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 104 of 220

latter has a different temperament profile: high novelty seeking with low harm avoidance and low reward dependence, corres ponding to the adventurous temperament profile. [black right-pointing arrowhead]P aranoid (which includes s uspicious ness , guarded attitude, and, serious antis ocial behaviors ). [black right-pointing arrowhead]Adult antisocial behavior (with no personality pathology in the background). P.2084

Narc is s is tic Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of narcis sistic personality dis order are a pervas ive s ens e of grandiosity (in fantas y or in need for admiration, a lack of empathy, and chronic, intens e envy. Diagnostic features als o include at least of the following: [black right-pointing arrowhead]G randios e s ens e of self-importance and s pecialnes s [black right-pointing arrowhead]P reoccupation with fantas ies of unlimited s ucces s, power, brilliance, beauty, or ideal love [black right-pointing arrowhead]S ense of [black right-pointing arrowhead]Interpersonal exploitation, such as taking advantage of others to 2684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 105 of 220

achieve own needs [black right-pointing arrowhead]Lack of empathy [black right-pointing arrowhead]E xces sive need for admiration and acclaim [black right-pointing arrowhead]Intens ive and envy [black right-pointing arrowhead]Arrogant and haughty attitude S ome of the as sociated features include [black right-pointing arrowhead]F ragile s elf-es teem (which exclus ively depends on external admiration) with hypers ens itivity to criticis m [black right-pointing arrowhead]High achievements more frequent than in any other pers onality [black right-pointing arrowhead]S trong feelings of shame and humiliation [black right-pointing arrowhead]E xhibitionis m (behavior motivated by the pleas ure of being at) [black right-pointing arrowhead]F ear of having imperfections and flaws revealed

C OMP L IC A TIONS C omplications include social withdrawal, depres sed dysthymic or major depres sive dis order in reaction to criticis m or failure.

2685 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 106 of 220

C OMOR B IDITY T hese patients are at increas ed risk for major and s ubs tance abus e or dependence (es pecially us e). T he mos t common cooccurring pers onality are borderline, antisocial, histrionic, and paranoid.

IMP A IR ME NT Impairment is frequently severe and typically includes marital problems and interpersonal relations hips in general.

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in men (50 to 75 percent of diagnosed men).

C OUR S E T he cours e is chronic. However, narcis sistic s ymptoms to diminis h after 40 years of age, when pes simis m develops .

E P IDE MIOL OG Y P revalence rates of 2 to 16 percent in the clinical population and less than 1 percent in the general population are reported in DS M-IV -T R .

P R E DIS P OS ING F E A TUR E S T here may be a higher risk for this personality dis order the offspring of narciss is tic parents who impart on their children an unrealis tic s ens e of grandiosity. In addition, most narcis sis tic persons are realis tically talented, beautiful, or highly intelligent, as these features serve 2686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 107 of 220

the nucleus around which the sense of s pecialness is further organized.

DIF F E R E NTIA L DIA G NOS IS Narciss is tic personality dis order is dis tinguis hed from manic or hypomanic episode by the episodic cours e, euphoria, and functional impairments in the latter two. Narciss is tic personality is dis tinguis hed from the personality dis orders: [black right-pointing arrowhead]Antisocial exploitation is more driven by the wish to establish one's dominance than by material gains, his tory of conduct dis order, and no exces sive need for admiration) [black right-pointing arrowhead]B orderline (which includes unstable self-concept, chaotic behaviors , destructive ges tures , chronic anxiety, and rarely achievements) [black right-pointing arrowhead]His trionic (which includes capacity for empathy, emotional dis play, rarely, uns crupulous nes s and exploitation of [black right-pointing arrowhead]Obs ess ivecompuls ive (which includes inflexibility, detailoriented behavior, and social isolation, in addition perfectionism and the belief that others cannot do things as well) [black right-pointing arrowhead]P aranoid and schizotypal (which include sus piciousnes s and withdrawal)

2687 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 108 of 220

His trionic Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of his trionic personality dis order are pervas ive and excess ive s elf-dramatization, excess ive emotionality, and attention seeking. Diagnos tic features also include at least five of the following: [black right-pointing arrowhead]Inappropriate seductiveness or provocativenes s [black right-pointing arrowhead]E xces sive need to in the center of attention [black right-pointing arrowhead]R apidly s hifting and shallow express ion of emotions [black right-pointing arrowhead]S ugges tibility [black right-pointing arrowhead]P hysical us ed for attention seeking purpos es [black right-pointing arrowhead]Impress ionistic speech lacking detail [black right-pointing arrowhead]S elf-dramatization, theatricality, and exaggerated express ion of [black right-pointing arrowhead]R elations hips cons idered to be more intimate than they really are S ome of the as sociated features include [black right-pointing arrowhead]Difficulties in achieving emotional intimacy in romantic or s exual relations hips 2688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 109 of 220

[black right-pointing arrowhead]C raving for excitement and s timulation [black right-pointing arrowhead]P romis cuity or complete sexual naiveté [black right-pointing arrowhead]Low tolerance for delayed gratification

C OMP L IC A TIONS C omplications include frequent suicidal ges tures and threats to coerce better caregiving. Interpersonal are uns table, shallow, and generally ungratifying. frequent marital problems secondary to the tendency to neglect long-term relations hips for the excitement of relations hips .

C OMOR B IDITY T hese patients are at increas ed risk for major somatization disorder, and convers ion disorder. T he common cooccurring disorders are narcis sis tic, antis ocial, and dependent.

IMP A IR ME NT Impairment is frequently only mild and typically personal romantic relationships .

S E X R A TIO T here s eems to be a general agreement that this occurs far more frequently among women. According DS M-IV -T R , the disorder might be equally frequent men and women.

2689 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 110 of 220

E P IDE MIOL OG Y P revalence rates of 2 to 3 percent in the general population and 10 to 15 percent for ps ychiatric and outpatients are reported in DS M-IV -T R .

F A MIL IA L P A TTE R N A ND G E NE TIC S T his dis order tends to run in families. A genetic link between histrionic and antis ocial personality dis order alcoholism has been s uggested.

DIF F E R E NTIA L DIA G NOS IS His trionic pers onality disorder is dis tinguis hed from the following personality dis orders: [black right-pointing arrowhead]Antisocial (which includes antis ocial behaviors and crime to gain power, or some other material gratification; history conduct dis order; no exces sive s elf-dramatization; no exaggerated emotional expres sion) [black right-pointing arrowhead]B orderline (which includes unstable self-concept, chaotic behaviors , destructive ges tures , chronic anxiety, and identity disturbance) [black right-pointing arrowhead]Narcis sistic (which includes fear of having hidden imperfections and revealed and a sens e of grandios ity and P.2085

Antis oc ial, Narc is s is tic , and 2690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 111 of 220

S pec trum Narciss is tic, antis ocial, and his trionic personality qualify for the so-called s pectrum disorders. T he three disorders have been s hown to aggregate in the s ame family and to cooccur in the s ame person. distinguishable disorders may be referred to as dis orders , if they meet the two conditions previous ly mentioned. S pectrum disorders sometimes reflect differential express ion of the s ame liability. Antisocial, narcis sistic, and his trionic personality dis orders the spectrum in which proneness to impuls ivity and aggres sion (ass ociated with high novelty seeking) interferes with character development and maturity. E mpirical data show that s ymptoms of the three tend to group around impulsivity, aggres sion, and dramatic affects . A s pectrum disorder may als o reflect less deviant form of the other on an underlying liability scale. In that regard, the underlying antisocial increase in s everity as one proceeds from histrionic personality (manipulation via narciss is tic pers onality exploitation), and antis ocial pers onality (violent and property crime).

B orderline Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of borderline pers onality disorder are pervas ive and excess ive instability of affects, selfand interpersonal relationships , as well as marked impulsivity. Diagnostic features als o include at leas t the following: 1. F rantic efforts to avoid real or imagined 2691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 112 of 220

(Note: Do not include suicidal or s elf-mutilating behavior covered in C riterion 5) 2. Uns table and intense interpers onal relations hips alternating between idealization and devaluation 3. Markedly and persis tently uns table s elf-image or of s elf 4. Impulsivity in at leas t two potentially s elf-damaging areas (s pending, s ex, substance abuse, binge and reckless driving) (Note: Do not include suicidal self-mutilating behavior covered in C riterion 5) 5. R ecurrent suicidal behavior, ges tures , threats , or mutilating behaviors 6. Ins tability of affect due to marked reactivity of mood 7. C hronic feelings of emptines s 8. Inappropriately intens e anger or difficulty controlling anger 9. S tres s-related, transient paranoid ideation or diss ociative s ymptoms S ome of the as sociated features include [black right-pointing arrowhead]T endency to undermine self when clos e to realizing a goal [black right-pointing arrowhead]F eeling more with nonhuman objects (pets and inanimate than in interpersonal relations hips

P R E DIS P OS ING F A C TOR S Numerous s tudies have pointed to early traumatic 2692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 113 of 220

experiences in the etiology of this pers onality disorder. R ecently, a tripartite etiopathogenetic model, including childhood trauma, vulnerable temperament, and a of triggering events , has been formulated. Dynamic biological psychiatry agree that a combination of early traumatic events and certain biological vulnerabilities (mostly in the emotional domain) repres ent primary etiological factors for this disorder. F amilial aggregation borderline pers onality disorder has been repeatedly demonstrated.

C OMP L IC A TIONS C omplications include psychotic-like symptoms (hallucinations , body image distortions, hypnagogic phenomena, and ideas of reference) in res pons e to premature death or phys ical handicaps from suicide suicidal gestures , failed suicide, and self-injurious

C OMOR B IDITY T hese patients are at increas ed risk for major subs tance abus e or dependence, eating dis order bulimia), pos ttraumatic s tres s disorder (P T S D), and B orderline personality dis order cooccurs with most personality dis orders.

IMP A IR ME NT Impairment is frequent and s evere and includes job loss es, interrupted education, and broken

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in women (75 percent of diagnosed cases 2693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 114 of 220

women).

C OUR S E C ours e is variable. It mos t commonly follows a pattern chronic instability in early adulthood, with episodes of serious affective and impuls ive dyscontrol. T he and the ris k of s uicide are the greatest at the young years and gradually wane with advancing age. In the fourth and fifth decades of life, these individuals tend to attain greater s tability in their relations hips and functioning.

E P IDE MIOL OG Y P revalence rates of 2 percent in the general percent for ps ychiatric outpatients , 20 percent for ps ychiatric inpatients , and 30 to 60 percent among patients with personality dis orders are reported in TR .

F A MIL IA L P A TTE R N A ND G E NE TIC S P hysical and sexual abus e, neglect, hos tile conflict, early parental loss or separation are more common in childhood histories of patients with this dis order. B orderline personality dis order is five times more among relatives of probands with this disorder than in general population. It als o increases familial risk for antis ocial pers onality disorder, s ubs tance abus e, and mood dis orders.

DIF F E R E NTIA L DIA G NOS IS B orderline personality dis order is distinguished from disorder, dys thymic disorder, and cyclothymia (with 2694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 115 of 220

depres sion and mood swings mimicking borderline affective problems) bas ed on efforts to avoid abandonment, unstable relationships with alternating between idealization and devaluation, identity disturbance, impuls ivity in potentially s elf-damaging chronic feelings of emptiness , and inappropriately intens ive anger or difficulty controlling anger (these symptoms are rarely obs erved in mood dis order, dysthymia, or cyclothymia). B orderline disorder s hares many features and is difficult to dis tinguis h from all personality dis orders, frequently as an exclus ion based on typical clinical s ymptoms for other pers onality disorders . B orderline disorder is distinguis hed from identity problems (the latter is limited to a stage).

C lus ter C P ers onality Dis orders Avoidant Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of avoidant personality dis order are pervas ive and excess ive hypers ens itivity to negative evaluation, s ocial inhibition, and feelings of Diagnos tic features also include at least four of the following: [black right-pointing arrowhead]Avoidance of occupational activities that involve significant interpersonal contact because of fears of criticis m, rejection, or disapproval [black right-pointing arrowhead]Unwillingness to be 2695 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 116 of 220

involved with others unles s certain of being liked [black right-pointing arrowhead]R es traint in intimate relations hips because of the fear of being s hamed ridiculed [black right-pointing arrowhead]P reoccupation of being criticized or rejected in social s ituations [black right-pointing arrowhead]Inhibition in new social s ituations becaus e of feelings of inadequacy [black right-pointing arrowhead]R eluctance to take personal risks or to engage in any new activities, because they may prove embarrass ing P.2086 [black right-pointing arrowhead]V iews s elf as inept, personally unappealing, or inferior to others S ome of the as sociated features include [black right-pointing arrowhead]F earful and tense demeanor [black right-pointing arrowhead]F ear of blushing or crying in front of others in respons e to criticism [black right-pointing arrowhead]S ocial is olation accompanied by craving social relations and fantas izing about ideal relationships with others

C OMP L IC A TIONS C omplications include social phobia.

2696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 117 of 220

C OMOR B IDITY T hese patients are at increas ed risk for mood and disorders (es pecially s ocial phobia, generalized type). most common cooccurring disorders are schizotypal, schizoid, paranoid, dependent, and borderline.

IMP A IR ME NT Impairment can be s evere and typically includes occupational and s ocial difficulties.

S E X R A TIO According to DS M-IV -T R , this dis order is equally men and women.

E P IDE MIOL OG Y P revalence rates of 0.5 to 1.0 percent in the general population and 10 percent for psychiatric outpatients reported in DS M-IV -T R .

C OUR S E F requently begins in childhood with shynes s and fear strangers and new situations . Dis figuring illness and shyness in childhood predis pos e children for this personality dis order.

DIF F E R E NTIA L DIA G NOS IS Avoidant personality dis order is difficult to distinguis h from s ocial phobia (many authors believe that these alternative labels for the s ame or s imilar condition). In social phobia, specific situations , rather than contact, are avoided. P anic dis order with agoraphobia manifests avoidance but usually after the onset of 2697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 118 of 220

attacks. Avoidant disorder is distinguis hed from the following personality dis orders: [black right-pointing arrowhead]S chizotypal and schizoid (s ocial is olation of avoidant personalities is accompanied by the des ire for s ocial relations , not obs erved in s chizoid and schizotypal disorder) [black right-pointing arrowhead]P aranoid (which includes guarded attitude, preoccupation with meanings , and cons pirational explanations of [black right-pointing arrowhead]Dependent (which focus ed on being taken care of rather than on the of negative evaluation)

Dependent Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of dependent pers onality disorder are pervas ive and excess ive need to be taken care of that to clinging behavior, s ubmis siveness , fear of and interpersonal dependency. Diagnos tic features also include at least five of the following: [black right-pointing arrowhead]Difficulty in making everyday decisions without excess ive reass urance advice from others [black right-pointing arrowhead]Need for others to as sume res ponsibility for major areas of his or her 2698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 119 of 220

[black right-pointing arrowhead]Difficulties disagreement with others because of fear of loss of support or approval. (Note: Do not include realis tic fears of retribution) [black right-pointing arrowhead]Lack of initiative [black right-pointing arrowhead]Unrealistic preoccupation with fears of being left to take care self [black right-pointing arrowhead]Urgent s earch for another relations hip as a s ource of care and when a clos e relations hip ends [black right-pointing arrowhead]E xtens ive efforts to obtain nurturance and support from others (to the point of volunteering to do unpleasant things) [black right-pointing arrowhead]Uncomfortable and helpless feelings when alone because of fears of being unable to take care of self An ass ociated feature includes [black right-pointing arrowhead]Low self-es teem self-doubt and s elf-defeating demeanor

C OMP L IC A TIONS C omplications include mood disorders , anxiety adjus tment disorder, and social phobia, as well as low socioeconomic s tatus , poor family, and marital functioning.

C OMOR B IDITY 2699 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 120 of 220

T hese patients are at increas ed risk for major anxiety disorders , and adjus tment disorder. T he mos t common cooccurring disorders are histrionic, avoidant, and borderline.

IMP A IR ME NT Impairment is frequently only mild and typically interpersonal relationships and occupational if independence is required.

S E X R A TIO T his dis order is equally frequent in men and women IV -T R ).

E P IDE MIOL OG Y T his dis order is reported in DS M-IV -T R to be the mos t frequent of personality dis orders.

F A MIL IA L P A TTE R N A ND G E NE TIC S T here is no known familial pattern for this disorder. C hronic phys ical illness or separation anxiety disorder predis pos e for dependent personality dis order.

DIF F E R E NTIA L DIA G NOS IS Dependent disorder is dis tinguis hed from dependency seen in mood disorders , panic disorder, and and as a result of a general medical condition. disorder is distinguis hed from the following personality disorders : [black right-pointing arrowhead]B orderline (which includes unstable, stormy relations hips and the 2700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 121 of 220

reaction to abandonment with rage, emptines s, and demands, as opposed to increas ing appeas ement submiss iveness seen with dependent pers onalities ) [black right-pointing arrowhead]His trionic (which includes gregarious flamboyance with active for attention) [black right-pointing arrowhead]Avoidant (which includes social is olation because of the fear of evaluation as oppos ed to clinging and s ubmis sive behavior of dependent pers onalities )

Obs es s ive-C ompuls ive Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of obs es sive-compuls ive personality disorder are pervasive and include preoccupation with orderlines s, perfectionis m, and mental and control, at the expens e of flexibility, openness , and efficiency. Diagnos tic features als o include at leas t four the following: [black right-pointing arrowhead]P reoccupation with details, rules , lists , order, procedures, organization, schedules to the extent that the major point of is lost [black right-pointing arrowhead]P erfectionism that interferes with tas k completion [black right-pointing arrowhead]E xces sive devotion work and productivity to the exclus ion of leisure activities and friendships (not accounted for by 2701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 122 of 220

obvious economic neces sity) [black right-pointing arrowhead] scrupulousness , and inflexibility about matters of morality, ethics , or values (not accounted for by religion or culture) [black right-pointing arrowhead]Inability to dis card worn-out or worthles s objects with no sentimental value [black right-pointing arrowhead]R eluctance to delegate tasks or work with others unless they exactly to his or her way of doing things [black right-pointing arrowhead]S tingines s (money viewed as s omething to be hoarded for future catas trophes ) [black right-pointing arrowhead]R igidity and stubbornness S ome of the as sociated features include [black right-pointing arrowhead]Decis ion-making difficulties when no strict rules or es tablis hed procedures dictate correct action P.2087 [black right-pointing arrowhead]Anger and when not able to maintain control of physical or interpersonal environment (anger is typically not expres sed directly) [black right-pointing arrowhead]E xces sive attentivenes s to their relative status in dominance– 2702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 123 of 220

submiss ion relations hips [black right-pointing arrowhead]C ontrolled and res tricted emotional express ion and reserved style [black right-pointing arrowhead]F ormal and s erious quality of everyday relations hips

P R E DIS P OS ING F A C TOR S It has been repeatedly demonstrated that obs ess ivecompuls ive personality dis order and OC D frequently coexist. Obsess ions and compuls ions have been repeatedly linked to high central s erotoninergic which is as sociated with anxiety in general, s upporting hypothes is that obs es sions and compuls ions repres ent ps ychological and behavioral mechanisms reflecting underlying anxiety.

C OMP L IC A TIONS C omplications include dis tres s and difficulties when confronted with new situations that require flexibility compromise and myocardial infarction (s econdary to features typical of type A pers onalities , s uch as time urgency, hos tility, and competitivenes s).

C OMOR B IDITY T hese patients are at increas ed risk for major and anxiety dis order. T here is equivocal evidence for increased ris k of OC D.

IMP A IR ME NT Impairment is frequently severe and typically includes 2703 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 124 of 220

occupational and s ocial difficulties.

S E X R A TIO According to DS M-IV -T R , this dis order is twice as in men as in women.

E P IDE MIOL OG Y P revalence rates of 1 percent in the general population and 3 to 10 percent for ps ychiatric outpatients are reported in DS M-IV -T R .

F A MIL IA L P A TTE R N A ND G E NE TIC S S ome s tudies have demonstrated familial aggregation this disorder.

DIF F E R E NTIA L DIA G NOS IS Obsess ive-compuls ive personality dis order is from OC D based on true obs es sions and compulsions the latter. T his personality disorder is distinguis hed the following personality dis orders: [black right-pointing arrowhead]S chizoid (which includes lack of capacity for intimacy and social is olation secondary to emotional detachment, as oppos ed to devotion to work and discomfort with emotions ) [black right-pointing arrowhead]Antisocial (which includes material goals in antis ocial behavior and criminality as opposed to hypermorality of personalities ) [black right-pointing arrowhead]Narcis sistic (which includes s ens e of grandiosity, s elf-aggrandizement, 2704 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 125 of 220

exhibitionis m, and fear of having hidden and flaws revealed)

P ers onality Dis order Not S pec ified (NOS ) T his dis order is diagnos ed when the DS M-IV -T R dysfunctional personality (i.e., general criteria for a personality dis order) are met, but no specific criteria for any of the subtypes are obs erved. F or example, a may not meet criteria for any of the clas sified disorders may s till manifes t features from more than one disorder (mixe d pe rs onality dis orde r) which, together, distress or impairments in s ocial or profes sional functioning. T his category is als o us ed when the judges that a specific pers onality disorder that is not included in DS M-IV -T R is appropriate (e.g., depres sive personality or pass ive-aggres sive pers onality).

S ummary Des c ription of the DS MTR P ers onality Dis orders Qualitative features that are diagnostic of a personality disorder as clas sified in DS M-IV -T R are summarized in T able 23-13. C loninger has als o provided practical to detail thes e general features, s o that a clinician may decide whether a person has any personality disorder before proceeding to diagnose a s pecific cluster or category of illness . T he general features of all disorders are the character traits , whereas the clusters categories are determined by additional temperament features.

2705 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 126 of 220

Table 23-13 Qualitative C lus ters and S ubtypes of Pers onality Dis orders Ac c ording to the Americ an Ps yc hiatric C lus ter

S ubtype

Dis c riminating Features

Odd/eccentric

S chizoid

S ocially indifferent

 

P aranoid

S us picious

 

S chizotypal

E ccentric

E rratic/impuls ive

Antisocial

Dis agreeable

 

B orderline

Uns table

 

His trionic

Attention seeking

 

Narciss is tic

S elf-centered

Anxious/fearful

Avoidant

Inhibited

2706 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 127 of 220

 

Dependent

S ubmis sive

 

Obsess ive

P erfectionistic

Not otherwise specified

P as siveaggres sive

Negativis tic

 

Depress ive

P es simis tic

Adapted from American P s ychiatric As sociation. Diagnos tic and S tatis tical Manual of Me ntal 4th ed. T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000.

Dis advantages of DS M-IV-TR C las s ific ation In addition to problems s hared by all categorical personality, the DS M clas sification has its s pecific limitations . F irst, DS M-IV -T R is an etiologically atheore tical of pers onality disorder based s olely on descriptive derived from observations of prototypical cas es . T his atheoretical approach was expected to s timulate work the etiopathogenetic unders tanding of deviant clas sified as pers onality disorders . However, this has been the cas e. T he introduction of descriptive criteria in DS M-III has inspired extensive res earch of some bas ic ps ychometric as pects of the personality dis order 2707 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 128 of 220

but rarely has ins pired s tudies of etiology, underlying dynamics, or pathogenes is . Although this emphas is on ps ychometrics obviously reflects an attempt of this new field to delineate its s ubject, it is als o reflective of the purely des criptive approach, which provided no etiopathogenetic models or hypotheses for tes ting. F or example, the DS M criteria have been of little or no help developing the psychobiological model described here. S econd, the DS M-IV -T R describes as pathognomic for personality disorder maladaptive res ponse patterns are enduring, that is, appearing before adulthood with long-term duration. In practice, however, it can be to dis tinguis h long-term maladaptation that is indicative personality dis order from chronic personality changes caus ed by other factors, such as other mental (e.g., chronic depress ion) and long-term s ituational (e.g., job-related timidity), and by other medical (e.g., irritability ass ociated with hyperthyroidism). P.2088 T hird, the DS M-IV -T R definition of pe rs onality inherently imprecis e, as it requires that maladaptive behaviors caus e clinically significant subjective distress clinically s ignificant impairment in social and function, or both. S ubjective dis tre s s us ually pres ents self-es teem, anxiety, guilt, depress ion, and hypochondriasis. T hes e s ymptoms are frequently diagnosed as Axis I dis orders while the background personality dis order is overlooked. T he quantifier s ignificant is an arbitrary diagnostic element that can hardly be made objective. E ditors : S adock, B e njamin J .; S adock, V irginia A

2708 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 129 of 220

T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > C LINIC AL AND P S Y C HO ME T R IC

C L INIC AL AND PS YC HOME TR IC IS S UE S P art of "23 - P ers onality Dis orders "

E go-S yntonic and A lloplas tic of P ers onality Dis order P atients with personality dis order typically blame other people or unfavorable circumstances for their own problems . T his externalizing of res ponsibility is a result the following two characteris tics. F irs t, mos t of these patients perceive their own deviant behaviors as appropriate and adequate; in other words, their are ego-syntonic. T he exceptions to this are patients dependent and avoidant personality dis order. B oth disorders are characterized by prominent anxiety as sociated with maladaptive behaviors , and this caus es the patients to perceive their s ymptoms as disturbing, that is, ego-dystonic. S econd, patients with personality dis order try to others , not thems elves ; in other words, their attitude is alloplas tic. T he exceptions to this rule are patients with avoidant and schizoid pers onality disorder. Avoidant persons usually try to improve their own performance avoid negative evaluation by others . S chizoid are socially detached to the extent that they are usually indifferent to what others might do, think, or feel. 2709 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 130 of 220

P ers onality Dis order: S oc ial or Diagnos is ? One of the general DS M-IV -T R requirements for disorder is that maladaptive behavior “deviates from the expectations of the individual's culture.” T his requirement introduces a significant s ocial connotation what was meant to be a clinical clas sification. Indeed, clinicians frequently diagnos e pers onality dis order solely on the extent to which certain behavior is to the local s ociety. S ociocultural pres sures are always norm favoring, promoting phenotypes that fall within the range of accepted behavior norms . As shown later in the text, temperament profiles with high reward dependence a low incidence of diagnosed personality dis order, whereas thos e with high harm avoidance or high seeking, or both, increas e this ris k. In most W es tern societies, the normative phenotype is not the one with average personality traits (as one would expect, given adaptive flexibility of such configuration) but the one high reward dependence (high reward dependence means much eas ier conditioning of s ocially accepted behaviors than is the case with other two temperament traits). In a s imilar way, child psychiatry clas sifies three broad groups of mental disorders : One group is characterized high novelty seeking (e.g., ADHD and conduct one group is characterized by high harm avoidance depres sive and anxiety disorders ), and one group is characterized by low reward dependence (e.g., C hildren with thes e extreme temperaments are 2710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 131 of 220

and treated to change their behavior, whereas children with high reward dependence (s ociable, attached, and dependent) are s electively permitted to develop with no corrective intervention. T his raises a question, which is beyond the s cope of this chapter, about the role of modern human society in engineering psychological profiles of its members . S uffice it here to s ay, biological adaptation appears to have become les s critical for survival than behavioral and s piritual adaptation. selection is not targeting humans' morphological anymore, but, rather, their personality features and awarenes s. T hrough its suppres sion of certain temperament traits and its modeling effects on development, modern human society appears to have important role in this proces s.

C ategoric al vers us Dimens ional A pproac h to P ers onality Dis order Medical diagnosis has historically been categorical, most clinicians tend to think categorically for two F irst, one of the most important functions of diagnos is prescribe appropriate corrective action, that is, T he decis ion whether a pers on is affe cte d or (s ick or not s ick) is functionally equivalent to the whether that pers on needs treatment (hence, diagnosis facilitates treatment decisions in practical S econd, categorical s ys tems simplify profess ional communication, as they describe prototypical cas es meet all or most of the diagnostic criteria. J ust one category, for example, antis ocial pers onality, can communicate a great deal of vivid clinical information about the patient. However, categorical descriptions convey useful information only about prototypical and 2711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 132 of 220

severe cases but little or no information about atypical, mixed, or mild cas es.

C ategoric al Approac h T he categorical approach adopts the medical model that a personality dis order is pre s e nt or abs e nt that individuals are affe cte d or unaffe cte d. C ategorical models are optimal for discontinuous variables (e.g., marital s tatus and s kin cancer). However, when distinguishing characteris tics of a dis order are variants normality, s uch as pers onality traits , any categorical decis ion about the pres ence or abs ence of a disorder arbitrary. In other words, one of the major of categorical models of personality dis order is that es tablis h arbitrary cutoff points or thres holds for continuous behavior traits . T his becomes clear in mild cas es that are close to the cut-off point, which cannot be well class ified as affe cte d or unaffe cte d. In attempt to minimize this problem, DS M-IV -T R now clinicians to class ify maladaptive pe rs onality traits that not meet the threshold for a pers onality disorder on Nevertheles s, the categorical approach is not optimal patients who do not perfectly fit their pigeonhole in the clas sification, s o an additional was tebasket category atypical or mixe d cases has to be es tablis hed, and this often is used to des cribe most cases of pers onality disorder. F inally, the categorical approach does not es tablis h a pres criptive relations hip between diagnos is and treatment. R eflecting a significant overlap of diagnostic criteria for personality dis order subtypes , categorical s ys tems us ually yield multiple pers onality diagnoses for individual patients . In such cases, 2712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 133 of 220

priorities are eas ily and frequently confus ed.

Dimens ional Approac h Dimens ional models define a number of graded and continuous behavior dimens ions and s pecify individual differences as quantitative variations along these dimensions . T hese models are optimal for features that vary quantitatively and that have different adaptive significance in different s ituations (such as personality traits). T hese models account for the fact that everyone multiple pers onality traits , more or les s prominent and adaptive, rather than being s imply pres ent or absent. eliminates the need for multiple and overlapping categorical diagnos es . B y quantifying one's position on continuous personality trait, dimensional models information about individual patients more than categorical models . P ers onality dimensions are as applied to the common atypical and mild cases as they to the rare prototypical and severe cases . Lastly, by dimensional system, one can easily manipulate mathematically complex data and can include many variables . P.2089 R es earch has s hown that normal pers onality traits tend generalize to pers onality disorders , indicating that traits may be conceptualized as extreme variants of normal, adaptive behaviors. Note, however, that dimensional models do not answer the ques tion of it about s ome traits that makes them dis orders. Natural breaks or points of rarity on the continuum of normal maladaptive pers onality traits have not been detected. 2713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 134 of 220

extreme s tanding alone is not s ufficient to be dysfunctional (e.g., people with low reward can be well adapted in their environment). T o make more prescriptive of treatment and more compatible categorical diagnoses, dimens ional models have to introduce cut off points for continuous traits (which are always arbitrary) or, as proposed here, have to use probability estimates for categorical pers onality based on the s everity of measured personality traits.

Meas urement of P ers onality Dis orders S elf-R eport or Interview? Interviews are cons idered more reliable and valid diagnostic tools than s elf-reports for meas uring personality dis order, although no data for a definite advantage of one of these formats have been As many of these patients tend to be biased regarding their ego-syntonic deviant behaviors, interviewing the patient reduces this problem, because unclear, inconsistent, or defens ive responses can be clarified, the patient's demeanor and appearance can be On the negative side, interviews tend to be affected by systematic biases, ideological orientation, experience, rating idios yncrasies of interviewers . In self-reports , res ponse sets (e.g., careless inconsistency, and exaggeration) and validity items can be meas ured help in interpretation. R ecently, a set of performance scales, independent of the item content, bas ed on the observed regularities in the technical pattern of res ponding to questions has been defined. T hes e performance s cales are used to tes t the validity of s elf2714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 135 of 220

reported pers onality traits . S pecifically, s elf-report to questions , regardles s of the content of the ques tions, tends to follow specific patterns that correlate with personality traits . F or example, the number of items that are otherwis e rarely found in the general population correlates with low reward dependence. performance s cales are used to predict scores on each the temperament and character dimens ions, which are then compared with self-reported, content-dependent scores on these same traits . S ubstantial s core between s ubje ctive and pe rformance -bas e d s cores on personality traits indicate s ignificant bias or intentional misrepres entation. F urther improvement of this basic might be accomplished by us ing neural networks to detect content-independent response patterns that typical of each pers onality trait. S elf-reports and interviews depend on the patient's accuracy, hones ty, and level of insightfulness . Hence, collection of data from collateral informants and expert ratings is us ually considered critical to ensuring highquality personality diagnosis .

S tate–Trait E ffec t Most Axis I dis orders have their less severe variants or representatives on Axis II (T able 23-14). T he s tate –trait distinction between s ymptoms reflecting long-term personality traits and those reflective of trans ient Axis I states can be difficult. Indeed, trans ient variation in emotional state can influence s elf-report and clinical evaluation of long-term personality characteris tics. T he susceptibility to such s tate effects has been for some categorical measures of personality 2715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 136 of 220

T he state effect can be reduced, although not when subjects are repeatedly reminded to des cribe us ual, not their current, behavior, feelings, and contrast to categorical diagnos is , only thos e personality that underlie s usceptibility to depress ion anxiety, such as neuroticism and harm avoidance, tend covary with mood and anxiety s tates. Also, increases in anxiety or depres sion lead to mild and transient in self-directedness and cooperativenes s. person with no enduring pers onality disorder may act immaturely when depres sed or under s tres s. S elfof other dimens ional traits —novelty seeking, reward dependence, and pers istence, in particular—are largely independent from and unaffected by comorbid mood anxiety states.

Table 23-14 Phenotypic between Axis I and Axis II Axis I Dis orders : Major Variant

Axis II Dis orders : Minor Variants

S hared S ymptoms

S chizophrenia spectrum

S chizoid

Negative and positive

2716 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 137 of 220

 

S chizotypal PD

 

Delusional disorder

P aranoid

S us piciousness

Major depres sion

Depress ive PD

P ronenes s to depres sed mood; self-destruction

 

B orderline PD

 

C yclothymia, bipolar disorder, mania

Narciss is tic PD

Mood swings; impulsiveness

 

His trionic PD

 

 

Antisocial PD

 

Obsess ivecompuls ive disorder

Obsess ivecompuls ive PD

Hypochondrias is ; inflexibility

S ocial phobia

Avoidant

S hynes s; behavior

2717 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 138 of 220

P anic dis order with agoraphobia

Dependent PD

Dependency

P D, personality disorder.

C ategoric al Tes ts for Pers onality Dis order T he majority of categorical tes ts for personality are based on the DS M criteria and s hare all the and disadvantages of that polythetical categorical approach. In the DS M-III field trials , the interrater was 0.61 and the tes t-retest reliability was 0.54 for any personality dis order. T he reliability is us ually lower for individual s ubtypes than for the pres ence vers us of any pers onality disorder becaus e of the difficulty in distinguishing among the s ubtypes. Among the categorical self-reports , the two mos t frequently us ed are the P ers onality Diagnos tic Ques tionnaire (P DQ) and the Minnesota Multiphas ic P ers onality Inventory (MMP I) s cales for pers onality disorders (MMP I-P D). T he P DQ is a self-report vers ion the DS M-III-R criteria for pers onality disorders , along the impairme nt-dis tre s s s cale to quantify the impairment or subjective distress required by DS M In practice, this ins trument has been s hown to overdiagnose pers onality disorders when compared to 2718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 139 of 220

expert clinical diagnosis . T he MMP I-P D scales were derived from the MMP I item pool to evaluate s ymptoms for DS M-III pers onality disorders . T he MMP I-P D scales are incorporated into so that, in addition to evaluating personality dis order other clinical s yndromes, clinicians and researchers also use other MMP I s cales (e.g., for lies , validity, and defens iveness ) for validity and response set analyses. Among the interviews that categorically diagnos e personality disorders , the most commonly us ed is the S tructured Interview for DS M-IV P ers onality Dis orders (S IDP -IV ). T he original S tructured Interview for Dis orders (S IDP ) was developed for pers onality described in DS M-III, and it has been regularly updated with each new DS M revision and edition (S IDP -R for III-R and S IDP -IV for DS M-IV ). T o increase its P.2090 validity, the S IDP -IV requires that ans wers for selected questions be obtained from a collateral informant. T his tes t can be combined with a 10-minute S IDP -IV s creen personality dis order, which can cons iderably reduce tes ting time in populations with many individuals who not have pers onality disorder. Other popular interviews for categorical class ification of personality dis orders include the S tructured C linical Interview for DS M-III-R P ers onality Dis orders R evised II), the Diagnostic Interview for P ers onality Dis orders (DIP D), and the P ers onality Dis order E xamination T he P DE is available in an international version from World Health Organization in several languages and 2719 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 140 of 220

diagnoses according to the IC D in addition to DS M-III-

Dimens ional As s es s ment of Dis orders His torically, pers onality has been studied and us ing dimensions or traits , and personality dis order has been s tudied categorically, as discrete entities of ps ychopathology. Hence, conceptual advances in the of normal behavior and personality have had little or no effect on research in the field of personality dis order vice versa. F or example, if the features as sociated with E ys enck's model of pers onality, that is , neuroticism, extrovers ion, and tough-mindedness , are combined, res ulting combinations do not corres pond clos ely to traditional categories of pers onality disorder. T he popular five-factor model of normal personality has been recently advocated to account for underlying dimensions of pers onality disorder as well. However, ability of the five-factor model to account for the underlying s tructure of personality dis order has been tes ted primarily in nonclinical s amples and normal individuals . T he few s tudies that tested the five-factor model in clinical samples showed that neuroticism, extrovers ion, and low agreeableness predict disorder s ymptoms. After controlling for age and depres sion (cons idered standard for high-quality personality diagnos is ), only high neuroticism and low agreeableness remained as significant predictors of personality dis order symptoms . T hes e two dimens ions define pe rs onality dis orde r in a nons pecific way, as a general predis pos ition to ps ychopathology (i.e., high neuroticism) accompanied by an antagonis tic behavior 2720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 141 of 220

facade (i.e., low agreeableness ). In addition, tends to be confounded with nonspecific factors (s uch depres sion or anxiety), which reduce its ability to distinguish pers onality disorder, other ps ychopathology (e.g., mood and anxiety disorders ), and well-adjus ted individuals with high neuroticism. S everal lines of evidence s uggest that some common features, distinct from other forms of psychopathology that caus e personal dys function, characterize disorder s ubtypes clas sified in DS M-IV -T R as discrete categories . F or example, DS M-IV -T R arranges all personality dis orders into three clus ters (A, B , and C ), comprised of a number of pers onality disorder with similar clinical features. C lus ter A includes with predominantly odd and eccentric s ymptoms (e.g., paranoid and s chizoid personality dis order), C lus ter B includes subtypes with dramatic, erratic, and impulsive symptoms (e.g., his trionic, antis ocial, and borderline personality disorders ), and C luster C includes subtypes with fearful and anxious s ymptoms (dependent, and obses sive pers onality disorders ). T hese clusters represent three independent dimensions underlying personality dis order subtypes within each of the However, the ability of thes e three dimensions to discriminate s ubjects with and without pers onality disorder or to distinguis h between pers onality disorder subtypes has not been tested. Dimens ional tests of pers onality disorders are self-reports (except for T yrer's P ers onality As ses sment S chedule). T he mos t frequently us ed are the Millon Multiaxial Inventory (MC MI); the previous ly mentioned Neuroticis m E xtrovers ion Openness P ers onality 2721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 142 of 220

(NE O-P I), which evaluates the five-factor pers onality model; and the T C I, which evaluates the s even-factor ps ychobiological pers onality model. T hes e tests have originally designed to evaluate normal personality (the NE O-P I), ps ychiatric patients (the MC MI), and normal deviant personality (the T C I). T he NE O-P I was previous ly vis à vis the homogeneity of its component traits and its us efulnes s in clinical work with personality disorder. T he other two tes ts are briefly discus sed T he MC MI-II (des igned to match DS M-III-R personality disorder categories) evaluates long-term behavior traits systematized as ten bas ic pe rs onality patte rns avoidant, schizoid, pass ive-aggres sive, narcis sis tic, antis ocial, hys terical, compuls ive, aggres sive, and selfdefeating) and three pathological pe rs onality dis orde rs (borderline, schizotypal, and paranoid). T he latter the severity of the ten basic personality patterns . T he also evaluates nine Axis I clinical syndromes . S ome suggest that MC MI-II tends to overdiagnos e personality disorder in comparis on to expert clinicians . A s tudy comparing the MC MI-II to the T C I pointed to a cons iderable overlap of MC MI-II measures of Axis I syndromes and Axis II personality dis orders. T he number of proposed dimensions that underlie personality ranges from 2 to 24 in the literature, in most models , it can be reduced to four dimensions (aloof, anxious, anankas tic, and adventurous ). T he number of underlying dimens ions and the content of dimensions that purport to describe personality and its disorders most efficiently are still vigorous ly debated. ambiguity arises because factor analys es of behavior unrelated individuals are always compatible with an 2722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 143 of 220

infinite number of rotations of the inferred phenotypic factors . F ortunately, s tructural equation analys is of the caus es of individual differences in the resemblance in pairs varying in the degree of genetic relationship can specify a unique model of the genetic s tructure of personality. In what follows , the distinction between temperament and character is us ed to improve the etiopathogenetic understanding and the diagnosis of personality dis order. In the treatment section of the chapter, the concepts of temperament and character us ed to outline treatment guidelines for patients with personality dis order.

Temperament and C harac ter (TC I) T he T C I evaluates four major temperament dimensions (harm avoidance, novelty s eeking, reward and persis tence) and three major character dimens ions (s elf-directedness , cooperativeness , and s elftranscendence). E ach of these main temperament and character dimens ions is compos ed of component (or s ubscales ) to evaluate respons e patterns elicited by specific s timuli (e.g., harm avoidance is obs erved in different s ettings as worry and pes simis m or fear of uncertainty, s hynes s, or excess ive fatigability, or a combination of thes e). T he s even major dimensions their component traits are pres ented T able 23-15.

