TRAUMA- AND STRESSOR-RELATED DISORDERS

Basic Terminologies:

- Stressors are external events or situations that place physical or psychological demands on us.
- Stress is the internal psychological or physiological response to a stressor.

After exposure to traumatic incidents, there are four common outcomes or trajectories:

 Resilience—relatively stable functioning and few symptoms resulting from the trauma
 Recovery—initial distress with reduction in symptoms over time
 Delayed symptoms—few initial symptoms followed by increasing symptoms over time
 Chronic symptoms—consistently high trauma-related symptoms that begin soon after the event

ADJUSTMENT DISORDER (AD)

Descriptions

It occurs when someone has difficulty coping with or adjusting to a specific life stressor—the reactions to the stressor are
disproportionate to the severity or intensity of the event or situation.

Common stressors such as interpersonal or family problems, divorce, academic failure, harassment or bullying, loss of a job, or
financial problems may lead to an AD.

Diagnostic Criteria

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the
onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

- Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context
and the cultural factors that might influence symptom severity and presentation.
- Significant impairment in social, occupational, or other important areas of functioning.

C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a
preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

ACUTE STRESS DISORDER

Diagnostic Criteria

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a
family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting
human remains, police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through
electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation,
avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

1. Intrusion symptoms

- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may
occur in which themes or aspects of the traumatic event(s) are expressed.
 - Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children,
there may be frightening dreams without recognizable content.
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present
surroundings.) Note: In children, trauma-specific reenactment may occur in play.
- Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).

2. Negative Mood

- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

3. Dissociative Symptoms

- An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a
daze, time slowing).
- Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).

4. Avoidance Symptoms

- Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the traumatic event(s).

5. Arousal Symptoms

- Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).

- Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression
toward people or objects.
- Hypervigilance.
- Problems with concentration.
- Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3days and up to a month is needed to meet
disorder criteria.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical
condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

POST-TRAUMATIC STRESS DISORDER (PTSD)

Diagnostic Criteria

For individuals above 6 years old

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s)occurred to a close family member or close friend. In cases of actual or threatened death
of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting
human remains: police officers repeatedly exposed to details of child abuse).

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:
 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s)were recurring. (Such
reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present
surroundings.)
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s)occurred, as evidenced
by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic
event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad, ”“No one can
be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame
himself/herself or others.
4. Persistent negative emotional state(e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:

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

F. Duration of the disturbance (Criteria B,C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical
condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in
response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of,
one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of
time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is
experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g.,
blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate).

For children 6 years and younger

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

- Directly experiencing the traumatic event(s).

- Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.
- Learning that the traumatic event(s)occurred to occurred to a parent or caregiving figure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present
surroundings.) Such trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic event(s).

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s)
or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or
worsening after the event(s):

Persistent Avoidance of Stimuli

- Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).
- Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic
event(s).
- Negative Alterations in Cognitions
- Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
- Markedly diminished interest or participation in significant activities, including constriction of play.
- Socially withdrawn behavior.
- Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts(with little or no provocation) typically expressed as verbal or physical aggression
toward people or objects (including extreme temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

E. The duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in in relationships with parents, siblings, peers, or other
caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical
condition.

Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in
response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of,
one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of
time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is
experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g.,
blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate).

ETIOLOGICAL CONSIDERATIONS

Biological

- Many individuals who develop trauma-related disorders have a nervous system that is more reactive to fear and stress when
compared to people who are exposed to trauma but do not develop a disorder.
- Although our biological systems are designed for rapid recovery from traumatic events and for homeostasis (physiological
balance), some people are more prone to the physiological reactivity associated with chronic stress reactions.
- The normal response to a fear-producing stimulus is quite rapid, occurring in milliseconds, and involves the amygdala, the
part of the brain that is the major interface between events occurring in the environment and physiological fear responses. In
response to a potentially dangerous situation, the amygdala sends out a signal to the sympathetic nervous system, preparing
the body for action (i.e., to fight or to flee).
- The hypothalamic-pituitary-adrenal (HPA) axis (the system involved in stress and trauma reactions) then releases hormones,
including epinephrine and cortisol. These hormones prepare the body for “fight or flight” by raising blood pressure, blood
sugar levels, and heart rate; the body is thus prepared to react to the potentially dangerous situation. Cortisol also helps the
body return to normal (i.e., restore homeostasis) after the stressor is removed.
- However, people who develop a trauma- or stressor-related disorder, their amygdala and HPA axis are overreactive and
continue to demonstrate physiological stress reactions even when the stressor is no longer present.
- Individuals with trauma-related disorders also show minimal fear extinction (i.e., a decline in fear responses associated with
the trauma).
- Researchers believe that deficiencies in fear extinction occur when the medial prefrontal cortex is unable to adequately
inhibit fear responses; when fear extinction does not occur, various trauma-related cues continue to trigger fear reactions
- Impaired fear inhibition and difficulty discriminating safe situations is a hallmark of PTSD
- Those with PTSD demonstrate an enhanced startle response, exaggerated physiological sensitivity to stimuli associated with
the traumatic event, and diminished ability to inhibit fear responses.

Why does this reactivity occur in the first place (i.e., why homeostasis is not restored soon after the trauma)?

Possible Reasons:

- It is possible that the chronic release of stress hormones such as cortisol alters brain structures associated with stress
regulation. The brain is particularly vulnerable to the effects of cortisol during childhood, a time when the brain is still
developing. Disruptions caused by excess cortisol can lead to neuronal loss and affect brain areas such as the hippocampus,
amygdala, and cerebral cortex.
- Genetic differences are also implicated in vulnerability to trauma-related disorders.
- Genetic research involving PTSD focuses on individuals with two short alleles (SS genotype) of the serotonin transporter
gene (5-HTTLPR). Those with this genotype appear to have increased stress sensitivity and are more prone to the heightened
anxiety reactions associated with PTSD.

Psychological

Threat Perception

The severity of perceived life threat, rather than actual life threat, may be the best predictor of whether a person will develop PTSD.
Perceived threat, more than actual threat, is a better predictor of many of the symptoms of PTSD.

Locus of Control

The person’s beliefs about whether she or he can control future events are also important.

Victims who perceive (perhaps with justification) that future negative events are uncontrollable are much more likely to have severe
PTSD symptoms than those victims who perceive some future control.

Suppression of Anger

Victims who suppress their feelings of anger may have an increased risk of developing PTSD after a traumatic experience (e.g., rape).

Intense anger may interfere with the modification of the traumatic memory (to make it more congruent with previous feelings of
safety). Anger also inhibits fear, so the victim cannot habituate to the fear response.

Individuals with pre-existing conditions (e.g., depression and higher anxiety) or negative emotions (e.g., hostility and anger)

They may react more intensely to a traumatic event because they ruminate about the event and overestimate the probability that
aversive events will follow.

A tendency to generalize trauma-related stimuli to other situations (e.g., a rape survivor avoiding contact with men) and to avoid
situations associated with the trauma can maintain the fear response because the person is not able to learn that such situations are not
dangerous; in other words, there is less opportunity for fear extinction.

Negative cognitive styles and dysfunctional thoughts

 Example: I feel so helpless; The world is so dangerous

They may interpret stressors in a catastrophic manner and thereby increase the psychological impact of trauma.

 Example:Among child and adolescent survivors of assault and motor vehicle accidents, those with thoughts such as “I will
never be the same” were more likely to develop PTSD symptoms.
 Negative thoughts such as these may produce sustained and heightened physiological reactivity, making the development of
PTSD more likely. 
 On the other hand, a positive cognitive style that results in active problem-solving, reframing traumatic events in a more
positive light, and optimistic thinking can increase resilience and reduce risk of PTSD.

Social

Availability of social support

Protective factors such as the person’s level of social support may help to prevent or limit the development of PTSD and other
psychological consequences.

Unfortunately, simply having a social support network may not be enough. The tendency of the victim to withdraw and avoid
situations is an inherent part of the disorder. This avoidance may mean that victims do not take advantage of social support, even if it
is available to them.

The reactions of one's family members and friends may lead to further problems and may make a person feel less in control and more
alienated from other people.

Those victims with extensive social support networks were less likely to be anxious or depressed, but social support did not
specifically reduce the frequency or severity of PTSD symptoms. This pattern suggests that the needs of trauma survivors must be
addressed broadly.

Nevertheless, social support may dampen the anxiety associated with a trauma or prevent negative cognitions from occurring.

 Social Isolation
 Less than optimal social support during childhood
 Exposure to childhood traumas (sexual and/or physical abuse)
 Severe bullying
 Preexisting family conflict, maltreatment, or overprotectiveness
Sociocultural

The attitudes that society holds toward victims of sexual assault are also important in relation to social support.

Some people apparently believe that certain women somehow deserved to be raped. These women undoubtedly receive less social
support than other victims.

People may also be more supportive after hearing the details of an assault that was clearly nonconsensual—one in which the victim
violently fought back when attacked by a stranger—than when the circumstances surrounding the assault were more ambiguous.

Perceived discrimination based on race or sexual orientation is also associated with increased risk for PTSD.

 Experiences or perceptions of discrimination can increase anxiety and lead to the development of negative thoughts about
oneself and the world.

Greater prevalence of trauma-related disorders in women was due, in part, to more frequent exposure to violent interpersonal
situations.

TREATMENT

The most effective forms of treatment for PTSD involve the use of either cognitive-behavior therapy or antidepressant medication,
alone or in combination.

Certain antidepressant Medications

 They help in altering serotonin levels, decreasing reactivity of the amygdala and desensitizing the fear network.

The psychological intervention that has been used and tested most extensively is prolonged exposure.

This procedure starts with initial sessions of information gathering.

 These are followed by several sessions devoted to reliving the traumatic scene in the client’s imagination.
 Clients are instructed to relive the event by imagining it and describing it to the therapist, as many times as possible, during
the 60-minute sessions.
 Sessions are recorded, and patients are instructed to listen to the tape at least once a day.
 Patients are also required to participate in situations outside the therapy sessions that are deemed to be safe but also elicit fear
or avoidance responses.

Another therapy that is being used is trauma-focused cognitive-behavioral therapy (TF-CBT)

 It focuses on helping clients identify and challenge dysfunctional cognitions about the traumatic event and current beliefs
about themselves and others.
 This therapy addresses underlying dysfunctional thinking or pervasive concerns about safety.
 For example, battered women with PTSD often have thoughts associated with guilt or self-blame.
 Cognitions such as “I could have prevented it,” “I never should have . . . ,” or “I’m so stupid” can maintain PTSD symptoms.
 Therapy involving education about PTSD, developing a solution-oriented focus, reducing negative self-talk, and receiving
therapeutic exposure to fear triggers (such as photos of their abusive partner or movies involving domestic violence) reduced
PTSD symptoms

Eye movement desensitization and reprocessing (EMDR)

 Clients are asked to visualize their traumatic experience while following a therapist’s fingers moving from side to side.
 The therapist prompts the client to substitute positive cognitions (e.g., “I am in control”) for negative cognitions associated
with the experience (e.g., “I am helpless”).