Table 23-15 Temperament and C harac ter Inventory S c ales and S ubs c ales 2723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 144 of 220

T emperament    Harm avoidance (HA)       HA1: worry and pess imism vs. uninhibited optimism       HA2: fear of uncertainty       HA3: s hynes s with s trangers       HA4: fatigability and as thenia    Novelty seeking (NS )       NS 1: exploratory excitability vs. stoic rigidity       NS 2: impulsivenes s vs. reflection       NS 3: extravagance vs. reserve       NS 4: disorderlines s vs . orderlines s    R eward dependence (R D)       R D1: s entimentality       R D2: s ociability vs. aloofnes s

2724 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 145 of 220

      R D3: attachment vs. detachment       R D4: dependence vs. independence    P ersistence (P S )       P S 1: eagernes s of effort vs. laziness       P S 2: work hardened vs. spoiled       P S 3: ambitiousness vs . underachieving       P S 4: perfectionis m vs. pragmatism C haracter    S elf-directedness (S D)       S D1: res ponsibility vs . blaming       S D2: purpos efulnes s vs . lack of goal direction       S D3: res ourcefulness vs . helples sness       S D4: s elf-acceptance vs . self-striving       S D5: congruent s econd nature    C ooperativeness (C O)

2725 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 146 of 220

      C O1: s ocial acceptance vs . s ocial intolerance       C O2: empathy vs . s ocial dis interes t       C O3: helpfulness vs. unhelpfulness       C O4: compass ion vs. revengefulness       C O5: pure hearted vs. s elf-serving    S elf-transcendence (S T )       S T 1: s elf-forgetful vs. s elf-cons cious       S T 2: transpers onal identification vs. s elfdifferentiation       S T 3: spiritual acceptance vs . rational       S T 4: enlightened vs. objective       S T 5: idealistic vs. practical

T he T C I is a family of tes ts with s everal specialized designed for varying types of informants (s elf-report, ratings , and interviewers), varying age groups (7 to 14 years of age for the junior T C I and 15 years or age or for the adult T C I), scope of information (temperament character, or both), level of clinical detail (140 items for 2726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 147 of 220

major dimens ions only or 240 items for multiple facets each dimens ion). T he tes t meas uring the temperament dimensions only was originally called the P ers onality Q ue s tionnaire (T P Q). In the T P Q, novelty seeking, harm avoidance, reward dependence, and persis tence were all meas ured, but pers is tence was originally s cored as a component of reward T he name of the tes t was changed to T C I when the character scales were added and when persistence recognized as a fourth, s eparately inherited dimension in twin studies in Aus tralia P.2091 and the United S tates . T he self-report version of the 240-item test available in true–false and five-point formats . Its psychometric properties are presented in T C I Manual. T he ability of the T C I to predict categorical diagnos es personality dis orders was clinically tes ted in samples of ps ychiatric inpatients and outpatients with and without personality dis orders and varying mood and anxiety C orrelation and regres sion analys es consis tently demonstrate that low scores on character dimens ions, es pecially self-directedness and cooperativeness , are as sociated with high symptom counts for any disorder, for each of the DS M clusters of personality disorder (T ables 23-16 and 23-17) and for each clinical subtype of personality dis order, with or without Axis I s yndromes and independent of age. As s hown in T able 23-17, the T C I character scales of s elfcooperativeness , and s elf-transcendence predict the number of pers onality disorder s ymptoms, after 2727 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 148 of 220

controlling for age, anxiety, and depres sion. C learly, scores on P.2092 character traits repres ent a core feature (common denominator) of all personality dis order clusters and subtypes .

Table 23-16 C orrelations betwee Temperament and C harac ter Inven S c ales and the Total Number of for Pers onality Dis orders and C lus C lus ter B , and C lus ter C Pers ona Dis order S ubtypes    

Inpatients (N = 136) Total Number Pers onality Dis order C lus ter C lus ter C lu Sx A Sx B Sx C S

Novelty

.22 c

.02

.44 a

–

Harm

.31 b

.23 b

.08

.4

2728 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 149 of 220

R eward dependence

-.14

-.37 a

-.08

-.

P ers is tence

0

-.07

.04

-.

S elfdirectedness

-.56 a

–.35 a

–.43 a

–.

C ooperativenes s

–.44 a

–.44 a

–.40 a

–.

.02

–.08

.03

.

S elftranscendence

S x, symptoms. aP

T able of C ontents > V olume II > 23 - P ers onality Disorders > R E F E R E NC

R E FE R E NC E S Allport G . P ers onality: A P s ychological London: C onstable; 1937. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd ed. Was hington, DC : AP A P ress ; 1980. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd ed. R ev. Was hington, DC : AP A P ress ; 1987.

2796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 217 of 220

American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. Was hington, DC : AP A P ress ; 1994. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. T ext Was hington, DC : AP A P ress ; 2000. B ayon C , Hill K , S vrakic DM, P rzybeck T R , Dimens ional as sess ment of pers onality in an sample: R elations of the systems of Millon and C loninger. J P s ychiatr R e s . 1996;30:341–352. *C loninger C R : A s ys tematic method for clinical description and clas sification of pers onality Arch G e n P s ychiatry. 1987;44:573–588. C loninger C R : A practical way to diagnos e disorder: A propos al. J P e rs Dis ord. 2000;14:99– P.2104 C loninger C R . Implications of comorbidity for the clas sification of mental dis orders: T he need for a ps ychobiology of coherence. In: Maj M, G aebel W, Lopez-Ibor J J , S artorius N, eds. P s ychiatric C las s ification. C hichester, UK : J ohn W iley and 2002:79–106. C loninger C R . F e e ling G ood: T he S cience of W e ll New Y ork: Oxford University P res s; 2004. 2797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 218 of 220

C loninger C R . T he genetics and ps ychobiology of seven factor model of personality. In: S ilk K , ed. R eview of P s ychiatry. V ol 17. W ashington, DC : AP A (in pre s s ). *C loninger C R , P rzybeck T R , S vrakic DM, W etzel R . T e mpe rame nt and C haracte r Inventory: A G uide to Deve lopme nt and Us e . S t. Louis, MO: C enter for P sychobiology of P ers onality, W ashington 1994. C loninger C R , S vrakic DM: Integrative approach to ps ychiatric as sess ment and treatment. P s ychiatry. 1997;60:120–141. C loninger C R , S vrakic DM, P rzybeck T R : A ps ychobiological model of temperament and Arch G e n P s ychiatry. 1993;50:975–990. C os ta P T , McC rae R R . T he NE O P e rs onality Manual. Odes sa, F L: P sychological As sess ment R es ources ; 1985. E ys enck HJ . T he B iological B as is of P e rs onality. S pringfield IL: C harles T homas ; 1967. G underson J , P hilips C . P ersonality Disorders . In: HI, S adock B J , eds. C omprehe ns ive T e xtbook of P s ychiatry. 7th ed. B altimore: W illiams & W ilkins ; J offe R T , B agby R M, Levitt AJ , R egan J J , P arker T ridimens ional P ers onality Questionnaire in major 2798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 219 of 220

depres sion. Am J P s ychiatry. 1993;150:959–960. J oyce P R , Mulder R T , C loninger C R : T emperament predicts clomipramine and desipramine res pons e in major depress ion. J Affect Dis ord. 1994;30:35–46. K ernberg O. B orde rline C onditions and P athological Narcis s is m. New Y ork: Aronson; 1975. Millon T . Manual for the MC MI II. 2nd ed. MN: National C omputer S ys tems; 1987. Mulder R , J oyce P : T emperament and structure of personality dis order s ymptoms. P s ychol Me d. 1997;27:99–106. *P erry C , V aillant G . P ersonality dis orders. In: S adock B J , eds . C omprehe ns ive T e xtbook of 5th ed. B altimore: W illiams & W ilkins ; 1989:1352– R eich J , F rances A: T he structural interview method diagnosing borderline dis orders. P s ychiatr Q . 1984;56:229–235. S chneider K . P s ychopathic P e rs onalities . London: 1956. S jobring H: P ers onality s tructure and development: model and its application. Acta P s ychiatr S cand 1973;244:1–204. *S vrakic DM, W hitehead C , P rzybeck T R , C loninger 2799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 220 of 220

Dimens ional diagnosis of personality dis orders by seven factor model of temperament and character. G e n P s ychiatry. 1993;50:991–999. S vrakic NM, S vrakic DM, C loninger C R : A general quantitative theory of personality development: F undamentals of a self-organizing ps ychobiological complex. Dev P s ychopathol. 1996;8:247–272. T ome MB , C loninger C R , W ats on J P , Is aac MT : S erotonergic autoreceptor blockade in the reduction antidepres sant latency: P ers onality variables and res ponse to paroxetine and pindolol. J Affect Dis ord. 1997;44:101–109. *T ulving E : E pis odic memory: F rom mind to brain. R ev P s ychol. 2002;53:1–25. World Health Organization. Inte rnational of Dis eas es . 10th ed. G eneva: World Health Organization; 1987. Zuckerman M: T he ps ychobiological model for impulsive uns ocialized s ens ation s eeking: A comparative approach. Neurops ychobiology. 1996;34:125–129.

2800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

01/01/2009

Page 1 of 41

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 24 - P s ychological F a ctors Affecting Medica l C onditions > 24.1: of P s ychos oma tic Medicine

24.1: His tory of Ps yc hos omatic Medic ine Harold I. K aplan M.D. P art of "24 - P sychological F actors Affecting Medical C onditions " E ditor's note: T he founding editor of this textbook, I. K aplan, M.D., had a long-standing interest in ps ychos omatic medicine and the history of ps ychiatry. wrote the section on the his tory of ps ychos omatic medicine for the firs t edition of this textbook and for subs equent edition thereafter until his death in 1998. following vers ion appeared in the sixth edition and is included here with minor changes made by the editors.

INTR ODUC TION P sychos omatic (ps ychophys iological) medicine has specific area of concern within the field of psychiatry for more than 50 years . It is imposs ible to trace its history, however, without immediately becoming involved with the idea of mindbody unity implied by the G reek words ps yche (breath, to breathe) and s oma (body). T he of mind and body and how they relate has been cons idered by all ages . T hat relations hip is reflected in various editions of the American P sychiatric Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs which, in 1980, deleted the nos ological term 2801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 2 of 41

ps ychophys iological (or ps ychos omatic) dis orde rs and replaced it with ps ychological factors affe cting phys ical conditions . T hat change was ill advised and continued question about how ps ychic and somatic holism was to defined. T he American B oard of Medical S pecialties the American B oard of P sychiatry and Neurology a s eparate board to be called the Ame rican B oard of P s ychos omatic Me dicine to take effect in 2005. T hat decis ion not only recognizes the importance of the field but also brings the term ps ychos omatic back in us e. T o speak of mind and body is to s uggest that other twos omes, such as mindbody, are more often seen as oppos ites than as polarities: materialimmaterial, knownunknown, objectives ubjective, matterspirit, visibleinvis ible, and realunreal. It als o is not different the belief of the common pers on, held onto from often in contradiction to later-formed beliefs , that his or her ps yche precedes his or her embodiment and will survive his body's dis integration. Although often cited contributing a mindbody (ps yche vs . s oma) split to Wes tern civilization, the G reeks , through a s mall group their philosopher-scientis ts , tried to dignify matter and raise it to a position of equality with s pirit, even to the eminence of preexistence. T heir atomis ts believed that from the clas hing of original atoms came all matter. is preeminent, s pirit or matter, mind or body? How to depends, to a certain extent, on the resolution of that question.

MINDB ODY P R OB L E M 2802 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 3 of 41

Prehis tory T he child of today has collected a small s torehous e of reliable information involving cause-and-effect relations hips , many concerned with the effect of wish will on his or her environment. C hildren know their and loves and how to move their fingers, which are part them, to get s omething for a more inclus ive s elf. T hey know that there is s ometimes light and sometimes darkness but have no idea why, although, as they culture teaches them why. F or the child of prehis toric times, the s torehous e of caus e-and-effect relationships was, however quickly expanding, s mall. S pirit was s till the prime force, the unseen but known power that controlled events as handedly and with as much determination as a dream overtakes one. B ecause the child of prehistoric times not wis h to die, to s uffer pain or weaknes s, or to be wounded, those happenings were attributed to the of an evil spirit or will. It could be the will of an enemy rival, the spirit of a violated place, the world-controlling spirits threatening him or her out of whims y, or the of the dead, angry at not receiving appropriate B ad things existed outs ide of the individual pers on and entered the body to attack. E ven death was not an indwelling potential, but a visitor who could s uddenly seen standing nearby during the moments before the stiffening of the body. Disease, in its more serious was the res ult of a body's being pos sess ed by an illintentioned s pirit. W ounds, however, were different. A hunter saw the enemy, the raised club, and the gas h or broken bone and lived through the course of healing; 2803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 4 of 41

early began to notice what helped or hindered the of healing and began to collect a body of rational observation concerning wounds . Dis eas e remained spiritual; as soon as humans the necess arily s harp stone tools (circa 10,000 B C ), began to bore holes in the s kulls of s ick pers ons to let evil out (F ig. 24.1-1). T repanation did not always kill its patients; a good number recoveredaided, it is by the power of the personality of the operating or medicine man. At one time, the s haman exorcised disease-bearing demon by wrestling with him in the and defeating him. Later, the more rational medicine might rub the patient, remove an object from the body the patient by sleight of hand, or bleed him. Whatever healer's approach, he or she always gave the patient a renewed will to health by the power of s uggestion, in best tradition of the doctorpatient relationship. T hus did primitive people emphasize a holistic concept, rather a dichotomized psyche and s oma.

2804 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 5 of 41

FIGUR E 24.1-1 A trepanned Neolithic s kull found at Nogent-Les -V ierges . S hamans bored holes in the s kull evil spirits es cape. (C ourtes y of the B ettmann Archive, New Y ork.) P.2106

E gyptians E gypt's embalmers were a separated cas te of the hereditary pries thood; when they cut into the bodies of 2805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 6 of 41

the dead to draw out, to was h, and to wrap in linen the intes tines, liver, and, usually, the kidney, they were leave the heart intact. F or there res ted the soul, the person's intelligence and emotions , his or her pers onal T he priest-phys icians of E gypt named many parts of body, but they referred to the nerves , mus cles, arteries, and veins by the s ame word and thought of those arrangements as channels in a branching system that connected the heart to the working parts of the eyes , fingers , testicles, and toes . T hrough those conduits pas sed air, water, s emen, and all the other neces sary s ubs tances , including the initial breath of which was s aid to enter through the right ear; the of death made its way into the body through the left Like earlier people, the E gyptians imagined death and disease to come into the body from the outside. disease was attributed to the s ame trinity as it had earlier people: the gods , spiritses pecially those of the deadand the evil wishes of humans. T hoth, Isis, her s on Horus, and the vizier Imhotep 2800 B C ), who was eventually deified as a healing god because of his medical knowledge, were all called on aid in exorcising bad s pirits , but E gypt's three class es famous phys icians, magicians , and pries ts of S ekhmentmany of them s pecialists in the dis eases of specific part of the bodydid not rely on the gods to do work. T hey compiled medical observations to aid thems elves and their descendants in diagnosis and treatment. In the E bers papyrus (copied circa 1600 B C older manuscripts), 877 s ections dealt with treatment specific complaints ; in only 47 of them did the writer bother to diagnose the dis eas e, ass uming that 2806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 7 of 41

on the part of his readers. T he text proceeded in this manner: If you examine a man who s uffers from X, you may s ay it is X, and you may do for it x, x, or x. suggested included oral rites, manual rites, and drug doses . T he phys ician who chos e to us e a spell addres s the troubled organ directlyOh, failing eyes or might choos e manual rites and tie four or s even knots a thread or apply s aliva or mass age to the affected He might choos e to apply ointments or poultices of animal, vegetable, or mineral s ubs tances or choose the more expensive method of introducing drugs by recipe into the body, and he might do so with or without incantation. If the case looked incurable, he limit his actions to a comforting ritual and choose not to treat the patient furthera stand cons idered ethical. was a lot to choos e from, and the choice might be and effective, irrational and effective, or magical and ineffective. A different balance appeared in the roughly E dwin S mith papyrus , mainly a handbook for the treatment of wounds. As noted previous ly, in wounding, there is witnes s to the cause-and-effect connection; where cause is seen to be rational, treatment tends to so, too. Not s urprisingly, then, for the 48 wound cases described in the papyrus , only the rational treatments were sugges ted. P hysical surgery was developing out phys ical observations , pure magic became the for the otherwise incurable, and, in the middle ground internal and external medicine, various methods approaching body and mind were being tried.

B abylonians and As s yrians 2807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 8 of 41

T he medical texts of the conglomerate S umerianB abylonian-Ass yrian civilization (circa 2500 to 500 B C ) remarkably s imilar to the contemporary but more texts of E gypt. If you see X, begin most texts, and they on to recommend the same kinds of treatments magic and reasonoral and manual rites and the prescription of fanciful or effective drugs. T he overall sens e, however, is that those texts are heavily toward magic, and no exis ting text is totally rational. T he sophisticated herb doctors of that civilization's hereditary pries thood could cons ult texts dealing with hundreds of vegetable and mineral drugs . Its surgical doctors were common enough to be warned by Hammurabi's laws that patients dying under their knives would be avenged with the amputation of the surgeon's hand. Its exorcists had, at the tips of their tongues, the names of 6,000 demons known to cause 6,000 different complaints: Idpa attacked the throat, attacked the neck, and s o on. Idpa and Utuq and their cohorts were address ed directly and urged to leave the body, after which the doctor would try to repair the damage. As did the E gyptian phys icians, when the parted from his demon-vacated patient, he left him or with an amulet to wear over the skin where the demon had been. T he ultimate s ource of disease might be the gods who sent pain as punis hment for ritual or moral error, the neglected and angered dead, the hand of a ghos t from an unburied body, an ill wind, sorcery purchased the pocket-book of a malevolent person, or the patient he or s he had committed a ritual or moral sin. a pers on in pain was disgraced and urged to look into 2808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 9 of 41

or her s oul and to examine s ins until the charms of the priest freed him or her from sicknes s. Disease was of as having a caus e within the patient, rather than on him or her from the outs ide. T he sick man was a was the prevailing belief. T he patient prayed, and went to an exorcis t. Dis eas e in that connection ps ychos omatic in all its as pects .

J udeo-C hris tian Heritage F or the Hebrews , disease was predominantly the punis hment s uffered for the sin of having dis obeyed or His laws. I kill, and I make alive; I wound, and I heal, warned (Deuteronomy 32:39), and other healers in the form of doctors were scorned. F or group s in, there was group punishment of pestilence or plague. Dis obeying G od's law did have the direct result of less ening the community's degree of s anitation and hygiene, S abbath res t, abs taining from carnivorous animals , is olating lepers , and burying excrement in camp were some of the laws enforced by a pries thood that, in no way, was a body of public health officials trying to parasitic and epidemic disease. If thou wilt give ear to his commandments, and keep all statutes, I will put none of these dis eas es upon thee, I have brought upon the E gyptians : for I am the Lord healeth thee (E xodus 15:26). With laps es into E gyptian and As syrian demon belief, J ews generally upheld their laws and profited from their res pect for the power of contagion. P.2107 F or the sin of individual failure to obey G od, there was 2809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 10 of 41

punis hment of individual dis eas e. If the priests were public health officials , the prophets, like the s hamans before them, who could also see the invis ible and know the unknowable, were more the recours e of the s ick could not, by thems elves , find a new heart. Like the E gyptians , the J ews considered the heart to be the intelligence and will. T hey believed the will and the to be interacting and bound together: Make you a new heart and a new s pirit; for why will ye die? (E zekiel S ongs were thought to s oothe the heavy heart, and pleas ant words were thought to sweeten the soul and heal the body. Overall, to make oneself right with G od to find oneself on the road back to health. P ersons like K ing As a, who gave up and turned to herbalis ts, were criticized until the time of the second century B C . B y the sick among the J ews were urged to pray and then go to a doctor, for the Lord created doctors, too. of Maccabean times would whisper the ancient into the ear of a patient as he or s he s wallowed his or medicine: If thou wilt give ear to his commandments I put none of these diseases upon thee (E xodus 15:26). J esus, too, s aw the body and the spirit as a whole: Whatever his prophetic healing powers may have does not appear to have thought of disease as a punis hment for disobedience to law but more as an imbalance within the patient, an imbalance correctable a psychic act of faith. In locating the origin of dis eas e squarely within the patient, at least in mos t cases , did not differ s o much from the G reek civilization that preceded and s urrounded him as he did from the E uropean C hris tians who s ucceeded him.

2810 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 11 of 41

Greeks Like the rest of the ancient world, the G reeks were impres sed by E gypt's medicine. When they eventually deified their As klepios (Aesculapius), a man of the 13th century B C who had spread a knowledge of bandaging and herbal medicines and who had also advocated the humane treatment of the insane, they identified him E gypt's more ancient Imhotep. T here are s cores of references in T he Iliad (eighth century B C , disputed) to wounds; as in E gypt, the pries t-phys icians of G reece pass ed on to their sons observations on wounds and diseases . T hey did so through the centuries at medical schools that grew up at C nidus, where diagnos is was specialty; at C os , where prognos is was featured; and C rotona. E ventually, that priesthood lost its that the status be inherited. It was the deities who brought disease, and it was they who brought healing; spirit and body were an unity. T here were scores of temples to As klepios by the fifth century B C (F ig. 24.1-2), and the patient coming to such an ins titution planned to stay a few days to a regime that progress ed from bathing, dieting, and touring the temple's display of testimonials through praying, reporting s ymptoms, and being examined, to sacrificing an animal and sleeping in its s kin or a T hat was the sleep of incubation, taking place on ground. During this s leep, the pries t-phys ician might to the patient and make suggestions ; if surgery was required, it might be done on a drugged sleeper by a wearing the robes of the god; or, perhaps, no interview took place, and the arrival of the god occurred only in dreams . B y is olation during the temple s tay, the patient 2811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 12 of 41

was brought in touch with his or her emotions, with his her private spirit world, and perhaps reunified himself herself toward health. In the morning, his or her were interpreted by a pries t-phys ician, who pointed out elements of the dreams that could be us ed for Like other ancients, the priest-phys ician called believed in a relations hip between a life force and its housing, the body, and tried to cure the body by that force.

FIGUR E 24.1-2 As klepieion of E pidaurus in its pres ent status . T he labyrinthine structure of the tholos , where mental patients had to walk and to sleep to be able to reach the center. In the course of this highly s ymbolic proces s, they were healed by the god while dreaming. (F rom K ereny C . As kle pios . Arche typal Image of the P hys ician's E xis te nce. New Y ork: P antheon B ooks ; 2812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 13 of 41

with permiss ion.)

Hippoc rates S on of a physician of Asklepios , Hippocrates (460 to B C ) s tudied medicine at C os . He probably wrote only the 60 books attached to his name, one of them with the often-misquoted phras e: Life is s hort, but [the] [of medicine] is long [in the learning]. T he learning took lifetime and involved obs ervation, hypothes is , and the study of tradition. Hippocrates hims elf selected from E gyptian and the G reek traditions , and he ceas eless ly observed and hypothesized. Hethat is to say, the authors of the Hippocrates books wove together a categorization of temperaments with contemporary categories of elements and qualities, producing a of dis eas e that a number of clinicians today take as a simplified statement of the workings of the endocrine system. Dis eas e originated within the body and was due not to spirits but to an imbalance in fluid matter. T hat could be related to or even caus ed by a similar in the patient's external environment. Hippocrates the visiting doctor to cons ider the altitude, the wind direction, the purity of water s upply, and the season of year before making any diagnos is . He pointed out that citizens of cities in particular environments would run to phlegmatic or sanguine temperaments as a reflection the city's coldness or heat. P hys ical or fluid imbalance could be caused by emotional ups et, too. Hippocrates reported that fear produced s weat and that shame 2813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 14 of 41

brought on palpitations of the heart; he urged young phys icians to look at patients with kindly express ions never with impatience, because impatience could the return of health. He is s aid to have cured a king of intes tinal lesion by analyzing a dream. It was who wrote in order to cure the human body, it is to have a knowledge of the whole of things. Although he did not understand how amulets worked, admitted that they sometimes helped cure diseas es. was natural; to get that idea across to the family of a patient and to give hims elf credibility with them, the young doctor should be sure to predict death after viewing a new patient who showed s igns of its advent. If you cut into a head with a bad s mell and too mois t a brain, Hippocrates pointed out in S acred you plainly see that it is not a god but a dis eas e that the body. T he search for the location of the mind occupied the G reeks in a discus sion of the organ housing that and became temporarily complicated, but ultimately clarified, by a tendency to separate the functions of into various subdivis ions, s uch as life force, reason, cons ciousnes s, and the emotions . A hundred years Hippocrates , Heraclitus (535 to 475 B C ) had s tated soul or life force could not be contained in a particular organ, neither could the heart of the E gyptians nor the brain proposed by his predeces sor Alcmaeon (s ixth century B C ). Hippocrates cons idered the brain to be center of the s ens es and of reas on, but he agreed with others that a certain life force called P.2108 2814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 15 of 41

pne uma was more basic. B ecause pneuma controlled brain, it was the ultimate s ource of intelligence and T he discuss ion was to continue.

Idealis ts vers us A tomis ts Walking in the academy at Athens, P lato (427 to 347 imagined an ideal world; each palpable bird and each tangible tree he s aw was but a copy of the ideal bird the ideal tree in a perfect preexis ting mental world. Like the Orphics , who felt the s oul to be reincarnated in succes sive bodies, and like P ythagoras (sixth century who regarded the psyche as an immortal s elf, P lato spirit as superior, a mas ter to the s lave, matter. As an idealist, he went agains t the tendency of the preceding generations to dignify and to study matter, developed the theories of Democritus , the atomis t (born 460 B C ). As expres sed much later by Lucretius in O n the N ature the Univers e (55 B C ), the creed of the atomists begins matter. Matter precedes ps yche and is what the world made of, its irreducible parts being called atoms , movement and chance collis ion, gave rise to the world is known. T he human being is made up of a multitude atoms ; when he or s he dies , the atoms go back into the world, whereas , once the lute is broken, the mus ic obtainable from its s trings is no more. In the capital of the G raeco-R oman world, As clepiades century B C ) founded a medical theory s temming from atomism. In his system, the s oul had no location but the convergence of all perception; dis turbances of the pass ions could caus e mental disease, whereas too cons triction or relaxation in the vacuum or space 2815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 16 of 41

the gyrating atoms of the body caus ed phys ical In T imae us , P lato remarked that trouble in the soul bring trouble to the body, and, in C harmide s , P lato S ocrates, who had hims elf attributed the words to a king: As it is not proper to cure the eyes without the nor the head without the body, s o neither is it proper to cure the body without the soul. Aris totle (384 to 322 B C ) observed that the emotions of anger, fear, courage, and joy affect the body, and (first century B C ) pinpointed a dis turbance of the as one of the s ix major causes of paralysis. T he had gradually become a factor of mind or ps yche on attention was being focus ed.

G alen T he G reek physician G alen (130 to 200 AD) lived in where he attended the emperor Marcus Aurelius . looked on Hippocrates as an ancient, one from whom had learned and whos e techniques he attempted to reconcile with those of the P latonic idealists and with those of the atomistic materialis ts. In his compilation, G alen as sembled an eclectic and often confus ing summation of G reek medicine that was to be the foundation of E uropean medicine for 1,000 years to G alen s aw the brain as the center of s ens ation, motion, reason; it was a rational s oul. Like P lato, G alen named irrational subsouls . One was the energetic, irascible soul, located in the heart, and the other was the female s oul, situated in the liver. However, unlike P lato, G alen cons idered the three souls to be slaves, rather masters, of the body; material considerations of 2816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 17 of 41

dampness , s tructure, and animal s pirits circulating in body ultimately determined how one felt and thought. S oul, therefore, was material or of the body. T he E gyptian vis ion of the breath of life entering the conduits of the body through the right ear and of body fluids thereafter circulating in those branching tubes been reconceived in a number of ways by the G reeks. S toics , who were atomists, divided the kingdoms of the living into plant, animal, and man. P lants grew, animals grew and moved about, and man grew and moved and thought. Air or pneuma drawn into the body was adapted to each of those three functions of man. G alen us ed that framework and sugges ted that inges ted food was converted into blood in the liver and sent out as natural s pirits through the veins, from which the spirits performed the function of growth. One vein brought natural spirits to the right ventricle of the heart. T here pass ed through the s eptum (not known to be a s olid of mus cle) into the left ventricle, where, during the expansion of diastole, they mixed ever s o s lightly with pneuma drawn from the lungs . As vital spirits , that was pus hed out of the heart during s ys tole and carried through the body by the arteries to monitor locomotion. S ome of the vital spirits were carried to the brain and, pass ing through a network of s pecial vess els , became animal (from anima, s oul) spirits capable of caus ing thought. Animal s pirits pass ed outward through the by way of the nerves. G alen reported that he began treating one cas e of depres sion with two causative poss ibilities in mind: the phys ical caus e of the overbalance of black bile and the ps ychic caus e of inordinate des ire. An erratic pulse in 2817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 18 of 41

woman patient at the mention of the dancer P ylades caus ed him to choose the s econd alternative. He sometimes pres cribed herbals , such as opium, for emotional and phys ical complaints . R ather than embodying a single point of view, G alen can be cons idered an anthology of G reek medical opinion, offering to s ucceeding generations a view of holistic interplay between psyche and soma, an interplay that largely ignored as the tendency became, like that the G reeks, to emphas ize spiritual agents only in the etiology of disease.

Middle Ages T he E uropean tribesmen who finally occupied R ome brought with them a slighter tradition of medical observation. Although the works of many of the G reek Latin writers were trans mitted through the C hristian church, the Mediterranean's civilization of increasingly objective observation was run to ground by the return belief in spiritual powers , demons, witches, and sin. All those agents were accused of having produced during that period (500 to 1500 AD), and healing again became a spiritual iss ue. T he evil was within and sick person might consult a priest or the relics of a and promise to give up his or her own sin, lack of faith, evil impuls es in exchange for health. T he status of the phys ician fell. S ympathetic magic returned in the form amulets placed over the eye of the statue of a saint or eye-shaped talis man harbored by the patient with troubled vision.

R enais s anc e 2818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 19 of 41

After 1,000 years of religious dominance, interes t in caus es and cures of disease returned during the R enais sance. During the R enais sance (1400 to 1650 the study of the material world renewed itself, but was more than elevated to a position of a proper s tudy balance with spiritit eventually became the dominant virtually only credited field. T hat dominance was in the study of human health, which was divided into flouris hing investigation of the body's structures and an atrophying s tudy of the emotions.

Des c artes and an Interac ting Duality After C opernicus (1473 to 1543 AD) and the suntheory of the universe, things as they appeared to be no longer things as they were. R ene Des cartes (1596 1650 AD) began his ques t for knowledge by formerly held beliefs and s tarting fresh. He dismis sed as sumption and came quickly into hims elf, to his mind its s elf-awarenes s, not to his s enses , which told him bit of wax was hard and yellow and made a noise when struck, because only a few minutes later the s ame wax, warmed by fire, was soft, dark, and no longer of producing s ound; the s ens es were not reliable. If stripped away all apparent or s ens ual terms of what was wax? A mathematician hims elf, Des cartes agree with the mathematicians and phys icists, who ran back to Lucretius and the atomists , that the es sential quality of the wax was the s ame as the es sential P.2109 of all matter; it was extendable and movable. He again of his own mind and its relationship to objects. 2819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 20 of 41

C ould he be fooling himself a second time? C ould he casting onto wax his own mental s ens e of himself as extended and movable? P erhaps. W as there anything exis ting that was not a projection of his own mind? Des cartes decided, was the one thing man could not imagined. A man cannot s ens e himself to be eternal, immutable, omnipotent, or perfect, because he so obviously the oppos ite; those qualities, becaus e knows them, must then exis t outside man, in the in the pers on of G od. Having s atisfied himself as to the exis tence of spirit, Des cartes turned to matter. If G od is perfect, He does not deceive; if He does not deceive, then the world vis ible to the viewer is not a delus ion; it is real, although the relative realnes s of different kinds of sensual impress ions mus t be S pirit and matter are real, although s pirit precedes In the beginning, s piritual force without movement and extension created movement and extension, created hardnes s, yellowness , and the blue of the infinitely s oft C artesian dualism gave matter more importance than P latonic idealis m had but less importance than the atomists had given it. Descartes' followers occupied thems elves uns ucces sfully with examining the which matter that moves came into contact with mind; all concluded with Des cartes that soul and body the pineal gland. As materialism grew in strength, Des cartes' famous phras e cogito, ergo sum was being turned inside out into I am; therefore, I think.

19th and 20th C enturies In the 19th century, the mindbody schism spread to its furthes t division. T he 20th century witness ed a new 2820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 21 of 41

attempt to view mindbody holis tically.

The C ell T he ultimate s oma became the cell; the diseased cell became the s ource of bodily disease. R udolf V irchow to 1902) made clear through laboratory work that has its origin in the dis ease of the cell. F irs t, he showed a change toward pathology takes place within cells ; then, a change in the structure of the cell and, lastly, physiological disorder can be s een in the that make up the tiss ue of an organ. Louis P as teur (1822 to 1895) als o s tudied the single is olated in his laboratory. T he temple of the future, according to P asteur, was to be the laboratory. Within framework of laboratory-based somatic medicine, no generalizations were produced from the growing list of observations made on the relations hip between psyche and s oma. Indeed, the thoroughly somatic or tenor of the times was s hown by scientis ts, such as Huxley (1825 to 1895), who believed that mental in thems elves had no caus al s ignificance but were the product of somatic activity.

S igmund F reud It was S igmund F reud (1856 to 1939) who brought and s oma back together, us ing memory as the of the psyche. He demons trated the importance of the emotions in producing mental dis turbances and disorders . His early psychoanalytic formulations the role of psychic determinism in somatic convers ion reactions . His contribution to a more holistic outlook beyond reintroducing the interrelationship of ps yche 2821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 22 of 41

soma to reins tating the therapeutic doctorpatient relations hip, seen in the function of s haman and With transference and countertrans ference, F reud that relations hip out of the religious framework of hope and faith and into an intellectually understandable dynamis m. P icking up where the G reeks and R omans left off, F reud redignified the s tudy of the emotions as a separate s tudy and pointed to their relations hip with the soma in the new field of ps ychiatry.

E MOTIONS A ND C E L L TIS S UE Using F reud's ins ight, a number of workers in the early decades of the 20th century tried to expand the unders tanding of the interrelations hip of ps yche and soma. T he influence on adult organ tiss ue of various unresolved pregenital impulses was propos ed by K arl Abraham in 1927, the application of the idea of reaction to organs under the control of the autonomic nervous s ys tems was described by S andor F erenczi in 1926, the attaching of a s ymbolic meaning to fever and hemorrhage was sugges ted by G eorge G roddeck in and the poss ibility was suggested that troubled mental states translate into somatic activity that provides an underlying altered basis of activity, branching into a number of pos sible dis eas es. T wo trends were developing, one s uggesting that emotions led to specific cell and tis sue damage, and second holding that generalized anxiety created the preconditions for a number of not-neces sarily predetermined diseases. C ases of shell shock during War I and new endocrine s tudies provided the swell of interes t in theory evidenced in the 1930s . 2822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 23 of 41

Inc orporation of S tres s along Pathways In 1950, F ranz Alexander believed that, if a s pecific stimulus or s tres s occurred, it express ed its elf in the specific res ponse of a predetermined organ. He the fight-or-flight alert of the body against s tres s, as reported by W . B . C annon in 1932, to the problem. Alexander s aw conflict as a s tres s and s uggested that, when conflict pres ents itself to a person, he or s he may suppress the stress and produce, through the voluntary nervous s ys tem, a reaction such as the conversion described by F reud. On the other hand, after stress , he or she may, through the autonomic s ys tem, his or her s ympathetic respons es alert for heightened aggres sion or flight or his or her parasympathetic res ponses alerted for heightened vegetative activity. P rolonged alertness and tension can produce phys iological dis orders and eventual pathology of the organs of the vis cera. F or ins tance, Alexander, using much of F reudian ps ychodynamics , postulated that, in a pas siveperson without s omeone to satisfy his or her stress is created. T hat particular s tres s may stimulate keep alert the paras ympathetic nervous system, which means that too much gas tric acid is s ecreted, and hypermotility results, all of which may lead to a peptic ulcer. Another dependent pers on with a different set may, in repres sing conflict, s timulate the parasympathetic overfunctioning through pathways leading to colitis or as thma. S till other dependent in seeking to move beyond dependency, incorporate stress ; s uch a move entails overs timulation of the 2823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 24 of 41

sympathetic s ys tem, and the chronic alertness caus ed thereby produces migraine, hypertens ion, or arthritis . Alexander called thos e relations hips conflict Although many other workers us ed different specificity approaches, Alexander's C hicago P s ychoanalytic group has continued to s upport his original findings, dating back to the 1930s , and continues to publis h additional s upportive data. Although there is s ome validation of Alexander's there has been considerable disagreement on whether poss ible to demons trate the same s pecific conflicts in cases of the same dis eas e. It is als o ques tionable the conflicts postulated for one dis ease differ from as sociated with other diseases. In other words, it has been poss ible, thus far, to predict disease from conflict vice versa. In addition, it is highly doubtful whether specific ps ychological conflicts can be correlated or experimentally with specific physiological vegetative changes. Alexander's views have received s ignificant phys iological support from several hundred cas e reported in the literature. P.2110 A number of inves tigators have developed the pathway concept of cons tellations into other theories involving whole personality. T he ambitious, hard-driving man prone to coronary occlus ion, as described by F landers Dunbar in 1954, is no longer accepted as having predis pos ition enough to dictate death by coronary occlusion. However, he is not so different from the competitive, res tless , time-haunted, and coronarytype A pers on proposed by M. F riedman and R . H. 2824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 25 of 41

R os enman in 1959. F riedman and others later listed phys iological characteris tics of their type A person: plasma triglycerides, high choles terol level, hyperins ulinemic respons e to glucose challenge, and levels of noradrenaline pres ent in urine. S imilarly, correlations between cancer proneness and who repres s and deny emotional s tres s and who are extremely s ens itive to loss have been found in some cohorts of cancer patients.

Nons pec ific Inc orporation of S tres s T here are, it seems , four general types of reaction to the normal reaction, in which alert is followed by an of defense; the neurotic reaction, in which the alert or anxiety is so great that the defense becomes the ps ychotic reaction, in which the alarm may be misperceived or even ignored; and the psychosomatic reaction, in which defens e by the ps yche fails, and the is translated into s omatic systems , caus ing changes in body tis sue. T he second trend in ps ychosomatic has been that of inves tigating what happens to a a nons pecific way when faced with s tres s; chronic can be studied by itself without being tied to s pecific pathway reactions or ps ychic cons tellations . In the 1950s, Harold W olff and S tewart Wolf observed chronic hyperfunction or chronic hypofunction in the vascular and secretory activities of the mucos a of the gastrointestinal (G I) and res piratory systems can pathology. Overfunctioning of the mucos a was by Wolff with hostility, and underfunctioning was correlated with fear or sadnes s. T he patient's entire reactive patterning and his or her life history account 2825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 26 of 41

whether he or she reacts to stress by hyperfunctioning hypofunctioning. Other workers in the nonspecific group have demonstrated various poss ible mechanisms by which ps ychologically induced s tres s may cause organic in humans and animals . In 1950, Hans S elye thought the hypophyseal-adrenocortical axis res ponded to types of physical and ps ychic s tres s with hormonal changes that can ultimately caus e a variety of organic diseases , s uch as rheumatoid arthritis and peptic ulcer. S elye viewed s uch diseases as a byproduct of the attempt to adapt to stress from any s ource. E xperimental psychologis ts with a learning theory conception of behavior studied the effects of chronic unrelieved anxiety in humans and animals and found gastric hydrochloric acid production increas es under circums tances . B ecaus e s uch acidity is a precursor of peptic ulcer, they concluded that chronic anxiety, from any s ource whats oever, is the variable intervening between the behavioral and physical events involved in ps ychos omatic illness . Other animal experimenters success fully produced a variety of ps ychosomatic s ymptoms , such as certain res piratory conditions in animals , by experimentally creating s tres sful s ituations and inducing conflict. it can be as sumed that animals do not have a human being's capacity for symbolic thought, but because they do demons trate ps ychos omatic phenomena in to ps ychogenic s tres s, one wonders whether it is or practical to postulate the operation of specific ps ychological conflicts , which can hardly be meaningful 2826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 27 of 41

an animal, in the etiology of s uch dis ease. If, on the promise of reward, a pers on can control his or heart rate, s ys tolic blood press ure, temperature, and rhythm frequency, as occurs in biofeedback res earchin short, more of the autonomic system's reactions than before suppos edwhere does the power of control of the body by the will actually end? If human beings show altered electroencephalographic (E E G ) patterns in res ponse to words, and if people who tend to conform social pres sure show a lower level of skin potential than those who do not, what is the exact boundary between an organism and its environment? T he control the autonomic nervous system through such was sugges ted by Neal Miller in 1969. P avlovian conditioning has been s tudied intens ively by S oviet neurophys iologists as a causative agent in disease. T here are a multitude of unans wered but questions in the field of ps ychos omatic medicine. factors , what one may call the outer ps yche , have come to the fore as an area of study.