SOMATIC SYMPTOM AND DISSOCIATIVE DISORDER

Somatic Symptom Disorder

 Illness Anxiety Disorder

 Conversion Disorder (Functional Neurological Symptom Disorder)
 Factitious Disorder and Factitious Disorder Imposed on Another
 Factitious Disorder Imposed on Self
  Factitious Disorder Imposed on Another
 Causal Factors
 Treatment

Dissociative Disorders

 Dissociative Identity Disorder

 Dissociative Amnesia
 Depersonalization/Derealization Disorder
 Causal Factors
 Treatment of Dissociative Disorders

SOMATIC SYMPTOM DISORDER

Diagnostic Criteria 

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least
one of the following:

- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more
than 6 months).

Specify if:

With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly
involve pain.

Specify if:

Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).

Specify current severity:

Mild: Only one of the symptoms specified in Criterion B is fulfilled.

Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very
severe somatic symptom).

ILLNESS ANXIETY DISORDER

Diagnostic Criteria 

A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high
risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or
disproportionate.

C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.

D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits
maladaptive avoidance (e.g., avoids doctor appointments and hospitals).

E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of
time.

F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic
disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
Specify whether:

 Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
 Care-avoidant type: Medical care is rarely used.

CONVERSION DISORDER

FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER

Diagnostic Criteria

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

C. The symptom or deficit is not better explained by another medical or mental disorder.

D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.

FACTITIOUS DISORDER

Diagnostic Criteria

Factitious Disorder Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

B. The individual presents himself or herself to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy)

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with
identified deception.

B. The individual presents another individual (victim) to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: The perpetrator, not the victim, receives this diagnosis.

CAUSAL FACTORS

Biological Factors

Genetic factors only modestly contribute to these disorders, according to twin and family studies. Environment plays a much greater
role. However, biological vulnerabilities, such as lower pain thresholds, heightened sensitivity to pain, and greater sensitivity to
somatic cues, are suspected of playing a key role in the development of somatic symptoms and health anxiety.

A biological predisposition, hardwired into the central nervous system, can result in

 hypervigilance or exaggerated focus on bodily sensation,

 increased sensitivity to even mild bodily changes, and
 a tendency to react to somatic sensations with alarm

It is also possible that repetitive activation of the sympathetic nervous system due to chronic exposure to stressors can lead to
increased sensitivity of the nerves associated with pain and subsequent increases in pain sensation.

Studies have also suggested that conversion disorder may result from abnormal actions of inhibitory neural systems.
  Example: Bryan and Das (2012) compared MRI scans of a patient with conversion disorder (involving an inability to speak)
before and after successful psychotherapy. Before treatment, there was evidence of impaired connectivity in the speech
network; this abnormality was no longer evident after treatment

In contrast, individuals with SSD with predominant pain show increased excitability between areas of the brain related to emotional
behaviors. Can brain reactivity involving brain regions associated with pain be reduced or inhibited?

 Some studies have found that those with chronic pain conditions had reduced cerebral gray matter in the prefrontal areas of
the brain and increases in gray matter increased cognitive control over pain, reducing the perception of pain.

Psychological Factors

Psychodynamic Perspective

In psychodynamic theory, somatic symptoms defend against the awareness of unconscious emotional issues.

- Freud believed that hysterical reactions (biological complaints of pain, illness, or loss of physical function) were caused by
the repression of some type of conflict, usually sexual in nature. To protect the individual from intense anxiety, this conflict
is converted into a physical symptom.
- The psychodynamic view suggests that two mechanisms produce and then sustain somatic symptoms.
 The first provides a primary gain for the person by protecting him or her from the anxiety associated with the unacceptable
desire or conflict; the need for protection gives rise to the physical symptoms.
 This focus on the body keeps the person from becoming aware of the underlying conflict.
 Then a secondary gain accrues when the person’s dependency needs are fulfilled through attention and sympathy.
 Example: Some patients with conversion symptoms all relied on family members and friends to complete domestic tasks and
were receiving disability allowances.

Cognitive-Behavioral Perspectives

Some contend that people with SSD, conversion disorder, and factitious disorders assume the “sick role” because it is reinforcing and
because it allows them to escape unpleasant circumstances or to avoid responsibilities.

 Example: Men with supportive wives (attentive to pain cues) reported significantly greater pain when their wives were
present than when their wives were absent. 

Catastrophic misinterpretations of bodily sensations or changes in bodily functions might be important in the etiology of SSD and
illness anxiety disorder.

 Health anxiety arises because symptoms are interpreted as being very serious or due to catastrophic conditions that could
result in disability or death.
 Individuals’ preoccupation with disease and inordinately high anxiety levels are fueled by intrusive imagery such as
“visualizing that the doctor tells me that I have cancer” or “I’m lying on my death bed with my children and partner crying”
 According to this perspective, catastrophic cognitions related to somatic symptoms are more likely to develop in individuals
who are biologically or psychologically predisposed to having these thoughts—people who have somatic sensitivity, a low
pain threshold, a history of illness, or who or have received parental attention for somatic symptoms. It is hypothesized that
distressing cognitions develop in the following manner:
 External triggers (traumatic or anxiety-evoking stressors) or internal triggers (anxiety-producing thoughts such as “My father
died of cancer at age 47”) result in physiological arousal.
 The individual perceives bodily changes associated with these triggers such as increased heart rate or respiration.
 Thoughts and worries about possible disease begin in response to these physical sensations.
 These thoughts amplify bodily sensations, causing further physical reactions and concern.
 Catastrophic thoughts increase in response to the magnified bodily sensations, creating a circular feedback pattern.
 Consistent with this perspective, individuals with SSD tend to misinterpret and overestimate the dangerousness of bodily
symptoms.
 Example: Some individuals with SSD involving chest pain in the absence of cardiac pathology were highly attuned to
cardiac-related symptoms and exhibited anxiety reactions in response to heart palpitations and chest discomfort. Similarly,
individuals with health anxiety interpreted nine common bodily sensations as indications of disease.

Social Factors

Some individuals with SSD report being rejected or abused by family members and feeling unloved.
Some individuals may seek out contact with medical staff as a source of attention or comfort because of social isolation or an inability
to connect with family or friends.

The development of illness or injury sensitivity appears to be closely linked with parental characteristics such as being preoccupied
with or overly attentive to somatic complaints expressed by their children.

Additionally, individuals with SSD frequently have parents or family members with chronic physical illnesses or high health anxiety.

Sociocultural Factors

Cultural factors can influence the frequency, expression, and interpretation of somatic complaints. Risk factors associated with SSD
and related disorders include lower educational levels, ethnicity, and immigrant status.

Differences such as those just described may reflect different cultural views of the relationship between mind and body.

 The dominant view in Western culture is the psychosomatic perspective—that psychological conflicts are sometimes
expressed via physical symptoms. But many other cultures have a somatopsychic perspective—that physical problems
produce psychological and emotional symptoms. Although many of us believe that our psychosomatic view is the correct
one, the somatopsychic view is the dominant perspective in most cultures.

TREATMENT

Biological Treatment

Antidepressant medications such as selective serotonin reuptake inhibitors are sometimes used to treat SSD and illness anxiety
disorder.

Psychological Treatments

Treatment for SSD and related disorders focuses primarily on understanding the client’s view of his or her problem. Individuals with
somatic symptom, illness anxiety, and conversion disorders are often frustrated, disappointed, and angry following years of encounters
with the medical profession. They believe that treatment strategies have been ineffective and resent the implication that they are
“fakers” or “problem patients”.

A newer approach to treating SSD and illness anxiety disorder involves demonstrating empathy regarding the physical complaints,
accepting them as genuine, and providing information about symptoms that are often stress-related such as hypertension and
headaches.

In another approach, SSD is viewed within a social context—somatic complaints are seen as reflecting unsatisfying or inadequate
social relationships. Individuals who assume a “sick role” often control others through bodily complaints or receive some
reinforcement, such as escape from responsibility. Therapy is directed toward developing and improving the individual’s social
network and adaptive coping skills.

Because many patients with somatic symptom and health anxiety disorders appear to have cognitive distortions, such as a conviction
that they are especially vulnerable to disease, cognitive-behavioral approaches focused on correcting these misinterpretations are
successful.

Because individuals with SSD often show a fear of internal bodily sensations, cognitive-behavioral therapists include interoceptive
exposure (exposure to bodily sensations) during treatment. Therapists ask clients to perform activities that typically trigger anxiety
symptoms, such as breathing through a straw, hyperventilating, spinning, or climbing stairs, until feared reactions such as light-
headedness, chest discomfort, or increased heart rate occur. The activities are repeated until the bodily sensations no longer elicit
anxiety or fear.

Relaxation training can also effectively reduce the sympathetic nervous system activity found in individuals with somatic symptoms.
Mindfulness-based cognitive therapy is another approach that can lower anxiety. Clients learn to experience and observe their
problematic thoughts and symptoms without judgment or emotion, and without reacting to them. Instead of responding with fear and
anxiety, the individual merely observes and reflects on thoughts and physical reactions. This process weakens the connection between
emotional arousal and the symptoms and thoughts.

DISSOCIATIVE IDENTITY DISORDER

Diagnostic Criteria
A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an
experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied
by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These
signs and symptoms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with
ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not
better explained by imaginary playmates or other fantasy play.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol
intoxication) or another medical condition (e.g., complex partial seizures).

DISSOCIATIVE AMNESIA

Diagnostic Criteria

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with
ordinary forgetting. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or
generalized amnesia for identity and life history.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or
a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head
injury/traumatic brain injury, other neurological condition).

D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic
symptom disorder, or major or mild neurocognitive disorder.

DEPERSONALIZATION/DEREALIZATION DISORDER

Diagnostic Criteria

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:

1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts,
feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/
or physical numbing).
2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are
experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).

B. During the depersonalization or derealization experiences, reality testing remains intact.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical
condition (e.g., seizures).

E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive
disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

CAUSAL FACTORS

Biological Factors

Biological explanations for dissociative disorders have focused on disruptions in encoding of memories due to acute stress and the
inability to retrieve autobiographical material because of the release of hormones such as glucocorticoid, which may impede the recall
of traumatic events.
In dissociative amnesia, MRI scans show inhibited neural activity in the hippocampus apparently associated with memory repression,
and positron emission tomography (PET) scans show reduced metabolism in an area of the prefrontal cortex that is involved in the
retrieval of autobiographical memories.

Switching between personalities is associated with activation or inhibition of certain brain regions, particularly the hippocampus, an
area involved in memories and hypothesized to be involved in the generation of dissociative states and amnesia.

However, these patterns of brain activity are difficult to interpret because it is unclear what causes them and what specific role they
play, if any, in dissociative disorders.

Chronic activation of stress responses due to childhood trauma can result in permanent structural changes in the brain. Reduced
volume in the hippocampus and amygdala may hamper the ability of the brain to encode, store, and retrieve memory; comprehend
contradictory information; and integrate emotional memories. Such alterations may play an etiological role in dissociative amnesia,
DID, and depersonalization.

Psychological Factors

Psychodynamic Theory

Dissociative disorders are caused by an individual’s use of repression to block unpleasant or traumatic events from consciousness.
This process protects the individual from painful memories or conflicts.

 In dissociative amnesia and fugue, for example, memories of specific events or large parts of the individual’s personal
identity are no longer available to conscious awareness.
 Dissociation is carried to an extreme in DID.
 Here, the splits in mental processes become so persistent that independent identities are formed, each with a unique set of
memories.

Contemporary psychodynamic theorists propose a post-traumatic model of DID that focuses on the role of severe childhood abuse,
parental neglect or abandonment, or other early traumatic events. According to this model, the factors necessary for the development
of DID include:

 being exposed to overwhelming childhood stress, such as traumatic physical or sexual abuse;
 genetic or biological predispositions, psychiatric vulnerabilities, life stressors, and having the capacity to dissociate;
 encapsulating or walling off the experience; and
 developing different memory systems.
 According to the post-traumatic model, the split in personality develops because of traumatic early experiences combined
with an inability to escape them. If a supportive environment is not available or if the personality is not resilient, these factors
can result in DID.
 In the case of Sybil, who was severely abused by her mother, Dr. Wilbur—Sybil’s psychiatrist—speculated that Sybil
escaped “an intolerable and dangerous reality” by dividing into different personalities.
 Consistent with this perspective, most individuals diagnosed with DID do report a history of physical or sexual abuse during
childhood. In fact, individuals with DID have the highest rate of childhood psychological trauma compared to people with
other psychiatric disorders.
 To develop DID, the individual must have the capacity to dissociate—or separate—certain memories or mental processes in
response to traumatic events.
 The post-traumatic model presupposes exposure to childhood trauma.
 In most studies, information on child abuse is based on self-reports, is not independently corroborated, and involves varying
definitions and degrees of abuse.

Social and Sociocultural Factors

Sociocognitive model of DID

Individuals with the disorder learn about DID and its characteristics through the mass media and, under certain circumstances, begin
to act out these roles.

Vulnerable individuals may demonstrate these behaviors when therapists inadvertently use questions or techniques that evoke
dissociative types of problem descriptions by clients. Proponents of the sociocognitive model cite the large increase in DID cases after
mass media portrayals of this disorder as support for their perspective.
Therapists are also exposed to mass media portrayals of DID and may unconsciously encourage reports of DID from clients. This
would be referred to as an iatrogenic disorder—a condition unintentionally produced by a therapist through mechanisms such as
selective attention, suggestion, reinforcement, and expectations that are placed on the client.

 Although iatrogenic influences can occur in any disorder, such effects may be more common with dissociative disorders,
because of the high levels of hypnotizability and suggestibility found in individuals with these conditions.

TREATMENT

Treating Dissociative Amnesia and Dissociative Fugue

It has been noted that depression is often associated with the fugue state and that severe stress is associated with both dissociative
amnesia and fugue. A reasonable therapeutic approach is to treat these dissociative disorders indirectly by alleviating the depression
and the stress that may underlie dissociative symptoms with antidepressants, cognitive-behavioral therapy, and stress management
techniques.

Treating Depersonalization/Derealization Disorder

Various antidepressants and antianxiety medications may be prescribed to treat these symptoms. Because catastrophic attributions and
appraisals sometimes play a role in the development of depersonalization/derealization symptoms, some therapists focus on
“normalizing” minor dissociative reactions and thoughts in response to stressful situations.

Mindfulness techniques in which the individual focuses on the breathing process itself while nonjudgmentally observing dissociative
sensations can help reduce the fear and anxiety associated with depersonalization/derealization symptoms.

Behavioral techniques are occasionally used to treat depersonalization/derealization disorder.

Treating Dissociative Identity Disorder

Trauma-focused therapy is used to help the individual develop healthier ways of dealing with stressors. Trauma-focused therapy for
DID also helps the different identities or alters become aware of one another, consider each as legitimate parts of the individual, and
resolve their differences. Each of the personalities is validated for helping the main personality cope with stressors and traumatic
events. The desired outcome is an integration or harmony among the different alters and a final fusion of the personality states. In
other words, the goal is for the alters to be completely integrated, merged, and assimilated into one personality.

EATING DISORDERS

ANOREXIA NERVOSA

Descriptions

Anorexia nervosa is a condition characterized by extreme weight loss and one of its most obvious symptoms is extreme thinness. In
anorexia nervosa, the person eats only minimal amounts of food or exercises vigorously to offset food intake so body weight
sometimes drops dangerously.

A very frightening characteristic of anorexia nervosa is that most people with the disorder, even when clearly emaciated, continue to
insist they are overweight. Some may acknowledge that they are thin but maintain that some parts of their bodies are too fat. Ninety to
ninety-five percent of anorexics are female.

In anorexia nervosa, deaths also occur from physical complications of the illness and from suicide. Complications such as
osteoporosis, cardiovascular problems, anemia, and compromised immune function are common.

Associated Characteristics

Depression, anxiety, impulse control problems, loss of sexual interest, and substance use often occur concurrently with anorexia
nervosa. Many individuals with anorexia nervosa have difficulty regulating their emotions, a factor that may maintain disordered
eating patterns.

Obsessive-compulsive behaviors and thoughts that may or may not involve food are common in those with anorexia nervosa.

Anorexia nervosa is often comorbid with several other disorders, including substance abuse, obsessive-compulsive disorder (OCD),
several personality disorders, and especially with major depression

Diagnostic Criteria
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex,
developmental trajectory, and physical health.

Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that
minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a
significantly low weight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-
evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtypes

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss
is accomplished primarily through dieting, fasting, and/or excessive exercise.

Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

BULIMIA NERVOSA

Descriptions

Individuals diagnosed with bulimia nervosa realize that they have abnormal eating patterns and are distressed by that knowledge.
Sometimes, their eating episodes continue until they experience abdominal pain or induce vomiting. They also feel disgusted or
ashamed of their eating and hide it from others.

Some individuals with this disorder consume nothing during the day but lose control and binge in the late afternoon or evening. For
those who vomit or use laxatives to compensate for overeating, the temporary relief (from physical discomfort or fear of weight gain)
is followed by feelings of shame and despair. Binge-eating episodes may be followed by a commitment to fasting, severely restricting
eating, or engaging in excessive exercising or other physical activity.

Compared to anorexia nervosa, bulimia is much more prevalent. People with bulimia use a variety of measures—fasting, self-induced
vomiting, diet pills, laxatives, and exercise—to control the weight gain that accompanies binge eating. Side effects from self-induced
vomiting or from excessive use of laxatives include erosion of tooth enamel from vomited stomach acid; dehydration; swollen salivary
glands; and lowered potassium, which can weaken the heart and cause heart irregularities and cardiac arrest.

Associated Characteristics

Individuals with bulimia often use eating as a way of coping with distressing thoughts or external stressors. There is also a close
relationship between emotional states and disturbed eating. By and large, bulimic behaviors may represent maladaptive attempts at
emotional regulation.

Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most
individuals would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how
much one is eating).

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of
laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
BINGE-EATING DISORDER

Description

The essential feature of binge-eating disorder is recurrent episodes binge eating that must occur, on average, at least once per week for
3 months. An "episode of binge eating" is defined as eating, in a discrete period of time, an amount of food that is definitely larger
than most people would eat in a similar period of time under similar circumstances.

An occurrence of excessive food consumption must be accompanied by a sense of lack of control to be considered an episode of binge
eating. An indicator of loss of control is the inability to refrain from eating or to stop eating once started. Some individuals describe a
dissociative quality during, or following, the binge-eating episodes.

The type of food consumed during binges varies both across individuals and for a given individual. Binge eating appears to be
characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient.

Associated Characteristics

In contrast to those with bulimia nervosa, individuals with BED are often overweight. Binges are often preceded by poor mood,
decreased alertness, feelings of poor eating control, and cravings for sweets. Many with this condition are unduly influenced by their
weight or shape, a factor associated with feelings of depression, anxiety, and low self-esteem. Those who expect that eating will help
relieve emotional distress are more likely to engage in binge eating.

Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most
people would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how
much one is eating).

B. The binge-eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal.

2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very
guilty afterward.

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not
occur exclusively during the course of bulimia nervosa or anorexia nervosa.

OTHER SPECIFIED FEEDING OR EATING DISORDERS

Description

The category other specified feeding or eating disorders includes seriously disturbed eating patterns that do not fully meet the criteria
for anorexia nervosa, bulimia nervosa, or binge-eating disorder. This is the most commonly diagnosed eating disorder and accounts
for up to 30 percent of eating disorder diagnoses.

Examples of people who fit in this category include the following:

 Individuals of normal weight who meet the other criteria for anorexia nervosa
 Individuals who meet the criteria for bulimia nervosa or binge-eating disorder except that binge eating occurs less than once a
week or has been present for less than 3 months
 Individuals with night-eating syndrome, a distressing pattern of binge eating late at night or after awakening from sleep
 Individuals who do not binge but frequently purge (self-induced vomiting, misuse of laxatives, diuretics, or enemas) as a
means to control weight.

Many individuals who receive this diagnosis have emotional problems and later develop bulimia nervosa or binge-eating disorder.
ETIOLOGICAL CONSIDERATIONS

Psychological Factors

Body dissatisfaction arises when someone’s weight or body shape differs significantly from an imagined ideal. People who are highly
dissatisfied with their bodies are more likely to compare their bodies to those of other people and report lower self-satisfaction. Men
who highly value personal attractiveness and appearance report lower body satisfaction when exposed to TV commercials featuring
muscular men.

Maladaptive perfectionism is also a risk factor; it may interact with body dissatisfaction to influence the development of anorexia
nervosa and other eating disorders. Maladaptive perfectionism is composed of two dimensions: (a) inflexible high standards and (b)
negative self-evaluations following mistakes. Imposing perfectionist standards on someone’s weight, shape, or dieting may cause
disordered eating.

Individuals with eating disorders also appear to use food or weight regulation as a means of handling stress or anxiety. Dieting
may represent an effort to demonstrate self-control or to improve self-esteem and body image. people who binge often view eating as
a source of comfort and a way to counteract depression and other negative emotions. Individuals who believe eating will relieve
negative affect such as depression are more likely to binge.

Perceived or actual inadequacies in interpersonal skills are also associated with eating disorders, particularly when combined with
maladaptive perfectionism. Individuals with eating disorders often perceive low levels of social support, which may be due to a
passive interpersonal style. They also possess “self-uncertainty,” which involves a low self-concept and limited sense of self.

Mood disorders such as depression often accompany eating disorders. In some cases, disordered eating may be a symptom of
depression. However, research studies are still being done to determine if depression could be the result, not the cause, of having an
eating disorder.

Social Factors

People with anorexia nervosa have often had childhoods characterized by social discomfort, anxiety, and insecure attachments to
others. As adults, they are more likely to report no significant attachments to others, and as mothers, they are more likely to have
difficulty reading the interpersonal cues of their infants.

Some individuals coping with eating disorders report that their parents or family members frequently criticized them, had a negative
reaction to their eating issues, or blamed them for their condition. Childhood maltreatment and negative family relationships possibly
produce a self-critical style that causes depression and body dissatisfaction.

Peers can also produce pressure to lose weight, particularly when exposure to the ideal of thinness occurs during a critical period of
development such as adolescence or early adulthood.

Sociocultural Factors

Cultural attitudes and standards are also thought to play an important role in the development of anorexia nervosa. Culture has a
strong influence on standards for what is considered to be the ideal female shape. In Western culture, thinness is perceived as the
standard of beauty as well as an indicator of success and self-control.