S oc ial F ac tors In 1951, J urgen R ues ch, in studying communication between people, propos ed that psychos omatic are infantile in nature, because the s ick person, like the infant, expres ses his or her somehow uns peakable communication through his or her own viscera. T . H. Holmes and R . H. R ahe s howed that life cris es often precede illness and that there is s ome correlation the intens ity of the cris is and the length and the of the illness that follows ; the crisis ranked as the most intens e by s ubjects was the death of a spous e. Other 2827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 28 of 41

suggested a giving-upgiven-up complex, in which a person feels powerless to change his or her or himself or hers elf and eventually los es the will to try, becoming mentally or phys ically ill, perhaps because of changes in the immunological and neuroendocrine systems . Lack of affective involvement with their love-objects, called ale xithymia, in ps ychos omatic patients has been suggested by J ohn C . Nemiah and P eter C . S ifneos . of telephone-company employees s howed that the workers who developed heart dis eas e were apt to be hampered by poss es sing only a high school education. Another s tudy among monks s howed a higher of myocardial infarction among men ris ing from a low socioeconomic s tatus than among those from a middleclas s background. T he duration of a s ickness may connected with the pers on's bas ic attitude toward being sick.

Toward a C larified Interac tion In reports on the disorders now clas sified as ps ychos omatic, there is a tendency to is olate what becomes of the s tres s produced by conflict. T he are often s een as unres olved holdovers from the pregenital period: dependence vers us independence res ultant tens ions leading to ulcer, riddance versus retention and resultant tensions leading to intestinal disorders , and express ion or s uppress ion of anxiety or and res ulting tens ions leading to cardiovascular and vascular headache. T he panic at feared object los s person with a high demand for s upport, leading to hyperthyroidism, and rheumatoid arthritis, is not, strictly 2828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 29 of 41

speaking, a conflict. No discus sion of illnes s can fail to touch on terminal and the death that awaits everyone. T he organis m fail, but how? If not by direct violence or the ravages of parasitic and epidemic disease, then by the gradual deviations of cells and organic s ys tems from their activity. T he common pers on knows that one member his or her family takes the winter's virus into his or her res piratory tract, whereas another endures it as a stomach: to each his or her own s trengths and weaknes ses. A busload of people presents not only 40-odd lives , but also 40-odd deaths ; what percentage of them is hurried the effects of emotional res pons es on organ tiss ue is known. T he physician of today deals , like people of prehis tory, with the triad of death, disease, and K nowledge of their interrelations hip has increased, but time has not come when phys icians can s ay, as Hippocrates was wont to do, that the people who live at such an altitude in such a climate tend to such a body with such a chemical balance, and live in such a and die in such a manner. F or a s ummary of modern concepts of ps ychos omatic medicine, s ee T able 24.1-

Table 24.1-1 Major C onc eptual Trends in Ps yc hos omatic I. P s ychoanalytic 2829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 30 of 41

   S igmund F reud (1900) S omatic involvement in conversion hys teria, which is psychogenic in origine.g., paralysis of an extremity. C onversion hysteria always has a primary ps ychic caus e and meaning; i.e., it repres ents the s ymbolic expres sion of an uncons cious conflict. It involves organs innervated only by the voluntary neuromuscular or the s ens orymotor nervous P sychic energy that is dammed up is discharged through physiological outlets .    S andor F erenczi (1910) T he concept of hysteria is applied to organs innervated by the autonomic nervous s ys tem; e.g., the bleeding of ulcerative colitis may be described as specific ps ychic fantas y. (Dis eas es , s uch as known today as ps ychos omatic diseases that only in organs innervated by the autonomic system.) F erenczi's interpretation of symptoms as convers ion reactions was the first application of the concept to diseases s uch as    S mith E ly J elliffe, G eorge G roddeck (1910) organic diseases, s uch as fever and hemorrhage, held to have primary psychic meanings ; i.e., they interpreted as convers ion symptoms that the expres sion of unconscious fantas ies .    F ranz Alexander (1934, 1968) P s ychos omatic symptoms occur only in organs innervated by the

2830 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 31 of 41

autonomic nervous s ys tem and have no s pecific ps ychic meaning (as does conversion hysteria) are end res ults of prolonged phys iological states , which are the phys iological accompaniments of certain s pecific unconscious repres sed conflicts. certain cons titutional organic predispos ing in addition to the ps ychic factors involved, ps ychic energy is discharged phys iologically. Alexander's obs ervations were s upported by Weiner's 1957 s tudy of peps inogen P res ented first conceptualization of the biops ychos ocial model.    Helen F landers Dunbar (1936) S pecific personality pictures are as sociated with s pecific ps ychos omatic diseases, an idea similar to Meyer F riedman's 1959 theory of the type A coronary    Helen Deuts ch (1939), P hyllis G reenacre T rauma during birth, infancy, and childhood predis pos es to adult ps ychos omatic disease.    Angel G arma (1950) P eptic ulcer has a specific ps ychological meaning. G arma's idea is an of S igmund F reud's conversion concept to an innervated by the autonomic nervous system. It is similar to S andor F erenczi's concept.    J urgen R uesch (1958) Importance of the between pers ons i.e., communication between the 2831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 32 of 41

patient and the environment. A dis turbance in communication res ults in ps ychos omatic illness , regress ive type of communication. Developed concept of infantile pers onality as vulnerable to ps ychos omatic illness .    P eter S ifneos, J ohn C . Nemiah (1970) the concept of alexithymia. Developmental the capacity and the ability to expres s affect res ult in ps ychos omatic symptom C oncept of alexithymia modified later by S toudemire, who advocated the term emphasizing cultural influences on use of somatic language and s omatic symptom to express distress . II. P sychophysiological    W alter C annon (1927) Demonstrated the phys iological concomitants of some emotions and the important role of the autonomic nervous in producing thos e reactions . T he concept is on P avlovian behavioral experimental designs .    Harold W olff (1943) Attempted to correlate life stress (cons cious ) to physiological response, objective laboratory tes ts. P hysiological change, prolonged, may lead to s tructural change. He es tablis hed the bas ic res earch paradigm for the fields of psychoimmunology, ps ychocardiology, 2832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 33 of 41

ps ychoneuroendocrinology.    Hans S elye (1945) Under s tres s a general adaptation syndrome develops. Adrenal cortical hormones are res ponsible for the phys iological reaction.    J ohn Mason (1968) Individualized emotional res ponses are the dominant factor in determining the magnitude of stress related physiological reactions and the role of intervening variables or key factors in regulating reactions to stress . Mas on's concepts pres aged R ichard 1984 emphasis on the person's cognitive stress ful s timuli as a critical factor determining reactions .    Meyer F riedman (1959) T heory of type A personality as a ris k factor for cardiovas cular T he concept has predominated much of ps ychos omatic res earch for the past 30 years . basic concept was introduced by Helen F landers Dunbar as early as 1936.    R obert Ader (1964) E stablished the basic and the res earch methods for the field of ps ychoneuroimmunology. III. S ociocultural

2833 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 34 of 41

   K aren Horney (1939), J ames Halliday (1948), Margaret Mead (1947) E mphas ized the influence the culture in the development of ps ychosomatic illness . T hey thought that culture influences the mother, who, in turn, affects the child in her relations hip with the childe.g., nursing, child anxiety transmis sion.    T homas Holmes , R ichard R ahe (1975) the severity and the number of recent stress ful events with the likelihood of disease.    J ohn C as sel (1976) P s ychos ocial factors can as either stres sors or buffers in determining vulnerability to dis eas e. IV . S ystems theory    Adolph Meyer (1958) F ormulated the ps ychobiological approach to patient as ses sment that emphasizes the integrated as ses sment of developmental, psychological, social, and biological aspects of the patient's condition. B as ic concept of the biopsychos ocial model in his approach.    Zbigniew Lipowski (1970) A total approach to ps ychos omatic disease is neces sary. E xternal (ecological, infectious , cultural, environmental), internal (emotional), genetic, somatic, and 2834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 35 of 41

cons titutional factors as well as past and pres ent history are important and should be s tudied by inves tigators working in the various fields in they are trained.    G eorge E ngel (1977) C oined the term biops ychos ocial derived from general s ys tems theory and bas ed on conceptual ideas introduced much earlier by Alexander and Meyer.    Herbert W einer (1977) Integrative model of ps ychos omatic phenomena. He emphas ized the need not only to integrate biological, s ocial, and ps ychological factors contributing to dis eas e vulnerability but also to unders tand s uch at the genetic, molecular, and neurophys iological levels.    Leon E is enberg (1995) C ontemporary res earch demons trates that the mind/brain to biological and social vectors while being jointly cons tructed of both. Major brain pathways are specified in the genome; detailed connections are fas hioned by, and cons equently reflect, s ocially mediated experience in the world.

Adapted from Harold I. K aplan, M.D. P.2111 2835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 36 of 41

P.2112

S UG G E S TE D C R OS S C hapter 30 discuss es the various psychotherapies that us eful in the ps ychological management of disorders . A general history of ps ychiatry appears in S ection 55.1.

R E F E R E NC E S Abraham K . S ele cte d P apers in P s ychoanalys is . Hogarth P ress ; 1927. *Alexander F . P s ychos omatic Me dicine : Its Application. New Y ork: W . W. Norton; 1950. Alexander F , F rench T M, P ollock G H. S pe cificity. V ol. 1: E xpe rime ntal S tudy and R es ults . C hicago: Univers ity of C hicago P res s; 1968. *Avila LA: G eorge G roddeck: Originality and His t P s ychiatry. 2003;14:83. B ahnson MB , B ahnson C B : E go defens es in cancer patients. Ann N Y Acad S ci. 1969;164:546. B eaumont W . E xperiments and O bs ervations on the G as tric J uice and the P hys iology of Dige s tion. NY : F . P . Allen; 1833. C affrey B : A multivariate analys is of 2836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 37 of 41

factors in monks with myocardial infarctions . Am J Health. 1970;60:452. *C annon W B . T he W is dom of the B ody. New Y ork: Norton; 1932. Des cartes R . A Dis cours e on Me thod. London: Dent; Deutsch F : T he choice of organ in organ neuros is. P s ychoanal. 1939;20:1. Deutsch F : T hus speaks the body. T rans N Y Acad 1949;12:2. *Dunbar F . E motions and B odily C hange s . New C olumbia University P ress ; 1954. E neel G L. S election of clinical material in medicine: T he need for a new phys iology. Me d. 1954;16:368. F arrington B . G re ek S cience I and G re e k S cie nce If. London: P elican B ooks ; 1949. F erenczi S . F urther C ontributions to the T he ory and T e chnique of P s ychoanalys is . London: Hogarth 1926. F reud S . F ragment of an analysis of a cas e of S tandard E dition of the C omple te P s ychological S igmund F re ud. V ol 7. London: Hogarth P res s;

2837 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 38 of 41

F reud S . On narcis sis m: An introduction. In: E dition of the C omple te P s ychological W orks of F re ud. V ol 14. London: Hogarth P ress ; 1957:73. F riedman M, B yers S , R os enman R H: C oronaryindividuals (type A behavior pattern): S ome biochemical characteristics . J AMA. 1970;2:1030. F riedman M, R os enman R H: Ass ociation of specific behavior pattern with blood and cardiovas cular findings: B lood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary disease. J AMA. 1959;769:1286. G aldston I: P s ychosomatic medicine: P ast, pres ent, future. Arch Neurol P s ychiatry. 1955;74:441. G antt W H. E xperimental B as is for Ne urotic O rigin and Developme nt of Artificially P roduced Dis turbance s of B e havior in Dogs . New Y ork: P aul Hoeber; 1950. G reenacre P . T rauma, G rowth, and P e rs onality. W. W . Norton; 1953. G regerson MB : T he his torical catalyst to cure Adv P s ychos om Med. 2003;24:16. G rinker R . P s ychos omatic R e s e arch. New Y ork: W . Norton; 1953. G rinker R , R obbins F . P s ychos omatic C as e B ook. 2838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 39 of 41

P hiladelphia: B lakis ton; 1954. G roddeck G . T he B ook of the Id. New Y ork: Nervous Mental Dis eas e P ublis hing; 1929. Halliday J L. P s ychos ocial Medicine : A S tudy of the S ocie ty. New Y ork: W . W. Norton; 1948. Hinkle LE J r, W hitney LH, Lehman E W: Occupation, education, and coronary heart dis eas e. S cience. 1968;161:1238. Holmes T H, R ahe R H: T he s ocial readjus tment scale. J P s ychos om R e s . 1967;11:213. Horney K . T he Neurotic P ers onality of O ur T ime . Y ork: W . W . Norton; 1937. Liddell H. T he role of vigilance in the development of animal neuros es . In: Hoch P , Zubin J , eds . Anxie ty. Y ork: G rune & S tratton; 1950:117. Lipows ki ZJ : P sychosomatic perspectives. C an As s oc J . 1970;15:515. Lipows ki ZJ : P sychosomatic medicine in a changing society: S ome current trends in theory and res earch. C ompr P s ychiatry. 1973;14:203. Lipows ki ZJ , Lips itt DR , Whybrow P C . Me dicine : C urre nt T re nds and C linical Applications . Y ork: Oxford Univers ity P res s; 1977. 2839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 40 of 41

Lucretius . O n the N ature of the Unive rs e . Latham New Y ork: P enguin; 1951. Mahl G F : T he effect of chronic fear on gastric P s ychos om Me d. 1949;11:30. Mead M: T he concept of culture and the approach. P s ychiatry. 1947;10:57. Meltler C C . A H is tory of Me dicine . P hiladelphia: 1947. Miller NE : Learning of visceral and glandular S cience. 1969;163:434. *Nemiah J C , S ifneos P C . Affect and fantasy in with ps ychosomatic disorders . In: O Hill, ed. Mode rn T re nds in P s ychos omatic Me dicine . London: 1970:126. Novack DH: R ealizing E ngel's vis ion: medicine and the education of physician-healers. P s ychos om Me d. 2003;65:925. P lato. T he Dialogue s of P lato. London: C larendon 1871. R eeves J W . B ody and Mind in W es tern T hought. B altimore: P enguin B ooks; 1958. R ues ch J , B ates on G . C ommunication: T he S ocial 2840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 41 of 41

of P s ychiatry. New Y ork: W . W. Norton; 1951. S elye H. T he P hys iology and P athology of E xpos ure S tre s s . Montreal: Acta; 1950. S igeris t HE . A H is tory of Me dicine . V ol 1. New Y ork: Oxford Univers ity P res s; 1951. S igeris t HE . A H is tory of Me dicine . V ol 2. New Y ork: Oxford Univers ity P res s; 1961. Wolff HG . T he mind-body relationship. In: B ryson L, An O utline of Man's K nowledge of the Mode rn Y ork: McG raw-Hill; 1960:123. Wolf S , W olff HG . Human G as tric F unction. New Oxford Univers ity P res s; 1943. Zilboorg G , Henry G W. A H is tory of Me dical New Y ork: W . W . Norton; 1941.

2841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

01/01/2009

Page 1 of 32

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > 25 - R elationa l P roblem

25 R elational Problems Leah J . Dicks tein M.D. An adult's ps ychological health and sense of well-being depend to a s ignificant degree on the quality of his or important relationships—that is , on patterns of with one's partner and children, parents and s iblings, friends and colleagues. C los e relations hips acros s the cycle are relied on for personal growth, need fulfillment, and s upport. P roblems in the interaction between any these significant others mentioned may lead to clinical symptoms and impaired functioning among one or members of the relational unit. R elational problems can also exacerbate the course or complicate the of a ps ychiatric or other medical condition. C onvers ely, individual's other medical or ps ychiatric condition may provoke dysfunctional patterns of interaction with significant others. R elational problems that remain unrecognized and thus untreated often become chronic and progres sive, with increas ing impairment in the functioning of the couple, the family unit its elf, or other important relationships involved. R elationships have been the object of a growing of research s tudies . C ertain aspects of relational functioning have been extensively investigated. T hese include the relative frequency and patterning of the 2842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 2 of 32

interactions between intimate partners (i.e., trust, approach-avoidance, problem s olving, communication deviance, behavioral control, coercive process es, interactions, and gender iss ues ). C ognitive elements, as interpersonal attributions and s chemas and the expres sion and regulation of emotional tension partners and in the family, have als o been studied. A remarkable continuity of attachment patterns in adult relations hips has been demons trated. R es earchers explored the development of partner relations hips, differences between dis tres sed and nondistress ed and predictors of divorce. Attempts have been made to clas sify relations hips on the basis of res ources rules established, roles played by the participants , and styles used in conflict res olution. Until the 1990s , few inves tigators developed a culturally oriented unders tanding of observed interaction patterns; thus , previous research findings have generally not been applicable across cultures. In addition, the field lacks a coherent unifying theoretical framework within which various lines of inves tigation can be integrated. F urthermore, many important theoretical contributions developed in the clinical practice of couples , family, dyadic therapy have not yet been empirically tested. R elational problems may be a focus of clinical attention when a relational unit is distress ed and dys functional or threatened with diss olution and (2) when the relational problems precede, accompany, or follow other or medical disorders . Indeed, other medical or symptoms can be influenced by the relational context the patient. C onvers ely, the functioning of a relational is affected by a member's general and other medical or 2843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 3 of 32

ps ychiatric illnes s. R elational dis orders require a clinical approach than other disorders. Ins tead of primarily on the link between s ymptoms , s igns , and the workings of the individual mind, the clinician mus t also focus on interactions between the individuals involved and how thes e interactions are related to the general other medical or ps ychiatric s ymptoms in a meaningful way. 

DE F INIT ION



E T IOLOG Y



R E LAT IONAL P R OB LE M R E LAT E D T O A DIS OR DE R OR G E NE R AL ME DIC AL C ONDIT ION



P AR E NT –C HILD R E LAT IONAL P R OB LE M



P AR T NE R R E LAT IONAL P R OB LE M



S IB LING R E LAT IONAL P R OB LE M



R E LAT IONAL P R OB LE M NOT OT HE R W IS E



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > DE F INIT IO

DE FINITION P art of "25 - R elational P roblems" According to the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV re lational proble ms are patterns of interaction between 2844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 4 of 32

members of a relational unit that are ass ociated with symptoms or significant impairment in functioning in or more individual members or with s ignificant impairment in the functioning of the relational unit itself. DS M-IV -T R distinguis hes five categories of relational problems . T he first category, relational problem related a mental or general medical condition, deals with the as sociation between relationships and health. T he categories focus on problems in s pecific relational parent–child relational problem, partner relational problem, s ibling relational problem, and relational problem not otherwis e s pecified. In addition, in B , DS M-IV -T R features the G lobal Ass ess ment of F unctioning (G AR F ) S cale (s ee T able 7.9-4), which the clinician to rate the degree to which a relational unit meets the needs of its me mbe rs . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > E T IOLO G

E TIOL OGY P art of "25 - R elational P roblems" P eople communicate not only about pers onal iss ues external events, but als o about their relationships . Interpersonal problems are generally related to interactions that deal with the various components and functions of the relations hip its elf. T he topics of thes e interactions (i.e., what they are about) are class ified in broad categories. It is hypothes ized that all close relations hips fundamentally deal with iss ues of (1) attachment; (2) ranking order, s tatus, and dominance; 2845 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 5 of 32

autonomy and territorial control; (4) gender and (5) boundaries and loyalties ; and (6) cognitive interpretations of the world. T he lis t is s omewhat and not exhaustive. E xcept for cognitive other iss ues can also be observed in interactions nonhuman primates.

A ttac hment A core iss ue in all close pers onal relationships is the es tablis hment and regulation of the affiliative between the participants . In a typical attachment interaction, one person s eeks more proximity and and the other reciprocates , rejects, or dis qualifies the reques t. A pattern is shaped through repeated Attachment behavior between an infant and its primary caregiver leads to the development of an attachme nt which is a relatively s table communication pattern exhibited in close relationships . Dis tinct attachment have been observed in children and P.2242 adults . Adults with an anxious -ambivale nt attachment tend to be obs ess ed with romantic partners , extreme jealous y, and have a high divorce rate. P eople with an avoidant attachment s tyle appear relatively uninvested in clos e relations hips, often feel lonely, afraid of intimacy, and tend to withdraw when there is stress or conflict in the relations hip. B reak-up rates are high. P eople with a s e cure attachment s tyle are highly inves ted in relationships and tend to behave without much pos sess ivenes s or fear of rejection.

2846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 6 of 32

R anking Order Interactions that center on the acquisition of s tatus and dominance (i.e., on decision-making power and control over the partner) can be called ranking-orde r Although the bases of interpersonal influence are and difficult to s pecify, power and dominance are an is sue in close relationships . P eople tend to resent strategies of influencing to which they are particularly susceptible; for example, s ome partners are sensitive threats of withdrawal of affection, and others are to guilt induction. F unctional relations hips require a balance of power that is s atis factory to the participants and that facilitates conflict res olution rather than interactional gridlock. Acute power struggles us ually involve a perceived challenge to an existing dominance structure. An example of an es pecially dysfunctional exertion of power is the verbal or phys ical ass ault of a with suppos edly noncompliant behavior or of a spouse partner perceived as being insufficiently obs equious. V iolence is les s likely to occur in egalitarian

Territory P eople develop a sense of ownership over their own bodies , personal s pace and poss es sions, areas of res ponsibility, and the privacy of their minds. T erritorial interactions deal with pers onal autonomy and control res ources and center on the acquis ition, management, defens e of ownership rights . E ffective parenting gradual transfer of territorial control from the parents to the increasingly autonomous child. E s pecially the progres sive validation of children's s ens e of and control over their bodies (W ho can touch me? W ho 2847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 7 of 32

controls my food intake? ). Iss ues of pers onal autonomy often increas e drastically in adoles cence. Many experienced by couples are about territorial iss ues , privacy, control over one's time, res pons ibility for tasks chores , financial control, and who makes final T he person who performs the quality control over an is cons idered the owner of the territory, which is why comments, advice, and criticis m are often resented. In healthy relations hips, each partner is able to relinquis h autonomy and territorial control at different times , particularly with acute stress and illnes s. P roblems when such dependency is not tolerated, but als o when systematically encouraged and maintained. territorial interactions are als o common in the work environment when a pers on's area of res ponsibility is expanded to an unmanageable level or when a colleague threatens it.

S exuality and G ender C ommunications that expres s gender role expectations that s ignal the presence or absence of s exual attraction a part of most close relations hips. S exual interactions center on the express ion of s exual interes t and on the management of s exual tens ion between potential partners . C ultural norms and individual maturity dictate the relationships in which s exual interactions are and those that must be kept des exualized. C learly, and older adults carry the res ponsibility of neutralizing sexual tension that can aris e in relations hips with Many sexual partner relations hips are challenged by differences in desire (with women's s exual drive being insis tent than men's ) and by the tas ks of s ynchronizing individual s exual rhythms and maintaining appropriate 2848 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 8 of 32

and res pectful s exual tens ion in the relations hip.

B oundaries and L oyalties R elationships are constantly influenced, beyond prior experiences , by other people, external pres sures, and partner's outs ide activities and experiences. A marriage can be undermined by an adulterous relations hip, as as by exces sive jealousy about a partner's emotional involvement with an outs ide pers on or activity. Loyalty conflicts involving one's s pouse or partner and one's of origin are common in the beginning of a marriage. is also often experienced as competing with the relations hip. E ven a general medical or psychiatric condition can be seen as a rival when the patient prefer the emotional involvement with symptoms and treatments to involvement with his or her partner. E very clos e relations hip has to define its boundaries (e.g., the acceptable degree of outs ide interference, as well as acceptable degree of each partner's involvement with outside elements ).

C ognitive Interpretations Humans live in a symbolic world: the world of the and nonverbal—that is , body languages , ideas , values, goals . A major s ocialization tas k of parents is this s ymbolic world to their children. One's s ense of belonging depends on the social validation of one's and interpretations of the world. One's s ens e of identity to a large degree, a s ummary description of how one been defined by others acros s the life cycle. world view, values, and beliefs tend to caus e conflicts. Differences in how a conflict is interpreted by 2849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 9 of 32

participants tend to maintain it. A ps ychological mechanism that has cons is tently been found to create problems is that people tend to interpret their own behavior as s tate depe nde nt (a normal res ponse to the circums tances ) and their partner's behavior as trait de pendent (determined by s table character traits). cons istent finding is that of gender differences in about relations hips. W omen think about relations hips more and with more complexity than men do. T hey outwardly more dis tres sed about problems and have noted to be more likely to take action related to res olve them. C onceivably, women carry more than an equal of the respons ibility for relationships , because they are defined by s ociety as the relationship experts, and yet poss ess less power to invoke change. T hese interactions can take place without the appearing to pay cons cious attention to them. T hes e interactions often cons ist of an exchange of signals while the overt communication focus es on something completely different and s eemingly relations hip neutral. F or instance, while dis cus sing vacation plans , a couple may us e tone of voice and nonverbal mess ages to also exchange information who is going to be in charge. T hes e s ubtle exchanges confirm or challenge the existing power s tructure in the relations hip. If enough tension develops, the iss ue may brought to the forefront and discuss ed openly if the relations hip is bas ed on trust and respect for as well as for common foci of agreement. It is useful to distinguish between conflicts of intere s t conflicts of me aning. In conflicts of interes t, the agree on what the interaction is about, but each one 2850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 10 of 32

pursues a different outcome. In conflicts of meaning, partners s ee the interaction from a different perspective and give it a different meaning. F or instance, one may have a need for intimate conversation; the other partner has had a rough day and wants to be left alone. T he firs t partner may experience the other's reluctance listen and talk as a refusal to engage in intimacy, that partner may experience the insistence to lis ten and talk as an insensitive invasion of privacy. S uch misunderstandings P.2243 can escalate and lead to distorted global interpretations the partner and the relations hip. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > R E LAT IONAL P R OB LE M R E LAT E D ME NT AL DIS OR DE R OR G E NE R AL ME DIC AL C ONDIT

R E L ATIONAL PR OB L E M R E L ATE D TO A ME NTAL DIS OR DE R OR GE NE R AL ME DIC AL C ONDITION P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of relational problem related to a mental disorder or general condition “should be us ed when the focus of clinical attention is a pattern of impaired interaction as sociated 2851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 11 of 32

with a ps ychiatric disorder or a general medical in a family member.” S tudies indicate that satis fying relations hips may have health-protective influence, whereas relationship tends to be as sociated with an increas ed incidence of illness . T he influence of relational s ys tems on health been explained through ps ychophysiological that link the intens e emotions generated in human attachment s ys tems to vascular reactivity and immune proces ses. T hus , s tres s -related ps ychological or symptoms can be an express ion of family dys function. A person who feels ill first turns to the members of the family or to his or her partner. T heir opinions influence whether a pers on sees the s ymptoms as trivial or as a caus e for concern, as requiring home remedies or profes sional attention. T he family or partner als o participates, directly or indirectly, in the ongoing between patient and physician or other health profes sional, defining the type of medical problem that the patient is experiencing, how it s hould be dealt with, and what the family's or partner's role s hould be in managing the illnes s and s upporting the patient. T o a large extent, the ps ychological meaning of the illness the patient's cooperation and compliance with depend on the outcome of thes e relational interactions . F amily and partner relationship dynamics influence an individual's cours e of illnes s. C onversely, the illnes s of family member or partner influences the family's interactional dynamics . If the dis eas e proces s is chronic, an adjus tment of members' and partner's roles and respons ibilities is to be needed. T he patient's identification with the s ick 2852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 12 of 32

and the concomitant regress ion and dis ability are influenced by the interpersonal dynamics of thos e involved. In some cases, the family or s ignificant other, both, joins with the patient in a s truggle against and others who appear to refus e to acknowledge the patient's disability and therefore to deny financial S ometimes , medical symptoms are recruited to play a meaningful role in the interactional dynamics of the relational unit (e.g., to stabilize the patient's family, to regulate clos eness and dis tance among family or to communicate information that cannot be openly expres sed). T he role of marital and family interactions in the ons et cours e of ps ychiatric dis orders has been extens ively studied, in particular, for mood and anxiety dis orders, schizophrenia, substance-related dis orders, eating disorders , and pers onality disorders . Attempts have made to link dis tinct family dynamics to s pecific On the other hand, the following outline provides a somewhat s implified and generalized s ummary of the observed interactions . At first, the ps ychiatric symptoms displayed by a family member or s ignificant other elicit concern and care. roles within the family are adjus ted, often with other members taking charge and ass uming some of the patient's duties and responsibilities. F amily members define the patient's problem, give advice, propose solutions , and encourage the patient to overcome the difficulties or to seek help, or both. W hen the patient to improve, however, the family members or partner feel increasingly frustrated. Indeed, ps ychiatric are often hard to live with, and they can undermine the 2853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 13 of 32

family's and partner's energy and morale. T he mentally family member often behaves in a way that social interaction and increas es interpers onal conflict. extra efforts and tasks required of the other family members can often become more burdensome over In addition, s ignificant others may hold ps ychiatric patients more res pons ible for their own symptoms than they would general medical patients. As frustration mounts, the family members feel that they have limited options for dealing with their own feelings. T heir direct expres sion of anger, dis approval, and criticism is likely aggravate the ps ychiatric condition. On the other hand, family members and the patient's partner withdraw and exclude the patient from activities, the patient may feel neglected and abandoned. F inally, family members feel guilty about their feelings of frustration and try to compens ate for this with s elf-sacrifice, overprotection, overidentification with the patient. S uch overcompens ation indirectly express es the underlying hostility. T hese understandable family and partner adaptations represent behaviors that are rated high on s cales for hostility, criticis m, and overinvolvement, a constellation that has come to be known as expre s s e d e motion. E xpres sed emotion is a significant and robus t predictor relaps e in several psychiatric conditions , including schizophrenia and mood and eating dis orders. High expres sed emotion might also be as sociated with a wors ening of the course of Alzheimer's dis eas e and even play a role in general or other medical conditions , such as diabetes. T he interactional mechanis ms that account for the different express ed emotion res ponse 2854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 14 of 32

styles of family members are unknown. T he relationship between family interaction patterns ps ychiatric illnes s is likely to be bidirectional. T here is suggestion that, when a vulnerable family member excluded or rejected and is treated with criticis m and overinvolvement, psychiatric s ymptoms may develop. instance, the ris k of developing depress ion has been to be ten times greater for individuals experiencing relations hip dis tres s than the risk for individuals in nondis tres sed relations hips. T he mechanis ms described previous ly do not s upport notion that families caus e mental illness or relapse. neither the res earch data nor the complex and nature of family interaction patterns warrants s uch a conclus ion. Y et, mental health profess ionals have, in past, neglected the families and s ignificant others of patients in the name of confidentiality and therapeutic alliance or blamed them for causing the illness . T he clinician mus t appreciate the dedication of most and s ignificant others, their need to be involved in treatment decisions that affect them, and the fact that they are entitled to as sistance with the considerable burden of caregiving. Indeed, families are the primary caregivers of the sick and the dis abled, and it is that one-half to two-thirds of the persistently mentally ill population live with families. C aregiving is s tres sful, the burden of caring for ill family members falls disproportionately on the women in a family. F amily members who live with a mentally ill relative report high levels of s tres s, anxiety, depres sion, and resentment. cite increas ed marital strain, disrupted social life, and hardship for s iblings . In recent years, research into the 2855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 15 of 32

stress of caregiving and how to alleviate it has been initiated, partly in res ponse to the advocacy of s upport organizations , s uch as the National Alliance for the Mentally Ill. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > P AR E NT –C HILD R E LAT IONAL

PAR E NT–C HIL D PR OB L E M P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of parent–child relational problem should be us ed when the focus clinical attention is a pattern of interaction between parent and child (e.g., impaired communication, overprotection, inadequate discipline, neglect or P.2244 abuse) that is as sociated with clinically s ignificant impairment individual or family functioning or the development of clinically significant symptoms in parent child.

2856 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 16 of 32

P arents differ widely in sensing the needs of their S ome quickly note their child's moods and needs; are slow to respond. P arental res ponsivenes s in with the infant's temperament affects the quality of the attachment between infant and parent. A cons iderable body of res earch links an infant's attachment s tyle with social and emotional adjustment in childhood. S ecure ly attached children showed enhanced res ilience in a stress environment. Ins ecure children are more likely to anxious, aggress ive, and low on social competence. F urthermore, attachment-related factors , s uch as deprivation, major s eparations, los s of attachment and the development of dis organized-insecure attachment in res ponse to maltreatment, have been to be risk factors in the development of ps ychiatric disorders . R es earch on parenting s kills has isolated two major dimensions : (1) a permis sive-res trictive dimens ion and a warm-and-accepting versus cold-and-hostile A typology that s eparates parents on thes e dimensions distinguishes between authoritarian (res trictive and pe rmis s ive (minimally res trictive and accepting), and authoritative (res trictive as needed, but als o warm and accepting) parenting styles . C hildren of authoritarian parents tend to be withdrawn or conflicted; those of permis sive parents are likely to be more aggres sive, impulsive, and low achievers; and children of parents s eem to function at the highest level, s ocially cognitively. Y et, switching from an authoritarian to a permis sive mode may create a negative reinforcement pattern. T his interactional pattern s tarts with avers ive child behavior, s uch as whining or aggress ive 2857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 17 of 32

hyperactivity, in response to ins istent parental “stop it.” T hen, the parent backs down, which rewards child for behaving avers ively. At this point, the child deescalates , thus reinforcing the parent's permiss ive attitude. S uch coercive process es have been with a child's lack of s elf-regulation, rejection by peers , later academic failure, depress ion, delinquency, and antis ocial behavior. S ubstantial evidence indicates that marital discord problems in children, from depress ion and withdrawal conduct dis order and poor performance at school. T his negative effect may be partly mediated through triangulation of the parent–child relationships . T riangulation refers to the process in which conflicted parents attempt to win the s ympathy and s upport of child, who is recruited by one parent as an ally in the struggle with the partner. T he term has also been used the proces s by which parents focus on a behavioral or general health problem of the child as a s trategy for defus ing marital conflicts . Marital discord can also the parent–child relationship in a direct way, as emotions begin to contaminate all family relations hips. instance, angry interactions between spous es have linked to negative affect in the relationship between and infant. T he parent–child relationship is greatly influenced by marital and family environment. Divorces and stress the parent–child relations hip and may create loyalty conflicts . S tepparents often find it difficult to as sume a parental role and may res ent the s pecial relations hip that exis ts between their new marital and the children from that partner's previous marriages. 2858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 18 of 32

S ingle-parent families usually cons is t of a mother and children, and their relationship is often affected by financial and emotional problems . W omen who work outside the home out of need and to pursue jobs or careers often feel guilty about not having enough time with their children; yet, they are likely to s pend much time in child-rearing activities than fathers who als o outside the home. Normal developmental crises can also be related to parent–child problems . F or ins tance, adoles cence is a of frequent conflict, as the adolescent resists rules and demands increas ing autonomy, while s imultaneously eliciting protective control by displaying immature and dangerous behavior. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > P AR T NE R R E LAT IONAL P R O

PAR TNE R R E L ATIONAL PR OB L E M P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of partner problem should be us ed when the focus clinical attention is a pattern of interaction between spous es or partners characterized by communication (e.g., criticisms), 2859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 19 of 32

distorted communication (e.g., unrealistic expectations), or noncommunication (e.g., withdrawal) that is as sociated clinically s ignificant impairment individual or family functioning, the development of symptoms in one or both partners . A partner relationship involves two people who have made a commitment to maintain their relations hip. Usually, the partners live together and have sexual relations with one another. Many partner relationships socially s anctioned by marriage. S eparation and rates have increased rapidly in Western s ocieties s ince 1960s . An unexpected announcement by one s pouse decis ion to divorce often elicits an acute relational which the partners desperately seek profess ional help. S ociologists have found that increases in the divorce correlate with meas ures of women's economic and ps ychological independence. A s uggested explanation that women are less willing to stay in unhappy or marriages to the degree that they are no longer forced do so for economic reas ons , as well as the fact that domes tic violence is now univers ally recognized as an too common occurrence and one that is not to be tolerated. Nevertheless , for most women, divorce s till severe economic cons equences , because they als o less for the s ame work as men and, too frequently, do receive the financial child s upport decreed by the court. Using observational methods , J ohn G ottman has criticis m, contempt, defens iveness , and stonewalling 2860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 20 of 32

withdrawal from interaction) as interactive process es longitudinally predict which couples separate and T he best s ingle predictor is contempt, es pecially the contempt. F urthermore, there are gender differences ; women tend to s how more criticism than men do, and men s how more stonewalling. A cas cade has been propos ed in which complaining and criticizing leads to contempt, which leads to defens iveness , which leads withdrawal from the interaction. T hese same patterns probably als o occur in gay and les bian relations hips, although comparable data have not yet been reported. R elatively minor problems can escalate to levels as a res ult of unrecognized and yet natural interactional proces ses , s uch as the amplification of differe nce s and the polarization of ambivalence. S mall differences between partners, s uch as a s ubtle in sexual need, can amplify s pontaneous ly. T hen, gradually, the partner with the greater need may the only s exual initiator, overly focus ing on the other's sexual availability, whereas the other partner is likely to adopt a style of avoiding s ex and focusing on the first one's perceived or true sexual aggres siveness . T his preoccupation with one another's s exual des ire from the awarenes s of a pers on's own real needs , as person seems to always be “in the mood” and the other never. In a s pontaneous proces s of polarization, each partner express es an opposite position with regard to is sue about which they both feel ambivalent. An dilemma is thus externalized in the relationship. T he polarization of a couple's ambivalence about or about the decis ion to have children can als o lead to chronic emotional conflicts. 2861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 21 of 32

Many partners expect the other to regularly provide of commitment. T his may res ult from personal or concerns about the true (real) power balance in the relations hip. Indeed, the pers on who is more P.2245 to and dependent on the relationship may feel when, and if, faced with divorce threats. Unfortunately, violent behaviors can be an attempt to deny and to exert power. B eing rejected by an intimate can elicit traumatic memories of pas t attachment experiences and can lead to impulsive suicide attempts to violence toward the partner, more often s een in the male partner, who is sex role s ocialized to maintain in relationships to be cons idered “a real man.” An iss ue with s pecial importance for partner relational problems is pas s ionate love , defined as a special state mind characterized by emotional dependence on the person one is in love with and by s ymptoms such as an intrus ive preoccupation with that pers on, an intense for reciprocity of feelings, idealization, and an uncanny ability to s ee hope even when there is none. F alling in can occur at any age and has been described in all cultures. Unrequited love can lead to depres sion, tendency, violence, and partner homicidal ideation, observed more often in men. In addition, dis tres s and alienation in one's primary relations hip put one more at ris k for falling in love with someone else. V iolence can be ass ociated with relational problems. A pattern of wife beating, however, indicates individual impulse-control problems , impaired s ocialization, being victim of child abuse, and, usually, alcohol and 2862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 22 of 32

abuse, the latter enabling impulse dys control to Wife beating is found in every s ocioeconomic clas s and culture and at every income level. P regnancy is the ris k time for domes tic violence toward the woman. subjected to violence often res ults in depres sion and learned helpless nes s acros s the life cycle. W omen, as children, often are revictimized in adult significant relations hips . T he patient too often feels inhibited about divulging the s ecret of domestic violence and blames herself for its occurrence; thus , clinicians must develop an appropriate sensitivity to the poss ibility of spous al abuse, in which 5 percent of victims are men. patient, women and men, must be asked about experiences with violence across his or her life in the profes sional interview, regardless of sex, age, or socioeconomic, educational, racial, or faith E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > S IB LING R E LAT IONAL P R O B

S IB L ING R E L ATIONAL PR OB L E M P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of s ibling problem “should be us ed when the focus of clinical attention is a pattern of interaction between siblings , as sociated with clinically s ignificant impairment of functioning, or s ymptoms in one or more of the S ibling relations hips tend to be characterized by competition, comparis on, and cooperation. Intens e 2863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 23 of 32

rivalry can occur with the birth of a child and may as the children grow up, compete for parental approval, and meas ure their accomplishments against one Alliances between s iblings are equally common. may learn to protect one another against parental or aggress ion. In hous eholds with three children, one tends to become closely involved with one another, leaving the extra child in the position of outs ider. P arents tend to be more empathetic with the child who has the s ame s ibling pos ition that they experienced. R elational problems can aris e when s iblings are not treated equally; for instance, when one child is being idealized, while another is cas t in the role of the family scapegoat. Differences in gender roles and expres sed by the parents can underlie s ibling rivalry. P arent–child relationships also are dependent on personality interactions . R es earch has shown that 30 percent of a person's personality is due to genetic T hus, this is sue must als o be cons idered when to understand and to explain parent–child and sibling relations hips . T he notion that a child's resentment at a parental figure or a child's own disavowed dark emotions can be projected onto a s ibling and can fuel intens e hate relationship is an interes ting hypothes is. As people grow older, they often desire to reconnect with sisters and brothers and, cons equently, may take great effort to resolve longstanding sibling conflicts. A child's general, other medical, or ps ychiatric always s tres ses the sibling relationships. P arental and attention to the sick child can elicit envy in the siblings . In addition, chronic dis ability can leave the 2864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 24 of 32

child feeling devalued and rejected by s iblings , and the latter may develop a s ens e of superiority and may feel embarrass ed about having a dis abled s ister or brother. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > R E LAT IONAL P R OB LE M NO T S P E C IF IE D

R E L ATIONAL PR OB L E M OTHE R WIS E S PE C IFIE D P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of relational problem not otherwis e s pecified “should be us ed when the focus of clinical attention is on relational problems clas sifiable by any of the s pecific problems above (e.g., difficulties with superiors and coworkers ).” P eople become emotionally involved in peer at school and work and in relationships with teachers, superiors , students, and employees. T hey develop intens ive friendships and engage in complex around avocational interes ts and goals. P eople, across life cycle, may become involved in relational problems with leaders and others in their community at large. In such relationships , conflicts are common and can bring about s tres s -related symptoms. Many relational problems of children occur in the setting and involve peers. Impaired peer relations hips be the chief complaint in attention-deficit or conduct disorders , as well as in depress ive and other 2865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 25 of 32

disorders of childhood, adoles cence, and adulthood. R acial, ethnic, and religious prejudices and ignorance caus e problems in interpers onal relations hips. In the workplace and in communities at large, sexual is often a combination of inappropriate sexual inappropriate displays of abus e of power and and express ions of negative gender stereotypes, toward women and gay men, although als o toward children and adoles cents of both s exes. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "25 - R elational P roblems" C hild psychiatry is the subject of C hapter 32. C ouples family therapy are discuss ed in S ection 30.5. C hild and s exual abus e and neglect are dealt with in S ection 49.3. P hys ical and s exual abus e of adults is discuss ed S ection 28.6. S ection 18.1a deals with normal human sexuality and s exual dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > R E F E R E NC

R E FE R E NC E S Amato P R , B ooth AA. G e ne ration at R is k: G rowing an E ra of F amily U phe aval. C ambridge, MA: Univers ity P res s; 2000:319. 2866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 26 of 32

Anderson MA, G illig P M, S itaker M, McC los ky K , K , G rigsky N: “Why does n't she just leave? ” A study of victim reported impediments to her safety. J F am V iole nce . 2003;18:151–155. Aydin O, S ahin D: T he role of cognitive factors in modifying the intensity of emotional res pons es produced by facial express ions. P s ychol E duc. 2003;40:50–56. B elsky J , Y oungblade L, R ovine M, V olling B : marital change and parent-child interaction. J F am. 1991;53:487–498. *B erns tein AC . G ender in stepfamilies : Daughters fathers . In: S ilvers tein LB , G oodrich T J , eds. F amily T herapy: E mpowe rme nt in S ocial C ontext. Was hington, DC : American P sychological 2003. P.2246 *B orge L, Martins en E , R uud T , Watne O, F riis S : of life, loneliness , and lucid contact among long-term ps ychiatric patients. P s ychiatry S e rv. 1999;50:81. B urman B , Margolin G : Analysis of the as sociation between marital relations hips and health problems : interactional pers pective. P s ychol B ull. 1992;112:39. B utzlaff R A, Hooley J M: E xpres sed emotion and 2867 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 27 of 32

ps ychiatric relaps e. Arch G e n P s ychiatry. C hang T , Y eh C J : Using online groups to provide support to As ian-American men: R acial, cultural, gender, and treatment iss ues . P rof P s ychol R e s 2003;34:634–643. Davey A, E ggebeen DJ : P atterns of exchange and mental health. J G e rontol S e r B S oc S ci. 1998;53:86–95. Dicks tein LJ . Domes tic abuse as a ris k factor for and youth. In: S chetky DH, B enedek E , eds . C hild and Adole s ce nt F orens ic P s ychiatry. DC : American P s ychiatric P res s; 2001. Dres cher J , D'E rcole A, S choenberg E , eds . P s ychothe rapy with G ay Men and L e s bians : Dynamic Approache s . B inghampton, NY : T he P ark P res s/T he Haworth P ress , Inc.; 2003. *E dward J : T he loving side of the sibling bond: A for growth or conflict. Is s ue s P s ychoanal P s ychol. 2003;25:27–43. F letcher G J O, F itness J , eds . K nowledge S tructure s C los e R elations hips : A S ocial P s ychological Mahwah, NJ : E rlbaum; 1996. *G ottman J M. W hat P re dicts Divorce? T he B etwe e n Marital P roces s e s and Marital O utcomes . Hillsdale, NJ : E rlbaum; 1994. 2868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 28 of 32

*G ottman J M. T he Marriage C linic: A S cie ntifically Marital T he rapy. New Y ork: Norton; 1999. G ottman J M, K atz LF , Hooven C . Me ta-E motion: F amilie s C ommunicate E motionally. Mahwah, NJ : E rlbaum; 1997. G reg A, Howe D: S ocial unders tanding, attachment security of preschool children and maternal mental health. B r J De v P s ychol. 2001;19:381–393. Haglund K : P arenting a second time around: An ethnography of African-American grandmothers parenting grandchildren due to parental cocaine J F am Nurs . 2000;6:120–135. Hazan C , S haver P R : Attachment as an framework for res earch on clos e relations hips. Inquiry. 1994;5:1. Higgins J , G ore R , G utkind D, Mednick S A, P arnas S chuls inger F , C annon T D: E ffects of child-rearing schizophrenic mothers : A 25-year follow-up. Acta P s ychiatr S cand. 1997;96:402–404. Hinde R A. R elations hips : A Diale ctical P e rs pe ctive . UK : P s ychology P res s; 1997. *K as low F W , ed. Handbook of R e lational Diagnos is Dys functional F amily P atterns . New Y ork: W iley; Lasenza S : S exuality: P sychoanalytic pers pectives . 2869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 29 of 32

Marital T he r. 2004;30:53–56. Lefley HP , J ohnson DL, eds. F amilie s as Allies in T re atme nt of the Me ntally Ill: Ne w Dire ctions for Health P rofes s ionals . W ashington, DC : American P sychiatric P ress ; 1990. *Lewis J M: F or better or wors e: Interpersonal relations hips and individual outcome. Am J 1998;115:582. Looy HA. G ender and s exuality: C ons tancy and In: V ander S toep S W , ed. S cience and the S oul: F aith and P s ychological R es earch. Lantham, MD: Univers ity P res s of America, Inc.; 2003. *Lu L, Lin Y Y . F amily R oles and Happine s s in P ers onality and Individual Differe nce s . V ol 25. E ls evier S cience; 1998:195–207. Main M: Introduction to the s pecial section on attachment and ps ychopathology: Overview of the of attachment. J C ons ult C lin P s ychol. 1996;64:237. *Morrongiello B A, Hogg K : Mothers ' reactions to children mis behaving in ways that can lead to injury: Implications for gender differences in children's ris k taking and injuries. S ex R ole s . 2004;50:103–118. Nemeroff C B : Neurobiological cons equences of childhood trauma. J C lin P s ychiatry. 2004;65[S uppl 1]:18–28. 2870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 30 of 32

O'Leary K D, C hristian J L, Mendell NR : A clos er look link between marital discord and depres sive symptomatology. J S oc C lin P s ychol. 1994;13:33. Oliver LE : E ffects of a child's death on the marital relations hip: A review. O me ga J Death Dying. 1999;39:197–227. P atterson G R , S toolmiller M: R eplication of a dual model for boys ' depress ed mood. J C ons ult C lin 1991;59:49. P erlmutter R A. A F amily Approach to P s ychiatric Dis orde rs . W ashington, DC : American P sychiatric 1996. P hares V . “P oppa” P s ychology: T he R ole of F athe rs C hildre n's Me ntal W e ll-be ing. W estport, C T : P ublis hing G roup Inc.; 1999:150. P ruchno R , R os enbaum J . S ocial relationships in adulthood and old age. In: Lerner R M, E as terbrooks eds. Handbook of P s ychology: De ve lopmental V ol 6. New Y ork: J ohn W iley & S ons, Inc.; 2003. *R iley S . Art therapy with couples . In: Malchiodi C A, Handbook of Art T herapy. New Y ork: G uilford P res s; 2003. S anford K : E xpectancies and communication in marriage: Dis tinguishing proximal level effects distal level effects. J S oc P e rs R e lations hips . 2871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 31 of 32

402. S holerane G , P irooz MD, eds with LD S chwoer. of F amily and C ouple s T he rapy: C linical Was hington, DC : American P s ychiatric P res s, Inc.; S teinberg L: W e know s ome things: P arentrelations hips in retrospect and pros pect. J R e s 2001;1:1–19. *S wans on K M, K armali ZA, P owell S H, Miscarriage effects on couples ' interpers onal and relations hips during the firs t year after loss : perceptions. P s ychos om Me d. 2003;65:902–910. T s eung W , Hsu J . C ulture and F amily: P roblems T he rapy. New Y ork: Haworth P res s; 1991. Uebelacker LA, C ourtnage E S , W his man MA: of depress ion and marital diss atisfaction: marital communication style. J S oc P e rs 2003;20:757–769. V andervoort D, R okach A: P os ttraumatic syndrome: T he cons cious proces sing of the world of trauma. S oc B ehav P e rs . 2003;31:675–686. V erhuls t J : Limerence: Notes on the nature and of pas sionate love. P s ychoanal C ontemp T hought. 1984;7:115. V italiano P P , Y oung H, R us so J , R omano J , 2872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 32 of 32

Amato A: Does express ed emotion in s pouses subs equent problems among care recipients with Alzheimer's disease? J G e rontol. 1993;48:202. Walzer S , Oles T P : Managing conflict after end: A qualitative study of narratives of ex-spous es . F am S oc. 2003;84:192–200.

2873 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

01/01/2009

Page 1 of 60

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 26 - Additional C onditions T hat Ma y B e a F ocus of C linical 26.1: Malingering

26.1: Malingering Mark J . Mills J .D., M.D. Mark S . L ipian M.D., Ph.D. P art of "26 - Additional C onditions T hat May B e a C linical Attention" E ven judged by the es oteric entries in this textbook, malingering is an odd condition and not a true diagnosis. F irst, despite its formal presence in nosology since the third edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-III), it more badness than madness . S econd, although a theme in forensic evaluations largely because s ome ps ychiatric symptoms are difficult to objectively verifymalingered pain is apparently far more common litigation than are malingered ps ychos is or malingered cognitive impairment. T hird, the his toric methodology of ps ychiatrylis tening to and observing one's patientsis ineffective in detecting malingering. Despite thes e anomalies, unders tanding malingering is a us eful for the psychiatric practitioner because malingering probes fundamental concepts that underpin psychiatric diagnosis and its approach to patients . Malingered ps ychiatric symptoms also reveal how nonpsychotic individuals imagine the s ymptoms of psychotic illness . F or the forensic ps ychiatris t, newly developed and widely circulated psychological tests have significantly 2874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 2 of 60

honed the ability of forensic evaluators to detect malingering. S till, this ability attends best to the more flagrantly imagined psychiatric symptoms and the more fully elaborated cognitive impairments . T he in ps ychological tes ting require that the forensic practitioner become more familiar with this method of as sess ing malingering. F inally, malingering reminds psychiatrists to remain profes sionally humble, as they are accus tomed to attributing great value to their patients' s ubjective complaints . R arely do ps ychiatris ts fully cons ider the poss ibility that their patients are embellis hing their symptoms. T his behavior is often for a good reasonpsychiatrists perceive their patients' pain and to alleviate that pain. E ven when ps ychiatris ts cons ider poss ibility of symptomatic embellishment, their ability to detect that embellis hment is limited. P s ychiatry's strengththat is , its ability to lis ten to patientscan als o be downfall. If psychiatrists fail to recall that what they are being told is not necess arily true or accurate, they ris k furthering their patient's (or evaluee's ) misbehavior. C onvers ely, making an accusation of embellishment or outright feigning can rupture the therapeutic alliance beyond repair.

HIS TOR Y T he medical concept of malingering has its origins in philosophical dichotomy between reality and unreality, the ultimate express ion of which are questions about truth and falsity of life, generally. C entral to moral has been debate of the rightfulnes s or wrongfulnes s of person's deliberate us e of the capacity to deceive. At 2875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 3 of 60

conceptual extreme is F riedrich Nietzche, writing in W ill to P owe r, there is only one world, and that world is false, cruel, contradictory, mis leading, sens eles s. At oppos ite philos ophical pole is Nicolai Hartmann, who argues in his E thics that any lie injures the deceived in his life; it leads him as tray. T he following example illus trates s ome of these is sues . Although perceived as the head of one of the mos t powerful mob families , the evaluee had nearly a 30history of making psychiatric complaints . T hese history of head trauma with a reported 50 percent loss meas ured intelligence, a history of s peaking nonsense public, and nearly a 20-year history of hospitalized ps ychiatric treatment on an almos t annual basis . of this very substantial history, this individual's was delayed years after his arrest on a variety of racketeering charges. Once indicted, his attorneys is sues of competence to s tand trial. T hus, his mental state became a crucial is sue early in proceedings and remained important throughout his T he prosecution asked to have the defendant a team including a psychiatrist/neuroimagis t, a neurops ychologist, and a forens ic ps ychiatris t. T he of this evaluation was that the prosecution's experts became convinced that the evaluee was elaborating symptoms of cognitive impairment. S till, those experts were not convinced that, des pite his elaboration, he did not have s ome very mild and not legally relevant impairment. T he defens e presented eight experts who opined about the defendant's multiple problems. Overall, they 2876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 4 of 60

the defendant as having experienced clinically impairment from his days as a boxer, s chizophrenia had developed in his late 20s, and moderate disease that had developed over the previous few Once the court ruled that the defendant had s ufficient capacity to proceed to trial despite his purported impairments , the government pres ented cons iderable evidence of the defendant's ongoing role as the head his family. T hat evidence was sufficiently convincing the defendant was convicted on a majority of the brought agains t him. However, that led to a new inquiry into whether he was competent to have s entencing impos ed and what kind of facility would be bes t for him even the government's witness es had to admit, the defendant could be developing early cognitive P.2248 Again, the court found that the alleged problems were sufficiently great as to delay the impos ition of and the defendant was remanded to custody. T he defendant's family opined that he had been wrongfully convicted, and one of the major news documentary programs invited the defendant's forensic evaluators to discuss the ineptitude and zealotry of the government's experts. T he government monitored the defendant's behavior produced audio tapes of convers ations between him others . T he government has reindicted him, claiming the tapes reveal that he continued to run the family prison. At leas t one of the defendant's original experts , having heard selected portions of thos e tapes, now believes that the entire his tory of mental s tate 2877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 5 of 60

abnormalities presented by the defendant was malingered. F urther, that expert has opined that the defendant manifes ted no cognitive impairment on the reviewed tapes . T o the extent that the history is accurate, it apparently reveals a cognitive attempt to fabricate psychiatric symptoms going back more than 20 and, probably, than 30 years . In medicine, the tens ion between truth and lies is evidenced in the conflict between malingering and its detection. Mental illness , because it is often difficult to objectively verify, is an age-old favorite of the T hat individuals might feign or produce illness or for gain of s ome kind or to avoid duty has been known since antiquity. T he G reeks cons idered malingering in military service to be analogous to forgery, and both offens es were punis hable by death. T he penalty was mitigated to forced public exposure for 3 days , wearing floridly female regalia. Ulys ses is s aid to have faked to avoid duty in the T rojan W ar, us ing such tactics as yoking a bull and a hors e together, plowing the and s owing salt instead of grain. In an early attempt at detection, the son of the K ing of Ithaca was placed in furrow, directly in the line of Ulyss es ' oncoming plow. If were truly mad, it was reasoned, he would take no the boy. However, Ulys ses s werved to avoid the boy, action that was considered proof that his madnes s was ploy. In the second century AD, G alen wrote a treatiseO n F e igne d Dis eas es and the De te ction of T he min which described R oman cons cripts who cut off thumbs or 2878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 6 of 60

to ens ure unfitnes s for duty. In the 16th century, P aolo Zacchias , cons idered by many to be the father of medicine, wrote of madnes s, there is no dis eas e more easily feigned, or more difficult to detect. T ruth versus imposture was also dis cuss ed in T heodric B eck's 1823 E le me nts of Medical J uris prudence , the notable American text on the s ubject: In almos t every impos tors have sprung up who affect various maladies operate on the s uperstition or the curiosity of the short, then, is sues of malingering appear to be as old civilization.

DE F INITION A ND C OMP A R A TIVE NOS OL OG Y C ontemporary theoris ts share with their historical antecedents the cons truct that the fundamental characteristic of malingering is intentional falsity with incentive of gain of some kind. According to the revised fourth edition of the DS M (DS M-IV -T R ) T he es sential feature of Malingering is the intentional production of false or gross ly exaggerated phys ical or ps ychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining compens ation, evading criminal prosecution, or obtaining drugs. Under s ome circums tances , malingering may represent 2879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 7 of 60

adaptive behaviorfor example, feigning illnes s while a captive of the enemy during wartime. Malingering s hould be s trongly suspected if any combination of the following is noted: (1) medicolegal context of presentation (e.g., the pers on is referred by attorney to the clinician for examination or is (2) evident dis crepancy between the individual's stress or dis ability and the objective findings , (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen, and the presence of antis ocial pers onality disorder. Malingering differs from factitious dis order in that the motivation for the symptom production in malingering is an external incentive, whereas , in factitious disorder, external incentives are abs ent. E vidence of an need to maintain the sick role sugges ts factitious T his evidence is not present in malingering. F urther, malingering is differentiated from convers ion dis order other s omatoform dis orders by the intentional of symptoms and by the obvious, external incentives as sociated with it. In malingering, in contrast to disorder, s ymptom relief is not obtained by s uggestion hypnosis . T hus, malingering is distinguis hed from factitious disorder in its motivation: W hereas is prompted by a conscious desire to obtain external rewards or environmental outcomes , factitious disorder not. In the latter, a combination of intrapsychic needs manifesting themselves as a nearly irresistible des ire to as sume the s ick role is thought to motivate the deception of malady. 2880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 8 of 60

T he problems of diagnos tic differentiation are obvious : person might malinger to obtain tangible rewards (such disability payments) as sociated with the s ick role, but might still enjoy the nurturing and care that s uch a role provides . A person with factitious dis order might be res is tant to returning thes e financial as pects of being while s till clinging to (and needing) the emotional gratification that a person with this disorder is crave. Differentiating malingering from the somatoform disorders (e.g., convers ion dis order) is eas ier in that somatoform disorders lack the volitional component of malingering. In the s omatoform disorders , an emotional conflict is thought to be unconsciously transformed into a physical manifes tation of some kind. external environmental outcome or reward is sought. R ather, the defensive makeup of the person somatoform disorder is believed to be more tolerant of manifest turmoil in obs ervable, extrapsychic form than unobs ervable, emotional upset. Whereas the various diagnos tic schemes us ed and internationally agree on the centrality of volitional deception to malingering, there is more controvers y whether malingering should be considered a mental disorder at all. T his is important because, in mos t civil litigation, only mental disorders are compensable. T R clas sifies malingering with additional conditions that may be the focus of clinical attention. T hus , if occurs in as sociation with such mental dis orders as antis ocial personality dis order, factitious disorder, or a somatoform disorder, the diagnostician is enjoined to cons ider thos e diagnos es primary. In fact, a diagnosis 2881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 9 of 60

factitious disorder excludes a diagnosis of malingering. S till, as a V -code diagnos is , malingering is not s o much disorder as a kind of mis behavior.

Definitions of S ubtypes of It has been s uggested that malingering be cons idered as a dichotomous variable (a condition that is either present or abs ent), but as falling along a continuum in terms of (1) degree of intentionality, (2) degree of symptom exaggeration involved, and (3) degree of impairment (if any). In keeping with the concept of a continuum, the following definitions have been P.2249 P ure malingering: F eigning a disease or disability it does not exis t to any extent. P artial malinge ring: C onsciously exaggerating symptoms that really exist. F als e imputation: As cribing actual s ymptoms to a cons ciously understood to have no relation to the symptoms. Mis attribution: As cribing actual s ymptoms to a erroneously believed to have given ris e to them. misperception is often the product of unconscious proces ses that have interfered with reality testing, in its pure form, it does not cons titute malingering. the extent that the misattribution is consciously augmented (false imputation), malingering is at A female police officer filed a lawsuit against her former 2882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 10 of 60

department alleging that s exual harass ment at the workplace and wrongful termination for whis tle-blowing had res ulted in ps ychiatric damages . P sychiatric of the cas e s uggested that, although the officer had a major depres sive dis order, the purported harass ment not caused it. Ins tead, the officer was found to have a borderline pers onality disorder. A series of interactions born of this dis order had given ris e to the tensions that ultimately resulted in her profess ional difficulties . Although the officer's borderline pers onality disorder did, to a great extent, cause her to distort and truly mis perceive the s equence of events leading to termination (mis attribution to her gender rather than to her profess ional failures ), the officer also invented episodes of haras sment, pointing to these fantastic as the specific origins of her (exaggerated) symptoms (false imputation and malingering). In addition to the various degrees of malingering, forms of malingering have been identified and defined: S imulation: F eigning symptoms that do not exis t or gross , cons cious exaggeration of preexis ting symptoms. S imulation has s ometimes been as faking bad and pos itive malingering. Dis s imulation: C oncealing or minimizing exis ting symptoms. Diss imulation has also been called good, negative malinge ring, and de fens ive ne s s . term is s omewhat confus ing becaus e it has been used to refer to medical faking in generalthat as a s ynonym for malingering. S taged e ve nts : C arefully planning, orchestrating, 2883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 11 of 60

executing events, with the desired result being an actual injury or a credible explanation for a disability that will later be feigned. Data tampe ring: Altering diagnostic data or records simulate a disorder. S uch alteration might take the form of s elf-mutilation (to influence the outcome of phys ical examination), phys ical addition to or of substances from laboratory s pecimens (to the res ults of analys es performed on the or defacing or adjusting laboratory reports, instruments, and medicohistoricolegal documents. O pportunis tic malinge ring: E xploiting a naturally occurring event or preexisting medical condition for gain. Opportunistic malingering is distinguished partial malingering, which involves the of specific preexis ting s ymptoms. S ymptom inve ntion: F als ely and cons cious ly complaining of symptoms that are unrelated to any current or preexisting dis order or injury. An ins urance agency owner was apparently s truck by a rental-car company driver while in the process of another of the company's cars . T he victim reported that the car had run over his foot, causing his elbow to the windshield, followed by his head. A few days after the injury, on the fourth occas ion for which he had s ought medical attention, he reported, for the firs t time, symptoms cons is tent with pos tconcuss ive syndromeheadache, photophobia, difficulty concentrating, and memory loss . B ecause of these symptoms, he claimed he was incapable of continuing 2884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 12 of 60

overs ee his agency. He s ought multimillion-dollar compens ation. S everal of the defendant's experts advised couns el that even if head trauma had occurred, given that there was loss of cons cious nes s, a concus sion could not have occurred. T hus , although tendernes s and headache be part of the s ymptom complex, increasing or longstanding difficulties with memory would not be Another expert opined that the phys ics of the accident made a head s trike virtually imposs ible. F inally, a the immediate posttrauma medical records revealed the injuries to the foot and elbow were minor and that there had been no complaints of head trauma. Independent ps ychiatric examination of the plaintiff revealed no anomalies in his his tory but unearthed odd complaints of paranoia, profound intoxication, interes t in tattooing, nons pecific threats of violence agains t others , and s elf-mutilation (he carved on his and forearms with a hunting knife in a way that led to significant scarring). T he forens ic ps ychiatris t, although aware of the noncorroborative date of the injury, was deeply troubled about the self-mutilation, provisionally opining that it was inconsistent with malingering. Only when the other experts pointed to inconsistencies in own arena was he comfortable rendering a diagnos is malingering. Defense couns el, who had been convinced that the accident as reported had been elaborated, later found witness es who testified that the entire injury had been falsified and that the plaintiff was desperate for money. cours e, the case then s ettled for nuisance value. 2885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 13 of 60

E P IDE MIOL OG Y In the United S tates, malingering is not cons idered as a medical or ps ychiatric diagnosis. T herefore, traditional epidemiological cons iderations , s uch as the reliability diagnostic criteria and the validity of the diagnostic cons truct, are largely irrelevant. F urther, s ys tematic underreporting of malingering by health care hampers estimations as to the typical age of onset, s ex ratio, prevalence, or age-specific features. S everal underlie the reluctance of profes sionals to label malingerers and, ins tead, to refer to a vague lack of objective evidence in s upport of the patient's particular subjective complaints. Most clinicians were drawn to the mental health field of a desire to help others ; they find it distasteful, and a violation of the doctorpatient relationship, to call a a liar. C oncern over legal liability also inhibits the widespread labeling of malingering. Although expert tes timony about malingering, given in court and in good faith, is protected by immunity, a clinical label applied the outpatient office or emergency department often is not. F inally, physicians are concerned about the anger poss ibly, phys ical outbursts that might res ult if an individual's conscious attempts at deception are foiled his or her conscious s cheme to manipulate the s ys tem reward is dismantled. T hus , the method by which a in a clinical s etting is confronted is of paramount importance. Determining when it is necess ary to a client on his or her embellis hments depends on a thorough as sess ment of cos ts versus the benefits of confrontation. Indeed, in certain cas es, pacifying the patient by ignoring the embellishment may be of 2886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 14 of 60

harm than benefit. After a decis ion P.2250 to confront is made, the clinician must direct much into exploring with the patient the reas ons behind the malingering. An exploration may notably help with diagnosis and, thus , have treatment implications . According to limited epidemiological data, it is that a person, on average, lies twice a day, although same pers on may be completely truthful at other times . 1 percent pres ence of malingering has been estimated among mental health patients in civilian clinical with the estimate rising to 5 percent in the military. In a litigious context, during interviews of criminal the es timated prevalence of malingering is much higherbetween 10 and 20 percent. B ut thes e are only es timates; there is no comprehensive empirical data for this information. S ome criminals are s killful liars , and the capacity to lie develops early; approximately 50 percent of children presenting with conduct disorders are described as bringing to the clinician s erious lying-related is sues. It reasonably be as sumed that, in civil laws uits, those involving child custody or evaluations pertaining civil commitment, a similar elevation of the prevalence diss imulation (faking good) would become apparent if appropriate data were amass ed. T hus, although no familial or genetic patterns have reported and no clear sex bias or age at ons et has delineated, malingering does appear to be highly prevalent in certain military, prison, and litigious 2887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 15 of 60

populations and, in W estern s ociety, in men from youth through middle age. As sociated dis orders include disorder and anxiety dis orders in children and borderline, and narcis sistic personality dis orders in However, becaus e many behaviors have a genetic would be surpris ing if there were no familial patterns.

E TIOL OG Y Although no biological factors have been found to be caus ally related to malingering, its frequent ass ociation with antisocial personality disorder rais es the poss ibility that hypoarous ability may be an underlying metabolic factor. S till, no predis pos ing genetic, neurochemical, or neuroendocrinological forces are presently known. During the height of psychoanalytic influence, was cons idered to be a mental disease. K urt E is sler It can be rightly claimed that malingering is always a of a disease often more s evere than a neurotic disorder because it concerns an arres t of development at an phase. Although mos t analysts today accept the nondis ease concept of malingering, the malingerer is thought to be as controlled by the past as the neurotic except that the malingerer is unable to produce an neurotic s ymptom (the res ult of primitive ego and superego development). T he malingerer acts out cons ciously that which the neurotic is able to convert unconsciously. T he ps ychodynamic connection malingering and the s omatoform dis orders is a clos e At the other end of the etiological spectrum lie the theories of T homas S zas z, who has argued that malingering can be understood only in the context of 2888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 16 of 60

sociops ychology of games, systems , and interactions. Malingering would be meaningles s in a s trictly situation limited to physician and patient. In fact, if it to emerge only in such a context, it would have to be cons idered factitious dis order. According to S zasz, malingering is a relevant concept only when the and patient are part of a larger s ocial s tructure and a player in a social game. T he patient is out to s core, is society. T he physician's job is to officiate the proceedings, to prevent cheating, and to minimize any unfair advantage. As s uch, the prudent ps ychiatris t approaches every evaluation with the as sumption that patient being evaluated may s tand ready to us e mental infirmity to achieve questionable ends . S ociocultural forces must be cons idered as etiologically relevant in any analysis of malingering behavior. studies showing marked differences in readines s to complain of illnes s among different ethnic groups have been criticized on methodological grounds, it is accepted that the culture of work, ethical res ponsibility, and duty to country in the form of military service (with potential for s elf-sacrifice) varies from s ociety to subculture to subculture, and epoch to epoch. How acceptable, condemnable, or laudable malingering may within a sociocultural context will accordingly vary.

DIA G NOS IS A ND C L INIC A L In his 1823 Me dical J uris prude nce , B eck described the contexts that have mos t s timulated malingering throughout his tory. Dis eas es are usually feigned 2889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 17 of 60

one of three causesfear, s hame, the hope of gain. T hus , the individual ordered on service will pretend being afflicted with various maladies to es cape the performance of military dutythe mendicant, to avoid labour, and impos e on public and private beneficenceand the criminal, to prevent the infliction of punis hment. T he spirit of and the hope of receiving exorbitant damages, have also induced s ome to magnify s light ailments into s erious and illness . C ontemporary commentators have adduced eight patterns of malingering; however, thes e distinctions are less important than the common theme of s ymptom fabrication.

Avoidanc e of C riminal Trial, and Punis hment C riminals may pretend to be incompetent to avoid standing trial; they may feign ins anity at the time of perpetration of the crime, malinger s ymptoms to less hars h penalty, or attempt to act too incapacitated (incompetent) to be executed. T he following transcript from an E as t C oas t newspaper during the 1940s was quoted by Henry Davids on in the chapter on in his F ore ns ic P s ychiatry. 2890 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 18 of 60

X and Y who acted like mad in a murderous payroll robbery and like apes when brought to yesterday, were locked up out of the public gaze today to await their next appearance in court defens e lawyer contended that they were insane and they gave outward indications to the contrary. T hey walked into the courtroom with an apelike gait, arms hanging loosely, heads wabbling [s ic] from s ide to s ide with their chins held against their ches ts for pivots Attendants had to prod them along like animals . poked the fingers of his hand his mouth and gnawed them. Y ate pieces of paper from the X then rolled up a paper napkin and ate it. Y lowered his brow to the edge of the table and rubbed it like a hors e s cratching his on a post. X took a pair of s oiled underpants from his pocket and wrapped it around his neck. he licked it and wrapped it his head. At reces s, both had to be lifted from their chairs like sacks . T hey sloughed out of the room like apes

2891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 19 of 60

Avoidanc e of Military S ervic e or of Partic ularly Hazardous Duties P ers ons may malinger to avoid conscription into the armed forces, and, once conscripted, they may feign to escape from particularly onerous or hazardous

Financ ial Gain Modern malingerers may seek financial gain in the undes erved disability ins urance, veterans' benefits, workers' compens ation, or tort damages for purported ps ychological P.2251 injury. In the chapter on malingering and as sociated syndromes in the s econd edition of Ame rican P s ychiatry, David Davis and J ames Weis s P unton's des cription of a malingerer, circa 1903: A man named Moffett described his cane and screw racket, in he us ed a specially prepared to loosen the floor screws on streetcars and railroad cars , which he would then pretend to stumble and then ins titute a for injuries s ustained. He stated that he made it a univers al rule employ the very bes t doctors, because he found, by that they were the most eas ily fooled, whereas the companies 2892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 20 of 60

fleeced were better s atisfied with their opinions . In this he noted that he paid the bills promptly and willingly, even though at times he thought they were exorbitant, but this was done, he s aid, in order to them with the hones ty of his actions.

Avoidanc e of Work, S oc ial R es pons ibility, and S oc ial C ons equenc es Individuals may malinger so as to escape from vocational or social circums tances or to avoid the and litigation-related cons equences of vocational or improprieties . An owner of a previous ly success ful photographic equipment supplier declared bankruptcy in a way that government maintained was illegal. S ubsequently, the government indicted the defendant on various counts fraud. T he defendant's couns el maintained that the defendant was too depres sed to cooperate with him that, because of that depress ion, he experienced loss that made it imposs ible to understand what had occurred and, therefore, imposs ible to provide a meaningful defense. T he government's forensic ps ychiatris t evaluated the defendant to as certain the nature of his depress ion and to determine whether it caus ing cognitive problems. When asked early in his evaluation when his birthday 2893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 21 of 60

he res ponded, Oh, what does it matter, it was in the 50s. S imilarly, when queried about where he was born, said, S ome place in Hungary. E ven when press ed for specifics, he refus ed to elaborate. Y et, at many points in his evaluation, he responded with complete, often detailed, information about transactions not related to those for which he had been indicted. It was the impres sion of the evaluator that the defendant's was malingering in a gros s and inconsistent fashion, incompatible with the kinds of decreas es in cognitive that occasionally attend major depres sion. S till, becaus e the evaluator had not brought tes ts for the evaluation, he was somewhat cons trained when it came to tes tifying as to bases for his He noted, however, that the defendant s at downcast throughout the trial and that, at least when s peaking to couns el, he answered monosyllabically. T his behavior appeared cons is tent with major depres sion (s omething had not observed). However, during a break, the ps ychiatris t observed that the defendant was in an animated conversation with a courtroom visitor. T his behavior appeared antithetical to his demeanor so the ps ychiatris t mentioned it to couns el. A witness then arranged to be pres ent at a subsequent conversation between the defendant and the visitor. he tes tified that the defendant was animated, engaged, and polys yllabic. T he defendant's motion to s ecure time for trial preparation was denied, and he was sentenced for the alleged frauds. Had the defendant's malingering not been detected, he might have delayed ultimate conviction or received a mitigating sentence referable to his claimed depres sion. 2894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 22 of 60

Fac ilitation of Trans fer from Pris on Hos pital P ris oners may malinger (fake bad) with the goal of obtaining a transfer to a ps ychiatric hospital from which they may hope to es cape or in which they expect to do easier time. However, the pris on context may als o give to dis simulation (faking good); the pros pect of an indeterminate number of days on a mental health ward may prompt an inmate with true ps ychiatric symptoms make every effort to conceal them.

Admis s ion to a Hos pital In this era of deinstitutionalization and homeles sness , individuals may malinger in an effort to gain admis sion a psychiatric hospital. S uch institutions may be s een as providing free room and board, a s afe haven from the police, or refuge from rival gang members or drug cronies who have made street life even more unbearable and hazardous than it usually is. A robus t, neatly attired man presented to the emergency department in the early-morning hours . He stated that the voices were wors e and that he wis hed readmitted to the hospital. W hen the psychiatrist challenged him, obs erving that he had jus t been discharged that afternoon, that he routinely left the hospital in the morning and demanded rehos pitalization at night, and that, despite multiple hospitalizations, his reported his tory of hallucinations had been increasingly doubted, the man became belligerent. When the ps ychiatris t s till refused to admit him, the patient the ps ychiatris t's clothes , threatening him but inflicting 2895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 23 of 60

harm. T he psychiatrist as ked the hospital police to him off the grounds . T he patient was told he could s eek readmiss ion to his regular ward during the day. S ubsequent contact with the patient's ward revealed their diagnos es were s ubs tance abus e and his apparent s chizophrenia appeared never to have an actual is sue in his treatment.

Drug-S eeking Malingerers may feign illness in an effort to obtain medications , either for personal us e or, in a prison as currency to barter for cigarettes , protection, or other inmate-provided favors. T he plaintiff, a woman in her late 20s, was injured while dancing at a club. Although her claim initially appeared bona fide, subsequent investigation cas t doubt on the mechanism of injury that s he claimednamely, that a misplaced electrical cord under a carpet caused her to T his was true, s he claimed, despite the fact that she be dancing in a particularly jerky manner that could easily caus ed problems without tripping. S ubsequently, she s ought medical and surgical for torn cartilage in her injured knee. However, des pite fact that the initial s urgery went well, s he kept reinjuring the knee with various slips . As a res ult, s he requested narcotic analges ics. A careful medical record review revealed that s he was obtaining such medications from multiple practitioners and that s he had apparently at least one prescription. In reviewing the case before binding arbitration, it was opinion of the orthopedic and ps ychiatric consultants 2896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 24 of 60

although the initial injury and reported pain were real, plaintiff consciously elaborated her injuries to obtain desired narcotic analgesics.

C hild C us tody A final area in which malingering may be commonplace relates to litigation involving child cus tody and divorce. Minimizing difficulties or faking good for the s ake of P.2252 obtaining child cus tody can occur when one party accurately accuses the other of being an unfit parent to psychological conditions. T he accus ed party may compelled to minimize s ymptoms or to portray him- or herself in a positive light to reduce chances of being deemed unfit and los ing custody.

DE TE C TION OF MA L ING E R ING T he clinician mus t rely initially on interviewing s kills and history to detect malingering. Untrained observers do little better than chance in lie detection, and s ome studies have found police detectives do hardly better undergraduates in judging guilt vers us innocence. conceptual limitations , David R osenhan's study of malingerers faking psychosis as inpatients on a ward cas ts doubt on the ability of trained clinicians to differentiate real from feigned mental illnes s in certain contexts . Nevertheles s, several clues exis t, and, if properly they are us eful for the clinician who s us pects T he ps ychiatric conditions mos t likely to be malingered mental retardation, organic impairment, amnesia, 2897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 25 of 60

ps ychos is , and posttraumatic res idua, including and posttraumatic s tress disorder (P T S D).

Detec ting Dec eption P erpetrators' urges to confess s eem greates t shortly they have trans gress ed; during this period, their guilt is apparently at its most burdensome and is as yet by mental defens e mechanisms. Memory has yet to be distorted, either cons cious ly or unconsciously. T hus , effort s hould be made to interview the criminal shortly after the event, often a crime. Malingering is harder to maintain as the evaluative interview becomes increasingly lengthy, becaus e of fatigue and a pull toward reality. T herefore, when malingering is s us pected, the clinical interview s hould long and detailed. S ometimes , the interview s hould be intentionally excess ively detailed. S uch a process more opportunities for the evaluee to feel his guilt and the obs erver to note inconsistencies. R es earch on lying and malingering has shown that liars often s peak in high-pitched voices , make errors of grammar, and make s lips of the tongue. S tudents who instructed to lie hes itate or pause while lying and tend make irrelevant, rambling, and negative comments; the negativity is thought to be related to guilt. T he pass ive voice is more common than the active, discrepancies between verbal and nonverbal express ion (blinking, dilated pupils, rubbing, or stroking of the self) are and answers may appear rehears ed, overly facile, and T he clinician's s us picion should be aroused if an interviewee makes too many spontaneous ass urances veracity, such as W ould I tell you a lie? or T o be 2898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 26 of 60

hones t. P lanning a lie before the fact allows the liar to T hus, during the lie, he or s he requires fewer paus es words , phras es, or ideas ; has more control over tone of voice; and is able to project more confidently. P lanned are, cons equently, less easy to detect than thos e that unplanned. Among the mos t s ucces sful liars are thos e exaggerate their feigned s entiments by hamming; who have had s ome acting experience; thos e who are intelligent, creative, res ourceful, and have good and those who are smooth and practiced verbally. C ontrary to intuition and popular myth, facial and eye contact are generally poor indicators of truthfulnes s and may interfere with more s ensitive, but no means fully reliable, lie-detection modalities. One meas ured the ability to detect deception under three different conditions: (1) while watching and hearing a videotaped interview, (2) while listening to an audio recording of the interview but s eeing no visuals , and (3) while reading a transcript of the interview. Lis teners readers were far more s ucces sful at identifying than were watchers . T his s ugges ts that the vis ual cues during the interview serve primarily as distractions. At a fairly early age, children learn how to control their facial expres sions so as to conceal their emotions , refining skills through game playing and social interaction; the is particularly adept at deception. Liars do not necess arily make less eye contact, have eyes , s mile or gaze less , or adjust pos ture more than nonliars do. However, S igmund F reud's ass ertion that liar's unconscious guilt oozes out of every pore may at least be true below the neckline. A marked incongruity 2899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 27 of 60

between calmness of face and tension, fidgeting, and active movement of the les s controllable arms , hands , and feet is a good reas on to s us pect deception. is not a common pattern.

Detec tion of S pec ific Malingered C onditions Malingered Mental Defic ienc y or R etardation Mental retardation is difficult to feign in the United largely because the educational s ys tem requires evaluations of intelligencesometimes called aptitude or ability. T ypically, the school s ys tem is paced at one year for each year of mental age on the S tanford-B inet Intelligence S cale, with the first grade adjusted to a age of 6. T hus , a s tudent who has completed the ninth grade s hould have a mental age of approximately 14 A s udden adult score more than 2 or 3 years out of line with that formula, in the context of prior school s cores cons istently adhering to the predicted pattern, should arouse suspicion. In addition, malingerers may mis s questions on ps ychometric tests while correctly more difficult ones. It is always useful to check vocational and military if mental deficiency is claimed, although they are not always revealing. T hese s ources may provide further corroborative or contradictory ins tances of formal intelligence tes ting, and a marked dis crepancy claimed capacity and historical accomplis hment would further caus e to s uspect falsity. T able 26.1-1 some clues to the detection of malingered mental 2900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 28 of 60

deficiency or mental retardation.

Table 26.1-1 C lues to the of Malingered Mental Defic ienc y Mental R etardation 1. S triking dis crepancy between level of and level of intelligence 2. S triking dis crepancy between military and employment records and pres enting behavior and tes t performance 3. S triking dis crepancy between adult tes t performance and prior pattern of tes t 4. F ailure on easy items and s ucces s on difficult during evaluative testing 5. Incongruity of vocational and social with pres entation capabilities

Malingered C ognitive Dis orders A noteworthy dis crepancy reported between those who have dementia and those who are attempting to fake a cognitive disorder is the presence of marked in the former and its absence in the latter. If the 2901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 29 of 60

malingering follows a traumatic injury (e.g., head or toxin exposure), a careful s tudy of the known effects that insult is necess ary before the physician can the claimed sequelae with the plaus ible ones . Most persons attempting to malinger feign fairly blatant and dramatic symptoms ; however, paranoia, morbid depres sion, s uicidal behavior, and gross forgetfulnes s not be reas onable outcomes of a specific class of injury. T he patient's performance before and after the alleged incident s hould be thoroughly analyzed, as s hould the patient's behavior in P.2253 all s pheres of function since the ons et of the alleged deterioration. A pers on who performs well s ocially and when at leis ure while claiming inability to work s hould suspected of malingering. T able 26.1-2 s ummarizes guidelines for the detection of malingered cognitive disorders .