At the same time that contemporary cultural standards have emphasized thinness, women’s body weight has been increasing as a
result of improved health and nutrition. These circumstances have created a conflict between the ideal shape and many women’s
actual shape. The conflict often leads to prolonged or obsessive dieting, which can be a prelude to the development of anorexia
nervosa. The prevalence of anorexia nervosa is especially high among women who are under intense pressure to be thin, such as
dancers and models.

Women are socialized to be conscious of their body shape and weight. At an early age, girls are sexualized and objectified through
television, music videos, song lyrics, magazines, and advertising.

A process of social comparison occurs in which women and girls begin to evaluate themselves according to external standards.
Because these standards are unattainable for most women, body dissatisfaction occurs. Self-consciousness and frequent monitoring of
one’s external appearance can lead to anxiety or shame about the body. When women compare their body shape or weight with other
women’s, those with high body dissatisfaction report increased feelings of guilt and depression. Thoughts of “solutions” such as
dieting, purging, and extreme exercise increase, especially among those with the greatest body dissatisfaction. Thus, social
comparison appears to be a strong risk factor for eating disorders, especially among women who are dissatisfied with their bodies.

Biological Factors

Disordered eating appears to run in families, especially among female relatives.

Genetic influences may be triggered by physical changes such as puberty.

Differences in dopamine levels may explain why those with bulimia nervosa are more attentive to food stimuli and why individuals
with anorexia nervosa show less appetitive response to food images .

 Low levels of dopamine can increase hunger, whereas increased dopamine concentrations can decrease appetite
 Having genes associated with lower dopamine availability may interact with adverse childhood rearing experiences to result
in emotional eating patterns

Altered functioning of the appetitive neural circuitry (brain structures and processes that mediate appetite) also appears to influence
disordered eating patterns.

Abnormalities in ghrelin and leptin, gastrointestinal hormones, have been found in those with eating disorders.

TREATMENT

Treatment of Anorexia Nervosa

Because anorexia nervosa is a complex disorder, there is a need for teamwork among physicians, psychiatrists, and therapists. Because
an individual being treated for anorexia nervosa is starving, the initial goal is to restore weight and address the physical complications
associated with starvation. During the weight restoration period, new foods are introduced to supplement food choices that are not
sufficiently high in calories. 

Family therapy is often an important component of the treatment plan. This therapy may involve (a) having parents assist in the re-
feeding process by planning meals, (b) learning new family relationship patterns, (c) and reducing parental criticism by helping them
understand that anorexia nervosa is a serious disease. Parents are encouraged to help their children develop skills, attitudes, and
activities appropriate to their developmental stage.

Treatment of Bulimia Nervosa

Treatment involves an interdisciplinary team that includes a physician and a psychotherapist. To normalize eating patterns and
eliminate the binge/purge cycle is a primary goal of treatment. Cognitive-behavioral approaches can help individuals with bulimia
develop a sense of self-control. Common components of cognitive-behavioral treatment involve encouraging the consumption of three
or more balanced meals a day, reducing rigid food rules and body image concerns, identifying triggers for bingeing, and developing
strategies for coping with emotional distress. Adding exposure and response prevention procedures to therapy (i.e., exposure to cues
associated with bingeing and prevention of purging following a binge) appears to improve long-term outcomes for individuals with
bulimia nervosa). Antidepressant medications such as selective serotonin reuptake inhibitors are sometimes helpful in treating bulimia.

Treatment of Binge-Eating Disorder

In general, treatment follows two phases. First, factors that trigger overeating are determined; then clients learn strategies to reduce
eating binges.

Medications are sometimes effective in reducing or stopping binge eating; however, psychological interventions tend to produce the
best long-term results.

Although cognitive-behavioral therapy (CBT) can produce significant reductions in binge eating, it has less effect on weight
reduction. A newer form of CBT incorporates ways to address interpersonal difficulties and strategies for regulating negative emotions
that can trigger bingeing and purging, a focus similar to the emotional regulation and distress tolerance skills taught in dialectical
behavior therapy.

SYMPTOMS OF SCHIZOPHRENIA SPECTRUM DISORDER

Positive Symptoms

Positive symptoms associated with schizophrenia spectrum disorders involve delusions, hallucinations, disordered thinking,
incoherent communication, and bizarre behavior. These symptoms can range in severity, and persist or fluctuate. In the case above,
Many people with positive symptoms do not understand that their symptoms are the result of mental illness. Failing to recognize
symptoms of one’s own mental illness, or having poor insight, is most common among those with severe symptoms and those who
had difficulties functioning before the onset of their mental illness.

Delusions

Many individuals with psychotic disorders experience delusions. Delusions are false personal beliefs that are firmly and consistently
held despite disconfirming evidence or logic. Individuals experiencing delusions are not able to distinguish between their private
thoughts and external reality. Lack of insight is particularly common among individuals experiencing delusions; in other words, they
do not recognize that their thoughts or beliefs are extremely illogical.

Individuals with schizophrenia spectrum disorders experience a variety of delusional themes:

 Delusions of grandeur. Individuals may believe they are someone famous or powerful (from the present or the past).
 Delusions of control. Individuals may believe that other people, animals, or objects are trying to influence or take control of
them.
 Delusions of thought broadcasting. Individuals may believe that others can hear their thoughts.
 Delusions of persecution. Individuals may believe that others are plotting against, mistreating, or even trying to kill them.
 Delusions of reference. Individuals may believe they are the center of attention or that all happenings revolve around them.
 Delusions of thought withdrawal. Individuals may believe that someone or something is removing thoughts from their
mind.

A common delusion involves paranoid ideation, or suspiciousness about the actions or motives of others as illustrated in the
following case.

Hallucinations

A hallucination is a perception of a nonexistent or absent stimuli; it may involve a single sensory modality or a combination of
modalities, including hearing (auditory hallucination), seeing (visual hallucination), smelling (olfactory hallucination), touching
(tactile hallucination), or tasting (gustatory hallucination). Auditory hallucinations are most common; the voices can be malicious or
benevolent or involve both qualities.

Some individuals with hallucinations recognize that their perceptions are not real and try their best to “look normal” even when the
hallucinations are occurring. Hallucinations are particularly distressing when they involve dominant, insulting voices. Negative
hallucinations can be quite unsettling; those who hear negative voices often try to cope by ignoring them or by keeping busy with
other activities. Auditory hallucinations often seem very real to the individual experiencing them and sometimes involve relationship-
like qualities.

Cognitive Symptoms

Disordered thinking, communication, and speech are common characteristics of schizophrenia. Individuals experiencing these
symptoms may have difficulty focusing on one topic, speak in an unintelligible manner, or reply tangentially to questions. Loosening
of associations, also referred to as cognitive slippage, is another characteristic of disorganized thinking. This involves a continual
shifting from topic to topic without any apparent logical or meaningful connection between thoughts. This may occur when cognitive
confusion makes it difficult for the person to pay attention or respond to appropriate cues during conversation. Disorganized
communication often involves the kind of incoherent speech or bizarre and idiosyncratic responses.

People with schizophrenia may also demonstrate difficulty with abstractions and thus respond to words or phrases in a very concrete
manner. For example, a saying such as “a rolling stone gathers no moss” might be interpreted as meaning no more than “moss cannot
grow on a rock that is rolling.”

Individuals with schizophrenia also show overinclusiveness, or abnormal categorization in their thinking. For example, when asked to
sort cards with pictures of animals, fruit, clothing, and body parts into piles of things that go together, one man placed an ear, apple,
pineapple, pear, strawberry, lips, orange, and banana together in a category he named “something to eat.” When asked the reason for
including the ear and lips in the “something to eat” category, he explained that an ear allows you to hear a person asking for fruit, and
lips allow you to ask for and eat fruit.

Cognitive symptoms of schizophrenia also include problems with attention and memory and difficulty making decisions. As compared
with healthy controls, individuals with schizophrenia have moderately severe to severe cognitive impairment, as evidenced by poor
executive functioning— deficits in the ability to sustain attention, to absorb and interpret information and to make decisions based on
recently learned information. Difficulties with social-cognitive skills, social perspective taking, and understanding one’s own and
other’s thoughts, motivations, and emotions are also common. Cognitive symptoms are generally present even before the onset of the
first psychotic episode, tend to persist even with treatment, and are found (to a lesser degree) among nonpsychotic relatives of
individuals with schizophrenia.

Grossly Disorganized or Abnormal Psychomotor Behavior

The symptoms of schizophrenia that involve motor functions can be quite bizarre and extremely distressing to family members. Some
individuals with schizophrenia experience an episode of catatonia, a condition involving extremes in activity level (either unusually
high or unusually low), peculiar body movements or postures, strange gestures and grimaces, or a combination of these. People with
excited catatonia have very disorganized behavior and may be very agitated, hyperactive, and lack inhibitions. They may talk and
shout constantly, moving or running until they drop from exhaustion. They may appear to be acting “silly” and display loud,
inappropriate laughter. They sleep little and are continually on the go. Their behavior can become dangerous and involve violent acts.

In sharp contrast, people experiencing withdrawn catatonia are extremely unresponsive. They show prolonged periods of stupor and
mutism, despite an awareness of all that is going on around them. Some may adopt and maintain strange postures and refuse to move
or change position. They may stand for hours at a time, perhaps with one arm stretched out to the side. They also may lie on the floor
or sit awkwardly on a chair, staring, aware of what is occurring but not responding or moving. If someone attempts to change the
person’s position, they may persistently resist. Others exhibit a waxy flexibility, allowing their bodies to be arranged in almost any
position and then remaining in that position for long periods. The extreme withdrawal associated with a catatonic episode can be life-
threatening when it results in inadequate food intake.

Negative Symptoms

Negative symptoms of schizophrenia are associated with an inability or decreased ability to initiate actions or speech, express
emotions, or feel pleasure. Such symptoms include:

 avolition—an inability to initiate or persist in goal-directed behavior;

 alogia—a lack of meaningful speech;
 asociality—minimal interest in social relationships;
 anhedonia—reduced ability to experience pleasure from positive events; and
 diminished emotional expression—reduced display of emotion involving facial expressions, voice intonation, or gestures in
situations in which emotional reactions are expected.

DIFFERENT SCHIZOPHRENIA SPECTRUM DISORDERS

Delusional Disorder

Diagnostic Criteria

A. The presence of one (or more) delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the
delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously
bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better
explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

Specify whether:

 Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the
individual.
 Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but
unrecognized) talent or insight or having made some important discovery.
 Jeaious type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is
unfaithful.
 Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that he or she
is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed
in the pursuit of long-term goals.
 Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
  Mixed type: This subtype applies when no one delusional theme predominates.
 Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described
in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).

Brief Psychotic Disorder

Diagnostic Criteria

A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior. Note: Do not include a symptom if it is a culturally sanctioned response.

B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of
functioning.

C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic
disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.

Specify if:

With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances in the individual’s culture.

Without marited stressor(s): If symptoms do not occur in response to events that, singly or together, would be markedly stressful to
almost anyone in similar circumstances in the individual’s culture. With postpartum onset: If onset is during pregnancy or within 4
weeks postpartum.

Specify if:

With catatonia

Schizophreniform Disorder

Diagnostic Criteria

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully
treated). At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).