Table 26.1-2 C lues to the of Malingered C ognitive 1. Lack of marked perseveration 2. Implausible s ymptom profile given reported

2902 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 30 of 60

3. P sychotic symptoms confused with cognitive impairments 4. Unimpaired function in social and recreational realms in the face of gros s dis ability

Malingered A mnes ia Amnes ia, probably the most common clinical presentation of malingering (except for malingered which is not usually malingered in the homicide claimed by 30 to 35 percent of perpetrators of is easy to feign and difficult to demonstrate. At leas t s ix pos sible causes have been suggested for amnes ia: (1) convers ion dis order, (2) psychosis, (3) alcoholism, (4) head injury, (5) epilepsy, and (6) malingering. B efore malingering is ascribed, the should review and eliminate the other five potential caus es. A good diagnostic battery s hould include res ults on s kull X -ray, head computed tomography magnetic res onance imaging (MR I), and electroencephalography (E E G ); normal findings on a neurological examination; a life his tory incons is tent either convers ion disorder or alcoholis m (or other of intoxication); and a clinical examination and his tory inconsistent with either alcoholic amnes ia (alcoholinduced pers isting amnes tic dis order) or alcoholic ps ychos is (alcohol-induced psychotic disorder). 2903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 31 of 60

If thes e tests are negative, the clinician faces the more difficult task of amas sing evidencealbeit inferentialof malingering. Motivation is a key indicator. P revious amnes tic episodes without apparent motivational precurs ors lower the likelihood that the patient is malingering. S imilarly, a patient with histrionic traits is more likely to be experiencing true diss ociative amnes ia than one with primarily antisocial traits. T he timing of ons et and recovery and the correlation of the alleged amnestic epis ode with convenience are clues to the pres ence of malingering. G lobal amnesia somewhat more convincing than spotty, patchy, s elfserving amnesia. S potty amnes ia can be s een, for in a person who describes having difficulty with autobiographical memory (e.g., their date of birth, they are from, what age they got married) but has memory ability outs ide of autobiographical information. Additionally, there have been s everal reported of copycat amnesias after famous or highly publicized cases, s o an eye to recent sensational litigation is T able 26.1-3 s ummarizes s ome guidelines for malingered amnesia.

Table 26.1-3 C lues to the of Malingered Amnes ia 1. No history of amnes tic episodes

2904 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 32 of 60

2. Antis ocial pers onality traits more prominent histrionic personality traits 3. S potty, epis ode-specific amnes ia rather than global amnes ia 4. R ecent, widely publicized, suspicious ly familiar cases involving amnesia

In the context of forensic ps ychiatry and exculpation criminal blame, a claim of amnesia after s evere upset, as committing a murder, is a fairly common T o be useful in an insanity defens e, the claimed would generally have to have existed for an period before the criminal act and would have to have continued unabated throughout it; confusion regarding these sequencing iss ues caused the downfall of many malingerers.

Malingered P s yc hos is In ass es sing an apparently ps ychotic patient, the should obtain as much his torical and collateral as poss ible, es pecially if malingering is sus pected. Motivation, availability of coaching, and adherence of symptom picture to known disorder profiles are of us e as sess ing the plaus ibility of an evaluee's psychotic presentation. B eyond these initial as ses sments, a number of have been identified that, if present, raise the 2905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 33 of 60

of malingering. Malingerers tend to overact their part, often mis takenly believing that the more bizarre they appear, the more convincing they are. T he historic example dis cuss ed earlier of the two ape-men is a point. S chizophrenic patients tend to be reluctant to discus s symptoms, particularly if they are in the throes of a persecutory delusional ps ychosis . On the other hand, malingerers may be anxious to call attention to their illness es and to whatever outlandis h belief s ys tems are attempting to feign. T he form of schizophrenic thinking (a formal thought dis order) is far more difficult malingerers to imitate than is its content. T hus, it is less likely that malingerers will mimic loose tangential or circums tantial reas oning than that they describe or act out odd beliefs. Uns ophisticated malingerers often confus e madness with dumbness , supposing that s illy or childlike responses go hand in with bizarre, delus ional experiences . S uch faulty juxtapos ition may be evident during clinical interviews and can be highlighted on ps ychological tes ting. Malingerers may claim the sudden onset of a delusion. R ealis tically, delusional symptoms usually take weeks , months, or years to develop. P sychotic individuals experiencing an acute epis ode are likely to act in direct accordance with their delusional system, whereas malingerers claim to have done s o only when s uch concordance is opportunistic. T he dis crepancy is less striking once the ps ychos is has become more longstanding, as the chronic s chizophrenic may not be as dramatic in acting on delus ional beliefs as a younger, acutely psychotic person. 2906 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 34 of 60

Malingerers are likely to contradict thems elves in their accounts of the illnes s, and thos e contradictions may multiply as the interview progres ses. T hey may be led as tray by leading ques tions that the examiner knows ps ychologically abs urd, and they may make mis takes questioned rapidly or directly confronted. S pecific questions about the ons et and progres sion of a are often most revealing becaus e, even if a symptom is malingered currently, its typical development may not appreciated. T heir symptoms may fit no diagnostic and, when caught in such a discrepancy, they may s ulk laugh from embarrass ment. Malingerers s ometimes attempt to take control of the interview, behaving in an intimidating and blus tery manner. T hey are likely to repeat ques tions or ans wer questions s lowly, working to give thems elves more fabricate convincing responses. T hey present as blameles s within their feigned illnes s, yet they are to have nonps ychotic alternative motives for their behavior, such as killing out of revenge or out of paraphiliac desire. As is true of the form of schizophrenic thinking, malingerers are unlikely to success fully imitate the signs of res idual s chizophrenia. B lunted affect, concreteness , and odd, s chizoid relatedness are presentations familiar only to the most talented malingerers. T able 26.1-4 s ummarizes s ome features malingered delus ions.

Table 26.1-4 Features of Malingered Delus ions 2907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 35 of 60

1. Abrupt ons et and termination rather than development and hes itant abandonment 2. E agernes s to call attention to delusions and symptoms rather than reluctance to acknowledge them 3. B ehavior incons is tent with delusional content rather than reflective of delus ional content 4. T hought content gros sly disturbed in the face conventional and goal-directed thought process

P.2254 C riminal defendants attempting to malinger psychosis most frequently fake auditory hallucinations; thus , knowledge of the characteristics of general and detailed ques tioning into the nature of the claimed experience are mandatory if the clinician suspects malingering.

HAL LUC INATIONS T rue hallucinations tend to be as sociated with and are often a ps ychotic express ion of some need. Accusatory voices may repres ent unacceptable ps ychotic) guilt, horrifying creatures or threatening 2908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 36 of 60

animals may repres ent unacceptable aspects of the personality, and the belief that one is giving off a foul may repres ent severe depres sion and s elf-deprecatory delus ion. Individuals with schizophrenia frequently report that voices speak directly to them or pass judgment on S chizophrenic hallucinations tend to be intermittent than continuous, and more than 50 percent of schizophrenic individuals eventually acknowledge that they may have imagined their hallucinations . S ome reveal that 66 percent of s chizophrenic patients have auditory hallucinations and 33 percent have vis ual hallucinations . T he visual hallucinations almost always accompany the auditory hallucinations. V is ual hallucinations tend to be in color and of normal-sized people. Olfactory and gustatory hallucinations have reported in acute epis odes of s chizophrenia; olfactory hallucinations are of unpleasant odors and are rare. E ighty-eight percent of s chizophrenic individuals report that auditory hallucinations come from outside the and 75 percent report that they hear both male and voices. T he mes sage is usually clear; it is vague only 7 percent of the time and is accusatory approximately third of the time. Approximately 30 percent of schizophrenic individuals ans wer the voices they hear. C ommand hallucinations , although clinically are ignored by true ps ychotic individuals up to 60 of the time. T hey are more likely to be obeyed if the is familiar to the hallucinator or if they are one element developed delus ional s ys tem. Most truly ps ychotic individuals have developed 2909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 37 of 60

for coping with hallucinatory epis odes . C ommonly are changes of posture, distraction through activity or interpersonal contact, or ingestion of antipsychotic medication. Although the auditory hallucinations of truly ps ychotic pers ons tend to be general and basic, thos e malingerers are often s tilted, specific, and self-serving. Alcohol-induced psychotic disorder with hallucinations that follows the abrupt ces sation of previously high alcohol intake ordinarily produces vivid hallucinations . Although voices are extremely common, experience of noise, music, unintelligible voices, or tactile such as formication, are more frequent than in schizophrenia. S ubs tance-induced psychotic disorders generally involve unformed, indis tinct hallucinatory T able 26.1-5 s ummarizes s ome features of malingered auditory hallucinations .

Table 26.1-5 Features of Malingered Auditory Halluc inations 1. C ontinuous rather than intermittent 2. V ague, inaudible, or unintelligible rather than distinct 3. F ree-standing rather than as sociated with delus ions 2910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 38 of 60

4. S tilted in language and specific in tone rather basic and general 5. R eported in the firs t person rather than in the person 6. Uncontrollable rather than susceptible to strategies for containment 7. Irres istible rather than s us ceptible to

Malingered P os ttraumatic In today's too often litigious society, the psychiatrist be as ked to determine the veracity of ps ychiatric or behavioral s ymptoms that a person claims resulted trauma, whether psychological or physical in nature. actual incidence of malingered ps ychological after phys ical injury is unknown, but one s tudy found 48 out of 50 cases of pos taccident neuros is had 2 years after the legal claim had been s ettled, and a G eneral Accounting Office follow-up study reported in 1980 that approximately 40 percent of individuals cons idered to be totally dis abled had no dis ability whatsoever 1 year after that declaration. S uch data suggest that such claims are rife with embellis hed symptoms. T hey also underscore the importance of cons idering malingering when evaluating s uch claims. Malingerers in personal injury cas es seldom feign 2911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 39 of 60

ps ychos is . Much more common are claims of and, now that it has become widely publicized, of S uch ambulatory illness es allow malingerers to avoid res ponsibility and to escape from work, while sparing them the unpleas antness and the 24-hour s crutiny of hospitalization in a ps ychiatric setting. In attempting to distinguis h malingered from actual posttraumatic depres sion, it is helpful to determine signs and s ymptoms of depres sion not commonly to the lay individual. T he absence of diurnal variation, specifically early-morning awakening (as opposed to vague, generalized insomnia), of angry irritability, and diminis hed sexual interes t may sugges t imitation. S imilarly, the lack of a family history of the dis order or prior incidents is s us picious. P oss ibly mos t revealing of is a lack of depres sive withdrawal from enjoyable such as social and recreational activities , in the face of apparent total incapacity in avers ive domains, such as work. P T S D has become a particularly productive field for es pecially since the Department of V eterans Affairs publicized the P T S D criteria in the early 1980s and announced that any veteran meeting the criteria was eligible for governmental compens ation. In P T S D in pos ttraumatic depres sion claims , amas sing a picture of pretrauma functioning is crucial. Naturally, relation between the degree of the stress or and the alleged s ymptom clus ter, the temporal pattern, and any prior, concurrent, or s ubs equent symptoms and figure centrally in the evaluation. S ome s pecific clues to the malingering of P T S D exis t. patient with P T S D frequently focus es on the negative 2912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 40 of 60

features of the dis orderthe emotional numbnes s, indifference, and social withdrawal. In contras t, the malingerer may be more impress ed by (and, therefore, hopes to impress more with) the expres sionistic of nightmares and flashbacks. In true P T S D victims, nightmares tend to vary in content while hewing to the cons tant themes of terror and helpless ness ; are more likely to report reexperiencing exactly the dream, often described as a videotape-like reliving of alleged trauma itself. S ome malingerers are about the nature of the true flashback experience, confusing it with and des cribing it as a benign pictorial memory. P articularly in P T S D, with its clearly criteria and entirely des criptive diagnos is, a textbookperfect pres entation s hould rais e greater sus picion presentation characterized by a vague, more symptom clus ter. T able 26.1-6 lists a P.2255 number of items s ugges tive of malingering of ps ychological distress after a traumatic incident.

Table 26.1-6 Fac tors S ugges ting Malingering of Ps yc hologic al Dis tres s after Trauma 1. Ass ertion of inability to work in the face of unimpaired capacity for pleasurable activity 2913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 41 of 60

(recreation, social interaction) 2. S ubs cription to more obvious symptoms of publicized dis orders in the face of denial of more subtle features 3. S potty, ques tionable vocational his tory; to drift; fringe member of s ociety 4. E vas iveness during interview; unwillingness to concretely address a return to work, and s ocial expectation 5. G eneral presentation of sullenness , suspicious guardednes s, uncooperativenes s, or res entment 6. R efus al to comply with recommended or treatment procedures; avoidance of direct examination 7. History of disabling injuries and unusually frequent absences from work 8. T raits common to antisocial, narciss istic, borderline, or histrionic pers onality disorders 9. E nergetic and concerted purs uit of legal claim the face of alleged debility caused by depres sion posttraumatic s tres s disorder

2914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 42 of 60

10. R efus al of employment s uggested as despite alleged dis ability 11. S elf-depiction in exces sively favorable and capable terms before alleged trauma and collaps e

Objec tive Tes ting F or centuries, objective measures , such as reactions , have been us ed to differentiate the conniving from the s incere. F or example, realizing that s tres s caus e a reduction in saliva production, the B edouins required conflicting witness es to lick a hot iron; the whos e tongue s tuck to the iron was adjudged to be the liar. S imilarly, in ancient C hina, individuals in conflict each required to chew on a ball of rice and then to s pit out; the person whos e ejected rice was drier was cons idered to be the charlatan. T he contemporary technique for measuring psychophysiological stress is polygraph. However, the polygraph is not foolproof; at best, it is 80 to 90 percent reliable, a fact that has many jurisdictions to forbid its use in forens ic T he polygraph seems best at detecting lying in anxious but hones t individuals ; it is, therefore, prone to falsepositive res ults . P articularly dis heartening is the empirically verified, that some practiced s ociopaths can beat the lie detector. Amobarbital (Amytal)sometimes mis takenly cons idered 2915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 43 of 60

truth s erumand hypnotic techniques have also proved disappointing candidates in the s earch for objective evaluation. Approximately 50 percent of tes ted pers ons are able to maintain a lie under either of these techniques, and, in fact, some lies can actually become solidified under botched hypnotic circumstances. P sychological tes ting has increasingly proven the detection of malingering. B y far, the mos t widely ps ychological tes t for this purpose and the one with the broades t empirically validated data s et, is the Multiphasic P ers onality Inventory2 (MMP I-2). Among us eful validity indicators is the gauge known as the F K scale, obtained by subtracting the K raw score from the raw s core. Higher s cores on the F K index sugges t a likelihood that the s ubject is malingering overall. With K index of +10, one would be correct approximately percent of the time to ass ume that the entire MMP I-2 profile was malingered. Obvious ly, this is a significant indicator. C ons idered separately, both the F and K s cales can be further us e in evaluating an individual. T he F s cale has been proposed as an indicator of malingering, particularly when the s core approaches a t-score of above. T he F s cale is compos ed of items endors ed by than 10 percent of the population. T hus , s cores on this scale can inform a clinician about the frequency to odd, atypical items or s ymptoms are endorsed and, the likelihood of an individual faking bad. Nonetheles s, scores approximating 100 or above can s ignal not only invalid profile due to malingering but als o s imple uncooperativenes s, misunders tanding of the items, a for help from a patient who perceives the system as 2916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 44 of 60

advers arial, or frank psychosis. T hus , gathering a background history of the patient, including vocational, and ps ychiatric histories , becomes even es sential in clarifying the reasoning behind an elevated score. T he F validity s cale itself has additional subscales that also be us eful indicators of malingering. T he F (b), or back scale, was des igned to as ses s a fake bad mode res ponding by containing additional items that have a endors ement frequency (i.e., les s than 10 percent of nonpatient adults ). On this scale, evaluees should roughly equivalent to the overall F score. Nevertheles s, high T -scores on the F (b) indicate either generalized pathology or an attempt to exaggerate his or her level symptomology. S imilarly, the F (p), or F subs cale, is yet another notable marker of malingering. T his s ubscale is composed of s ubtle items that are endors ed by nonpatients or those who have an obvious ps ychos is . T herefore, s cores on the F (p) scale can be as additional data to further evaluate a profile for faking bad. S cores on the K scale similarly tap into malingering, the oppos ite end of the continuum. Unlike the F scale, K s cale is compos ed of rather understated items difficulties that few individuals would deny. A significant score on the K scale, then, is a good meas ure of defens iveness and can identify individuals attempting present thems elves in a positive light. Higher scores on K s cale (a t-score of approximately 70 or above) that either the patient is attempting to des cribe him- or herself in an overly favorable manner and denying difficulties or that he or she is nay-saying (answering 2917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 45 of 60

on all items ). F inally, the variable res ponse incons is tency (V R IN) true res ponse incons is tency (T R IN) scales offer a level of analys is of malingering potential. T he V R IN comprised of pairs of items that are s imilar or oppos ite content. T hus , high s cores on this scale sugges t indis criminate responding, which may be a res ult of malingering. S imilarly, the T R IN s cale is made up of items but only includes items that are oppos ite in T hus, a +1-point score would be generated on the scale for each oppos ite pair that the evaluee true to and a 1-point score would be generated for oppos ite pair that the evaluee answered false to. C ons equently, then, the T R IN is a good scale for inconsistencies in res ponses related to ans wering true false on all items. In summary, it has been sugges ted that the MMP I-2 be most fruitfully us ed if the F s cale (including the F [b] F [p]), K s cale, F K index, and V R IN/T R IN s cores are computed and the subject is then reinterviewed concerning the endors ed critical items. S uch an combination with a detailed background his tory, can further light on the reas oning that prompted the res ponse pattern. E ven without s uch reevaluation, the scale alone can be useful when the other sources of potential contamination can be eliminated. A further use of the MMP I-2 in the detection of malingering has involved an analysis of the ratio of versus obvious indicators of pathology endors ed. In an analys is , as in the setting of a clinical interview, malingerers are more likely to s ubscribe to blatant, indicators of pathology than to more subtle ones. Over 2918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 46 of 60

time, new indicators of malingering are being and cons ultation with a knowledgeable ps ychologist is important if testing is to be fully used as a s ource in evaluating malingering. P.2256 T he plaintiff, a federal employee with a history of filing multiple claims alleging dis crimination at work, claimed be incapacitated from work because of recurrent symptoms of P T S D aggravated by his work as a fire suppress ion agent. T he defendant's ps ychiatric revealed a pleas ant and s eemingly cooperative man provided a history s imilar to that incorporated in his complaint. In the course of his evaluation, he was adminis tered an MMP I-2 that, when scored, revealed score of 120. T he ps ychiatris t used this information, other inconsistencies adduced during the discovery proces s, to opine that the plaintiff's symptoms of P T S D were malingered. Upon receipt of the ps ychiatris t's the plaintiff wrote a long diatribe complaining about the ps ychiatris t's lack of profess ionalism during his T his appeared to the ps ychiatris t to reflect the plaintiff's displeas ure with his malingering diagnosis. Ultimately, plaintiff, who had admitted during a detailed deposition examination that he had repeatedly lied in documents supporting his claims of dis crimination, s ettled his s uit nuisance value. B es ides the MMP I-2, other pers onality inventories can insight into an evaluee's propens ity for malingering. A and promis ing meas ure, known as the P ers onality As s es s ment Inve ntory (P AI), has fewer questions than 2919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 47 of 60

MMP I-2 but allows graduated ans wers, which avoids forcing an evaluee to ans wer only true or fals e. It als o typically allows the test-taking proces s to be completed less than 1 hour. B ecause it provides an as sess ment of clos ely an individual's answers fit certain patternsfor example, malingeringit als o provides useful information about an individual's approach to an evaluation. Many forens ic evaluators find that us ing the two tests in conjunction is helpful. Other psychological tests provide a more focus ed exploration of a particular as pect of malingering. T he V alidity Indicator P rofile (V IP ) provides information cognitive malingering. Most evaluees complete it in than 1 hour; thus, like the P AI, it can be included as a s ingle daylong as sess ment. T he S tructured Interview R eported S ymptoms (S IR S ), developed by R ichard is an excellent instrument for as sess ing feigned T he R ors chach, although an excellent test, es pecially scored with the publis hed and validated E xner s ys tem, not an appropriate instrument for making the diagnosis malingering. S coring for that determination is generally cons idered too s ubjective, despite its power in dynamic is sues. Nevertheless , as noted els ewhere in section, s avvy malingerers appear to increasingly favor nonps ychotic diagnos es; thus, its us e may be circums cribed. Neurops ychological tes ting has been advanced as an the evaluation of head-injured patients. In one s tudy, Hals tead-R eitan B attery, which includes the W echsler Adult Intelligence S cale (W AIS ) and the firs t edition of MMP I, were adminis tered to 16 volunteer malingerers 16 nonlitigating patients with head injuries, and the test 2920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 48 of 60

res ults were sent to 10 neuropsychologists for blind ratings . Although the overall levels of impairment were equivalent in both groups , the patterns of impairment were not. T he malingerers scored mos t poorly on the obvious items, whereas the injured individuals failed subtle ones. C ons idering the results of all three tes ts together, the neurops ychologists correctly clas sified percent of the malingerers and 94 percent of the nonlitigating injured patients. T hes e are dramatic and unders core the us e of neurops ychological in cases that rais e cognitive malingering is sues. T hus, although ps ychological and neurops ychological tes ting can be very helpful, they are neither infallible uniformly dispositive. S till, well-chos en psychological can be of enormous benefit in detecting malingering. R arely, however, is one test res ult so aberrant that it, its elf, confirms a malingering diagnosis .

DIF FE R E NTIA L DIA G NOS IS Malingering mus t be differentiated from the actual phys ical or ps ychiatric illness suspected of being F urthermore, the pos sibility of partial malingering, an exaggeration of existing symptoms, mus t be entertained. T here also exists the poss ibility of unintentional, dynamically driven misattribution of genuine s ymptoms (e.g., of depress ion) to an incorrect environmental caus e (e.g., to sexual haras sment rather than to narcis sistic injury). A middle-aged manager of a department s tore made error in his 23rd year of s ervice. When two department supervis ors one retiring and the other incomingdisputed 2921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 49 of 60

the rightful ownership of a s eas onal bonus check, the manager did not contact upper management for a solution. An individual with clear-cut narciss istic personality dis order, the manager took matters into his own hands. He divided the check three ways, one-third going to each supervis or, and one-third going to T he manager was put on sus pension for inappropriate dispensation of company funds. T his epis ode was only the most serious of an series of poor decisions , and the company sugges ted the manager allow hims elf to be ps ychiatrically at company expens e. Outraged at the s uspens ion after these years of devoted s ervice and the suggestion that would do anything wrong, the manager instead quit his position and sued the company for race discrimination age discrimination. P sychiatric examination revealed a man with depres sion that was clearly the product of a narcis sistic wound who appeared utterly convinced of truth of the mis attribution of his misfortune, which had been dynamically driven outward. A diagnosis of malingering would have been as inappropriate in this as were the plaintiff's allegations of race- and agemotivated discrimination. It s hould als o be remembered that a real psychiatric disorder and malingering are not mutually exclus ive. A patient was admitted to a V eteran's Administration hospital with complaints consistent with P T S D. he denied auditory hallucinations , he was troubled by recurrent nightmares and frightening flashback experiences , both involving a terrifying event he had witness ed while serving with the infantry in V ietnam. 2922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 50 of 60

T ime and growing trust in the therapist resulted in an admis sion by the patient that he experienced auditory hallucinations and had for years ; in fact, his history became, increas ingly, clearly that of Antips ychotic agents greatly relieved his s ymptoms. Ultimately, it was dis covered that the patient had never served in V ietnam, had never witness ed any lifethreatening trauma, and had never experienced or recurrent nightmares . He did, however, continue to benefit from profes sional antips ychotic medication and was dis charged with the correct diagnosis of paranoid schizophrenia. F actitious disorder, G anser's syndrome, and disorders (es pecially conversion dis order) can be with malingering. F actitious disorder is distinguis hed malingering by motivation (sick role versus tangible whereas the somatoform dis orders involve no volition. In conversion disorder, as in malingering, objective s igns cannot account for s ubjective and P.2257 differentiation between the two dis orders can be T able 26.1-7 lists s ome variables that may aid in distinguishing between thes e two conditions .

Table 26.1-7 Fac tors Aiding in Differentiation between Malingering and C onvers ion Dis order 2923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 51 of 60

1. Malingerers more likely to be s uspicious , uncooperative, aloof, and unfriendly; patients with conversion disorder likely to be friendly, appealing, dependent, and clinging 2. Malingerers may try to avoid diagnostic evaluations and refuse recommended treatment; patients with convers ion dis order likely to evaluation and treatment, s earching for an 3. Malingerers likely to refuse employment opportunities des igned to circumvent their disability; patients with convers ion dis order likely accept s uch opportunities 4. Malingerers more likely to provide extremely detailed and exacting descriptions of events precipitating their illness ; patients with convers ion disorder more likely to report historical gaps , inaccuracies, and vagaries

G ans er's s yndrome, or the syndrome of approximate answers , is rare and described primarily in pris on populations. It involves the production of answers to questions that are relevant but not quite correct, such stating that the product of 7 4 is 29. It is clas sified in IV -T R as a dis sociative disorder not otherwis e has variously been regarded as a factitious disorder, a 2924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 52 of 60

hysterical phenomenon, a psychotic dis order, and frank malingering. S everal s tudies of undergraduates to feign madness res ulted in the malingerers producing approximate ans wers s trikingly reminiscent of G ans er's syndrome. T hat finding lends credence to F rederick Wertham's famous 1949 as sertion that A G ans er a hypothetical pseudos tupidity which occurs almost exclusively in jails and in old-fas hioned G erman It is now known to be almos t always due more to cons cious malingering than to unconscious

C OUR S E A ND P R OG NOS IS Malingering pers ists as long as the malingerer believes apt to produce the desired rewards . In the abs ence of concurrent diagnoses , once the rewards have been attained, the feigned s ymptoms disappear. In s ome structured s ettings , s uch as the military or pris on units, ignoring the malingered behavior may result in its disappearance, particularly if an expectation of productive performance, despite complaints, is made clear. In children, malingering is mos t likely as sociated a predisposing anxiety or conduct disorder; proper attention to this developing problem may alleviate the child's propensity to malinger. Malingerers are unlikely to comply with disordertreatments that are offered. If they are confronted with their malingering directly, they are likely to s eek out doctors until they can find a phys ician who unwittingly complies with their manipulations. S ymptoms are likely abate only when the des ired outcome has been or when it becomes clear that the malingering is futile. that point, malingerers are likely to discontinue 2925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 53 of 60

abruptly. However, as would be expected, the more the malingering has been reinforced, the more likely it is to recur. S ucces sful malingerers are apt to malinger repeatedly throughout their lives on jus t as many occasions as society, however unwittingly, rewards

TR E A TME NT It is obvious that malingerers do not wis h to be treated; the last thing they desire is to have their condition detected or diagnosed. T hey are cons cious ly the system in the hopes of achieving personal gain or benefit. S till, the appropriate s tance for the ps ychiatris t is neutrality. If malingering is suspected, a careful inves tigation s hould ensue. If, at the conclusion of the diagnostic evaluation, malingering s eems mos t likely, patient should be tactfully but firmly confronted with the apparent outcome. However, the reasons underlying rus e need to be elicited and alternative pathways to the desired outcome explored. C oexisting ps ychiatric disorders should be thoroughly ass es sed. Only if the patient is utterly unwilling to interact with the phys ician under any terms other than manipulation s hould the therapeutic (or evaluative) interaction be abandoned.

S UG G E S TE D C R OS S T he somatoform disorders , including convers ion are discus sed in C hapter 15; further differentiation of disorders from malingering may be found in that F actitious disorders are discuss ed in C hapter 16. Dis turbances of perception, including hallucinations , of experience, including delus ions, are discus sed in 2926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 54 of 60

C hapter 8 on clinical manifestations of ps ychiatric disorders . S chizophrenia is dis cuss ed in C hapter 12, dementia is dis cuss ed in C hapter 10, and mental retardation is dis cuss ed in C hapter 34. Dis sociative amnes ia is address ed in C hapter 17. Depres sive are reviewed in C hapter 13. V arious personality and traits , including borderline, narcis sistic, histrionic, antis ocial personality dis order, are elucidated in 23. P s ychological and neurops ychological tes ting are addres sed in S ections 7.5, 7.6, and 7.7.

R E F E R E NC E S B agby R M, Nicholson R , B uis T : Utility of the subtle items in the detection of malingering. J P e rs As s es s . 1998;70:405. B as h IY , Alpert M: T he determination of malingering. Ann N Y Acad S ci. 1980;347:86. B eaber R J , Marston A, Michelli J , Mills MJ : A brief meas uring malingering in s chizophrenia individuals. Am J P s ychiatry. 1985;142:14781481. B eck T R . E le me nts of Me dical J uris prude nce . V ol 1. Albany, NY : W ebsters & S kinners ; 1823. B en-Avi I, R abin S , Melamed S , K reiner H, R ibak J : Malingering ass es sment in behavioral toxicology: why, and how. Am J Ind Med. 1998;34:325. *B utcher J N, Miller K B : P ersonality ass es sment in personal injury litigation. In: Hes s AK , W einer IB , 2927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 55 of 60

Handbook of F ore ns ic P s ychology. 2nd ed. New Wiley; 1999. C arus o K A, B enedek DM, Auble P M, B ernet W: C oncealment of ps ychopathology in forensic evaluations : A pilot study of intentional and unins ightful dis simulators. J Am Acad P s ychiatr 2003;31(4):444450. C atton J . B ehind the S ce ne s of Murde r. New Y ork: 1940. C houinard MJ , R ouleau I: T he 48-P ictures T est: A alternative forced-choice recognition tes t for the detection of malingering. J Int Ne urops ychol S oc. 1997;3:545. Davids on HA. F ore ns ic P s ychiatry. 2nd ed. New R onald P ress ; 1965. Davis D, W eiss J MA. Malingering and ass ociated syndromes. In: Arieti S , B rody E B , eds. Ame rican Handbook of P s ychiatry. 2nd ed. V ol 3. New Y ork: B ooks ; 1974. DeP aulo B M, R os enthal R : T elling Lies . J P e rs S oc 1979;37:1713. E dens J F , G uy LS , Otto R K , B uffington J K , T omicic P oythress NG : F actors differentiating s uccess ful unsuccess ful malingerers. J P e rs As s e s s . 2001;77 (2):333338. 2928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 56 of 60

E is sler K R . Malingering. In: W ilbur G B , W, eds . P s ychoanalys is and C ulture . New Y ork: International Univers ities P res s; 1951:218. E xner J E . T he R ors chach: A C omprehe ns ive 3rd ed. New Y ork: Wiley; 1993. F ord C V . L ie s ! L ie s ! L ie s !!! T he P s ychology of Was hington, DC : American P sychiatric P ress ; 1996. G oodwin DW, Alders on P , R os enthal R : C linical significance of hallucinations in psychiatric study of 116 hallucinatory patients . Arch G e n 1971;24:76. G riffin G A, G las smire DM, Henders on E A, McC ann II: redesigning the R ey screening tes t of C lin P s ychol. 1997;53:757. G roth-Marnat, G . Handbook of P s ychological 3rd ed. W iley, New Y ork; 1999. G uriel J , F remouw W : As ses sing malingered posttraumatic disorder: A critical review. C lin R ev. 2003;23(7):881904. *Hadjistavropoulos T . C hronic pain on trial: T he influence of litigation and compens ation on chronic pain s yndromes . In: B lock AR , K remer E F , eds. of P ain S yndrome s : B iops ychos ocial P e rs pe ctive s . Mahwah, NJ : E rlbaum; 1999. 2929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 57 of 60

P.2258 Hall HV , P ritchard DA. Dete cting Malinge ring and Dece ption. Delray B each, F L: S t. Lucie P ress ; 1996. Hawk G L, C ornell DG : MMP I profiles of malingerers diagnosed in pretrial forensic evaluations . J C lin 1989;45:673. Larrabee G J : Detection of malingering us ing atypical performance patterns on s tandard tes ts . C lin Neurops ychol. 2003;17(3):410425. Lipian MS . S omatoform dis orders. In: P rice DR , Haley P R , eds . T he Ins ure r's Handbook of C laims . S eattle, WA: I.W. P ublications ; 1995:83. Lykken DT : T rial by polygraph. B ehav S ci L aw. Marcus E H: T he dilemma of the malingering patientlitigant. Am J F orens ic P s ychiatry. 1987;7:3. Mckinzey R K , R uss ell E W: A partial cros s -validation Hals tead-R eitan B attery malingering formula. J C lin Nue rops ychol. 1997;19:484. Merydith S P , Humphreys J K , E bener DJ : distortion of the 16P F by welfare recipients . J P e rs 1997;69:376. O'B ryant S E , Hilsabeck R C , F isher J M, McC affrey of the trail making test in the as sess ment of 2930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 58 of 60

in a s ample of mild traumatic brain injury litigants . Neurops ychol. 2003;17(1):6974. Osimani A, Alon A, B erger A, Abarbanel J M: Use of S troop phenomenon as a diagnostic tool for malingering. J N eurol Ne uros urg P s ychiatry. P ollock P H, Quiley B , W orley K O, B as hford C : mental disorder in prisoners referred to forensic health services . J P s ychiatr Ment He alth Nurs . P rice J R . Malingering and s ymptom exaggeration. P rice DR , Lees -Haley P R , eds . T he Ins ure r's P s ychological C laims . S eattle, W A: I.W. 1995. R es nick P J : T he detection of malingered mental B ehav S ci L aw. 1984;2.21. R es nick P J : Malingering. J F ore ns ic P s ychiatry. R eynolds C R , ed. Dete ction of Malingering during Injury L itigation. C ambridge, MA: P erseus 1998. R ogers R . S tructure d Interview of R e ported (S IR S ). Odess a, F L: P sychological Ass ess ment 1992. *R ogers R , ed. C linical As s e s s me nt of Malingering As s es s ment. 2nd ed. New Y ork: G uildford; 1997.

2931 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 59 of 60

R ogers R , C ruis e K R : As ses sment of malingering simulation des igns: T hreats to external validity. L aw Hum B e hav. 1998;22:273. R ogers R , Harrell E H, Liff C D: F eigning neurops ychological impairment: A critical review of methodological and clinical cons iderations . C lin R ev. 1993;13:255. R ogers R , S alekin R T , G oldstein A, Leorand K : A comparis on of forens ic and nonforensic malingerers: prototypical analys is of explanatory models . L aw B ehav. 1998;22:353. R os enhan D: On being s ane in ins ane places . 1973;179:250. S chmand B , Lindeboom J , S chagen S , Heijt R , Hamburger HL: C ognitive complaints in patients whiplas h injury: T he impact of malingering. J Ne urol Neuros urg P s ychiatry. 1998;64:339. S chretlen D: T he use of psychological tests to malingered s ymptoms of mental disorders . C lin R ev. 1988;8:451. S iegler M, Os mond H: T he s ick role revisited. S tud Has tings C e nt. 1973;1:41. S mith G P , B urger G K : Detection of malingering: V alidation of the S tructured Inventory of Malingering S ymptomatology (S IMS ). J Am Acad P s ychiatry 2932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 60 of 60

1997;25:183. S zasz T S : Malingering: Diagnos is of s ocial condemnation. Arch Neurol P s ychiatry. *T rueblood W , S chmidt M: Malingering and other validity considerations in neuropsychological evaluation of mild head injury. J C lin E xp 1993;15:578. Wang E W , R ogers R , G iles C L, Diamond P M, Wang LE , T aylor E R : A pilot s tudy of the P ers onality Ass es sment Inventory (P AI) in corrections: of malingering, s uicide ris k, and aggres sion in male inmates. B ehav S ci L aw. 1997;15:469. Wertham F . T he S how of V iole nce . New Y ork: 1949. *Williams R W , C arlin M: Malingering on the W AIS -R among dis ability claimants and applicants for vocational ass is tance. Am J F orens ic P s ychol. Ziskin J : Malingering of ps ychological disorders . S ci L aw. 1984;2:39.