B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for
recovery, it should be qualified as “provisional.”

C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 ) no major
depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred
during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the
illness.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition.

Specify if:

With good prognostic features: This specifier requires the presence of at least two of the following features: onset of prominent
psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity: good
premorbid social and occupational functioning; and absence of blunted or flat affect. Without good prognostic features: This
specifier is applied if two or more of the above features have not been present.

Specify if:

With catatonia

Schizoaffective Disorder

Diagnostic Criteria

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with
Criterion A of schizophrenia.

Note: The major depressive episode must include Criterion A1 : Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime
duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual
portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Specify whether:

 Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.
 Depressive type: This subtype applies if only major depressive episodes are part of the presentation.

Specify if: With catatonia

Schizophrenia

Diagnostic Criteria

A. Two (or more) of the following, each present for a significant portion of time during a 1 -month period (or less if successfully
treated). At least one of these must be (1 ), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent
derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional
expression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as
work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms
(or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or
by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 ) no major
depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred
during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the
illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of
schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are
also present for at least 1 month (or less if successfully treated).

Substance/Medication-Induced Psychotic Disorder

Diagnostic Criteria

A. Presence of one or both of the following symptoms: 1. Delusions. 2. Hallucinations.

B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a
medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a psychotic disorder that is not substance/ medication-induced. Such evidence of an
independent psychotic disorder could include the following: The symptoms preceded the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication:
or there is other evidence of an independent non-substance/medication-induced psychotic disorder (e.g., a history of recurrent non-
substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the
symptoms in Criterion A predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

ETIOLOGY

Biological Dimension

 Genetics and heredity play an important role in the development of schizophrenia.

 The disorder is now understood to result from interactions among a large number of different genes.
 Closer blood relatives of individuals diagnosed with schizophrenia run a greater risk of developing the disorder
 An individual has a 16% chance of developing schizophrenia if his/her parent has this disorder and his cousin has a 4%
chance of developing schizophrenia.
 Monozygotic (identical) twins: If one twin receives the diagnosis of schizophrenia, the risk of the second twin developing the
disorder is less than 50 percent.

Neurostructures

How do genes produce a vulnerability to schizophrenia?

Individuals with schizophrenia have decreased volume in the cortex and other areas of the brain.

Ventricular enlargement may be an early indication of an increased susceptibility to schizophrenia

How might decreased cortex volume and enlarged ventricles predispose someone to develop schizophrenia?

 These structural characteristics may result in atypical or weak connectivity between the various brain regions, leading to
reductions in integrative functioning in the brain and impaired cognitive processing. Thus, ineffective communication
between different brain regions may lead to the cognitive symptoms (e.g., disorganized speech and impairment in memory,
decision making, and problem solving), negative symptoms (e.g., lack of drive or initiative), and positive symptoms (e.g.,
delusions and hallucinations) that are found in schizophrenia.
 In addition, some of the abnormalities found in the brains of individuals with schizophrenia may result from the use of
antipsychotic medication rather than the disorder itself.

Biochemical Influences

Abnormalities in certain neurotransmitters including dopamine, serotonin, GABA, and glutamate have also been linked to
schizophrenia. According to the dopamine hypothesis, schizophrenia may result from excess dopamine activity in certain areas of the
brain.

The use of cocaine, amphetamines, alcohol, and especially cannabis appears to increase the chances of developing a psychotic
disorder. Methamphetamine use may result in a fivefold increase in the likelihood of psychotic symptoms during intoxication. When
distressing psychotic symptoms such as delusions or hallucinations develop during substance use or intoxication, a diagnosis of
substance/medication-induced psychotic disorder may be appropriate. The effects of cannabis occurs in a dose-dependent manner—
the higher the intake of cannabis, the greater the likelihood of psychotic symptoms.

Although the prevalence of schizophrenia is roughly equal between men and women, the age of onset is earlier in males than in
females. Later age of onset found in women is due to the protective effects of estrogen, which diminish after menopause.
  Levels of estrogen also affect the availability of dopamine, which may influence cognitive functions such as working
memory
 Estrogen may protect against psychotic symptoms

Psychological Dimension

Individuals who develop schizophrenia have certain cognitive attributes, dysfunctional beliefs, and interpersonal functioning that may
predispose them to the development of psychotic symptoms. Among healthy adolescents, poorer interpersonal functioning during
adolescence predicted bizarre experiences, perceptual abnormalities, and persecutory ideation.

These communication problems and the lack of insight that frequently occurs with schizophrenia may result, in part, from deficits in
the theory of mind—the ability to recognize that others have emotions, beliefs, and desires that may be different from one’s own.
Thus, individuals with schizophrenia may operate based on their own perspectives without understanding that others have their own
viewpoint.

Early cognitive deficits are also associated with schizophrenia.

 Early behavioral disturbances and cognitive and language deficits were evident in some individuals diagnosed with
schizophrenia.
 Low cognitive ability test scores in childhood and adolescence predicted the presence of psychotic-like experiences and
clinically significant psychotic symptoms in middle age; the low scores may represent early evidence of abnormalities in
neural development.
 A decline in verbal ability between ages 13 and 18 was associated with an increased risk of developing a psychotic disorder.
These cognitive decrements may be an indication of brain abnormalities that result in less “cognitive reserve” and reduced
opportunity for the brain to bounce back from neurological insult.

Certain personal cognitive processes involving misattributions or negative attitudes can lead to or maintain psychotic symptoms such
as delusions.

 Negative symptoms such as limited motivation and restricted affect may be due to individuals’ beliefs that they are worthless
and that their condition is hopeless.
 The combination of low expectancy for pleasure and success combined with low motivation may maintain negative
symptoms.
 An individual’s interpretation of events may be the primary cause of the distress and disability associated with schizophrenia.
 In other words, pessimistic interpretations may produce and maintain negative symptoms.

Social Dimension

Peer victimization and maltreatment during childhood or other significant social stressors may alterneurodevelopment in a manner that
increases susceptibility to schizophrenia.

 Those who experienced maltreatment by an adult or bullying by peers had a higher risk of psychotic symptoms.
 Being in a traumatic accident was associated with only a slightly increased risk of psychotic symptoms.

Individuals with psychosis were 3 times more likely to report severe physical abuse from mothers before 12 years of age than were
individuals without psychosis. In contrast, among adolescents with symptoms that appeared to put them “at imminent risk” for the
onset of psychosis, positive remarks and warmth expressed by caregivers were associated with decreases in negative and disorganized
symptoms and improvement in social functioning.

Expressed emotion (EE), a negative communication pattern found among some relatives of individuals with schizophrenia, has been
associated with higher relapse rates in individuals diagnosed with schizophrenia. EE is determined by a variety of factors, including
critical comments made by relatives; statements of dislike or resentment directed toward the individual with schizophrenia by family
members; and statements reflecting emotional overinvolvement, overconcern, or overprotectiveness with respect to the family member
with schizophrenia.

Possible relationships between high rates of expressed emotion and relapse rates in patients with schizophrenia:

 A high EE environment is stressful and may lead directly to relapse in the family member who has schizophrenia
 An individual who is more severely ill has a greater chance of relapse and may cause more negative or high EE
communication patterns in relatives.
  The effects of EE and illness are bidirectional: Odd behaviors or symptoms of schizophrenia may increase the likelihood that
family members criticize, overprotect, or react to the symptoms with frustration, which in turn produces increases in
psychotic symptoms.

Sociocultural Dimension

Social adversities, when combined with other risk factors, appear to produce a threefold increase in the risk of developing
schizophrenia compared to children not exposed to adversities.

Residing in a neighborhood or community with others of the same ethnic background may serve as a buffer to social adversity and
reduce risk of developing psychotic symptoms.

The stress of migration and experiences of discrimination as a member of a visible minority may act as additional stressors in
predisposed individuals. Although we do not know the exact relationship between social stress and increased risk of schizophrenia,
one hypothesis points to the excess dopamine release that occurs in response to chronic stress.

TREATMENT

Antipsychotic Medications

Antipsychotic medication can reduce intensity of symptoms; second, dosage levels should be carefully monitored; and third, side
effects can occur as a result of medication and may affect a person’s willingness to take prescribed medications. Conventional and
atypical antipsychotics can effectively reduce the severity of the positive symptoms of schizophrenia, such as hallucinations,
delusions, bizarre speech, and disordered thought.

 Conventional antipsychotic medications (such as chlorpromazine/Thorazine or haloperidol/Haldol) have dopaminergic

receptor–blocking capabilities (i.e., they reduce dopamine levels), a factor that led to the dopamine hypothesis of
schizophrenia.
 The newer atypical antipsychotics (such as risperidone/Risperdal, olanzapine/ Zyprexa, quetiapine/Seroquel,
aripiprazole/Abilify, and lurasidone/Latuda) act on both dopamine and serotonin receptors.

Many individuals treated with antipsychotic medications develop extrapyramidal symptoms, which include parkinsonism (muscle
tremors, shakiness, and immobility), dystonia (involuntary muscle contractions involving the limbs and tongue), akathisia (motor
restlessness), and neuroleptic malignant syndrome (muscle rigidity and autonomic instability, which can be fatal if untreated). Other
symptoms may involve the loss of facial expression, shuffling gait, tremors of the hand, rigidity of the body, and poor balance.
Although many symptoms are reversible once medication is stopped, some symptoms (e.g., involuntary movements) can be
permanent.

The most beneficial treatment for schizophrenia is a combination of antipsychotic medication and psychotherapy, according to most
clinicians today.

Psychosocial Therapy

Psychotherapeutic work with individuals with schizophrenia often focuses on the direct teaching of social skills, including
conversational skills. It is beneficial when communication skills are taught directly and practiced in role-play situations.

Inpatient Approaches

Both milieu therapy and behavioral therapy can be beneficial for individuals with schizophrenia receiving inpatient treatment. In
milieu therapy, the hospital environment operates as a community within which those with schizophrenia exercise a wide range of
responsibilities and help make decisions. Psychosocial skills training focuses on increasing appropriate self-care behaviors,
conversational skills, and job skills. Undesirable behaviors such as “crazy talk” or social isolation are decreased through reinforcement
and modeling techniques. These approaches have been effective in helping many people with schizophrenia achieve independent
living. 

Cognitive-Behavioral Therapy

Therapists teach coping skills that allow clients to manage their positive and negative symptoms, as well as the cognitive challenges
associated with schizophrenia. Cognitive-behavioral treatment to address concerns such as these often includes the following steps.

 Engagement. The therapist explains the therapy and works to foster a safe and collaborative method of looking at causes of
distress, drawing out the client’s understanding of stressors and ways of coping.
  Assessment. Clients are encouraged to discuss their fears and anxieties; the therapist shares information about how symptoms
are formed and maintained.
 Identification of negative beliefs. The therapist explains to the client the link between personal beliefs and emotional distress,
and the ways that beliefs such as “Nobody will like me if I tell them about my voices” can be disputed and changed to “I
can’t demand that everyone like me.
 Normalization. The therapist works with the client to normalize and decatastrophize the psychotic experiences.
 Collaborative analysis of symptoms. Evidence for and against the maladaptive beliefs is discussed, combined with
information about how beliefs are maintained through cognitive distortions or inferences.
 Development of alternative explanations. The therapist helps the client develop alternatives to previous maladaptive
assumptions, using the client’s ideas whenever possible.