2933 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

01/01/2009

Page 1 of 64

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > 27 - C ulture-B ound S yndrome

27 C ulture-B ound S yndromes Manuel Trujillo M.D. 



DE F INIT ION C ULT UR E AND T HE DE V E LOP ME NT OF P S Y C HOP AT HOLOG Y



E P IDE MIOLOG Y



AS S E S S ME NT AND E V ALUAT ION



C ULT UR AL F OR MULAT ION IN DS M



C ULT UR E -B OUND S Y NDR OME S



T HE R AP IE S



P S Y C HOP HAR MAC OLOG Y



S T ANDAR DS





C ULT UR AL P R OF IC IE NC Y T HR OUG H T HE C AR E S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > DE F INIT IO

DE FINITION 2934 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 2 of 64

P art of "27 - C ulture-B ound S yndromes " T he term culture -bound s yndrome us ually denotes arrays of behavioral and experiential phenomena that to present thems elves preferentially in particular sociocultural contexts and that are readily recognized illness behavior by most participants in that culture. syndromes are commonly ass igned culturally explanations and interpretations that, in turn, generate set of culturally congruent remedies, us ually in the form healing rituals performed by someone to whom the community ass igns a therapeutic role. C ulture-bound syndromes tend to encompas s a wide range of ps ychological, s omatic, and behavioral manifestations. Ataque de ne rvios , a syndrome that is widely prevalent in Latin America, among U.S . and in other Latin and Mediterranean cultures , erupts a florid combination of anxiety symptoms , s omatic experiences , and erratic behavior. Its sufferers may experience intense heat ris ing from the chest, may many dis sociative s ymptoms , and may faint or s eize. observer may report out-of-control behavior, shouts screams , sobbing, trembling, and purpos eless motor behavior. Its victims may jump, run, or throw agains t walls or may enact random aggres sive acts suicidal gestures. Dis sociation seems to be at the core amok, a s yndrome observed in wide areas of Malays ia, Asia, the P acific, andles s oftenin P uerto R ico and the Navajo Indians . After an initial period of intense brooding and withdrawal, amok s ufferers enter a period diss ociation marked by motor automatis ms and of random violence with or without persecutory ideas 2935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 3 of 64

amnes ia. A glos sary of primary symptoms present in culturedisorders was compiled by C . C . Hughes , who reports, decreasing frequency, the presence of s ymptoms of anxiety, apathy and withdrawal, angry and aggres sive behaviors , bizarre and unconventional complex motor behaviors (e.g., taking off clothing, thrashing about, shouting and swearing, and inappropriate dancing), depres sion, dis sociation, gas trointes tinal (G I) hallucinations , sleep disorders with parasomnias, and many others. A W estern clinician or res earcher trying to unders tand culture-bound syndromes might frame his or her quest with the following caveats : 1. All societies harbor individuals who exhibit acute chronic behavior that is at variance with the mores standards of the community and that becomes problematic for the individual or for other members the community, or both. All societies in the anthropological record hold explanatory for such behavior, as sign it a label, and attribute to meaning and value (acceptance or s tigma) as they prescribe a s ocial role (s upport or sanction) to the victims of such behavioral epis odes. T o the degree aberrant behavior earns the label of illness , all provide a vas t array of remedies aimed at its amelioration and confer s pecific benefits to those hold the s ick role. 2. S ocieties vary widely in the way in which they aggregate s ymptoms to construct and to label disorders , in the thres holds of tolerance for 2936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 4 of 64

behavior, in the entitlements provided pers ons who fall ill, and in the proces s and systems that are designed for the care of the afflicted. T hese parameters thems elves (symptom aggregates, thresholds of tolerance, and s ys tems of care) are subject to cons iderable historical change. J us t in Wes tern societies, s ymptom aggregates have cons iderably during the 20th century. S uffice it to the rarity of presentations of grand hysterics in Wes tern clinics today as compared with their florid abundant presence in the era of J ean Martin Diagnos tic labels have changed as well; witnes s fate of the diagnos is of homosexuality, earlier regarded as a psychiatric condition s ubject to diagnosis and treatment in a social atmos phere of legal sanction and moral rejection, and now cons idered a normal variant of sexuality deserving equal and full protection in the various bills of rights and codes of law. C hanges in thresholds of have a more mixed record. P rogres s has to be in the reduction of the stigma attached to patients with schizophrenia earlier in the era of indus trialization. W estern communities, however, erect s ignificant barriers to thes e patients in terms their fuller reintegration to community living, employment, and valued social roles ; thus, the paradox observed in many outcome research that monotonously confirm the better outcomes of these dis orders in s o-called less advanced but tolerant and welcoming communities. 3. C linicians and researchers who operate in W es tern cultures and s ocieties tend to cons ider the Wes tern 2937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 5 of 64

biomedical intellectual tradition (including the Diagnos tic and S tatis tical Manual of Me ntal [DS M] and the Inte rnational S tatis tical Dis e as es and R e late d He alth P roble ms [IC D]) as objective referent. As it were, the Wes tern edifice of diagnoses and treatment is unwittingly as cribed the value of the s o-called objective norm agains t which other ethnic labels are contras ted and evaluated. T his viewpoint permits W estern cons ider the psychiatric knowledge produced by cultures as culture bound. S cientific humility would compel phys icians to as k the question that, if all nosologies (and treatment systems ) are culture has the W estern s ys tem of aggregating s yndromes , producing labels , and as signing value and meaning emerged outside of the bounds of W es tern culture? more balanced view would invite examination of the cultural ass umptions under which the Wes tern of diagnos is and care operates. It might also the unique set of stress ors that give rise to s uch Wes tern disorders as anorexia nervosa, bulimia nervos a, chronic fatigue syndrome, and type A personality. 4. Ins ofar as ps ychiatric dis orders, whatever their biological determinants , find express ion through the final common pathway of pers onal beliefs and behavioral anomalies and dis turbances, all known societies have found ways to differentiate normal abnormal behavior (diagnos is ) and have devised to attribute caus ality and motivation to such (explanatory frameworks ). Likewise, all societies develop means for the treatment of s uch ailments 2938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 6 of 64

(healing rituals and practices) and ins titutions for containment of those who fail to recover or attain limited improvement. P.2283 T hroughout his tory, ps ychiatric illnes ses have carried special intellectual, moral, religious , and, often, literary meanings and have been burdened with the heavy of social s tigma and destructive attributions of Malevolence, s in, pos sess ion by evil s pirits, the punis hment of implacable gods, and the like have all cast in the role of providing reass uring motives for the tragic fate of psychiatric illness , as they were discarded reasonable explanation for all of those behaviors cons idered more normal. In the context of W es tern medicine, ps ychiatry has evolved a model for the unders tanding and treatment of mental illnes s, the biome dical model, which emphas izes the concept of ps ychiatric disorders as naturalistic entities , each poss ess ing a s eparate and distinct structure and that can be clas sified, explained, and treated. T he presumes that the illnes s is located within the individual and is caus ed by a primary brain malfunction. for example, once explained by s pirit poss ess ion, and, such, reflecting a disturbance in the relations hip the patient and the world of s pirits , is seen by as a disturbance of brain function arising from of gene or neurotrans mitter functions. T hus , the current biops ychos ocial model that is prevalent in Wes tern ps ychiatry, aided by impress ive advances in molecular biology, psychopharmacology, and 2939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 7 of 64

brain imaging, is heavily weighted toward the biological component of the equation. Unlike during the earlier of the 20th century, the model currently deemphasizes ps ychological and social variables of the equation, minimizing the etiogenic, pathogenic, and pathoplastic roles of psychological conflict and unconscious and of powerful s ocial is sues, s uch as s ocial standing, employment s tatus, s ocial role conflict, poverty, racial discrimination, and the like. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR E AND T HE P S Y C HO P AT HOLO G Y

C UL TUR E AND THE DE VE L OPME NT OF PS YC HOPATHOL OGY P art of "27 - C ulture-B ound S yndromes " T he rendition of the biops ychos ocial model currently in vogue holds that mos t, if not all, ps ychiatric dis orders represent the behavioral express ionunder certain environmental conditionsof presumed brain alterations undergirded by abnormal genes or abnormal gene expres sion. In this model, there are four pos sible steps the development of abnormal behavior and ps ychopathology: (1) genetic variations or and alterations in gene express ion, (2) abnormalities in brain phys iology, (3) class ical conflict s ituations aris ing within the mind, and (4) intensely advers e conditions. Although the model has rallied substantial 2940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 8 of 64

support for the contributions of each of the levels described previously to the development of the clas sic ps ychiatric syndromes, it has not yet achieved scientific evidence (unquestioned markers) for any of them. T here is , furthermore, cons iderable ambiguity scientific controversy regarding the weight that each of these factors holds in the development of a particular disorder, as well as regarding the rules that govern the interrelations hip between genes , brain phys iology, personal psychology, and environmental stress ors. It is conclus ively known, for example, whichif anygenes are neces sary or sufficient for the development of schizophrenia, how they determine and alter brain phys iology to produce schizophrenia's characteristic behavioral alterations, or the pathways through which environmental and s ociocultural conditions suppress or facilitate the actual development of overt ps ychopathology. E qual ambiguity governs the model that creates the cons truct of illne s s . R ecent, well-conducted, epidemiological s tudies have establis hed that the presence of behavioral abnormalities; s ubjective such as anxiety and depres sion; and even psychotic symptoms in unselected community samples is more widespread than once thought. A study by J im van Os colleagues, publis hed in the Archive s of G ene ral in 2001, found an incidence level of 12.9 percent of ps ychotic symptoms , s uch as delus ions , hallucinations , persecutory beliefs , or experiences of thought interference, or a combination of thes e. T hes e s ubjects not fulfill criteria for a DS M-III-R diagnosis, had never sought help for their experiences, and reported no 2941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 9 of 64

suffering or dysfunction related to the presence of their symptoms. Only approximately one-third of all the subjects who reported any ps ychotic s ymptoms met criteria for a psychiatric disorder. Little is formally known of the process es that govern aggregation of such s ymptoms and experiences into groupings or about the thresholds that determine their caus ing sufficient pers onal s uffering or community concern to trigger help-seeking behavior. Little is also known about the s ocial determinants of acceptance or rejection of s uch s yndromes or which pattern of help seeking, of the many available to individuals in all societies, is s ought by a particular s ufferer. T he culturally s yntonic s yndrome of taijin kyofus ho can fruitfully examined through the s teps defined T aijin kyofus ho, a common phobia in J apan, as first systematized by S homa Morita in the early 1920s a fear of interpersonal relations. Its sufferers exhibit anxiety centered on the potential violation of the crafted rules of s ocial interactions imposed on J apanese society by rapid urbanization that seems to been accompanied, in J apan, by the rapid rise of the kyofus ho s yndrome. T he sequence of the s ocial construction of illness can be described as follows : F irst, there is the exis tence of an attitude of enhanced awarenes s and preoccupation with the pres entation of the self that the development of timid, s hy, and humble behavior. the development of rapid, large-scale s ocial change (urbanization, for example) alters the lands cape of personal s pace, forcing wides pread contact with a number of people outside of the rigidly codified network 2942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 10 of 64

of relationships formerly normative in more traditional J apanese social environments. T hes e new conditions exacerbate latent anxiety about one's impact on others putting the individual on s tage at all times , thus multiplying the opportunities for inappropriate or awkward interpersonal behavior. S uch a faux pas may subjectively experienced as a humiliating interpersonal offens e and perceived as evidence of pers onal failure. attendant anxiety and preoccupation with one's own behavior may reach s uch prevalence and intensity that prompts s ociety to confer on thes e patients the label of abnormal (beyond the acceptable thres hold) and to cons ider such behavior sociodystonic. T he final s tep in sequence requires s ociety to develop therapeutic strategies to alleviate the fate of such patients . T he of the suffering is probably not equally dis tributed in the general population. Here, like in many other s ocially shaped conditions, many variables may modulate the appearance and outcome of the full s yndrome. T hos e people who are temperamentally predis pos ed to s hy anxious behavior may show earlier or more s evere the illnes s. S uch may also be the cas e for people who experienced significant lack of support or blatant emotional deprivation through their development. C onvers ely, it is known that high intelligence, extens ive education, and belonging to dens e s ocial networks frequently act as protective factors .

C ultural P s yc hiatry C ultural ps ychiatry can be defined as the body of knowledge that aims to define the impact of culture on the diagnosis and treatment of mental and to provide guidance for the design and 2943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 11 of 64

implementation of culturally competent s ys tems of C ultural ps ychiatry engages the universality and the divers ity of human experience and s trives to illuminate impact of culture on the vulnerability, pathogenes is , phenomenology, subjective experience, course, and outcome of ps ychological disorders . P.2284 C ultural ps ychiatry is a truly interdisciplinary endeavor draws from many other basic and applied dis ciplines . S ocial, cultural, and medical anthropology lend insights regarding how particular social worlds are ordered and how such order is dis rupted in res pons e to historical change. It supplies descriptions of people's behavior in particular ecologies , native views of health and illness , descriptions of native healing rituals and s ys tems . Of particular importance for the understanding of culturebound syndromes , cultural anthropology may help agains t what Arthur K leinman has called the category fallacy: the application of a category (a ps ychiatric example) that is valid in one cultural context to another cultural context without regard for the rich s ymbolic and interactional soil in which a particular human behavior embedded. F rom s ociology and medical s ociology, ps ychiatry draws an understanding of the relationship mental disorders to s uch variables as economic employment and occupational opportunities , demography, and the s ocial conditions that promote social affiliation or disaffiliation. E pidemiology is central cultural ps ychiatry ins ofar as it provides data about differential incidence and prevalence of ps ychiatric disorders in different populations and may help track 2944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 12 of 64

emergence of new clinical entities under rapidly social conditions . W itnes s the sudden emergence of disorders , including frank bulimia, in certain isolated societies after the s udden introduction of W estern television programs. Although no longer as intensely cultivated, cros s-cultural developmental has helped elucidate the role of culture in the development of personality traits. S uch analysis can facilitate the unders tanding, for example, of the development of an intens e and powerful male identity the P apua New G uinean S ambian tribe, des cribed by G ilbert Herdt, through the repeated and ritualized cultivation of malenes s, and it can als o illuminate the prevalence of antisocial traits in inner city ecologies are characterized by expos ure to poverty, domes tic violence, s ocial dis organization, and family breakdown. T he history of cultural ps ychiatry parallels the growth of clinical ps ychiatry. E mil K raepelin and S igmund F reud figure prominently in both. K raepelin, for example, for the development of a s ubs pecialty of ps ychiatry: comparative psychiatry (ve rgle ichende ps ychiatrie ), observation of differential pathoplas ty between his G erman patients and the J avanese and other patients whom he obs erved during a lecture tour through As ia. F reud wondered about and ultimately as serted the universality of the oedipal situation, however filtered experience may have been through context-specific renditions . As it turned out, this original link between anthropology and psychoanalysis continued a fruitful dialogue through the work of R uth B enedict, Margaret Mead, and other workers, such as B ronis law Abram K ardiner, R alph Linton, and many others . T he 2945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 13 of 64

two decades have seen a veritable explos ion of in cultural ps ychiatry, including innovative theoretical work (K leinman and Lawrence K irkmayer), propos als (Lloyd H. R ogler and P eter G uarnacia), and observations and ethnographic des criptions (S pero Mans on on Native Americans and Monica McG oldrick P edro R uiz on inner city His panics ). R ecent advances cross -ethnic ps ychopharmacology augur well for the methodological rigor, as well as for practical

C ulture T he ambiguity of the term culture is as vast as the of definitions propos ed: More than 160 are recorded in E nglis h s ocial science literature. However difficult to define, everyone seems to know what culture means intuitively develops a holis tic view of it and a universe referents: meanings, values , mores , and traditions , es sential to individual and group identity. T he end this process is a relatively unified world view easily among members of a group. F or clinical ps ychiatric purposes, the best definition be the one provided by the National Institute of Mental Health's C ulture and Diagnos is G roup: C ulture refers to meanings , values and behavioral norms that are and transmitted in the dominant society and within its social groups. C ulture powerfully influences cognition, feelings and self-concept as well as the diagnostic and treatment decisions . T wo aspects s tand out from this definition for their potential import in the development of On the one hand, culture influences cognitions , and s elf-concept, thus exerting powerful influence on 2946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 14 of 64

central mediators of health and pathology. C ulture als o influences the presentation of distress , the diagnostic proces s, and treatment decisions, thus becoming a partner in the therapeutic therapistpatient relations hip. F inally, culture represents a normative framework that shapes behavior and molds identity and accomplis hes such aims by defining normality and deviance, preferred values and behaviors while pros cribing and sanctioning others. S uch sanctions may promote or healthy adaptations.

R ac e and E thnic ity T he terms culture , race , and ethnicity are often used interchangeably and with cons iderable lack of E ven when us ed in the s cientific literature, the terms such lack of precise boundaries that their us e has to be cons idered colloquial. R ace is most often us ed to human groups s haring phenotypically compelling characteristics (e.g., s kin color and eye morphology) are often interpreted to mean strongand widespreadgenotypic homogeneity. In fact, no such genotypic homogeneity has been described for any group, and the genetic variability between individuals of the same race may be larger than that between of different races. Des pite race's lack of significance in denoting a genotype, and probably because it is s o outwardly it may be a s ource of cons iderable s uffering for if the social context discriminates between people on basis of racial characteris tics and ascribes value to one to the detriment of another. R acially based is thus a source of considerable human s uffering for 2947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 15 of 64

victim and may become a difficult obstacle in the path toward a healthy sense of pers onal value and identity. R es earchers have noted the distortions that can be in the diagnos tic process of patients of another race. In United S tates , African Americans have been s hown, for example, to be overdiagnos ed with s chizophrenia and underdiagnosed with bipolar and other mood dis orders. V arious factors have been called to account for this variance, including cultural distance between patient examiner; misinterpretation of interpersonal and nonverbal behavior, s peech, vocabulary, and and misinterpretation of the presenting s ymptom P recis ion in the differential diagnos is of s chizophrenia from mood disorders is of extreme importance in terms prognos is and treatment, as well as in the recognition treatment of preventable s ide effects . T he term ethnicity, denoting a s hared s ens e of identity, common ancestry, and s hared history and beliefs , is increasingly gaining ascendance among cross -cultural res earchers because of its heuris tic value. It denotes is sues of clinical import: the development of personal identity, socialization, and group affiliation so often derailed or arrested by ps ychopathology. Likewis e, in multicultural s ituations, ethnicity and ethnic identity can be, and should be, carefully explored in the clinical situation. S uch iss ues as key ethnically shaped developmental experiences , participation in rituals and rites of pass age, relative adherence to family roles , religious obs ervance, s tyles of dres s, dating and many others are often prone to evoke guilt, selfdoubt, family conflict, and other forms of psychological distress or dys function. 2948 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 16 of 64

As directed by the DS M-IV -T R , the ethnic or cultural identity of the individual should be a key factor in the development of a patient's P.2285 cultural formulation and should als o be s ys tematically evaluated in the clinical proces s. K ey determinants , gender identity, s exual orientation, language clas s description, and religious and s piritual beliefs , to be ass ess ed as the clinician formulates the cultural dimensions of the patient's pres enting problem.

C ulture and P s yc hopathology In an earlier paper, the author described as an tas k of cultural psychiatry the description and of the pathways through which culture affects ps ychopathology and described the following: 1. G enerating ps ychopathology by presenting stress es that tax the individual's ps ychological life behavior. C hronic s ocial conditions, such as unemployment, and pervasive racism, cons is tently generate high rates of dis tres s and the populations exposed to them. 2. R educing psychopathology by enacting protective factors against external or internal s tres sors . In this regard, J avier I. E s cobar, among others , has called attention to the low prevalence for mos t ps ychiatric disorders among low-acculturation Mexican Americans and recent Mexican immigrants, which be due to a protective effect of their traditional culture's emphasis and pervasive use of s upportive 2949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 17 of 64

extended family networks . 3. P romoting or modulating s ocial change, thus increasing or reducing the psychological s tres ses as sociated with change. 4. Affecting the onset, pathoplas ty, course, and of conventional ps ychiatric s yndromes, such as schizophrenia or bipolar disorders . 5. Affecting the tolerance for certain behavioral, subjective, and clinical s ymptoms or unus ual states and thus promoting the pathogenic is olation healing integration into the wider s ocial group of the individual displaying such signs and symptoms . 6. P atterning culture-specific idioms of dis tre s s , sanctioned ways for individual or group express ion subjective dis tres s.

C ulture and S ymptom E xpres s ion It is a known phenomenon that culture affects the freedom with which patients acknowledge to to family members, and to clinicians the nature and of perceived subjective experiences and bodily dysfunctions. T he E pidemiological C atchment Area study, for example, appeared to confirm that P uerto reported somatic symptoms out of proportion to the of the population, res ulting in a higher mean number of somatization s ymptoms in the Diagnostic Interview S chedule. Although a later analysis indicated that mos t the variance could be accounted for by the undetected presence of ataque de nervios , the less on nevertheless remains: Not only does culture affect the expres sion of 2950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 18 of 64

distress by patients, but it may als o affect the of unfamiliar expres sions of s uffering by clinicians. Although the us e of rating s cales and interview facilitates the accurate collection of addres sed the clinician operating acros s the language and cultural barriers must be aware that these ins truments cannot capture those symptoms that, whatever their are not reported in the s cale. R es ults from the International P ilot S tudy of showed that, s urprisingly, the reliability of s ymptoms collected through patient reports (such as the pres ence hallucinations and delusions ) was higher than that of signs observed by the clinicians (problems with affect) the historical data (social relations , work his tory) by various other means. An accurate and mental s tatus examination remains the cornerstone of clinician's work.

A c c ulturation Acculturation, the proces s by which people originating from certain cultures (guests ) migrate, interact, and ultimately ass imilate into another culture (host), is a proces s of great mental health interest and is more s o in a century of great migratory currents. In according to W illiam Davis , only approximately 300 people (approximately 5 percent of the global still retain a strong identity as members of an culture, rooted in his tory and language and by myth memory to a particular place. V igorous intercultural interaction is thus the norm more than the exception in world immersed in the process of globalization. A host factors and variables governs this proces s and dictates 2951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 19 of 64

impact on the individual. T he relative opennes s and tolerance and the prevailing expectations of the host society are viewed as determinant. In the United example, the waves of immigrants of the late 19th and early 20th centuries encountered expectations of quick as similation to and internalization of the mores and customs of the host society: the me lting pot metaphor. Immigrants arriving after W orld War II, aided by improvement in communication and travel tended to preserve more of their native languages and cultures and more ongoing contact with their lands of origin. At the level of the individual, acculturation denotes the proces s by which people change their behaviors , attitudes, and life goals as a res ult of exposure to a different cultural system. Insofar as this proces s affects parameters critical to the development of a valued selfconcept and of the s ocial efficacy necess ary to this process presents notable risks to the subject's health. At a minimum, the proces s of acculturation represents an additional stress or for the individual and or her family. More recent concepts of acculturation support four outcomes for such a proces s: 1. Ass imilation, by acquiring the behaviors and values the hos t culture with minimal participation and endors ement of beliefs and practices of the former one. 2. Integration, which requires a comfortable balance behavior and values originating from both cultures, leading to practical adaptation and a valued s ens e 2952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 20 of 64

ethnic identity. 3. S eparation, whereby the s ubject retains his or her traditional identity and shows reluctance to accept most behaviors and values from the new culture. 4. Marginalization, whereby the s ubject neither maintains a strong allegiance to his or her native culture nor incorporates the values predominant in or her new environment. T he resulting fragile identity and brittle s ocial support network impose a serious burden of stress on the individual and may impair his or her mental health. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > E P IDE MIO LOG

E PIDE MIOL OGY P art of "27 - C ulture-B ound S yndromes " T he last few decades have witness ed the production of significant res earch illuminating diverse as pects of cultural practice. Of great interest for those res pons ible the organization of ps ychiatric care are the ongoing findings of psychiatric epidemiology acros s cultures. C laims have repeatedly been made that African His panics , As ians, and other minorities experience levels of ps ychological distress and dis order than the mains tream population. Although the scientific s tatus of those claims remains uns ettled, a large portion of the alleged ethnic differences dis appears when age, socioeconomic s tatus , and education are controlled for. 2953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 21 of 64

T he National Institute of Mental Health's C atchment Area S tudy found few ethnic differences in rate of DS M-IV diagnos es after it controlled for socioeconomic conditions. Lifetime rates for phobic disorder were significantly higher among African res pondents, with young His panics s howing a higher prevalence of alcohol abus e. Other studies conducted P.2286 by the Ins titute for Health S tatis tics demonstrated that, despite s imilar demographic characteris tics, the prevalence of major depress ive dis order for mainland P uerto R icans was significantly higher than for is land P uerto R icans . F rom the s tandpoint of the policy maker, however, minority status is often linked to economic, social, and educational dis advantages . T hese parameters , with the many s tres sors ass ociated with racial and minority status and the los ses and uncertainties of the migratory experience, may dras tically increas e the rate distress , symptoms, or diagnoses. T he planner and organizer of ps ychiatric services needs to be attuned to pockets of ris ing ris k in the target population. of underus e of mental health s ervices, repeatedly in minority populations , s uch as Asians , may lead the culturally competent mental health planner to interventions des igned to counter the effect of the cultural values and attitudes that inhibit s elf-referral. T he epidemiological literature, fortunately, does not only bad news. F ollowing the recommendations of J . E scobar, researchers and policy makers s hould als o become more cognizant of the potential benefits of 2954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 22 of 64

as cription to an ethnic minority s tatus. F or example, Mexican Americans with low acculturation s tatus are reported to dis play low prevalence for mos t psychiatric disorders . Whatever the protective factor (social perhaps ), it s hould be identified and targeted for blending into preventative s trategies and interventions . If all organized s ys tems of ps ychiatric care ought to be sens itive to population-based program planning, the mandate is all the more compelling for those serving minority populations, for they confront stress factors and adaptive challenges with potential pathogenic impact and for which preventive strategies may be desired. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > AS S E S S ME NT AND

AS S E S S ME NT AND E VAL UATION P art of "27 - C ulture-B ound S yndromes " E ntry into the s ys tem of care always requires a comprehensive as sess ment process of which the status examination and the dynamic formulation are features. Additional medical and ps ychological tes ts frequently requested to aid in diagnosis and treatment planning. B oth process es are fraught with complexities and the potential for distortions when conducted acros s the language and cultural barriers . Authors such as Del C astillo and Luis R . Marcos have reported thes e distortions for His panics , although reaching opposite 2955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 23 of 64

conclus ions as to whether ps ychopathology, evaluated acros s the language barrier, is as sess ed as greater interviews are conduced in the patients' native or in their secondary language. On the basis of clinical s tudies, Marcos has recommended s teps that clinicians may take to correct for those dis tortions . T he neces sity to evaluate, concurrently with the diagnostic interview, parameters s uch as the patient's language dominance, language proficiency, and language preferences , as well as the as sess ment of the patient's place in the acculturation s pectrum, can eas ily be transformed into guidelines for the evaluation of acros s the language barrier. T he quality and outcome this process can then be tracked through continuous quality-improvement activities. S ys tems of care can develop s imilar guidelines for the and interpretation of ps ychological tests . C linical must be encouraged when applying to a particular group norm derived from another group. Additional is sues, s uch as differential validity, reliability, measurement equivalency, and test bias, complicate the tas k of drawing clinically valid when us ing ps ychological ins truments whose ps ychometric properties are derived from a particular ethnic population to as sess the clinical status of a of another population group. A gold s tandard in this regard is the development, for a given population, of culturally s yntonic psychological tests . F or Hispanics , example, G ius eppe C onstantino has developed the Me-A-S tory (T E MAS ) tes t, a projective tes t cons is ting vivid colorful pictures that portray situations involving typical conflict in urban s ituations. T he test achieves 2956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 24 of 64

significant interrater reliability, internal consistency, and predictive validity. As more of these instruments available, culturally competent s ys tems of care may to develop guidelines for their us e that guard agains t perpetuation of bias. In the absence of ethnicityvalidated tes ts , such systems may encourage the us e relatively culture-free instruments (B ender-G estalt and P orteus -Maze, for example) and widely trans lated s elfrating scales , s uch as the symptom checklist-90 and Zung S elf-R ating Depres sion S cale. Wes termeyer, others , has demonstrated that self-rated s cales and ps ychiatris t-rated s cales have shown s trong reliability cross -culturally. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR AL F OR MULAT IO N

C UL TUR AL FOR MUL ATION DS M P art of "27 - C ulture-B ound S yndromes " A glos sary of culture-bound syndromes , included in IV -T R 's broad cultural offering, allows diagnosticians to cons ider them as alternative or complementary entities in many cases. T he clinician is als o invited, the requirement of the cultural formulation, to systematically explore his or her patient's cultural the perceived causes or explanatory models that the individual and the reference group us e to explain and to seek its treatment, the cultural factors related to ps ychos ocial environments and levels of functioning, 2957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 25 of 64

most importantly, the cultural elements of the between the individual and the clinician. T he ends with overall cultural as sess ment for diagnos is and care, which enjoins the clinician to note how cultural cons iderations specifically influence diagnosis and T he adoption by DS M-IV of cultural cons iderations , including the cultural formulation, represents an unques tionable achievement in creating a minimum worldwide standard of cultural adequacy. In practice, however, the outline is infrequently us ed, even in of care with heavy representation of ethnic minorities patients and providers. Organizers of psychiatric care a s ignificant opportunity for movement toward cultural adequacy by introducing the completion of the cultural formulation as a bas ic cultural competence standard in their facilities ' quality improvement process . P ayers regulators can be encouraged to monitor compliance to require increas ing levels of completion. Academic medical centers and res idency training programs , required by their chartering organizations to promote cultural competence, can s erve a key function in the diss emination of models of cultural as sess ment the training proces s. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR E -B O UND

C UL TUR E -B OUND S YNDR OME S P art of "27 - C ulture-B ound S yndromes " 2958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 26 of 64

T he AP A's glos sary lists and describes briefly s ome of best-studied culture-bound syndromes and idioms of distress that may be encountered in clinical practice in North America.

A mok A diss ociative episode characterized by a period of brooding followed by an outburs t of violent, aggres sive, homicidal behavior directed at people and objects. T he episode tends to be precipitated by a perceived s light insult and s eems to be prevalent only among men. T he episode is often accompanied by persecutory ideas, automatis m, amnes ia, exhaus tion, and a return to a premorbid state after the episode. S ome instances of may occur during a brief psychotic epis ode or the ons et or exacerbation of a chronic psychotic T he original reports that used this term were from Malaysia. A similar behavior pattern is found in Laos, P hilippines, P olynes ia (cafard or cathard), P apua New G uinea, and P uerto R ico (mal de pe lea) and among Navajo (iich'aa). P.2287

L os s B urton-B radley reports the following case from which illus trates an epis ode of amok after s evere bereavement: In 1846, in the province of P enang, Malaysia, a elderly Malay man suddenly s hot and killed three and wounded ten others. He was captured and brought 2959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 27 of 64

trial, where evidence revealed that he had suddenly his wife and only child, and, after his bereavement, he became mentally disturbed.

Interpers onal Ins ults Another cas e reported by B urton-B radley, from his New G uinea s tudy, illustrates the role of intolerable as precipitants of amok: T his patient was a healthy young adult man, who came from the Hinterlands of Abau, C entral Dis trict. At time of the act, he was working with a building gang on F ergus on Is land. He was a foreigner to his work mates , of whom called him an Abau bush piga grave ins ult. night, at approximately 6:30 P M, the others were in dormitory reading or lying down, when the patient in with a 12-inch bus h knife and suddenly attacked going from bed to bed hacking at them with the knife, mostly in the vicinity of the head and neck. S ix died, or later, some with terrible wounds , their heads being almos t chopped off. F inally, another man in the vicinity heard the nois e and came in with a rifle and one T he amok attempted to attack him, was fired at, and did not ceas e attacking. He was then put out of action the butt of the rifle and died. Another interesting ques tion relating to the boundaries the amok s yndrome has been rais ed by the C anadian inves tigator Arboleda-F lorez. His analys is of three American cas es of mass , random s hootings and perpetrated by young men led him to ass ert the universality of amok behavior. T here are two points of viewthe particularis tic and the universalis tic 2960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 28 of 64

perspectives . T he particularis tic pers pective posits the exis tence of a culture-bound syndrome, amok, that is defined by a particular phenomenology: the clas sic episode of frenzied, random killing triggered by a significant emotional cris is , preceded by a period of brooding and followed by amnesia. T he subject, in this view, is mos t often ps ychologically average but a s ocial milieu of shared beliefs and expectancies amok. T he universalis tic perspective argues that amok not a culture-bound s yndrome, but a syndrome that be found in any culture that undergoes rapid s ocial change, s tres sing vulnerable, alienated individuals their coping limits and leading them to des perate of pers onal as sertiveness . Whereas the incidence of in underdeveloped or developing countries has decreased, occurrences of s udden mas s violence in indus trial s ocieties appear to be rapidly increas ing. Arboleda-F lorez reported three s uch cases: the the T ower, the Memorial Day Man, and the C algary S niper. T hree young men (ages 22 to 25) chose murderous rampages as final expres sions of their despair. T he three had lived quiet, res tricted social had acted in respons e to actual or perceived and s hared pers onal histories punctuated by family dysfunction, epis odes of violence, and ps ychiatric and personality dis orders. Additionally, workplace shootings have become increasingly common in North America. According to Handgun F ree America, there have been more than 100 deadly workplace s hootings over the 15 years alone.

A taque de Nervios Ataque de ne rvios is an idiom of dis tres s that is 2961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 29 of 64

reported among Latinos from the C aribbean but recognized among many Latin American and Latin Mediterranean groups. C ommonly reported s ymptoms include uncontrollable shouting, attacks of crying, trembling, heat in the ches t ris ing into the head, and verbal or phys ical aggress ion. Dis sociative seizure-like or fainting epis odes, and suicidal ges tures prominent in s ome attacks but abs ent in others . A feature of an ataque de nervios is a sense of being out control. Ataque s de nervios frequently occur as a direct res ult of a s tres sful event relating to the family (e.g., of the death of a clos e relative, a s eparation or divorce from a spouse, conflicts with a spouse or children, or witness ing an accident involving a family member). may experience amnesia for what occurred during the ataque de ne rvios , but they otherwise return rapidly to us ual level of functioning. Although des criptions of ataque s de ne rvios most closely fit with the DS M-IV description of panic attacks, the as sociation of mos t ataque s de ne rvios with a precipitating event and the frequent absence of the hallmark symptoms of acute of apprehension distinguis h them from panic dis order. Ataque s s pan the range from normal expres sions of distress not as sociated with having a mental disorder symptom presentations as sociated with the diagnosis anxiety, mood, dis sociative, or somatoform disorders . In a community study in P uerto R ico, 16 percent of 1,000 people interviewed reported having had at leas t distinct episode of ataque de nervios . Almos t 75 patients regis tered in community mental health clinics New Y ork and B os ton als o reported having least one episode of the syndrome in their life. S uch 2962 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 30 of 64

reports were us ually not produced spontaneously but were elicited only after careful s crutiny on the part of clinician, rais ing the question of how many other bound syndromes are miss ed under the conditions of a conventional ps ychiatric interview anchored in the decis ion tree flowing out of the s tructure of DS M-IV -T R . Detailed phenomenological portraits of the s yndrome have been developed by P eter G uarnacia us ing representative samples of affected individuals . T he full syndrome profile may display symptoms repres enting alterations of bodily sens ations (chest tightnes s and suffocation, heart palpitations , trembling, shortness of breath), emotional expres sion (anger, fear, express ion, suicidal feelings and ges tures), and dis rupted cons ciousnes s (fainting, los s of cons cious nes s, diss ociation, derealization, blurring of vision). F inally, motor and behavioral dys control (screaming, s houting, crying uncontrollably) and verbal or physical lend the s yndrome its clas sic or characteris tic

C omorbidities R es earch on the comorbid relationship of ataque de to other DS M-IV -T R ps ychiatric disorders shows a very rate of comorbidities . Up to 63 percent of ataque de patients in a P uerto R ican s ample met criteria for ps ychiatric diagnosis, with anxiety and affective representing the most common comorbidities . V arious inves tigators reported that the presence of s pecific symptoms may predict the comorbid diagnos is ; for example, the prominent presence of fear (and bodily s ens ations ) links with comorbid anxiety and disorders , whereas the pres ence of overt anger and 2963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 31 of 64

aggres sive behavior s eems to favor the affective comorbid pathway. Drawing from ps ychoanalytic conceptualizations , anxiety may repres ent a s ignal of presence of unacceptable impulses, whereas the of anger and aggres sion may lead to an aftermath of and depres sion.

B ilis and C olera (A ls o R eferred to Muina) T he underlying caus e of bilis and colera is thought to strongly experienced anger or rage. Anger is viewed among many Latino groups as a particularly powerful emotion that can have direct effects on the body and exacerbate exis ting symptoms. T he major effect of to dis turb core body balances (which are unders tood balance between hot and cold valences in the body between the material and spiritual aspects of the body). S ymptoms can include acute nervous tens ion, trembling, screaming, s tomach disturbances , and, in severe cases, los s of consciousness . C hronic fatigue res ult from the acute epis ode.

B oufe Dlirante B oufe dlirante is a syndrome obs erved in W est Africa Haiti. T his F rench term refers to a s udden outburst of agitated and aggres sive behavior, marked confusion, ps ychomotor excitement. It may P.2288 sometimes be accompanied by vis ual and auditory hallucinations or paranoid ideation. T hese episodes res emble an epis ode of brief psychotic disorder. 2964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 32 of 64

B rain F ag B rain fag is a term initially us ed in W est Africa to refer condition experienced by high school or univers ity students in respons e to the challenges of schooling. S ymptoms include difficulties in concentrating, remembering, and thinking. S tudents often state that brains are fatigued. Additional somatic symptoms are us ually centered around the head and neck and pain, pres sure or tightnes s, blurring of vision, heat, or burning. B rain tiredness or fatigue from too much is an idiom of dis tres s in many cultures and resulting syndromes can resemble certain anxiety, depres sive, somatoform disorders .

Dhat Dhat is a folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns with the discharge of semen, whitish dis coloration of urine, and feelings of weakness and exhaus tion. It is to jiryan (India), s ukra prameha (S ri Lanka), and s hen(C hina).

Falling Out or B lac king Out E pisodes of falling out or blacking out occur primarily in the s outhern United S tates and in C aribbean groups . are characterized by a s udden collaps e, which occurs without warning but s ometimes is preceded by feelings of dizziness or s wimming in the head. T he individual's eyes are us ually open, but the person inability to see. T he person us ually hears and what is occurring around him or her but feels powerless move. T his may corres pond to a diagnosis of 2965 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 33 of 64

disorder or a diss ociative dis order.

G hos t S ic knes s A preoccupation with death and the deceased as sociated with witchcraft) frequently observed among members of many American Indian tribes . V arious symptoms can be attributed to ghos t s ickness , bad dreams, weakness , feelings of danger, loss of fainting, dizzines s, fear, anxiety, hallucinations, los s of cons ciousnes s, confusion, feelings of futility, and a suffocation.

Hwa-B yung (A ls o K nown as WoolHwa-B yung) Hwa-byung is a K orean folk s yndrome that is literally translated into E nglis h as anger s yndrome and is to the suppres sion of anger. T he s ymptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations , generalized aches and pains, and a a mass in the epigas trium.

K oro K oro is a term, probably of Malaysian origin, that refers an episode of sudden and intens e anxiety that the (or, in women, the vulva and nipples) will recede into body and pos sibly caus e death. T he syndrome is in south and eas t Asia, where it is known by a variety local terms, such as s huk yang, s hook yong, and s uo (C hines e); jinjinia be mar (As sam); or rok-joo occasionally found in the W es t. K oro at times occurs in localized epidemic form in east Asian areas . T his 2966 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 34 of 64

is included in the s econd edition of the C hines e C las s ification of Me ntal Dis orde rs (C C MD-2). Although the term and the s yndrome were firs t to the W estern biomedical literature by B lonk in 1895, report depended on the description given to him by an informant, himself a sufferer of koro. T wo years later, V ors tman reported two cas es , at leas t one of them witness ed by him. J ames E dwards provides the description of this report: A C hines e patrol officer induced V ors tman to him to a village in the S ingtan district to provide aid to a member of the native elite. T he patient was in bed, surrounded by a retinue and with an old man sitting at the foot of the bed. Having no information the patient's s ymptoms during the preceding days , V ors tman's examination and ques tioning failed to yield much ins ight into the man's problem. V ors tman that alcohol abuse, a common native habit, was the background for this cas e. T he C hines e official who accompanied V ors tman related to him that, for the las t days , the patient's penis had withdrawn into his and, as a preventive meas ure, the old man at the foot the bed had been gripping his master's obstinate limb. knowing the local term for the dis eas e, V orstman the term koro from B lonk's report. R . B ernstein and A. G aw have propos ed a definition of and advanced criteria for the diagnos is , recommending inclusion in the DS M. T he es sential feature of this disorder is a complaint of genital 2967 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 35 of 64

retraction with fear of impending death, occurring where culturally sanctioned beliefs of folk or pathology are present. men, the mos t common is that of the penis s hrinking into the abdomen and resultant among females, the s hrinking of the labia or breasts and death. T he person may appear be in a state of acute dis tres s attempt to pull his penis , have family members or friends hold onto the penis , or use clamps or strings tied to the penis to retraction. T he complaint is always accompanied by panic, fear, or anxiety. T hese authors propose the following diagnostic criteria: A feeling of overwhelming panic ass ociated with sens ation of or belief in genital retraction. A fear of impending death, s hould the genitals be allowed to fully retract. A tendency to prevent retraction by holding onto penis , enlis ting help in doing so from friends or relatives , or using devices attached to the penis . Aside from the belief and its ramifications , behavior not obvious ly odd or bizarre. T he individual has never met criteria for any Axis I 2968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 36 of 64

disorder, other than somatoform dis order, and it cannot be es tablished that an organic factor and maintained the disturbance. S pe cify type: In/not in a c ultural c ontext S ingle/epidemic c as e S ubjective ideas of genital change may be more in the general population and among other psychiatric disorders than generally realized. One s tudy reported 20 percent of a male s chizophrenic s ample concerns about changes in the size of their genital although these experiences seemed to repres ent overvalued ideas or delusions without the distinct characteristics of the koro disorder. T he fact that genital retraction symptomatology has reported in as sociation with stimulant abuse (amphetamines) and heroin withdrawal, as well as in context of epileptic confus ional states , cerebral brain tumors , and other alterations of brain physiology, should prompt physicians confronted with a complaint genital retraction to carefully rule out the presence of organic pathology. T he presence of s omatic and concern merits a differential diagnosis of disorder, undifferentiated s omatoform dis order, or dysfunction not otherwise class ified. T he presence of anxiety and panic merit a differential diagnos is of panic disorder.

L atah 2969 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 37 of 64

L atah is hypersensitivity to s udden fright, often with echopraxia, echolalia, command obedience, and diss ociative or trance-like behavior. T he term latah is of Malaysian or Indones ian origin, but the syndrome has been found in many parts of the world. Other terms for condition are amurakh, irkunii, ikota, olan, myriachit, me nke iti (S iberian groups ); bah ts chi, bah-ts i, P.2289 and baah-ji (T hailand); imu (Ainu, S akhalin, J apan); mali-mali and s ilok (P hilippines). In Malaysia, it is more frequent in middle-aged women.

L oc ura L ocura is a term us ed by Latinos in the United S tates Latin America to refer to a s evere form of chronic ps ychos is . T he condition is attributed to an inherited vulnerability, the effect of multiple life difficulties , or a combination of both factors. S ymptoms exhibited by persons with locura include incoherence, agitation, auditory and vis ual hallucinations , inability to follow of social interaction, unpredictability, and poss ible violence.

Mal de Ojo Mal de ojo is a concept widely found in Mediterranean cultures and els ewhere in the world. Mal de ojo is a phrase translated into E nglis h as evil e ye . C hildren are es pecially at risk. S ymptoms include fitful sleep, crying without apparent cause, diarrhea, vomiting, and fever child or infant. S ometimes adults (especially women) the condition. 2970 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 38 of 64

Nervios A common idiom of distress among Latinos in the S tates and Latin America. A number of other ethnic have related, although often s omewhat dis tinctive, of ne rve s (s uch as ne rvra among G reeks in North Nervios refers to a general state of vulnerability to life experiences and to a s yndrome brought on by life circums tances . T he term ne rvios includes a wide of symptoms of emotional dis tres s, somatic and inability to function. C ommon symptoms include headaches and brain aches, irritability, s tomach disturbances , s leep difficulties , nervousness , easy tearfulnes s, inability to concentrate, trembling, tingling sens ations, and mareos (dizziness with occas ional like exacerbations). Nervios tends to be an ongoing problem, although variable in the degree of disability manifested. Nervios is a broad syndrome that spans range from cas es free of a mental disorder to res embling adjustment, anxiety, depres sive, somatoform, or ps ychotic dis orders . Differential depends on the cons tellation of symptoms the kind of s ocial events that are ass ociated with the and progres s of ne rvios , and the level of dis ability experienced.

P ibloktoq P ibloktoq is an abrupt dis sociative epis ode by extreme excitement of as long as 30 minutes ' and frequently followed by convuls ive seizures and lasting as long as 12 hours . T his is obs erved primarily arctic and s ubarctic E s kimo communities, although regional variations in name exist. T he individual may 2971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 39 of 64

withdrawn or mildly irritable for a period of hours or before the attack and typically reports complete for the attack. During the attack, the individual may tear his or her clothing, break furniture, s hout obs cenities , feces , flee from protective s helters , or perform other irrational or dangerous acts.

Qi-G ong P s yc hotic R eac tion Q i-gong is a term des cribing an acute, time-limited characterized by diss ociative, paranoid, or other or nonpsychotic symptoms that may occur after participation in the C hines e folk health-enhancing of qi-gong (meaning exercise of vital energy). vulnerable are individuals who become overly involved the practice. T his diagnosis is included in the C C MD-2.

R ootwork R ootwork is a set of cultural interpretations that as cribe illness to hexing, witchcraft, sorcery, or the evil another pers on. S ymptoms may include generalized anxiety and G I complaints (e.g., naus ea, vomiting, and diarrhea), weakness , dizziness , the fear of being and, s ometimes , the fear of being killed (voodoo R oots, s pells , or hexes can be put or placed on other persons, causing a variety of emotional and problems . T he hexed pers on may even fear death until root has been taken off (eliminated), usually through work of a root doctor (a healer in this tradition), who also be called on to bewitch an enemy. R ootwork is in the southern United S tates among African American E uropean American populations and in C aribbean societies. It is also known as mal pues to or brujeria in 2972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 40 of 64

societies.

S angue Dormido (S leeping B lood) S angue dormido is found among P ortugues e C ape Is landers (and immigrants from there to the United and includes pain, numbness , tremor, paralys is , convuls ions, s troke, blindness , heart attack, infection, miscarriage.

S henjing S huairuo (Neuras thenia) In C hina, s henjing s huairuo is a condition characterized phys ical and mental fatigue, dizziness , headaches, pains , concentration difficulties , sleep dis turbance, and memory loss . Other symptoms include G I problems, dysfunction, irritability, excitability, and various signs suggesting dis turbance of the autonomic nervous In many cas es, the symptoms would meet the criteria DS M-IV -T R mood or anxiety disorder. T his diagnosis is included in the C C MD-2.

S hen-K 'uei (Taiwan); S henkui S he n-k'ue i or s henkui is a C hinese folk label des cribing marked anxiety or panic s ymptoms with accompanying somatic complaints for which no phys ical cause can be demonstrated. S ymptoms include dizziness , backache, fatigability, general weakness , insomnia, frequent and complaints of s exual dys function (s uch as ejaculation and impotence). S ymptoms are attributed to excess ive s emen loss from frequent intercours e, masturbation, nocturnal emiss ion, or pass ing of white, turbid urine believed to contain semen. E xces sive loss is feared becaus e of the belief that it repres ents 2973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 41 of 64

loss of one's vital es sence and can thereby be life threatening.

S hin-B yung S hin-byung is a K orean folk label for a s yndrome in initial phas es are characterized by anxiety and somatic complaints (general weaknes s, dizzines s, fear, insomnia, and G I problems ), with subsequent and poss ess ion by ances tral s pirits.

S pell A s pell is a trance s tate in which individuals with deceased relatives or with s pirits. At times , this as sociated with brief periods of personality change. culture-specific s yndrome is seen among African Americans and E uropean Americans from the southern United S tates . S pells are not considered to be medical events in the folk tradition but may be mis construed as ps ychotic epis odes in clinical s ettings .

S us to (Fright or S oul L os s ) S us to is a folk illness prevalent among s ome Latinos in United S tates and among people in Mexico, C entral America, and S outh America. S us to is also referred to es panto, pas mo, tripa ida, pe rdida de l alma, or chibih. is an illnes s attributed to a frightening event that the soul to leave the body and res ults in unhappiness sicknes s. Individuals with s us to also experience strains in key social roles . S ymptoms may appear any from days to years after the fright is experienced. It is believed that, in extreme cases, s us to may result in T ypical symptoms include appetite disturbances , 2974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 42 of 64

inadequate or exces sive s leep, troubled s leep or feeling of sadnes s, lack of motivation to do anything, feelings of low self-worth or dirtiness . S omatic accompanying s us to include muscle aches and pains , headache, stomachache, and diarrhea. R itual healings focus ed on calling the soul back to the body and the person to restore bodily and s piritual balance. Different experiences of s us to may be related to major depres sive dis order, posttraumatic s tres s disorder and s omatoform disorders . S imilar etiological beliefs symptom configurations are found in many parts of the world.

Taijin K yofus ho T aijin kyofus ho is a culturally distinctive phobia in some ways res embling s ocial phobia in DS M-IV . T his syndrome refers to an individual's intense fear that his her body, its parts, or its functions displease, are offensive to other people in appearance, P.2290 odor, facial express ions, or movements. T his syndrome included in the official J apanese diagnostic s ys tem for mental disorders .

Zar Zar is a general term applied in E thiopia, S omalia, S udan, Iran, and other North African and Middle societies to the experience of spirits poss ess ing an individual. P ersons poss es sed by a s pirit may diss ociative epis odes that may include s houting, hitting the head against a wall, s inging, or weeping. 2975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 43 of 64

Individuals may s how apathy and withdrawal, refus ing eat or to carry out daily tasks, or may develop a longrelations hip with the poss es sing s pirit. S uch behavior is not considered pathological locally. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > T HE R AP IE

THE R APIE S P art of "27 - C ulture-B ound S yndromes " Much knowledge has accrued about the applications of standard, ps ychoanalytically bas ed psychotherapy to populations and ethnic backgrounds, other than whites Wes tern origin. T o the repeated obs ervation that ethnic communities are accepted for psychotherapy treatment lower rates and drop out earlier than their mainstream counterparts, researchers and clinicians have provided bounty of adaptations ranging from preparations for ps ychotherapy to s ubs tantive framework modifications. T he most daring s tep in this continuum is the development of culture-specific therapies empirically derived from culture-specific behavioral features. J os S zapocznick has, for example, developed and model of family therapy for Miami's C uban families by empirically derived values prevalent in that such as s trong familial affiliation and a preference for hierarchical family s tructures . While encouraging openness to s uch technologies, systems of care s hould establish s tandards and that aim to obtain clinical and functional outcomes 2976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 44 of 64

equivalent to the mains tream s tate-of-the-art efficacy studies, equally avoiding, promoting, and discouraging particular approaches until unques tionable evidence of efficacy and effectivenes s is developed. C ognitive and cognitive behavior therapies may some modicum of freedom from cultural bias to the degree that cognitive therapists work with the s pecific pathogenic beliefs of the patient, whatever the cultural origin of s uch beliefs. Its application to minority populations experiencing anxiety and depres sive may be an area of promis ing cros s-cultural res earch. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > P S Y C HO P HAR MAC O LO

PS YC HOPHAR MAC OL OGY P art of "27 - C ulture-B ound S yndromes " A rich lode of research findings mus t be codified by systems of ps ychiatric care that aim to improve the practice of ethnic ps ychopharmacology. G uidelines include (1) factual knowledge about differential pharmacogenetics and pharmacodynamics and (2) relational knowledge regarding the impact of giving or withholding medications . E xpectations about the us e of medications , as well as (3) the parallel us e of herbs, which is widespread in many cultures , are by culture-specific beliefs about caus ation of illnes s recovery and may need active inquiry by the clinician. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > S T ANDAR D

2977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 45 of 64

S TANDAR DS P art of "27 - C ulture-B ound S yndromes " Over the las t few decades , largely through the efforts multiple cultural advocacy organizations , there has significant growth of guidelines and standards guide the behavior of clinicians working cross T he efforts of the AP A in addres sing cultural in DS M-IV -T R have already been noted. Its P ractice G uidelines for the P s ychiatric E valuation of Adults als o includes cons iderations for s ociocultural diversity, encourage clinicians to adopt a nonjudgmental attitude toward the patient's culturally mediated explanation of illness and encourage the use of culturally competent cons ultants and the aid of s tructured interviews , questionnaires, and rating s cales, thus incorporating guideline knowledge reviewed earlier about the distortions to which the evaluation of patients through cultural barrier is subject. T he American P s ychological Ass ociation has publis hed own G uidelines for P roviders of P sychological S ervices E thnic, Linguistic, and C ulturally Diverse P opulations , which encourages practitioners to recognize ethnicity culture as s ignificant parameters in unders tanding ps ychological process es and pres cribes an attitude of res pect for client's values and beliefs . P res criptions for cultural competency for systems of care have been compiled by the C hild Development C enter at G eorgetown University and by the Divis ion of Mental Health and S ubstance Abuse of S an F rancisco's 2978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 46 of 64

Department of P ublic Health, among others. T he Mental Health S ervices has developed a set of C ultural C ompetence S tandards in Managed Health C are for F our Unders erved/Underrepres ented R acial/E thnic G roups . T hese standards are noteworthy including guidelines for all levels of the s ys tem of care: policy making, top and middle management, front-line staff, consumers and their families , and community stakeholders . T he s tandards require the care system's driven awarenes s of community health and mental disparities, invoke explicit demonstration of cultural competence through various as ses sment and es tablis h s pecific targets and benchmarks for outcomes , s uch as improving access to care, benefit design, process of treatment planning, and clinical and functional outcomes of care. It requires culture-specific knowledge of the clinical is sues mos t frequent in the patient's cultural background, such as s ymptom and s ymptom expres sion that are characteristic of the patient's cultural reference groups and the culturesyndromes ass ociated with them. T ools for monitoring cultural competence in health care are als o appearing. A noteworthy example is the to monitor providers' cultural competence, which was developed by the Latino C oalition for a Healthy T he project attempted to define dimensions of culturally competent health care practices through the efforts of culturally competent phys ician panels, s upplemented review of external expert cons ultants . T he project developed s everal tools , s uch as a culturally competent patient satis faction s urvey and a provider s elfsurvey, an instrument intended to be us ed as a guide 2979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 47 of 64

detect areas of knowledge or s kills in which additional training may be useful to the clinician. In summary, the las t few decades have seen a ris e in the diversity of the U.S . population, with large numbers of monolingual immigrants making their way this country from non-Wes tern countries . Awarenes s regarding immigrant and ethnic minority health is also growing, together with knowledge regarding the broad impact of culture on health and mental health, the specific pathways for this influence through impact on epidemiology, ass ess ment, diagnos is , and treatment. However extensive in theory, and despite increasing availability of s tandards and guidelines that may guide the behavior of ps ychiatric care this body of knowledge is only s lowly making its way to the clinicianpatient interaction. Only a small minority of mental health clinicianpatient interactions taking place the vast health care system of the United S tates are culturally adequate, and a far smaller percentage can said to be culturally competent. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR AL P R O F IC IE NC Y T HE C Y C L E OF C AR E

C UL TUR AL PR OFIC IE NC Y THR OUGH THE C YC LE OF C AR E P art of "27 - C ulture-B ound S yndromes "

2980 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 48 of 64

C ulturally compe te nt organizations are defined as that govern the practice of their clinicians through the incorporation into their treatment guidelines of the growing body of evidence made available by cultural res earch. R ogler has developed a conceptual that organizes mental health res earch (in his cas e, for His panics ) into an experimentally valid sequence of that parallel a patient's path while s eeking and an episode of care. In R ogler's framework, research, P.2291 teaching, and other forms of cultural clinical evidence be arranged into five phas es that aim to represent the patient's cours e through the cycle of care, beginning the emergence of the emotional problem (phas e one ), through culturally mediated help-seeking efforts (phas e two), to diagnosis and ass es sment (phas e thre e ). denotes the patient's experience with therapeutic interventions , and the cycle ends (phas e five ) with the patient's reintegration to the community. P sychiatric care organizations would do well to conceptualize their approach to patient care using this framework. T his would allow them to develop a determining and making available to clinicians unique demographic and epidemiological s ervice area characteristics and needs at one end of the cycle one ) and to carefully monitor the clinical and functional outcomes of care at the point of community (phas e five ). T he protection of continuity of care would much des irable by-product of organizing care and about care along the same five-phase continuum. 2981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 49 of 64

P has e One P roblems, and potential res ponses to them, ass ociated with phase one are summarized in T able 27-1. large portion of alleged ethnic differences in the prevalence of ps ychiatric dis orders disappears when studies are controlled for age, s ocioeconomic s tatus, education, the fact s till remains that some differences remain. African Americans , for example, have been to have a higher 6-month prevalence rate for cognitive impairment, drug abus e, panic attacks , and phobias whites or His panics.

Table 27-1 Phas e One: of Mental Health Problems Minority Population C harac teris tic s

Potential Mental S ys tem Approac hes

Demographics as sociated with increased ris k

P opulation-based approaches to case finding: primary prevention

Inferred increas ed incidence, and level of

E arly cas e finding, immediate identification through linkages : 2982

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 50 of 64

primary health sources Migration-induced s tres s    V ia loss of status

Outreach to immigrant social s ervices system

   V ia loss of support

 

   Acculturation

Acculturation therapy

B ecaus e of the impact of advers e s ocioeconomic conditions, such as poverty, employment difficulties , immigration status, ethnic communities have demographic features as sociated with increased ris ks . Dohrenwend and others have demons trated that the of all ps ychiatric dis orders in the lowest s ocioeconomic levels is approximately 2.5 times the rate in the highest level. T his 2.5-to-1.0 relationship extends beyond diagnostic categories to basic dimensions of mental health, such as anxiety, depress ion, self-es teem, and functional adaptation. S ys tems of care s erving such high-ris k populations ongoing process es for determining unique communitybased needs. F or this purpos e, they ought to use all available methodologies, such as health and s ocial databases , community forums , and available epidemiological data. T hes e data can guide proactive population-based approaches to cas e finding, early 2983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 51 of 64

identification, and, pos sibly, prevention efforts,

P has e Two Help-seeking behavior, after an individual experiences mental health problem, is a proces s s ubject to great culturally based differences. T hresholds for pain and dysfunction, tolerance for deviations from norms, perceptions of s tigma, and availability of alternative res ources to cope with ps ychological distress shape when and where of the process of help-seeking cons ultation. Help-seeking factors may affect the us e mental health services by minorities. Hispanics, for example, have been found to underus e outpatient ps ychiatric programs and nonpublic psychiatric while having high rates of us e of public inpatient Data on African American patients s how a disproportionately high rate of admis sion to all types of inpatient facilities . T hese patients may enter health treatment s ervices at later s tages in the cours e of their illness than their white counterparts. T able 27-2 s hows reported use trends for ethnic and potential approaches to counter the negative effects of existing use and continuity patterns. competent systems of care need to develop policies track use patterns , addres s its dis parities when found, aim to obtain clinical and functional outcomes as clos e poss ible to thos e reported by s tate-of-the-art efficacy studies. T he working group on C ultural C ompetence in Managed Mental Health C are includes among its for cultural competence for managed care the following:

2984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 52 of 64

Table 27-2 Phas e Two: HelpS eeking B ehavior Minority Population C harac teris tic s

Mental Health S ys tem

Underus e of mental programs in outpatient and private psychiatric services

P rimary prevention, outreach program

 

Links with primary care providers

Overuse of public inpatient services

F amily ps ychoeducation programs

   Alternative resource theory

Integration of folk healing s ys tems

      F amily

P sychoeducation

      F olk healer network

User-friendly intake systemflexible appointments

2985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 53 of 64

   B arrier theory

 

      C ultural: health

C ommunity-based, culturally s yntonic services

      B elief systems

 

      Ins titutional barriers

Use of bilingual, bicultural s taff

T he Health P lan s hall develop maintain a database which s hall track utilization and outcomes the four groups across all levels care, ensuring comparability of benefits, acces s, and outcomes. T he Health P lan s hall also and manage databases of social and mental health indicators on the covered population for the four groups and the community large.

P has e Three T he cultural challenges of ass es sing patients across language and cultural barriers have been discus sed at 2986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 54 of 64

length earlier. B ecaus e of the robus tnes s of the findings and the importance of adequate diagnos is and as sess ment to treatment planning and care outcomes , area is mature for vigorous interventions by culturally competent health care organizations . At a minimum, ethnic minority client should have a cultural formulation completed as part of the intake ass es sment. Agencies should also es tablish guidelines covering the us e of ps ychological tes ting of language and acculturation as sess ment and a process of differential diagnosis that encourages explicit cons ideration of culturally idioms of distress and culture-bound syndromes . T able 3 lists the res earch evidence and potential approaches correct detected dis tortions .

Table 27-3 Phas e Three: Mental Health As s es s ment R es earch Findings

C ulturally C ompetent Approac hes

P sychological tes ting bias

Use of trans lated and validated instruments

P rojective tes ting bias

C orrection of bias 2987

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 55 of 64

C linical ass es sment of ps ychopathology

S ys tematic language as sess ment

 

S ys tematic acculturation as sess ment

   Increas ed mis diagnos is

Ins titutional knowledge about as sess ment problems

   Increas ed ascription of ps ychopathology

 

Use of revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs cultural approach

 

 

   Differential diagnosis for culture-bound syndromes

 

   S ystematic us e cultural formation

2988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 56 of 64

P has e F our High attrition rates after the initial therapeutic contacts have been repeatedly reported for His panics , As ians , African Americans, rais ing many questions about the appropriatenes s of traditional ps ychotherapeutic for thes e populations and about the effectiveness of standard application. In respons e to this s ituation, res earchers have devis ed multiple strategies ranging efforts to provide a few preparations for ps ychotherapy sess ions and culturally derived modifications of the ps ychotherapeutic frame to the development of syntonic therapies . Many pres criptions are als o available in the clinical and res earch literature for the integration into mainstream treatments P.2292 of the patient's native concepts of illness , as well as healing practices. Agencies providing s ervices to s ignificant numbers of ethnic minority patients need to develop guidelines for their therapy process to direct clinicians as to when how to integrate folk therapies into their treatment. decis ions need to be mediated by the ongoing of the patient's language competence, acculturation status , and voiced preference.

P has e F ive T he patient's reintegration into his or her community of origin is the ideal outcome of treatment and a main of the community ps ychiatry movement. T he ideal is 2989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 57 of 64

unfortunately obs erved more in the breach than in the fulfillment. Disruptions to the continuity of care are overwhelming to mainstream and minority populations . Little, if any, systematic data exis t regarding ethnic minority indicators of reintegration success , s uch as rehospitalization rates and rates of resumption of personal, or profes sional role s tatus . P s ychiatric care organizations need to take the lead in developing benchmarks and encouraging s trategies of aggress ive outreach. T able 27-4 s pells out iss ues that need to be cons idered cross -cultural practice and res earch. Access to participation in specialized psychiatric and services ought to be emphasized to counter the of many minority patients to s eek services provided in strictly medical s etting and on a sporadic bas is rather in a mental health s etting on a continuous bas is .

Table 27-4 Phas e Five: Pos ttreatment Adjus tment and C ommunity R eintegration R es earch Findings

C ulturally C ompetent Approac hes

R ehospitalization rates

C ulturally realistic 2990

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 58 of 64

discharge planning Difficulty in ass umption of community, family, work role functions , as function of sociodemographic status

   Network involvement

 

   F amily involvement

 

   E xtensive use of ps ychoeducation

 

   E ducation to continuous rather than periodic use of health care

Network functioning (s mall, clos e increas ed for rehos pitalization)

 

E xpres sed emotionrole of ps ychoeducation

Motivate family

 

Maintain contact with folk network

Low use of pos ttreatment services

User-friendly, community-based

2991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 59 of 64

services    B arrier theory, health services

 

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "27 - C ulture-B ound S yndromes " P opulation genetics is covered in S ection 1.17, and mental health in S ection 3.7, and anthropology and cultural psychiatry in S ection 4.1. C linical ps ychiatric disorders are covered in C hapter 8. International psychiatric diagnos is is dis cus sed in 9.2. C ulture-bound syndromes with ps ychotic features covered in S ection 12.16f. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > R E F E R E NC

R E FE R E NC E S American Medical Ass ociation. C ultural C ompetence 2992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 60 of 64

C ompendium. C hicago, 1999. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. Was hington, DC : American P sychiatric As sociation; 1994. American P s ychiatric Ass ociation. American Ass ociation practice guidelines for the psychiatric evaluation of adults . Am J P s ychiatry. 1995;152 [S uppl]:6578. *American P s ychological Ass ociation. American P sychological As sociation G uidelines for the of psychological services to ethnic, linguis tic, divers e population. Am P s ychol. 1993;48:4548. B elkin G S : Hard ques tions in court: C ulture and ps ychiatry on trial. C ult Me d P s ychiatry. B hugra D, Mas trogianni A, Maharajh H, Harvey S : P revalence of bulimic behaviours and eating in schoolgirls from T rinidad and B arbados . P s ychiatry. 2003;40:408428. *B luestone H, V ela R M: T rans cultural as pects in the ps ychotherapy of the P uerto R ican poor in New Y ork C ity. J Am Acad P s ychoanal. 1982;10:269. C alifornia Mental Health Directors Ass ociation. C ompete ncy G oals , S trate gie s and S tandards for Health C are to E thnic C lients . S acramento, C A: 2993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 61 of 64

Mental Health Directors Ass ociation; 1995. C omas-Diaz L. C linical G uide line s in C ros s -C ultural Health. New Y ork: W iley; 1988. C ons tantino G , Malgady R G , R ogler LH. T e chnical Manual: T he T E MAS T e s t. Los Angeles: Wes tern P sychological S ervices; 1988. C ons tantino G , Malgady R G , R ogler LH, T s ui E : Dis criminant analys is of clinical outpatient and public school children by T E MAS . A thematic apperception tes t for His panics and B lacks. J P e rs As s e s s . 1988;52:670678. C ros s T L. T owards a C ulturally C ompe tent S ys te m Was hington, DC : T echnical As sistance C enter. G eorgetown University C hild Development C enter; 1989. C ultural C ompe te nce S tandards in Manage d Me ntal Health C are for F our Unde rs e rve d/Unde rre pre s ente d/R acial/E thnic C enter for Mental Health S ervices ; 1997. Del C astillo J : T he influence of language upon symptomatology in foreign-born patients. Am J P s ychiatry. 1970;127:242244. *Derogatis LR , C ovi L, Lipman R S : S ocial class and as mediator variables in neurotic s ymptomatology. G e n P s ychiatry. 1971;25:3140. 2994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 62 of 64

Dohrenwend B P , Dohrenwend B S , G ould MS , Link Neugebauer R , W uns ch-Hitzig R . Me ntal Illne s s in Unite d S tates . New Y ork: P reeger; 1980. E scobar J I: Immigration and mental health: W hy are immigrants better off? Arch G e n P s ychiatry. F aison W E , Arms trong D: C ultural aspects of in the elderly. J G e riatric P s ychiatry Ne urol. 2003;16:225231. G aw A, ed. C ulture, E thnicity and Mental Illne s s . Was hington, DC : American P sychiatric P res s; 1993. G uarnaccia P , R ogler HL: R esearch on culturesyndromes: new directions. Am J P s ychiatry. 1999;156:13221327. K eel P K , K lump K L: Are eating dis orders culturesyndromes? Implications for conceptualizing their etiology. P s ychological B ull. 2003;129:747769. K leinman A. R ethinking P s ychiatry: F rom C ultural C ate gory to P e rs onal E xperie nce . New Y ork: F ree 1988. Marcos LR , Alpert M, Urcuyo L, K es selman M: T he of interview language on the evaluation of ps ychopathology in S panis h-American patients. Am J P s ychiatry. 1973;130:549553. Marcos LR , T rujillo M. C ulture, language and 2995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 63 of 64

communicative behavior: T he psychiatric of S panish Americans. In: Duran R P , ed. L atino and C ommunicative B e havior. Norwood, NJ : Ablex P ublis hing; 1981. Mezzich J E , K leinman A, F abrega H, B arron DL, C ulture and P s ychiatric Diagnos is : A DS M-IV Was hington, DC : American P s ychiatric P res s; 1996. P arzen MD: T owards a culture-bound insanity defens e? C ult Me d P s ychiatry. R egier DA, Myers J K , K ramer M: T he NIMH E pidemiological C atchment Area P rogram. Arch P s ychiatry. 1984;91:934941. R ogler LH, Malgady R G , R odriguez O. His panics Me ntal H ealth: A F rame work for R es e arch. Malabar, R obert E . K rieger P ublishing C ompany; 1989. R uiz P . C ros s -cultural psychiatry. In: Oldham J , R iba eds. Annual R evie w of P s ychiatry. V ol 14. DC : American P s ychiatric P res s; 1995. R uiz P , ed. E thnicity and P s ychopharmacology. Was hington, DC : American P sychiatric P res s; 2000. S imons R C , Hughes C C , eds . T he C ulture -B ound S yndromes . Dordrecht, the Netherlands : R eidel P ublis hing C ompany; 1985. S zapocznick J , S copetta MA, K ing OE : T heory and 2996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 64 of 64

practice in matching treatment to the s pecial characteristics and problems of C uban immigrants . J C ommunity P s ychol. 1978;6:112. *T irado M. T ools for Monitoring C ultural Health C are . S an F rancisco, C A: Latino C oalition for Healthy C alifornia. T rujillo M. C ultural P sychiatry. In: S adock B J , eds. K aplan and S adock's C ompre hens ive T e xtbook P s ychiatry. 7th ed. P hiladelphia, P A: Lippincott & W ilkins ; 2000. Wes termeyer J : T wo self-rating scales for among H-mong refugees: Ass ess ment in clinical non-clinical s amples . J P s ychiatr R es . *Y ee T T . G e ne ral P rinciple s for Des igning and C ulturally C ompe te nt P rograms . S an F rancisco, C A: Department of P ublic Health. Divis ion of Mental and S ubstance Abus e; 1993. Zung W F : A s elf-rating depress ion scale. Arch G e n P s ychiatry. 1975;12:6370.

2997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

01/01/2009

Page 1 of 119

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 28 - S pecial Areas of Interes t > 28.1: P s ychiatry and Medicine

28.1: Ps yc hiatry and R eproduc tive Medic ine S arah L . B erga M.D. B arbara L . Parry M.D. J ill M. C yranows ki Ph.D. P art of "28 - S pecial Areas of Interes t" T he phys iological proces ses as sociated with mens trual cycling, pregnancy, postpartum, and menopaus e occur within the context of a woman's ps ychological and interpersonal life, interfacing with ps ychos ocial functioning throughout adolescence, adulthood, midlife, and late life. R eproductive events proces ses have both phys iological and ps ychological concomitants. T he fields of ps ychiatry and reproductive medicine are jus t beginning to elaborate the multiple mechanisms by which psyche and s oma interact to determine a woman's gynecological and psychological function. F or instance, premenstrual dys phoric mood, cognitive, and behavioral changes that occur in as sociation with the menstrual cycleexemplifies a somatops ychic disorder in which biological changes occurring in the s oma trigger changes in ps ychological state. In contrast, functional forms of hypothalamic anovulation repres ent a ps ychos omatic illness that originates in the brain but alters s omatic functioning. 2998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 2 of 119

Unfortunately, traditional medicine s eparates the treatment of reproductive events and proces ses from of psychological functioning. T his imposed dichotomy between mind and body undermines the unders tanding and treatment of both reproductive and ps ychiatric dysfunction in women. F or example, postpubertal are approximately twice as likely as men are to major depress ion, with depres sion rates peaking during female reproductive years. Y et, few obs tetricians in the United S tates routinely screen for depress ion among patients. Hence, depres sion during pregnancy and the postpartum period often goes unidentified and undertreatedleading to negative cons equences for both the woman and her children. In keeping with a biops ychosocial model, this chapter highlights the bidirectional interactions between psyche and s oma related to women's reproductive functioning. T aking a developmental approach, key concepts about reproductive physiologyranging from early sexual differentiation to menstrual phys iology and gonadal cess ation ass ociated with menopauseare incorporated each section. T he overall aim is to illustrate how the interaction between reproductive process es and ps ychos ocial events manifests as ps ychiatric or gynecological dis orders and how recognition of these interactions can improve our approach to both gynecological and ps ychiatric treatments.

R E P R ODUC TIVE DE VE L OP ME NT Fetal and Neonatal Development T he sex of an embryo is determined during the 2999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 3 of 119

proces s. T he normal chromos omal contribution of the oocyte (egg) is 23 (including an X chromos ome), and sperm contributes 23 (including an X or a Y T he translation of gonadal sex into phenotypic sex depends directly on the type and s ecretory activity of gonad formed and on the res ponsiveness of target in the developing fetus to gonadal products . T he fetal tes tes begin to s ecrete tes tos terone and mllerianinhibiting s ubs tance (MIS ) toward the end of the firs t trimes ter. If s ecretion is absent or compromis ed or if fetal tiss ues are androgen insensitive, a spectrum of incomplete mas culinization ensues. Also, excess expos ure at this time from maternal or fetal s ources , as occurs in fetal congenital adrenal hyperplasia, can partially masculinize a female fetus. S exual differentiation of the central nervous system is believed to depend on the presence or absence of circulating levels of testosterone. T he fetal testes begin secrete testosterone in the late firs t trimes ter in to placental human chorionic gonadotropin (hC G ), whereas the fetal ovary does not. T he organizational effects of tes tos terone on the developing C NS are to depend primarily on in situ aromatization (the conversion of androgens to estrogens by the enzyme aromatase) of testosterone to es tradiol. In contras t, es trogens from fetal or placental sources do not cross bloodbrain barrier and are not thought to imprint the developing C NS . Also, testosterone may bind directly (without convers ion to estradiol) to androgen receptors the C NS . T he behavioral consequences that early to testosterone have on the developing brain are not but gender asymmetries may reflect central 3000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 4 of 119

key brain areas with high aromatas e activity (which, can convert testosterone to estradiol) and those with androgen receptors . In the nonhuman primate brain, androgen receptors are located in the hypothalamus, amygdala, and prefrontal vis ual and somatosens ory cortices . T he as ymmetry in exposure to tes tos terone present in early neonatal life. In late pregnancy, gonadotropin s ecretion is res trained by placental production; when that res traint is lost at the time of gonadotropin s ecretion ris es dramatically in both boys , but not in girls , the gonadotropin rise is followed an elevation of testosterone concentrations to adult T hus, by 2 years of age, the brains and bodies of girls boys have been expos ed to dramatically different of sex s teroid s ecretion. T he degree to which genderrelated behavioral as ymmetries are accounted for by differences in hormone exposure is open to debate, clearly, a mechanism for inducing differences exists . In summary, the fetal s ex steroid exposures exert organizational effects on the fetal C NS .

Puberty In humans , the postnatal gonadal hiatus involves the desynchronization and suppres sion of the gonadotropin-releas ing hormone (G nR H) puls e by undetermined central mechanis ms that are largely gonad independent. P uberty, the pos tnatal P.2294 res umption of gonadal activity, is also a centrally proces s that depends on synchronization of the releas e of hypothalamic G nR H. G nR H neurons are 3001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 5 of 119

endogenously puls atile and active during fetal and neonatal life. In experimental conditions with primates , entire pubertal proces s can be initiated and completed simply by providing exogenous puls es of G nR H or by stimulating the dormant G nR H neurons with excitatory amino acids . Although prenatal exposure to sex has organizational effects on the developing brain, the reinitiation of gonadal activity during puberty is viewed exerting primarily activational influences on the brain behavior. R ecent neuroimaging data s uggest, however, that there are further s exually dimorphic organizational effects as well.

Gender T he phenotypic s ex of an individual depends on chromosomal s ex and on expos ure and target tiss ues to endogenous and exogenous s ex G e nde r refers to the s elf-image and sex-role identity of person. G ender is determined not only by exposure res ponsiveness to sex s teroids, but als o by and behavioral patterns that are learned in early from parental, familial, and s ocietal models. G ender develops acros s the life cycle in respons e to and biological life events . Notions of gender direct career, and other behavioral choices and may depart biological options . F or example, a woman with mlle rian age ne s is has ovaries but no uterus and vagina. Her childbearing and sexual options are cons trained biologically, yet her sens e of gender-appropriate may drive her to purs ue a heteros exual relations hip motherhood via s urgical and technological advances. Although gender is influenced by cultural expectations, 3002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 6 of 119

each individual understands and res ponds to these expectations differently. T o s afeguard gender development, ps ychiatris ts and psychologis ts mus t unders tand the medical and technological options available to individuals with dis orders that alter phenotypic s exual development, and pediatricians , internists , and gynecologists must be mindful of the ps ychological effects of thes e dis orders . Honesty is important, but physicians mus t convey information in a sens itive fashion. T he clinical objective is to maintain a flexible minds et to facilitate and s upport appropriate developmental choices. Dis orders of sexual development in phenotypic girls generally present at birth or at the time of expected puberty. Adre noge nital s yndrome can be caus ed by congenital adrenal hyperplas ia in female fetus es ; the adrenal secretes exces s androgens , which then masculinize the external genitalia and, pos sibly, the In female infants, the mas culinized genitalia are usually recognized in the delivery room. S urgery to reduce size and create or widen the vaginal introitus may be neces sary at a later date to restore the external appearance. However, the internal reproductive tract is normal, and puberty generally occurs around the time if adrenal replacement therapy is adequate. medical and surgical interventions, concerns over for sexual function may emerge, particularly in late adoles cence or young adulthood. T urner's s yndrome (XO gonadal dys genesis) may be recognized at birth becaus e of the ass ociated phys ical stigmata, whereas XX gonadal dysgenes is us ually at puberty. F rom a reproductive pers pective, the two 3003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 7 of 119

conditions are similar in that the ovaries do not contain res ponsive oocytes due to premature atres ia of failure of germ cell migration. Donor oocytes allow the option of pregnancy. Other dis orders of sexual development include feminization and its variants , in which the gonads are tes tes , but the fetus is phenotypically female because a defect in the androgen receptor confers androgen insensitivity. B ecaus e the testes are normal, they MIS and mlle rian re gre s s ion (regres sion of the anlage would develop into the uterus and tubes) occurs. T he vagina ends blindly, and the presenting complaint is us ually primary amenorrhea. T he larche (onset of development) occurs at the normal time becaus e, at puberty, the testes s ecrete testosterone, which then is aromatized to es tradiol, which s timulates the growth of breast tis sue. Orchiectomy (removal of the testes) is recommended after puberty to avoid the risk of gonadoblastoma, unless there is partial androgen sens itivity, in which case it is performed earlier to the pubertal development of hirs utis m and partial masculinization. T here are many types of androgen receptor defects spectrum of clinical presentations . S ome individuals phenotypically like men and may present with infertility secondary to azoos permia or oligospermia. A related disorder occurs when there is an inefficiency of the enzyme 5-α-reductase, which converts tes tos terone to dihydrotes tos terone (DHT ); DHT is required for full masculinization of the external genitalia. B oys with a deficiency of that enzyme may look phenotypically or incompletely masculinized at birth. At puberty, 3004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 8 of 119

masculinization, including phallic enlargement, may develop as the increased tes ticular s ecretion of tes tos terone partially overcomes the enzyme and more dihydrotestosterone is made. F ertility is preserved in this condition, so it is prudent to rear the as a male if pos sible. Neonatal treatment with dihydrotes tos terone may help to masculinize the genitalia. X Y gonadal dys gene s is is caus ed by a s treak gonad to secrete tes tos terone and MIS generally, the uterus, tubes , and vagina are pres ent. T his condition is when thelarche and menarche do not occur. A can confirm the XY chromos omal status. B ecause the gonads are inactive hormonally, they should be before puberty to avoid the risk of malignant degeneration. E xogenous hormone replacement is required to stimulate puberty and cause the of s econdary s exual characteris tics. If donor oocytes available, pregnancy is poss ible after in vitro and embryo transfer. T elling a young adolescent and parents about the diagnos is can be difficult, but it is to be honest, particularly because surgery will be to remove the gonads. A clinician who deals with patients with disorders of development must have a clear unders tanding of the phys iology of s exual differentiation, including that of the brain, as well as a sensitive perspective on the among gender, sexuality, and reproductive capacity.

E arly S exuality T he behavior of children can be understood by acknowledging the s exual motivations that, until 3005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 9 of 119

F reud's time, had been ass umed to be quies cent until adoles cence. T he fact that incest, sexual abus e, and sexual taboos that may occur in childhood have aftereffects , even in adult life, bespeaks the importance childhood s exuality in establis hing healthy In puberty, the overriding influence on s exuality is the dramatic change in the hypothalamic-pituitary-gonadal axis that occurs in both males and females at that time. Major hormonal changes , combined with the iss ue of identity diffusion, contribute to the characteristic in relationships , particularly between male and female peers and between adolescents and their parents. In adulthood, one of the major indicators of maturity is capacity to establish healthy s exual relations hips. is in harmony with other components of the s elf and others , sexuality is an integral component of the adult character.

Adoles c enc e C arol G illigan noted in her longitudinal studies of girls before and during adoles cence that there appears to marked decline in s elf-es teem occurring after puberty. P readolescent girls exhibit a s ens e of self-confidence belief that they can influence the course of events in lives . During adolescence, that s elf-es teem and belief their own efficacy appear to diminis h. Adolescent girls generally expres s less confidence in their abilities to P.2295 change the world around them, accompanied by a of intimidation and pas siveness . 3006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 10 of 119

B efore puberty, boys are more vulnerable than girls are depres sive illnes s. Over the cours e of adoles cence, however, a dramatic shift occurs, with girls displaying a precipitous rise in depress ion rates that far outstrips negligible (if exis tent) increas e displayed by adoles cent boys . B y age 15, girls are twice as likely as boys are to experienced a lifetime epis ode of major depres sion. gender difference pers ists for the next 35 to 40 years , es sentially spanning female reproductive years . T he predominance of depres sion in women and the adoles cent onset of this gender difference have now replicated cross -nationally. Indeed, the gender in lifetime rates of major depres sive disorder is to be one of the most robus t findings in the field of ps ychiatric epidemiology. Negative life events and chronic ps ychos ocial stress ors known to place individuals at risk for major depres sive episodes . A number of theories about the gender difference in depress ion point to the fact that women more likely than men are to experience certain types of traumatic life events, s uch as phys ical or sexual abus e, chronic life stress ors, such as s ingle parenthood, discrimination in the workplace, or financial adversity. general, however, such theories fail to account for the adoles cent onset of the gender difference in Indeed, growing evidence indicates that puberty may sens itize girls to the depress ogenic effects of life S pecifically, postpubertal women appear to be at heightened ris k for experiencing depres sion when with social s tres sors , s uch as conflicts, breaches , or within interpersonal relationships . R ecent theories have s ought to explicate pertinent 3007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 11 of 119

biological and ps ychosocial factors that may interact to sens itize women to the depres sogenic effects of interpersonal life stress . Men and women tend to different interpersonal goals and pers onal s elf-views. Women tend to focus on relations hip intimacy and, thereby, to develop a strong affiliative style in their relations hips , as well as a sense of s elf in connection others . Men, in contrast, tend to focus on is sues of individuation and ass ertiveness within s ocial and to develop an agenic and autonomous s ens e of T he proces s of gender role development is likely the res ult of interactive biological and social process es . Although gender role socialization may begin well puberty, s ocial pres sures to conform to stereotypically feminine vers us masculine gender roles likely intensify during the adoles cent transition, as the development of secondary s ex characteris tics make adolescents look like adults and they begin to engage in greater levels of cross -sex interaction and dating. Importantly, hormonal changes in the reproductive neuroendocrine axis at puberty may potentiate and interact with this proces s to promote an adoles cent intensification of gender-based behaviors . S ome have s peculated that increase in testosterone in boys and the attendant aggres siveness , often directed at girls, contribute to a change in girls ' behavior during adoles cence. A large proportion of s elf-es teem in girls tends to be based on sens e of fulfillment in relationships , whereas s elfboys is largely attributable to a s ens e of achievement work, activities , and sports . T herefore, changes in relations hips between the sexes during adoles cence affect girls and boys differently and have different 3008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 12 of 119

cons equences for their mental health. T he need in dominance in relations hips, precipitated by surges in tes tos terone at puberty, may contribute to, and be a prerequisite for, a sense of s elf-es teem and s elf-worth. contrast, pas sivity in girls relative to this dominance in boys may be required to maintain the relations hip, is girls' major source of self-es teem. T hus , changes in reproductive neuroendocrine axis in girls and boys at puberty may s et the s tage for alterations in the power balance of relations hips , which may affect the pers on's sens e of self, s elf-es teem, and mental health. in a s tudy of hormone replacement given to adoles cent boys and girls with delayed puberty, testosterone precipitated aggress ion in boys, whereas es trogen provoked aggress ion in girls. T his finding would that es trogen, per s e, is unlikely to be the cause of the increased depres sion and loss of self-es teem observed adoles cent girls . However, thes e researchers also that, whereas tes tos terone treatment was related to perceptions of athletic abilities in boys , es trogen was related to s elf-perceptions of romantic appeal and clos e friends hips in girls . Neurohormonal process es ass ociated with regulated by female reproductive hormones may contribute to the intensification of affiliative behaviors observed in girls at puberty. R ecent theories have implicated the hypothalamic neurohormone oxytocin in facilitating such affiliative behaviors as maternal and adult pair-bond formation in mammalian females. Oxytocin is known to s timulate s uch female functions as milk ejection during lactation and uterine contractions at parturition and appears to be critically 3009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 13 of 119

regulated by estrogen and proges terone. S . E . T aylor et al. have argued that the oxytocincaregiving s ys tem may lie at the core of a uniquely biobehavioral res ponse to s tres s. F or decades , the flight res pons e has been regarded as the prototypic of the human s tres s respons e. His torically, however, a majority of exis ting human res earch examining the neuroendocrine parameters of the fight-or-flight has been bas ed on s tudies of men, largely because of unknown and potentially confounding effects of cyclic variations in female reproductive hormones on neurohormonal stress res pons es . T hese res earchers propos ed the exis tence of a uniquely female respons e stress , which they have termed the te nd-and-be frie nd re s pons e . B ecause mammalian females typically bear greater role in the care and protection of young res ponses to stress that promote fighting or fleeing via sympathetic and hypothalamic-pituitary-adrenal (HP A) activation may not be the most adaptive. F or example, such a fight-or-flight res pons e may be compromised by female reproductive roles (e.g., pregnancy) and may endanger the s afety of offs pring under her care (e.g., a fleeing res ponse that res ults in the abandonment of defens eless offspring). Ins tead of fighting or fleeing, quieting and tending to the needs of offspring when under s tres s and affiliating with other adults to promote the protection of ones elf and one's offs pring may represent a more adaptive female res pons e to environmental threats . B ehavioral evidence in humans supports gender-linked differences in affiliation and, specifically, affiliation under conditions of s tres s. T aylor et al. posit that the biobehavioral mechanism 3010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 14 of 119

behind the tend-and-befriend res ponse is bas ed on the oxytocin-mediated caregiving system that, for women, serves to decrease sympathetic and HP A respons es to stress , while s imultaneous ly promoting affiliative res ponses . T he concept of a uniquely female res ponse to s tres s would have broad implications for unders tanding of s tres s sensitivity, stress res ponses , ris k of ps ychopathology in women. F urther research is needed, however, to test this provocative model.