More recently, instead of trying to eliminate or combat hallucinations, therapists teach clients to accept them in a nonjudgmental
manner. In mindfulness training, clients learn to let go of angry or fearful responses to psychotic symptoms; instead, they are taught to
let the psychotic symptoms come into consciousness without reacting (e.g., just noticing the voices or thoughts rather than believing
them or acting on them; accepting them even if one does not like them). This process enhances feelings of self-control and
significantly reduces negative emotions.

A form of cognitive therapy, integrated psychological therapy (IPT), has also produced promising results. IPT specifically targets
deficits found in individuals with schizophrenia, such as basic impairments in neurocognition (e.g., attention, verbal memory,
cognitive flexibility, concept formation), deficits in social cognition (e.g., social-emotional perception, emotional expression),
interpersonal communication (e.g., verbal fluency and executive functioning), and problem-solving skills.

Interventions Focusing on Family Communication and Education

Family intervention programs have not only reduced relapse rates but have also lowered the cost of care. They have been beneficial
for families with and without negative communication patterns. Most programs include the following components:

 normalizing the family experience;

 demonstrating concern, empathy, and sympathy to all family members;
 educating family members about schizophrenia;
 avoiding blaming the family or pathologizing their coping efforts;
 identifying the strengths and competencies of the client and family members;
 developing skills in solving problems and managing stress;
 teaching family members to cope with the symptoms of mental illness and its repercussions on the family; and
 strengthening the communication skills of all family members.

Family approaches and social skills training are much more effective in preventing relapse than drug treatment alone. Combining
cognitive-behavioral strategies, family counseling, and social skills training seems to produce the most positive results. The use of
medication combined with psychosocial interventions has provided hope for many individuals with schizophrenia.

SEXUAL DYSFUNCTIONS

Sexual dysfunctions include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder,
genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature (early) ejaculation, substance/medication
induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction. Sexual dysfunctions are a
heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond
sexually or to experience sexual pleasure. An individual may have several sexual dysfunctions at the same time. In such cases, all of
the dysfunctions should be diagnosed.

For each disorder:

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active.
 Acquired: The disturbance began after a period of relatively normal sexual function.
 Specify whether:
 Generalized: Not limited to certain types of stimulation, situations, or partners.
 Situational: Only occurs with certain types of stimulation, situations, or partners.
 Specify current severity:
 Mild: Evidence of mild distress over the symptoms in Criterion A.
  Moderate: Evidence of moderate distress over the symptoms in Criterion A.
 Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

The Sexual Response Cycle

1. The appetitive phase is characterized by a person’s interest in sexual activity. The person begins to have thoughts or
fantasies about sex, feels attracted to another person, or daydreams about sex.
2. The arousal phase, which may follow or precede the appetitive phase, involves heightened and intensified arousal resulting
from specific and direct sexual stimulation. In a male, blood flow increases in the penis, resulting in an erection. In a female,
the breasts swell, nipples become erect, blood engorges the genital region, and the clitoris expands.
3. The orgasm phase is characterized by involuntary muscular contractions throughout the body and the eventual release of
sexual tension. In males, muscles at the base of the penis contract, propelling semen through the penis. In females, the outer
third of the vagina contracts rhythmically.
4. The resolution phase is characterized by relaxation of the body after orgasm. Males enter a refractory period during which
they are unresponsive to sexual stimulation. However, females are capable of multiple orgasms with continued stimulation.

Delayed Ejaculation

A. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered
sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay:

1. Marked delay in ejaculation.

2. Marked infrequency or absence of ejaculation.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or
other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Erectile Disorder

A. At least one of the three following symptoms must be experienced on almost all or all (approximately 75%-100%) occasions of
sexual activity (in identified situational contexts or, if generalized, in all contexts):

1. Marked difficulty in obtaining an erection during sexual activity.

2. Marked difficulty in maintaining an erection until the completion of sexual activity.
3. Marked decrease in erectile rigidity.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or
other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Female Orgasmic Disorder

A. Presence of either of the following symptoms and experienced on almost all or all (approximately 75%-100%) occasions of sexual
activity (in identified situational contexts or, if generalized, in all contexts):

1. Marked delay in, marked infrequency of, or absence of orgasm.

2. Markedly reduced intensity of orgasmic sensations.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress
(e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical
condition

Female Sexual Interest/Arousal Disorder

A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:

1. Absent/reduced interest in sexual activity.

2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate.
4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual
encounters (in identified situational contexts or, if generalized, in all contexts).
5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual).
6. Absent/reduced genital or non-genital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual
encounters (in identified situational contexts or, if generalized, in all contexts).

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a non-sexuai mental disorder or as a consequence of severe relationship distress
(e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical
condition.

Genito-Pelvic Pain/Penetration Disorder

A. Persistent or recurrent difficulties with one (or more) of the following:

1. Vaginal penetration during intercourse.

2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better
explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other
significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Male Hypoactive Sexual Desire Disorder

A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of
deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and
sociocultural contexts of the individual’s life.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better
explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not
attributable to the effects of a substance/medication or another medical condition.

Premature (Early) Ejaculation

A. persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following
vaginal penetration and before the individual wishes it.

Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities,
specific duration criteria have not been established for these activities.

B. The symptom in Criterion A must have been present for at least 6 months and must be experienced on almost all or all
(approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts).

C. The symptom in Criterion A causes clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or
other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Etiological Considerations

Biological Dimensions
Environmental and relationship variables influence sexual dysfunction to a greater degree than biological factors. However, lower
levels of testosterone and higher levels of estrogens such as prolactin have been associated with lower sexual interest in both men
and women and with erectile difficulties in men. Not surprisingly, drugs that suppress testosterone appear to decrease sexual desire in
men. Conversely, the administration of androgens (hormones such as testosterone, which promotes male sexual characteristics) is
associated with reports of increased sexual desire in both men and women. The relationship between hormones and sexual behavior,
however, is complex and difficult to understand. Many people with reduced sexual desire have normal testosterone levels.

Medications that treat medical conditions such as hypertension, ulcers, glaucoma, allergies, and seizures can also affect sex drive. Use
of drugs, alcohol use and antidepressant medications are also associated with sexual dysfunctions, as are certain medical conditions.
Some researchers believe that alcohol abuse is the leading cause of both erectile disorders and premature ejaculation. However, not
everyone who takes antihypertensive or antidepressant medications, consumes alcohol, or is ill has a sexual dysfunction. In some
people these factors may combine with a predisposing personal history or with current stressors to produce problems in sexual
function.

Penile hypersensitivity to physical stimulation may also influence sexual functioning in men. In other words, for some men, premature
ejaculation may be physiological. Men who ejaculate early may be “hardwired” to have a sensitive and more easily triggered sensory
and response system.

Psychological Dimensions

Sexual dysfunctions may result from psychological factors alone or from a combination of psychological and biological factors.
Psychological causes for sexual dysfunctions include predisposing or historical factors, as well as more current problems and
concerns. Stressful situations and the presence of anxiety disorders tend to inhibit sexual responding and functioning in both women
and men. Guilt, anger, or resentment toward a partner can also interfere with sexual performance.

Apprehension about sexual functioning plays a key role in erectile disorder, especially for men who report that sex is very important to
them or to their partner. Men with psychological erectile dysfunction often report anxiety over sexual overtures, including a fear of
failing sexually or being seen as sexually inferior, as well as anxiety over the size of their genitals. Performance anxiety and taking on
a “spectator role” can exacerbate erectile dysfunction.

Previous and current sexual experiences may influence a man’s sexual expectations and responses in other ways. Men with early
ejaculation, for example, report having a lower frequency of sexual intercourse than those without this condition. For men with early
ejaculation, having fewer sexual experiences may predispose them to greater excitement and arousal. In addition, they may have fewer
opportunities to learn how to delay an ejaculatory response. It is important to note that one successful form of sexual therapy for
premature ejaculation teaches men to attend more to somatic feedback and to adjust their thoughts and behaviors to delay an
impending ejaculation.

Situational anxiety or emotional factors resulting from sexual abuse or other negative childhood sexual experiences often interfere
with sexual functioning in women. Other factors associated with sexual dysfunction in women include: having a sexually
inexperienced or dysfunctional partner; fear of being an undesirable sexual partner; worry that they will never be able to attain
orgasm; concern about pregnancy or sexually transmitted disease; an inability to accept the partner, either emotionally or physically;
and misinformation or ignorance about sexuality or sexual techniques.

Negative thoughts (“my partner doesn’t really care about me”) and dysfunctional beliefs (“sexual desire is sinful”) also play a role in
female sexual dysfunction. Such thoughts and beliefs are associated with sexual interest/arousal and orgasmic difficulties, as well as
painful intercourse.

Focusing on one’s body can also influence the sexual responsiveness of women. Women who are self consciousness about their
attractiveness or who focus excessively on their bodies experience more difficulty with sexual arousal.

Social Dimension

Social upbringing and current relationships both influence sexual functioning. The attitudes parents display toward sex and their
expression of affection toward each other can affect their children’s attitudes. A strict religious upbringing is associated with sexual
dysfunction in both men and women. Traumatic sexual experiences involving rape or sexual abuse during childhood or adolescence
are also factors to consider. Women who have been raped or who were subjected to molestation as children may find it difficult to
trust and establish intimacy and exhibit various sexual dysfunctions.

Relationship issues are often at the forefront of sexual disorders. Marital satisfaction, for example, is associated with greater levels of
sexual arousal and sexual frequency between partners, whereas relationship dissatisfaction can lead to sexual interest and arousal
disorders. Specifically, sexual satisfaction is increased when relationships are caring, warm, and affectionate and when couples
communicate openly about sex and sexual activities. It is important to note that men and women may define sexual satisfaction
differently. For many women, for example, closeness to a partner is more important than the frequency of orgasms or the intensity of
sexual arousal.

Sociocultural Dimension

Cultural scripts about sex result from gender role socialization. It is through this process that we learn social and cultural beliefs and
expectations regarding sexual behavior. Examples: For men (the bigger the sex organ, the better); For women (men are only after one
thing) Because these scripts often guide our sexual attitudes and behaviors, they can exert a major influence on sexual functioning.

Sexual orientation is also a sociocultural influence that may affect sexual responsiveness and sexual dysfunction in gay men and
lesbians. Lesbians and gay men must also deal with societal or internalized homophobia, which may inhibit openly expressing
affection toward one another. Finally, gay men are forced to deal with the association between sexual activity and HIV infection.
These broader contextual issues may create diminished sexual interest or desire, sexual aversion, or negative feelings toward sexual
activity.

TREATMENT OF SEXUAL DYSFUNCTION

Biological Interventions

Biological interventions may include hormone replacement, special medications, or mechanical means to improve sexual functioning.

Medications are also used to treat erectile disorder. One form of medical treatment for erectile dysfunction involves injecting
medication (Alprostadil) into the penis or inserting a suppository with the medication into the opening at the tip of the penis.

Oral medications such as Viagra, Levitra, and Cialis are frequently used to treat erectile disorder. Although biological treatments are
increasingly important in treating sexual dysfunctions, they deemphasize the role of psychological and social factors. Because
relationship, sociocultural, and psychological factors are often involved, treatment needs to include more than medications or other
biological means to boost sexual interest or desire.

Psychological Treatment Approaches

Psychological treatment is recommended when relationship or psychological issues, including prior traumatic experiences, play a role
in sexual dysfunction. General psychological treatment approaches include the following components

 Education. The therapist replaces sexual myths and misconceptions with accurate information about sexual anatomy and
functioning.
 Anxiety reduction. The therapist uses procedures such as desensitization or graded approaches to keep anxiety at a minimum.
The therapist explains that constantly observing and evaluating one’s performance can interfere with sexual functioning.
 Maladaptive thoughts and beliefs. The therapist helps the client identify and change negative thoughts and beliefs that
interfere with sexual functioning.
 Structured behavioral exercises. The therapist gives a series of graded tasks that gradually increase the amount of sexual
interaction between the partners. Each partner takes turns touching and being touched over different parts of the body except
for the genital regions. Later the partners fondle the body and genital regions without making demands for sexual arousal or
orgasm. Successful sexual intercourse and orgasm are the final stage of the structured exercises.
 Communication training. The therapist teaches the partners appropriate ways of communicating their sexual wishes to each
other and strategies for effectively resolving relationship conflicts.

In addition to these general psychological treatments, sex therapists can also focus on specific aspects of sexual dysfunction. Some
specific nonmedical treatments for other dysfunctions include:

 Female orgasmic dysfunction. Both structured behavioral exercises and communication training have been successful in
treating sexual arousal disorders in women. Masturbation appears to be the most effective way for women with orgasmic
dysfunction to have an orgasm. The procedure involves education about sexual anatomy, visual and tactile self-exploration,
use of sexual fantasies and images, and masturbation, both individually and with a partner. High success rates are reported
with this procedure, especially for women who have never experienced an orgasm. However, this approach does not
necessarily lead to a woman’s ability to achieve orgasm during sexual intercourse.
 Early ejaculation. In one technique, the partner stimulates the penis until the man feels the sensation of impending
ejaculation. At this point, the partner momentarily stops the stimulation and then continues it again. This pattern is repeated
until the man can tolerate increasingly greater periods of stimulation before ejaculation.
 Vaginismus. The results of treatment for vaginismus have been uniformly positive. The involuntary spasms or closure of the
vaginal muscle can be deconditioned by first training the woman to relax and then inserting successively larger dilators while
she is relaxed.
GENDER DYSPHORIA

Gender Dysphoria in Children

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as
manifested by at least six of the following (one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different
from one’s assigned gender).
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire: or in girls (assigned gender), a
strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine
clothing.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of
rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
7. A strong dislike of one’s sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match
one’s experienced gender.

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of
functioning.

Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as
manifested by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in
young adolescents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s
experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex
characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different
from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of
functioning.

ETIOLOGICAL CONSIDERATIONS

Biological Influences

Biological research suggests that neurohormonal factors and genetics may be involved in the development of a transgender identity. It
does appear that gender orientation can be influenced by a lack or excess of sex hormones.

It is important to note, however, that the limited research in this area makes conclusions about hormonal influences very tentative.
Some researchers believe that gender identity is malleable. For example, most transgender children have normal hormone levels,
raising doubt that biology alone determines masculine and feminine behaviors. Although neurohormonal levels are important, their
degree of influence on gender identity in human beings may be minor. Researchers are also looking into any specific neurological
characteristics associated

with a transgender identity.

Transgender individuals may dissociate (detach) bodily emotion from body image, a possible mechanism for coping with their lifelong
gender incongruence.

Brain alterations in transgender adults—unique patterns that are associated with psychosocial distress and social exclusion.
Psychological and Social Influences

Psychological and social explanations for gender dysphoria must also be viewed with caution. Some researchers have hypothesized
that childhood experiences influence the development of a transgender identity and gender dysphoria. Factors proposed to contribute
to the disorder in boys include parental encouragement of feminine behavior, discouragement of the development of autonomy,
excessive attention and overprotection by the mother, the absence of male role models, a relatively powerless or absent father figure, a
lack of exposure to male playmates, and encouragement to cross-dress.

Psychosocial stressors such as stigma, lack of societal acceptance, or difficulty obtaining adequate health care may play a role in the
distress and impairment associated with gender dysphoria. In fact, the transgender community has been described as the “most
marginalized and underserved population in medicine”.

TREATMENT OF GENDER DYSPHORIA

People with gender dysphoria often decide to pursue gender reassignment therapies, which involve changing their physical
characteristics through medical procedures such as hormone treatment or surgery. Hormone therapy (taking hormones associated with
the perceived gender) as part of gender reassignment has decreased the distress and psychological reactions associated with gender
dysphoria, and has improved the quality of life and sexual functioning in many transgendered individuals.

In addition to hormone therapy, some transgender individuals, choose to have gender reassignment surgeries that change their existing
external genital organs to those of the other gender. For men, the genital surgeries involve altering the penis and scrotum and
constructing female genitalia. The skin of the penis is used in this construction because the nerve endings that are preserved enable the
experience of orgasm. Sexual reassignment for those who are biologically female involves removal of the breasts, and, in some cases,
individuals chose to have surgery to construct an artificial penis.

PARAPHILIC DISORDERS

Paraphilic disorders included in this manual are voyeuristic disorder (spying on others in private activities), exhibitionistic disorder
(exposing the genitals), frotteuristic disorder (touching or rubbing against a nonconsenting individual), sexual masochism disorder
(undergoing humiliation, bondage, or suffering), sexual sadism disorder (inflicting humiliation, bondage, or suffering), pedophilic
disorder (sexual focus on children), fetishistic disorder (using nonliving objects or having a highly specific focus on non-genital body
parts), and transvestic disorder (engaging in sexually arousing cross-dressing).

Voyeuristic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the
process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.

C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.

Exhibitionistic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting
person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.

Specify whether:

 Sexually aroused by exposing genitals to prepubertal children

 Sexually aroused by exposing genitals to physically mature individuals
 Sexually aroused by exposing genitals to prepubertal children and to physically mature individuals

Frotteuristic Disorder
A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person,
as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.

Sexual Masochism Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or
otherwise made to suffer, as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Specify if:

With asphyxiophilia: If the individual engages in the practice of achieving sexual arousal related to restriction of breathing.

Sexual Sadism Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another
person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.

Pedophilic Disorder

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual
activity with a prepubescent child or children (generally age 13 years or younger).

B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A.

Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.

Specify whether:

 Exclusive type (attracted only to children)

 Nonexclusive type

Specify if:

 Sexually attracted to males

 Sexually attracted to females
 Sexually attracted to both
 Specify if: Limited to incest

Fetishistic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific
focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically
designed for the puφose of tactile genital stimulation (e.g., vibrator).

Specify:

 Body part(s)
 Nonliving object(s)
 Other
Transvestic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from crossdressing, as manifested by fantasies, urges, or
behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Specify if:

 With fetishism: If sexually aroused by fabrics, materials, or garments.

 With autogynephiiia: If sexually aroused by thoughts or images of self as female.

ETIOLOGY AND TREATMENT

Although it is likely that multiple factors contribute to the development of paraphilic disorders, we still have much to learn about
paraphilias. Investigators have attempted to find genetic, neurohormonal, and brain anomalies that might be associated with paraphilic
disorders. Some of the research findings conflict with each other; others need replication and confirmation.

There is evidence that some men may be biologically predisposed to some paraphilias such as pedophilic disorder, as pedophiles have
been found to have neurological abnormalities, including less white matter. Even if biological factors are found to play a role in the
development of paraphilias, psychological factors also contribute in important ways.

Among early attempts to explain paraphilic disorders, psychodynamic theorists proposed that these sexual behaviors represent
unconscious conflicts that began in early childhood. Castration anxiety in men, for example, is hypothesized to be an important
etiological factor underlying transvestic disorder, fetishistic disorder, exhibitionistic disorder, sexual sadism disorder, and sexual
masochism disorder. The psychodynamic treatment of sexual deviations involves helping the client understand the relationship
between the sexual behavior and the unconscious conflicts that produce it.

Research looking into the characteristics of sex offenders has provided insight into early psychosocial variables that may influence
their behavior. For example, juvenile sex offenders are more likely to have unusual sexual interests, low self-esteem, and anxiety.
Additionally, they are more likely to have early exposure to sex, sexual violence, pornography or a history of being sexually
victimized.

Learning theorists stress the importance of early conditioning experiences in the etiology of paraphilias. In other words, paraphilias
may result from accidental associations between sexual arousal and exposure to certain situations, events, acts, or objects.

Paraphilias often develop during adolescence when sexual interest and arousal are particularly susceptible to conditioning.
Additionally, if an adolescent masturbates while engaged in sexually deviant fantasies, the conditioning may hamper the development
of normal sexual patterns. Behavioral approaches to treating sexual deviations have generally involved one or more of the following
elements: (a) weakening or eliminating the sexually inappropriate behaviors through processes such as extinction or aversive
conditioning; (b) acquiring or strengthening sexually appropriate behaviors; and (c) developing appropriate social skills. The
following case study illustrates this approach.

One of the more unique treatments for exhibitionism involves aversive behavior rehearsal in which shame or humiliation is the
aversive stimulus. The technique requires that the person exhibit himself in his usual manner to a preselected audience of women.
During the exhibiting act, the person must verbalize a conversation between himself and his penis. He must talk about what he is
feeling emotionally and physically and must explain his fantasies regarding what he supposes the female observers are thinking about
him. One premise of this technique is that exhibitionism often occurs during a state similar to hypnosis, when the exhibitionist’s
fantasies are extremely active and his judgment is impaired. This method forces him to experience and examine his actions while
being fully aware of what he is doing.

The results of behavioral treatments are generally positive, although the majority of research involves single participants rather than
group experimental designs. Additionally, in many studies several different behavioral techniques are incorporated, making it difficult
to evaluate specific techniques. In a recent review of research involving treatment for those who sexually abuse children, the results
were discouraging—neither psychological nor pharmacological interventions had much effect on reoffending.
TYPICAL SIGNS AND SYMPTOMS OF MENTAL DISORDER

Classification according to Mental State Examination

A. Consciousness- the state of being awareof and responsive to one’s surrounding. Disturbances of consciousness are mostoften
associated with brain pathology.
1. Clouding Consciousness- The personis not fully awake, alertand oriented. Occurs indelirium, dementia, andcognitive
disorder.The person is drowsy anddoes not react completelyto stimuli.There is disturbance ofattention,
concentration,memory, orientation andthinking.
2. Delirium -Acutereversible mentaldisordercharacterized byconfusion andsome impairmentof
consciousness;Generallyassociated withhallucination orfear.
3. Disorientation - Confusion; impairment of awareness of time, place and person (the position of the self in relation to other
persons).
4. Stupor- State of decreased reactivity to stimuli; indicates a condition of partial coma or semi coma. Patient who is mute and
immobile (akinetic mutism) but fully conscious. Seen in psychotic depression, catatonic states.

B. Attention- the amount of effort exerted in focusing on certain portions of an experience; ability to sustain a focus on one
activity; ability to concentrate.
1. Distractibility- Inability to focus one’s attention; the patient does not respond to the task at hand but attends to irrelevant
phenomena in the environment.
2. Selective Inattention-Here the patient blocks out anxietyprovoking stimuli.
3. Hypervigilance- excessive attention and focus on all internal and external, usually secondary to delusional or paranoid states.

C. Emotions- complex feeling state with psychic, somatic and behavioral components.

Affect- observed expression of emotion, possibly inconsistent with patient’s description of emotion.

1. Appropriate Affect- Emotional tone in harmony with the accompanying idea, thought, or speech
 2. Inappropriate affect- Emotional tone out of harmony with the idea, thought, or speech accompanying it.
3. Blunted affect- Disturbance of affect manifested by a severe reduction in the intensity of externalized feeling tone.
4. Restricted or Constricted Affect- Reduction in intensity of feeling tone, less severe than blunted affect but clearly reduced.
5. Flat Affect- Absence or near absence of any signs of affective expression.

Mood- Pervasive and sustained feeling tone that is experienced internally and that, in the extreme, can markedly influence virtually all
aspects of a person’s behavior and perception of the world. Distinguished from affect, the external expression of the internal feeling
tone.

1. Euthymic Mood- Normal Range of mood, implying absence of depressed or elevated mood.
2. Expansive Mood- Expression of feelings without restraint, frequently with an overestimation of their significance or
importance. Seen in mania, grandiose delusional disorder.
3. Irritable Mood- State in which a person is easily annoyed and provoked to anger.
4. Mood Swings- Fluctuation of a person’s emotional feeling tone between periods of elation and periods of depression.
5. Elevated Mood- Air of confidence and enjoyment; a mood more cheerful than normal but not necessarily pathological.
6. Euphoria - Exaggerated feeling of well -being that is inappropriate to real events. Can occur with drugs such as opiates,
amphetamines and alcohol.
7. Depression- Characterized by feeling of sadness, loneliness, despair, low self-esteem etc. The term refers to either a mood
that is so characterized or a mood disorder.
8. Anhedonia- Loss of interest in and withdrawal from all regular and pleasurable activities. Often associated with depression
9. Alexithymia- Inability or difficulty in describing or being aware of one’s emotions or moods.
10. Mania- Mood state characterized by elation; agitation, hyperactivity, hypersexuality, and accelerated thinking and speaking
(flight of ideas).
11. La belle Indifference Inappropriate attitude of calm or lack of concern about one’s disability. May be seen in patients with
conversion disorder

Other Emotions

1. Anxiety- Vague apprehension caused by anticipation of danger which may be internal or external.
2. Free Floating Anxiety- Severe, pervasive, generalized anxiety that is not attached to any particular idea, object, or event.
3. FearUnpleasurable- emotional state consisting of psychophysiological changes in response to a realistic threat or danger.
4. Agitation- Severe anxiety associated with motor restlessness
5. Ambivalence- Coexistence of two opposing impulses toward the same thing in the same person at the same time.
6. Abreaction- Emotional release or discharge after recalling a painful experience.

Physiological Disturbances Associated withMood

1. Anorexia-loss or decrease in appetite

2. Hyperphagia- Exaggerated Increase inappetite
3. Insomnia- Lack or diminished ability tosleep
4. Diurnal Variation-Mood is regularly worston the morning, immediately afterawakening and improves as the dayprogresses.
5. Diminished Libido- Decreased sexualinterest
6. Fatigue- a feeling of weariness, sleepiness or irritability after aperiod of mental or bodily activity.
7. Pica- craving and eating non-food substance
8. Pseudocyesis-rare condition inwhich non-pregnant patient has the signs and symptoms of pregnancy. “False pregnancy”.
9. Bulimia-Insatiable and gluttonous eating but induces self-vomiting after.

D. Thinking- goal-directed flow of ideassymbols and associations initiated by a problemor task and leading toward reality-
oriented conclusions.

Forms- the way in which a person put together ideas and associations

Disturbances in Form of thought

Formal Thought Disorder- Disturbance in the form of thoughtrather than the content of thought;thinking characterized by
loosenedassociations.

1. Neologism- New word or phrase whose derivationcannot be understood; combining syllables ofother words. (e.g.,
kotakomokpis;takotakosaipis at lamok).
2. Word Salad- Incoherent, essentiallyincomprehensible mixture of wordsand phrases commonly seen in faradvanced cases of
schizophrenia.(e.g., “salamat ng takip ng perangmgahayop ng coke”)
 3. Circumstantiality- Indirect speech that is delayed in reaching the point but eventually gets from original point to desired goal.
(e.g. When asked about a bruise on her arm, the patient recounts everything else that happened that same day before
explaining how she was injured.)
4. Incoherence- Communication that is disconnected, disorganize or incomprehensible
5. Perseveration- Pathological repetition of the same response to different stimuli, as in a repetition of the same verbal response
to different questions.
6. Echolalia- Another’s speech is automatically imitated.
7. Derailment-Gradual or sudden deviation in train of thought without blocking
8. Flight of ideas- Rapid continuous verbalizations of words constant shifting from one idea to another; ideas tend to connected
and in the less severe form a listener may be able to follow them
9. Clang Association- Association or speech directed by the sound of a word rather than by its meaning; words have no logical
connection.
10. Blocking- Abrupt interruption in train of thinking before a thought or idea is finished; after a brief pause, person indicates no
recall of what was being said or was going to be said (also known as thought deprivation).

Contents- what a person is actually thinking about.

Disturbances in Content of Thought

1. Delusion- False beliefs, based on incorrect inference about external reality, not consistent with patient’s intelligence and
cultural background; cannot be corrected by reasoning.

Delusion Types:

a. Bizarre Delusion- False belief that is patently absurd or fantastic in non-bizarre delusion content is usually within range of
possibility
b. Mood-congruent delusion- Delusion with content that is mood appropriate
(e.g., “I am responsible for the destruction of the world”- depressed patients)
c. Mood-incongruent delusion- Delusion based on incorrect reference about external reality, with content that has no association
to mood or is mood inappropriate.
(e.g., “I must be praised because I’m Jesus Christ”- depressed patients)
d. Delusion of Poverty- False belief that one is bereft or will be deprived of all possession.
e. Delusion of self-accusation- False feeling of remorse and guilt. Seen in depression with psychotic features.
(e.g., “I am the reason why he died. I made his life miserable”)
f. Paranoid Delusion-Includes:
 Delusion of Persecution-False belief of being harassed or persecuted.
 Delusion of Grandeur- Exaggerated conception of one’s importance, power or identity.
 Delusion of Reference-False belief that the behavior of others refers to oneself; which persons falsely feel that others are
talking about them
g. Delusion of Control- False belief that a person’s will, thoughts, or feelings forces feelings are being controlled by external
forces.
 Thought withdrawal-Delusion that one’s thoughts are being removed from forces from one’s mind by other people or
forces.
 Thought insertion-Delusion that thoughts are being implanted in one’s mind forces mind by other people or forces.
 Thought broadcasting-feeling that one’s thoughts are being broadcast or projected into the environment.
h. Delusion of Infidelity- False belief that one’s lover is unfaithful. Sometimes called pathological jealousy.
i. Erotomania- Delusional belief, more common in women than in men, that someone is deeply in love with them.

E. Perception- Conscious awareness of elements in theenvironment by the mental processing of sensory stimuli.Sometimes
used in a broader sense to refer to themental process by which all kinds of data, intellectual,emotional, as well as sensory, are
meaningfully organized.
1. Hallucination- False sensory perception occurring in the absence of any relevant external stimulation of the sensory modality
involved

Disturbances of Perception

Hallucination Types:

a. Hypnagogic Hallucination- false sensory perception occurring while falling asleep; generally considered nonpathological
(commonly visual)
 b. Hypnopompic Hallucination- false sensory perception occurring while awakening from asleep: generally considered non-
pathological.
c. Auditory Hallucination- false perception of sound, usually voices but also other noises such as music
d. Visual Hallucination- Hallucination primarily involving the sense of sight.
e. Olfactory Hallucination- false perception of smell. Common in medical disorders.
f. Gustatory Hallucination- false perception of taste. Common in medical disorders.
g. Tactile Hallucination- false perception of touch.
h. Lilliputian Hallucination- false perception in which objects are seen as reduced in size (also termed as micropsia)
i. Mood-congruent hallucination- Hallucination with content that is consistent with either a depressed or manic mood (e.g.
depressed patients hearing voices telling them that they are bad persons)
j. Mood Incongruent hallucination- Hallucination not associated with real external stimuli, with content that is not consistent
with either depressed or manic mood (e. g., in depression, hallucinations not involving such themes as guilt, deserved
punishment, or inadequacy.)
k. Hallucinosis-hallucination, most often auditory that are associated with chronic alcohol abuse.
l. Synesthesia-sensation or hallucination caused by another sensation (e.g., An auditory hallucination accompanied or triggered
by visual sensation; a sound as being seen or visual experience as being heard.
m. Trailing Phenomenon- perceptual abnormality associated with hallucinogenic drugs in which moving objects are seen.
n. Command Hallucination- false perception of orders that a person may feel obliged to obey or unable to resist (do something
or say negative things about them)

F. Memory- functions by which information stored in the brain is later recalled to consciousness.

Disturbances of Memory

1. Amnesia- Partial or total inability to recall past experiences; may be organic or emotional origin.
a. Anterograde- amnesia for events occurring after a point in time.
b. Retrograde-amnesia for events occurring before a point in time.
2. Paramnesia- Falsification of memory by distortion of recall.
 Confabulation-gaps in memory are unconsciously filled with false memories.
 Déjà vu – the subject feels that the current situation has been seen or experienced before.
 Déjà entendu – the illusion of auditory recognition
 Déjà pensé – the illusion of recognition of a new thought
 Jamais vu – failure to recognize a familiar situation
3. Hypermnesia- The degree of retention and recall is exaggerated.
4. Lethologica- Temporary inability to remember a name or proper noun
5. Blackout- Amnesia experienced by alcoholics about behavior during drinking sessions.

G. Motor Behavior- the aspect of the psyche the includes impulses, motivations, wishes, drives, instincts and cravings as
expressed by a person’s behavior or motor activity.

Disturbances in Motor Behavior

1. Echopraxia- automatic imitation by the patient of another person’s movements.

2. Catatonia- Motor anomalies in non-organic disorders
 Catatonic Excitement- agitated, purposeless motor activity.
 Catatonic Stupor- Markedly slow motor activity.
 Catatonic Rigidity- Fixed and sustained motoric position that is resistant to change.
 Catatonic posturing- Voluntary assumption of an inappropriate or bizarre posture, generally maintained for long period of
time.
3. Waxy flexibility-the person can be molded into a position that is then maintained.
4. Negativism-Motiveless resistance to all attempts to be moved or to all instructions (german term:Gegenhalten)
5. Stereotypy-repeated regular fixed patterns of movement (or speech)
6. Over-Activity
 Psychomotor Agitation- excessive motor and cognitive overactivity. Usually, non-productive
 Tic- Involuntary, spasmodic motor movement
 Somnambulism- In this condition (also known as sleep walking) a person who rises from sleep and is not fully aware of the
surroundings carries out a complex sequence of behaviors.