ME NS TR UA L C YC L E S Mens trual Phys iology Mens trual cyclicity res ults directly from ovarian E ach ovarian cycle starts with the development of a or cohort of follicles , one of which becomes dominant. follicles are composed of an oocyte surrounded by granulosa cells , which, in turn, are s urrounded by theca cells . As shown at the top of F igure 28.1-1, follicular development is initiated by the hypothalamic release of G nR H at a puls e frequency P.2296 of approximately one pulse every 90 minutes . G nR H stimulates the release of the pituitary gonadotropins, luteinizing hormone (LH), and follicle-stimulating (F S H). In turn, LH s timulates ovarian theca cells to synthes ize and secrete androgens ; F S H induces cell development, including the enzyme aromatase, converts the thecally produced androgens to the presence of a constant G nR H pulse frequency of 3011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 15 of 119

pulse each 90 minutes , the secretion of LH and F S H in follicular phase will be regulated primarily by es tradiol feedback at the level of the pituitary. R ising es tradiol concentrations s uppres s F S H, thereby limiting the of follicles that become mature oocytes capable of ovulating.

3012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 16 of 119

FIGUR E 28.1-1 S chematization of the human mens trual cycle. E 2, es tradiol; F S H, follicle-stimulating hormone; G nR H, gonadotropin-releas ing hormone; LH, luteinizing 3013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 17 of 119

hormone; P , proges terone. As illustrated in the middle panel of F igure 28.1-1, es tradiol concentrations ris e exponentially to exceed a critical thres hold and remain elevated for at least 36 which is the pattern one fully mature follicle produces , LH s urge is triggered and ovulation (releas e of the from the follicle sac) ensues approximately 36 hours T hereafter, granulos a cells transform into secreting luteal cells , and the ovulated follicle, then, is referred to as the corpus luteum, which secretes proges terone. F igure 28.1-1 displays the levels of LH, F S H, es tradiol, proges terone throughout the menstrual cycle and corres ponding follicular events. T he target tis sues for ovarian s teroids include the endometrium, whos e developmental s equence is illustrated along the bottom panel, and the hypothalamic G nR H puls e generator, frequency, as indicated in the top right panel, is s lowed dramatically by the combination of estrogen and proges terone s ecreted during the postovulatory or phase of the mens trual cycle. T his inhibition of G nR H followed by decreased secretion of LH and F S H s o that new follicular development is prevented until the luteum regres ses . As proges terone concentrations G nR H pulsatility increas es , and gonadotropin, F S H, s ecretion rises . T he phases of the mens trual be termed follicular and luteal in reference to ovarian events or prolife rative and s e cre tory in reference to endometrial events. 3014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 18 of 119

It is generally ass umed that regular mens trual cyclicity intervals of 25 to 40 days s ignals ovarian cyclicity and ovulation, but, as illus trated in F igure 28.1-2, that as sumption is erroneous. A normal luteal phase has a length of more than 11 days and midluteal of progesterone secretion that exceed 10 ng/mL (30 nmol/L). T he woman whose hormonal levels across a mens trual cycle are depicted in the bottom two panels F igure 28.1-2 had a 39-day cycle. However, this cycle luteal phase whos e adequacy, with a length of 16 days a peak progesterone concentration of 19.1 ng/mL, be doubted. In contras t, the woman whose hormonal concentrations are s hown in the top two panels had an overall cycle length of 25 days. Although her estradiol levels rose to almost 300 pg/mL, the elevation in and LH was not followed by a rise in proges terone secretion. T hus, she had bleeding when her es tradiol concentration fell, but the cycle was anovulatory.

3015 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 19 of 119

FIGUR E 28.1-2 Daily concentrations of luteinizing 3016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 20 of 119

hormone (LH), estradiol (E 2), and proges terone (P ) obtained in two women from the ons et of one epis ode mens trual bleeding to the next. As thes e examples demons trate, mens es and cycle interval cannot be us ed to determine if a woman is not ovulatory or if the luteal phas e was normal. T he clinician who is linking a P.2297 ps ychological state to a reproductive event must know how to determine the pres ence or abs ence of gonadal activity. Ovarian activity can be es timated by weekly es tradiol and progesterone concentrations from the ons et of one epis ode of mens trual bleeding to the next. T esticular activity can be es timated from one or random determinations of testosterone. T hes e as sess ments may not detect subtle compromise of gonadal function that may impair fertility, however, and further cons ultation with an appropriate specialist may needed. Mens trual cycles can be expected to become more regular with advancing gynecological age (time since first menses ) and, in the absence of pathology, generally remain regular until 5 to 10 years before menopaus e. During the perimenopausal years , ovarian function is characterized by higher es tradiol and lower proges terone s ecretion. Ovarian function does not gradually decline but rather becomes erratic and unpredictable, with the potential for exposing the brain and s oma to large fluctuations in hormone 3017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 21 of 119

Premens trual S yndrome P remens trual s yndrome and the related condition, pre me ns trual dys phoric dis orde r, are s omatops ychic conditions that occur in res ponse to the expected fluctuations in sex s teroids as sociated with ovulatory mens trual cycles. P remens trual syndrome and premenstrual dys phoric dis order are not viewed by all identical disorders . P remenstrual dys phoric dis order is listed as a diagnos tic category for further s tudy in the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ). T hes e changes disturb psychological functioning in women. In contrast, functional hypothalamic arises in the ps yche and affects the s oma. In dysphoric disorder, menstrual cycles are hormonally normal, and the s oma is preserved at the expense of ps yche. F rom an evolutionary perspective, women are accustomed to periodic pregnancy and lactation. T here may be unappreciated physical and emotional cons equences from inces sant ovulation; recurrent hormonal periodicity may trigger mood dis orders in women with predis pos ing inherent vulnerabilities .

Func tional Hypothalamic F unctional hypothalamic anovulation or amenorrhe a is cons equence of a nonorganic reduction in G nR H that res ults in reduced pituitary secretion of gonadotropins and s ubs equent anovulation. P reviously referred to as idiopathic or ps ychoge nic amenorrhe a in ps ychiatric literature, functional hypothalamic is a diagnos is of exclus ion. T his implies that the capable of res ponding to appropriate gonadotropin 3018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 22 of 119

of either endogenous or exogenous origin; that there no structural abnormalities of the thyroid, adrenal, pituitary, or brain; that the use of drugs , including antips ychotic medications , does not account for the suppress ion of G nR H; and that the patient is not Neuroimaging may be needed to es tablis h that there no s ignificant anatomical lesions of the brain or T wo major questions concerning the pathogenesis of functional hypothalamic anovulation remain F irst, the peripheral and central s ignals that disrupt pulsatility are poorly understood. S econd, how do behavioral, cognitive, and personality variables activate the neural systems to disrupt G nR H s ecretion? and patients alike wonder what lifes tyle variables or contribute to this type of ovulatory dysfunction and what pharmacological and nonpharmacological interventions should be considered. T he idea that psychogenic stress can induce dysfunction in women was formally introduced in 1946. T he best biochemical evidence in support of the that s tres s impairs G nR H release in women with hypothalamic amenorrhea is the consistent that the activity of the HP A axis is increas ed. F or prospective study found that young American women who developed trans ient amenorrhea while s tudying in Is rael had higher urinary cortisol concentrations on than did thos e whose menses remained regular. T here appears to be a doserespons e relations hip the type, s everity, and number of stress es on one hand the proportion of women who develop anovulation on other hand. B iological and ps ychological may confer resis tance or s ens itivity to various 3019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 23 of 119

E xercise, low weight and weight loss , affective and disorders , various personality characteris tics s uch as perfectionism and unrealis tic expectations , drug use, variety of external and intrapersonal stress es have linked to the development of anovulation. Mos t women with functional hypothalamic anovulationwhen carefully evaluateddis play more than one of thes e traits or behaviors . R ecent evidence sugges ts synergism metabolic s tres sors that s uppress the hypothalamicpituitary-thyroidal axis, such as excess ive exercis e and nutritional res triction, and psychosocial challenges that activate the HP A axis . T hus, multiple chronic stress ors more likely to induce functional hypothalamic than is a single larger magnitude s tres sor. R ecovery is poss ible if res ponse patterns to ongoing ps ychos ocial demands are developed that are les s activate the central and metabolic process es that pulsatile G nR H releas e. T he current standard of other than observation, is to offer pharmacological interventions , s uch as oral contraceptives or hormonal replacement, if fertility is not des ired and ovulation induction if fertility is s ought. However, pharmacological intervention alone does not lead to spontaneous recovery and cannot be expected to ameliorate stress -induced alterations in central neurotransmis sion and hypothalamic function or to revers e ongoing metabolic derangements secondary to exercise or weight los s. F or instance, bone accretion not proceed apace in the face of metabolic even if exogenous hormone replacement is given in supraphys iological doses . Although women with functional hypothalamic anovulation frequently do not 3020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 24 of 119

meet DS M-IV -T R criteria for eating dis orders or disorders , all of thes e s tates are characterized by cortis ol secretion, which alone can alter thyroid secretion and action and alter metabolism and central s ignals . T hus, it is not s urprising to find that with amenorrhea due to decreased G nR H drive, of cause, have lower bone mineral density. pharmacological intervention alone may mas k of psychological dysfunction and forestall the development of more effective respons e patterns. Als o, ovulation induction may place low-weight women with functional hypothalamic amenorrhea who conceive at for premature labor and intrauterine growth retardation. F etal neuropsychological development may be compromised by the concomitant pres ence of hypothalamic hypothyroidism (s ick euthyroid or hypercortis olemia if ovulation is pharmacologically induced. If the parenting s kills of women with functional hypothalamic are impaired by ongoing stress , their children may be at risk for poor psychosocial C learly, treatment s trategies need to cons ider that and mild ps ychological dysfunction can play an role in the genesis of this form of anovulation. If an disorder is recognized, specialized ps ychiatric indicated. P sychobiological characteris tics can predispose a to chronic activation of central neural proces ses in res ponse to commonplace events . G lobal dysfunction, including inhibition of G nR H puls atility, can res ult. Although identifying the P.2298 3021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 25 of 119

neuromodulators that mediate the development and maintenance of the disruption of G nR H is of academic interes t, clinicians must make s ure that all other caus es of anovulation and amenorrhea have been excluded before recommending psychological, or behavioral interventions.

FE R TIL ITY A ND INF E R TIL ITY Gametogenes is G ame toge ne s is , the production of oocytes and s perm, occurs as a result of puberty. G ametogenesis is the minimum phys iological requirement for fertility. In women, the ovary mus t have oocytes that respond appropriately to gonadotropin input with the maturation of an oocyte that is ovulated. In men, the testes mus t able to manufacture normal s perm capable of the layer of granulosa cells surrounding the oocyte and then fusing with the outer oocyte cell wall, the zona pellucida. T he fallopian tube must be capable of oocyte capture, and the density of s perm in the fallopian tube must be s uch that there is juxtaposition of s perm and oocyte. T he s perm must be able to negotiate the layers granulosa cells surrounding the oocyte (cumulus) and with the outer cell membrane of the oocyte (zona pellucida) to release the paternal deoxyribunucleic acid (DNA) into the oocyte cytoplasm. T hereafter, the tube must be capable of timely transfer of the fertilized or zygote to the primed endometrium of the uterus . Implantation mus t occur, and normal fetal development must ens ue for the pregnancy to continue. In the of medical intervention, the customary manner in which ovulated oocytes are fertilized is via coitus or sexual 3022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 26 of 119

intercours e.

Human S exual R es pons e It has been s aid that the mos t important sexual organ the brain. T his truis m is meant to emphasize the role of des ire and comfort in mediating s exual and expres sion. B rain centers mediate libido in a way. Other brain centers influence the selection of partners and the circums tances under which sexual longings are express ed. Hormones made by the and tes tes , s uch as es trogens and androgens, bind in certain brain centers and increas e s exual interest. and how this s exual interest gets express ed as depend on a number of factors, including general and well-being, the availability of a partner, a s ens e of what is appropriate, and prioritization of this interes t above other interes ts and obligations. One of the major aims of s ocial and cultural institutions is to channel or direct s exual interest in a manner that minimizes outcomes , s uch as sexually transmitted diseas es, while ensuring that children will be born and pros per. S exual interes t can be inhibited by any number of negative emotions , including anger, fear, worry, and dis like, and a marked decline in health or hormones . J ust like other personality factors, sexual interes t, or libido, has a spectrum, with some people having more and others S exuality is the term used to refer to a person's gender identity, feelings, sexual orientation, and attitudes, and distinct from the expres sion of s exuality and sexual behavior. T he human sexual res ponse has been described as a with four s tagesexcitement, plateau, orgas m, and 3023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 27 of 119

res olution. T he s exual respons e cycle is not s imply a mechanical chain of events, however; it involves biological respons es to ps ychological and s ens ory T hus, the trans ition from one s tage of the human res ponse to another is not automatic, even if it is stereotypical. T he human s exual respons e also important biological events . F irst, there must be vasoconges tion, a process in which an increased of blood concentrates in the tis sues of the genitals and female breas ts. S econd, mus cle tone mus t increase. these two process es to take place, the nervous s ys tem must function appropriately and there can be no significant peripheral nerve impairments. If these biological process es cannot take place becaus e of illness , a person may have s exual feelings, but these feelings may not lead to a class ical s exual respons e, as vaginal lubrication or full penile erection. V aginal lubrication in women and penile erection in are the most noticeable s igns of the excitement phase. women, this phase als o involves internal vaginal and nipple erection. In the plateau phas e, the outer portion of the vagina swells, and the external as pects the female genitalia, the labia, thicken and change to a darker color because of vasoconges tion. In men, the increase in s ize and are pulled up agains t the body. A called a s e x flus h may develop on the upper torso. In sexes, orgas m involves a s eries of muscular that then diminis h in intens ity and rapidity. In women, there are muscular contractions of the outer portion of vagina, the uterus , and the anal s phincter. In men, begins with contractions in the pros tate and seminal vesicles, which caus e ejaculation. During the res olution 3024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 28 of 119

phase, the changes revers e to an unarous ed s tate. but not women, have a refractory period after orgas m which ejaculation and orgasm cannot occur. In women, the orgas mic res ponse is the same, regardles s of there is manual s timulation of the clitoris or penile insertion, although the tempo of the s exual res pons e vary depending on the type of stimulation. Aging may be ass ociated with changes in s exuality. Although s exual interest declines to some degree with aging, older men and women who live together are sexually active than thos e who are not in a relationship B ecaus e women tend to live longer than men do, many elderly women will be without partners and will have limited opportunities for sexual express ion, even if drive is pres ent. In men, significant changes in and ejaculation occur with aging. As a man ages , it takes more s timulation to achieve an erection. In the plateau phase of s exual excitement is longer and not end in ejaculation. W hen ejaculation occurs, the of expulsion of s emen and the intens ity of ejaculation lower. After ejaculation, the erection res olves more and the refractory period increases. Many of these start to occur when men are in their 20s , and ageas sociated changes s hould be anticipated and viewed normal.

S exual Dys func tion in Women S exual dysfunction can be due to psychological, anatomical, and medication-related causes. T hes e are not mutually exclus ive. P s ychological causes inhibited sexual desire, which can be generalized or specific to one partner. If loss of libido is s pecific to one 3025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 29 of 119

partner, then the prognos is for recovery is good. If has always been low and is generalized, it is unlikely to change. Loss of interes t in a given partner is difficult to res tore, unles s it is a temporary res ponse to an event or iss ue that can be addres sed in some mutually satis factory way. E vents , s uch as childbirth, that alter image and self-identity in both men and women may affect relationships , libido, and the human sexual in a variety of ways . B ecaus e relations hips are by their nature ever changing, it is to be expected that the relations hip will change with time; however, that need not be for the worse. T he intimacy inherent in relations hips requires continual renewal, so sexual relations hips by nature may be vulnerable to the viciss itudes of life and aging. Decreased libido leads to les s s exual arousal and uns atisfactory s exual contact for one or both partners. If neither partner the sexual relations hip as es sential, then these developments may not threaten the s tability of the relations hip, but, if there is a mis match in outlook, alterations in libido and sexual express ion may the foundation of the relations hip. Hormonal changes can affect both libido and the reproductive tract. Loss of estrogen with menopause or from s urgical removal of the ovaries can lead to los s of vaginal lubrication. Intercourse may be painful, or, typically, there may be les s s exual sensation and P.2299 decreased arousal. T his may or may not decrease satis faction within the relations hip. Anatomical reasons for s exual dys function include 3026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 30 of 119

congenital malformations of the reproductive tract and res ults of surgery or childbirth. W hen extensive surgery performed that involves the external female genitalia, sexual dys function may be due to loss of s ens ation unavoidable injury to nerves, from pain at the s urgical from loss of hormones if the ovaries were removed, an altered sexual self-image, from fear or hes itation in partner, or from any combination of these factors . P sychiatric conditions often impact s exuality and behavior. T ypically, depres sion and anxiety s uppress and s exual performance. Organic conditions , s uch as endometriosis , ovarian and pelvic infections , can caus e painful intercourse and sexual dys function. Diabetes can lead to nerve injury thus, sexual dysfunction due to reduced s ens ation. neurological conditions and alcohol use disorders can impair s exual respons ivity. V aginis mus refers to a condition in which the muscles around the outer third of the vagina have involuntary spas ms in res ponse to attempts at vaginal penetration. Although this condition is generally thought to be ps ychological, women with vaginis mus typically enjoy foreplay and can become sexually arous ed and have orgasms. T he male partner may develop erectile dysfunction in respons e, particularly if he becomes impatient or feels guilty. Anorgas mia, or orgas mic dys function, refers to the to achieve an orgas m. T his is not always viewed as a problem by women who report it. Anorgas mia is to be the mos t common s exual dysfunction, but it mus t viewed in the context of each partner's des ires and expectations . T herapy is generally not success ful when 3027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 31 of 119

primary motivation for s eeking medical intervention is satis fy the male partner. T he male partner may feel sympathetic, but he als o may feel threatened, as many partners as sume res ponsibility for the other's sexual satis faction. A mis match in libido or expectations can more distress ing than an identified problem. Dys pareunia, or painful intercours e, can result from atrophy due to inadequate estrogen expos ure, from endometriosis, from pelvic infections, from other anatomical conditions , or from lack of s exual Medications that may interfere with s exual res pons ivity sexual interest include antidepres sants, combined hormonal, progestin-only contraceptives such as levonorgestrel implants (Norplant) and medroxyprogesterone (Depo-P rovera), and G nR H C ontraceptive agents and G nR H agonis ts likely act by altering hormone concentrations . In general, proges tins diminis h libido and s exual respons ivity, and es trogens increase both. Antidepres sants decreas e s exual drive res ponsivity by acting on important brain centers . S elective serotonin reuptake inhibitors (S S R Is) have as sociated with decreas es in orgas mic function and less en s exual interes t. F or S S R Is with s horter halfas sertraline (Zoloft) and paroxetine (P axil), it may be poss ible to reverse the effects on sexuality without interfering with the antidepress ant effect by taking weekend drug holidays . S ome antihypertens ives als o as sociated with diminished s exual drive or s atis faction. clos e temporal link exis ts between the s tart of treatment and decreas ed s exual drive or may be worth cons idering another medication, if a alternative exis ts. 3028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 32 of 119

Appropriate treatment depends on an accurate Organic or anatomical causes must be considered and require medical or surgical remedies . T he us e of may be helpful for women with vaginis mus. B ehavioral therapies, such as s ensate focus exercises, strategies for anxieties , relaxation training, training, and directed mas turbation have been alone or in combination. Depending on the couples couns eling and interpersonal therapy may be recommended. T he success of treatment depends on diagnosis.

Infertility Infertility is es timated to affect 10 to 20 percent of all couples. W ith the advent of sophisticated techniques both diagnosing and treating the caus es of infertility, many couples who might have remained childles s in a previous era or adopted a child to build a family can have biological children. C ommon causes of infertility include endometrios is , impaired s permatogenesis, damage to fallopian tubes or the vas deferens from infections or sterilization procedures, and ovulatory dysfunction or anovulation. T he bas ic infertility can involve a s emen analys is, hysterosalpingogram or sonohys terogram, hormonal s tudies , endometrial and diagnostic laparoscopy to define poss ible or causal factors (T able 28.1-1). Ovulation and adequacy can be monitored by obtaining serial blood samples or performing an endometrial biops y. In spermatogenesis is difficult to ass ess , because the takes 70 to 90 days to complete and the morphological features of sperm that can be as sess ed by a standard semen analysis do not correlate well with function (i.e., 3029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 33 of 119

ability to fertilize a human oocyte). Diagnostic and a s eemingly endless array of treatment can easily provoke tension, indecision, and in the couple with infertility.

Table 28.1-1 Tes ts in the Infertili Workup Pos s ible

Tes t

C omments

Anovulation

B as al body temperature chart

P atient mus each mornin

 

E ndometrial biops y

Office procedure in late luteal

 

S erum proges terone

S ingle or multiple bloo tes ts

 

Urinary ovulation detection kit

Home us e a midcycle to time

 

Ultrasound

V is ualize ovarian follic

3030 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 34 of 119

and their rupture Anatomic disorder

Hys terosalpingography X-ray in proliferative phase to de intrauterine contours an tubal patenc

 

S onohysterography

T ransvagina ultras ound examination with ins tillat of saline into uterine cavit define conto

 

Diagnos tic

V iew extern surfaces of internal structures

 

Hys teroscopy

V is ualize endometrial cavity direct

Abnormal S emen analys is spermatogenesis

Normal valu >20 million/ 2 mL volum

3031 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 35 of 119

60% motility  

P os tcoital tes t

Midcycle tim to look at spermcervic mucus interaction

Immunological disorder

Antisperm antibodies

Male semen

Azoos permia

T es ticular biops y

Determine eligibility for intracytopla sperm inject

 

S emen analys is for fructos e

Determine if deferens are patent

Adapted from B eckmann C R B , Ling F W , B arzensky B M O bs te trics and G yne cology for Medical S tudents . W illiam Wilkins , B altimore; 1992. T he sens e that the window of opportunity is narrow can engender panic; a woman's age correlates well with fecundity, and treatment success declines s harply after 37, even when ovulation occurs regularly. Although fertility als o declines with age in men, the decline is 3032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 36 of 119

gradual until age 50, and fertility may persist beyond 60. T he offs pring of older mothers have an increased chromosomal trisomies , particularly tris omy 21. An increase in autos omal dominant conditions has been reported in the offs pring of older P.2300 fathers . Of the identifiable causes of infertility, approximately 40 percent are thought to be due to factors , 40 percent to female factors , and 20 percent to both. Anovulation is the mos t common cause of in women. Approximately 20 percent of men with suboptimal s emen parameters have microdeletions of long arm of the Y chromos ome in a region thought to a critical role in spermatogenesis . Approximately 10 to percent of infertile couples have unexplained infertility, which means that there is no identifiable caus e. T he degree to which psychogenic or lifes tyle factors role in infertility is controversial. C ouples s hould not be told their infertility is related to stress unless there is documented evidence of sperm dysfunction, ovulatory dysfunction, or s exual dysfunction. However, because lifes tyle variables, s uch as tobacco exposure, alcohol cons umption, drug us e, exces sive exercis e, weight gain, and psychogenic stress , can compromis e reproduction, it is worth reviewing lifes tyle factors with couple and informing them of the potential adverse cons equences of these factors in a s upportive manner. P sychogenic variables can interfere with coital and reduce the likelihood of conception and can the central hypothalamic-pituitary drive to the gonad compromise the quality and quantity of gametes 3033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 37 of 119

produced. S tandard interventions were once limited to res torative surgery and gonadal s timulation, but they now include variety of as sisted reproductive techniques, including in vitro fertilization with embryo transfer (IV F -E T ) and intracytoplas mic s perm injection (IC S I). In ass is ted reproductive techniques , the ovaries are generally hypers timulated to produce at leas t three or four follicles from which the oocytes can be retrieved S perm and oocytes are then mixed and supported in to promote fertilization. If fertilization occurs , the ovum or zygote is trans ferred to the recipient's uterus . chance of implantation if three or more zygotes are transferred is generally around 50 percent, but it can lower if fewer embryos are available or if the woman is over age 38. Approximately 25 percent of implantations (as evidenced by a trans iently elevated serum β-hC G concentration) are not sustained. T he likelihood of a succes sful full-term pregnancy increases dramatically if fetal cardiac activity is obs erved approximately 2 after mis sed menses (i.e., 4 weeks after the gamete or embryo transfer). T he main indication for as sisted reproductive procedures is failure to conceive with conventional interventions . In some ins tances , the reproductive impairment is so s evere that conventional interventions are unlikely to offer s uccess and an reproductive procedure is recommended primarily. IC S I us ed when there is failed fertilization during a previous procedure or when too few s perm exis t for IV F . G amete intrafallopian trans fer (G IF T ) is a form of reproduction with s imilar rates of success in which 3034 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 38 of 119

four oocytes are mixed with s perm and placed into the fallopian tube during a laparoscopy. F ertilization occurs the tube and, thus , is not obs erved. IV F -E T has largely supplanted this procedure because G IF T requires a laparoscopy and general anes thes ia and becaus e pregnancy res ults are not better than with IV F -E F . When it is not pos sible to correct underlying causes , subs titutions are poss ible. Not only are donor s perm available, s o too are donor oocytes and s urrogate who will ges tate the embryo of another couple. can be cryopres erved indefinitely and potentially transferred to a biologically unrelated recipient or to the woman herself years after menopause. T reatments for infertility are expens ive and consume time and energy. A s ens e of ps ychological and invas ion is common. Infertile men and women may feel angry, damaged, or guilty. S tudies s uggesting a link between ovarian cancer and infertility further increase anxiety and psychological turmoil. T he potential for husbands and wives to res pond differently to the experience of infertility and its treatments , particularly of the ass is ted reproductive technologies, can customary adaptation patterns and lead to decompensation. E ven s ucces sful infertility treatment poses challenges . Ass is ted reproductive technologies a 25 to 30 percent chance of twins and an almos t 1 chance of triplets. If quadruplets or more res ult, the must grapple with the option of selective reduction. A multiple pregnancy increas es fetal and maternal risks, as congenital abnormalities and preterm labor. F urther, multiple ges tation complicates postpartum adjus tment and carries a lifelong parenting challenge. T here is 3035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 39 of 119

evidence that children born to previous ly infertile are viewed by their parents as s pecial. T hese parents have trouble s etting limits or may be overly protective. Whether or not it is treated, infertility can produce a of ps ychological reactions . R es ponses depend on personality attributes , including adaptability, cultural expectations , s upport s ys tems, knowledge about reproductive process es , and the attitudes of the clinicians . Infertility can damage s elf-image and impair sens e of health and integrity. S ome individuals feel that they are being made to suffer for past wrongs ; others blame the medical profess ion for being inadequate or inattentive. A sense of panic, helples sness , and loss of control may compromis e s elf-es teem. W omen and men alike are generally overwhelmed by the complexity, invas iveness , and uncertainty ass ociated with medical intervention or adoption. Almost all patients who infertility treatment (T able 28.1-1) experience a los s of privacy as they cope with phys icians, nurs es, carriers , psychologists, hospitals, and laboratory T he sens e of intimacy that reinforces marriage and mutuality may be challenged when s ex and procreation are separated by technology (T able 28.1-2). Ultimately, infertility presents the specter of a ps ychological death. T hus, it is not s urprising that patients with infertility as much anguis h and distress as patients newly with acquired immunodeficiency s yndrome (AIDS ).

Table 28.1-2 As s is ted Tec hniques 3036 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 40 of 119

Method

C omments

Ovulation induction or augmentation (multiple agents , particularly recombinant or highly purified gonadotropins )

S timulates multifollicular development and may produce multiple births ; us ed in anovulation, luteal phase deficiency, unexplained infertility, and as sisted reproduction

Induction of spermatogenesis

Used in men with hypothalamic hypogonadis m of or organic nature

Artificial insemination

Donor sperm is injected the uterine cavity or the fallopian tubes; the sperm the hus band may be used healthy

G amete intrafallopian transfer

T ransfer of collected and s perm into the tubes ; zygote may als o be transferred; used for infertility from endometriosis and 3037

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 41 of 119

unexplained infertility In vitro fertilization and embryo

T ransfer of developing embryos into the uterus after extracorporeal incubation of collected sperm with oocytes retrieved by laparoscopic surgery or by ultrasoundguided transvaginal as piration; us ed with occlusion of the fallopian tubes or s ignificant sperm dysfunction; permits preimplantation genetic diagnosis

Intracytoplas mic sperm injection

Injection in vitro of sperm head or sperm DNA to fertilization and production of embryos for transfer to receptive endometrium; may be used even if are barely viable; genetic caus es of male infertility may be transmitted to offspring

G amete donors

Donation of sperm or oocytes to another couple;

3038 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 42 of 119

can include oocytes only, oocyte cytoplasm only to res tore reproductive competence to aged donor s perm alone, or any combination; cytoplasmic transfer considered unethical and is illegal in some s tates S urrogate mother

S urrogate mother receives donated embryo and the baby to term; a highly controvers ial technique unclear legal ramifications

Data in part from S usman V . P regnancy in S ciences for Me dical S tudents . B altimore: Wilkins ; 1993. Ideally, psychological s upport s ervices should be for all individuals and couples undergoing active evaluation and intervention for infertility. Unlike the traditional medical model, in which diagnostic testing precedes and directs the course of treatment, in empirical therapy may precede more invas ive tes ting. C ause and effect can be difficult to identify, and magical or s uperstitious thought process es are patients and practitioners alike. Infertility can threaten 3039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 43 of 119

marital adjus tment, particularly if the partners react differently to the challenges . Although fertility is an attribute of a couple, blame may be prematurely or incorrectly as signed to one pers on in the dyad. In to individual or couples counseling, groups , such as R es olve, can offer support and information. W hen sperm, oocytes, or embryos or s urrogate motherhood being considered, a thorough psychological evaluation recommended in advance of treatment to ensure that parties agree to the treatment plan and understand the potential implications and ramifications . R eproductive technologies have made it poss ible to separate biological and social parenthood. A s ingle woman may choos e parenthood. T he us e of donor insemination or other fertility therapies in single women controvers ial. Most women who seek s uch s ervices cons idered the cons equences of s ingle parenthood feel that they will be able to rise to the challenges . Nonetheles s, psychological evaluation should be made available to ensure that important topics and cons equences have been cons idered. No long-term up on the mental health and development of children born to single mothers has been done. P.2301 Dys functional attitudes and dis harmony cons tantly threaten the infertile pers on. P rophylactic evaluation is preferred in all treatment s ettings , but specialized may not always be immediately available. S tress can compromise gametogenesis and libido, and infertility treatment alone can be s tres sful enough to activate the central mechanisms that compromis e reproductive 3040 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 44 of 119

function. P sychological s upport is intended to less en likelihood of this effect and revers e it if it is already occurring. P harmacological agents used to treat disorders of ovulation or to hyperstimulate the ovaries may alter and cognition. T he agents include clomiphene citrate (C lomid) and other anties trogens , G nR H analogs, gonadotropins , hC G , proges terone, and bromocriptine (P arlodel). Danazol (Danocrine), a s ynthetic androgen, be us ed to arrest the growth of endometriosis as a or medical adjunct to later infertility therapy. T reatment infertility itself is anxiety provoking becaus e of the uncertainty and s ens e of expectation. However, most the agents do alter es tradiol and proges terone levels , the res ultant hormonal fluctuations may trigger mood lability in sensitive individuals . Agents such as danazol, and bromocriptine may als o have direct on the brain. If the use of thes e agents is indicated, ps ychological support should be offered ins tead of anxiolytics and antidepres sants . A further concern of infertile couples is whether ass is ted reproductive techniques increas e the ris k of neurodevelopmental or other abnormalities, including childhood cancers. T he uncertainty as to whether there is a link between treatments and poor health outcomes in the mother or child only s erves to exacerbate anxiety and guilt. is a far more devastating disorder than mos t lay and phys icians realize.

Pregnanc y L os s Unlike infertility, which can continue indefinitely, pregnancy loss is a defined event with an end. Acute 3041 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 45 of 119

reactions to an isolated miscarriage or perinatal los s, as blame, guilt, anger, and denial, gradually lead to acceptance and resolution. A single miscarriage does predict poor future reproductive performance. pre gnancy los s , defined as three or more loss es before weeks of gestation, carries an unfavorable prognosis res embles infertility in its chronicity and sense of lost potential. Although it might be as sumed that grief and emotional turmoil would be related to ges tational age, as sumption is not supported by observations . W omen miscarry have more than twice the relative risk of a depres sion compared with community women. More half of women with a history of major depress ion experienced a recurrence after miscarriage. B ecause significant ris k of depress ion, acute intervention is recommended for all women and couples who a mis carriage or perinatal loss ; services s hould be extended beyond the acute event when indicated.

Ps eudoc yes is P s e udocye s is is the development of the clas sic of pregnancyamenorrhea, naus ea, breas t enlargement pigmentation, abdominal distention, and labor painsin a nonpregnant woman. P s eudocyes is demons trates the ability of the ps yche to dominate the soma, probably central input at the level of the hypothalamus . P redisposing ps ychological proces ses are thought to include a pathological wish for and fear of pregnancy; ambivalence or conflict regarding gender, s exuality, or childbearing; and a grief reaction to los t potential after miscarriage, tubal ligation, or hys terectomy. T he may have a true s omatic delus ion that is not s ubject to reality testing, but, often, a negative pregnancy tes t 3042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 46 of 119

or pelvic ultrasound s can leads to res olution. P sychotherapy is recommended during or after a presentation of ps eudocyes is to evaluate and treat the underlying ps ychological dysfunction. A related event, couvade, in which the father of the child undergoes a simulated labor as if he were giving birth, occurs in cultures.

Fertility C ontrol E lec tive A bortion E lective abortion is dis tinct from spontaneous abortion (i.e., mis carriage) (T able 28.1-3). E lective abortion is planned termination of a pregnancy. C enters for C ontrol (C DC ) s tatistics indicate that approximately 1.2 million abortions were performed in the United S tates 1997 (the mos t recent year with data available from all states )306 abortions for every 1,000 live births . In nations, mos t women who obtain abortions are young, unmarried, and primiparous ; in underdeveloped abortion is most common among married women with two or more children.

Table 28.1-3 Types of Abortion S pontaneous S pontaneous expulsion of the products of conception before viability (500 g or approximately wks from last mens es ) 3043 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 47 of 119

R ecurrent

T hree or more s pontaneous abortions

Miss ed

Abnormal development of an intrauterine pregnancy; us ually caus ed by the presence of a blighted ovum and lack of fetal development

T hreatened

Uterine bleeding or cramping and positive pregnancy test; mus t be distinguished from an ectopic (us ually tubal) pregnancy

Incomplete

S pontaneous pass age of a portion the products of conception and retention of placental fragments that res ult in ongoing bleeding

E lective

Induced by medical or s urgical techniques before fetal viability; techniques include dilation, evacuation, and curettage; suction curettage; injection into the amniotic sac of s aline or prostaglandins; hys terotomy; prostaglandins with antiproges tins (R U-486) or methotrexate; indications include the detection fetal abnormalities by ultrasound 3044

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 48 of 119

amniocentes is

C DC statis tics from 1999 es timate that 22 percent of abortions were performed at or under 6 weeks of gestation, 36 percent between 7 and 8 weeks , 20 between 9 and 10 weeks, and 10 percent between 11 12 weeks. T he remainder occurred after 13 weeks, P.2302 with 1.5 percent occurring after 21 weeks . T able 28.1-4 summarizes the most common abortion techniques. In contrast to what was previously thought, recent studies show no s ignificant untoward psychological effects of elective abortion on the mental health of women. In in one study comparing the outcomes of women who sought treatment in a clinic because they thought they were pregnant, women who were pregnant and chose abort were reported later to be doing better emotionally and in purs uing personal, educational, and work endeavors than were either thos e who were not or thos e who chose to continue the pregnancy. Another study suggested untoward consequences on the health and well-being of women who were denied the option to abort and, thus, were required to unwillingly 3045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 49 of 119

carry the pregnancy to term and then raise an child. T his study sugges ted untoward cons equences the mental health and well-being of the child as well. However, termination of a wanted pregnancy becaus e an abnormal karyotype or fetal anomalies can be traumatic, and supportive intervention is

Table 28.1-4 Abortion Type

B enefits

R is ks

C ervical dilation and evacuation of uterine contents by curettage or vacuum as piration

Most commonly performed procedure for termination of pregnancy; be done 24 wks ' gestation

Uterine perforation, adhes ions, hemorrhage, infection, incomplete removal of fetus and placenta (all rare)

Mens trual as piration (miniabortion)

C an be done within 13 wks of mis sed period

Implanted zygote not removed, uterine perforation

3046 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 50 of 119

(rare), failure recognize ectopic pregnancy Medical induction (cervical dilation with laminaria followed by high dose of oxytocin)

C an be used secondtrimes ter abortion

Water intoxication, uterine rupture, infection

Intraamniotic hyperosmotic solutions (s alting out)

C an be used secondtrimes ter abortions

Hyperos molar crisis, heart failure, peritonitis, hemorrhage, water intoxication, myometrial necros is

P ros taglandin (oral, intravaginal, cervical, or intraamniotic)

Noninvasive procedure; be us ed in conjunction with antiproges tins

E xpuls ion of live fetus, miss ed ectopic, hemorrhage, incomplete

3047 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 51 of 119

(R U-486) or methotrexate

abortion

Antiprogestins (R U-486)

Nons urgical; first trimester only

Incomplete abortion, hemorrhage

Methotrexate

Nons urgical; first trimester only

Leukopenia, hemorrhage, incomplete res ults

T echniques for inducing abortion (T able 28.1-4) have known for at least 5,000 years. In view of the ris ks of childbearing and the requirements of child rearing, induced abortion was viewed historically as a means of modulating the maternal and societal risks of childbearing. Induced abortion affords women a of autonomy over a unique and ps ychologically bodily function, but it arous es personal and public ambivalence and inspires controvers y. His torically, the concept of therapeutic abortion before quickening, which is generally defined as the time at the mother perceives fetal movements , was well In the United S tates, legis lative regulations regarding induced abortion were introduced in the early 1800s , their intent was to protect women from sepsis and complications as sociated with the procedures. Induced abortion, whether by surgical or chemical means, now 3048 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 52 of 119

entails minimal medical ris k and is clearly safer than carrying the pregnancy to term. C urrent legis lative attention has shifted from maternal health to the ethics of abortion and the right of women to exercise control over their bodily functions . T raditionally, ethical deliberations regarding abortion res erved for religions . B ecaus e of the divers ity of perspectives on the role of women and on procreation, cons ens us is neither likely nor necess arily desirable. Nonetheles s, the current legis lative debate centers on has the authority to regulate induced abortion and to degree. T he 1992 S upreme C ourt ruling in P lanne d P are nthood of S outheas te rn P enns ylvania v. C as e y the bas ic right of women to elect pregnancy termination before fetal viability, but also upheld the right of the to regulate and res trict abortion and to define viability. F urther, in s ome states (e.g., P enns ylvania), pregnant women los t the right to select whether they wis h to receive advanced life support in life-threatening T he F reedom of C hoice Act put before the U.S . recognized the right of states to regulate the strictly medical as pects of abortion to s afeguard maternal It restricts the freedom of a woman to terminate a pregnancy after, but not before, fetal viability. T his legis lative effort repres ented a compromis e between those who argue agains t any medical mediation of the proces s and thos e who would grant women complete autonomy. Application of this law would hinge on the interpretation of the phrase fe tal viability, a concept that not eas ily defined. Making the option of induced contingent on fetal viability reveals continuing ambivalence about allowing women the autonomy to 3049 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 53 of 119

make decis ions about phys iological proces ses that shape their lives. It is difficult to appreciate how a legis lative body can entrust the life of a child to the and s imultaneously limit the mother's autonomy in making reproductive decis ions. C urrent legis lative have focused on res tricting the techniques us ed to perform late-term abortions by criminalizing phys icians. T his debate regarding abortion is far from res olution P.2303 and is likely to continue as medical advances s uch as mifepristone (R U-486), the antiproges tin that can chemically induce abortion in the early firs t trimes ter, increase therapeutic options. T he medical ris ks of either surgical or medical abortion few, but both procedures require physician input. abortion, however, requires less phys ician input, it does require careful monitoring to ens ure that the abortion occurs in a timely fas hion. R arely, hemorrhage occurs that requires s urgical intervention or a Medical abortion can potentially increase a woman's autonomy of her reproductive capacity.

C ontrac eption Methods of contraception fall into four main categories barrier methods , hormonal agents, devices , and natural family-planning methods that abstinence around the time of ovulation (T able 28.1-5). T he perfect contraceptive would be completely free of adverse effects , and completely efficacious . no perfect contraceptive is now available, people must select a method that bes t meets their needs. 3050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

Page 54 of 119

the res ponsibility for choosing and us ing a falls primarily on the woman. T his can lead to lack of compliance, and marital disharmony. F or thos e stable relations hip, contraceptive counseling can both partners.

Table 28.1-5 C urrent Methods o Type

E ffic acy a

Advantages

Dis advan

B arrier (chemical or mechanical)    S permicidal agents

Moderate

R eadily available easy to use

Mess y; lo spontane requires forethoug

   Diaphragm, cervical cap

Moderate

Inexpens ive; does not interfere with mens trual cycle

User fam required; prescripti fitting req may inter with spontane requires forethoug

mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

01/01/2009

3051

Page 55 of 119

   Male

Moderate

R eadily available easy to use; protects agains t sexually transmitted diseases (S T Ds )

May inter with spontane requires forethoug

   F emale condom

Moderate

R eadily available easy to use; protects agains t

May inter with spontane requires forethoug

Hormonal (s uppress es ovulation and/or impairs endome    Oral contraceptives, contraceptive patches and rings

High

P rotect agains t uterine and ovarian cancer, S T Ds

P harmaco side effec require da weekly us regardles frequency sex; mus t prescribe monitored health ca profes sio

3052 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm