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The mood of depression may be described as a global loss of vitality in which all functions are affected and all performances depressed cholesterol ratio in eggs cheapest generic prazosin uk. The bizarre feelings that a patient with schizophrenia has about his body is a change in the way he expresses himself cholesterol lowering whole foods buy discount prazosin 2.5 mg on line, often further elaborated by delusions cholesterol medication causes muscle pain prazosin 5 mg fast delivery. It should be noted that the term vital is used rather differently in vital anxiety states cholesterol in eggs and chicken purchase generic prazosin. These states have been described (Lopez Ibor cholesterol levels malaysia purchase generic prazosin on line, 1966) average cholesterol per egg prazosin 5mg online, in which the anxiety is thought to be endogenous, developing relatively acutely in people of stable personality. Trethowan (1979) considered that lowering of vitality is fundamental to the experience of depressive illness. Excessive feelings of fear amounting to terror may remain associated with objects. The occurrence of certain ideas may regularly be associated with specifc pathological emotion, perhaps resulting in phobia (see Chapter 17). Feelings Directed Towards People these may be disturbed in a number of different ways. A girl described in Chapter 14, suffering from anorexia nervosa, would take great care to cook enormous meals for her twin sister, to whom she was very close; the sister became grossly obese while the patient vanished almost to a skeleton. Free-Floating Emotion this is commonly described in psychiatric disturbance, and in his original description of anxiety neurosis, Freud (1895) considered that the condition was characterized by free-foating anxiety. The patient describes himself as feeling generally anxious, not anxious about anything in particular but just anxious. Other free-foating affects occur, such as dread, restlessness, tension, gloom, despondency, euphoria, irritability and so on. Abnormality of Experience and Physiological Activity A speculative hypothesis that clinicians have found helpful is the term alexithymia, which was coined by Sifneos (1972) to describe a specifc disturbance in psychic functioning characterized by diffculties in the capacity to verbalize affect and elaborate fantasies. This was originally introduced to describe psychosomatic disorders occurring in individuals with diffculty expressing their emotions. The link with absence or diminution of fantasy is a consistent fnding (Nemiah and Sifneos, 1970). The communicative style shows markedly reduced or absent symbolic thinking so that inner attitudes, feelings, wishes and drives are not revealed; few dreams and a paucity of fantasies are reported (Taylor, 1984). Thinking is literal, utilitarian and concerned with the minutiae of external events. These individuals have great diffculty in recognizing and describing their own feelings and in discriminating between emotional states and bodily sensations. Alexithymic characteristics have been found especially among patients with psychosomatic disorders, somatoform disorders, psychogenic pain disorders, substance abuse disorders, post-traumatic stress disorder, masked depression, character neuroses and sexual perversions, but these fndings have not been consistently replicated. The Toronto Alexithymia Scale, which is the most widely used measure of alexithymia, has four factors: diffculty in identifying feelings, externally oriented thinking, diffculty expressing feelings and reduced daydreaming (Kirmayer and Robbins, 1993). The diffculty in identifying feelings and the diffculty in expressing them both appear to be correlated with somatosensory amplifcation (Nakao et al. This provides some validation of the idea that alexithymia is the basis for excessive somatization and that this may be caused by undue awareness of discrepant sensations that are then misconstrued as evidence of physical illness. Somatization in patients with mental disorder can be defned as the selective perception and focus on the somatic manifestations of the disorder with denial or minimization of the affective and cognitive changes (Katon et al. Murphy and co-workers (1967) studied basic depressive symptomatology in 30 countries and showed how culture changes illness and the way dysphoria is expressed. Bavington (1981), studying depression in a predominantly Pathan culture in Pakistan, found somatization to be expressed in 45 per cent of cases; hypochondriasis was present in 55 per cent, hysterical (dissociative) features in 60 per cent, feelings of guilt in 50 per cent, paranoid ideas in 38 per cent, suicidal thoughts in 75 per cent, diurnal variation in 18 per cent, retardation in 50 per cent and irritability in 80 per cent of depressed patients. Bavington explains these somatic ideas by the presence of vital feelings rather than poverty of language. Mumford (1992) found that patients with psychiatric disorders originating from India and Pakistan typically communicate their distress as somatic symptoms; somatic presentation was common in general hospital settings where psychiatric disorders were often unrecognized and untreated. The use of somatic symptoms and somatic metaphor to communicate emotional distress is found in all languages and cultures. Complaining of emotional dysphoria in terms of somatic symptoms may refect the limitation of the medical profession in listening to complaints rather than a poverty of language or paucity of verbal expression in the patient. Abnormalities of Evaluation the relationship between cognitions and emotions is diffcult to disentangle. Initially, it was thought that the emotional state determined the associated cognitions. These included arbitrary inferences, selective abstractions, overgeneralizations, magnifcation and minimization. Furthermore, there were cognitive schemas, that is, underlying assumptions about the self, the world and the future, that developed from previous experiences and that habitually infuenced how events in the world were appraised and these could induce mood change, either directly or via disruption in self-esteem. There are also abnormalities of appraisal of the facial or vocal expression of emotions in others. Prosopoaffective agnosia refers to the selective defciency in appreciating the emotional expression displayed in the face of others. This abnormality is distinct from prosopagnosia, in which only recognition of familiar faces is impaired. It is usually associated with acquired brain disease and has been reported in frontotemporal dementia, when it is also associated with impairment of recognition of vocal expression of emotion (Keane et al. In other words, it occurs in some patients but not in others and dissociates from impairment of face recognition per se. Prosodic aspects of speech such as pitch, duration and amplitude are part of the nonverbal cues that modify the meaning of the spoken word and indicate the emotional value of an utterance and the intention of the speaker (Mitchell and Ross, 2013). The mechanisms are unclear but are thought to include bilateral basal ganglia involvement in motor production of speech as a function of affective state and right lateralization of cortical processes in the monitoring and production of acoustic speech parameters (Pichon and Kell, 2013), and the degree to which there is unilateral right-sided or bilateral frontotemporal involvement in receptive emotional prosody is uncertain (Witteman et al. Receptive emotional dysprosody refers to the selective defcit in recognizing the emotional tone in speech. The evolutionary relationship between music and language is uncertain but it is thought that music and language may have a common origin as an emotional protolanguage that remains evident in overlapping functions and shared neural circuitry. In a study of 12 individuals with congenital amusia, a disorder characterized by defcits in acoustic and structural attributes of music, a marked impairment in receptive emotional prosody was demonstrated; suggesting that music and language share mechanisms that trigger emotional responses to acoustic attributes (Thompson et al. Although they are described separately, it is important to realize that these mood states may occur together. Mania and depression are not opposite mood states; they are both pathological, and the opposite of either would be freedom from morbid emotion. Agitation and overactivity may occur with depression, irritability and a feeling of frustration with mania. Of course, arguments advocating biochemical, psychodynamic or conditioning factors as initiating causes are not mutually exclusive. Depression affects virtually all physical and psychological functions, for example, using a tachistoscopic method, Powell and Hemsley (1984) were able to show that depression infuenced perception. The word depression is a misnomer, as depressive illness may occur without the patient making a complaint of depression as a symptom (depressio sine depressione). It was the term used by Lewis (1934) in his classic description of depressive states in a detailed study of 61 cases; this has infuenced all subsequent investigation of the condition. The mood varies from indifference and apathy to profound dejection, despondency and despair. A slowing down of the ability to initiate thought or action is noted by the observer as retardation. Psychic retardation is experienced subjectively as an inability to fulfl normal obligations, as loss of coping. There is a catastrophic lowering of self-esteem as a prominent cognitive component. Agitation and purposeless restlessness add to the discomfort and to the inability of the depressed person to achieve anything. Diurnal variation of mood is often prominent, with the patient feeling at his worst, and perhaps most suicidal, when he wakes early in the morning or, alternatively, somewhat later in the morning. The concealment is probably conscious and may be associated with habitual masking of the expression of emotion or alternatively aimed at avoiding treatment. Concentration, application and decision making become diffcult, painful and sometimes impossible. The person describes diffculty or impossibility in fantasy and recollection of emotion. Anxiety is a common concomitant with depression and may completely obscure the latter. In agitated depression, agitation and restlessness are extreme and the patient carries a serious risk of suicide. The affect of depression may be localized somatically in vital feelings (see above). There is usually a feeling of loss of capacity, helplessness and a feeling that the patient cannot cope. Feelings of guilt and unworthiness are prominent in depressive illness of the endogenous type. On the other hand, Shepherd (1993) considers that guilt feelings did not feature predominantly in depressive states described in pre-Puritan England. The patient may blame himself for having allowed himself to get into this state of mind. He is full of self-reproach and recrimination for all sorts of peccadilloes from the distant past. For all that goes wrong around him he takes personal blame; this may be of delusional intensity. As well as delusions of guilt and unworthiness, hypochondriacal and nihilistic delusions are relatively common in depression, especially when it occurs in the elderly. In practice, there is often a grey area between frank depressive delusions and emotionally laden views of the world. Alvarez (1971) has written a detailed study of suicide from a literary point of view. He is concerned with the background and the reasons for suicide and attempted suicide in many well-known writers, especially poets. Both the muse and madness as gifts of the gods have been a recurring theme from earliest times through such nineteenth century poets as Browning, Shelley, Coleridge and Byron to the modern American poets such as Sylvia Plath and Anne Sexton, among whom there was found to be a very high prevalence of manic-depressive illness and many suicides. In her enlightening study of manic-depressive illness and the artistic temperament, Touched With Fire, Jamison (1993) demonstrates differential rates for depressive illness and suicide in poets, artists and other writers and comments on this. Extreme mood swings are frequent, with enthusiasm and creativity during elation and stark despair when the poet fnds him or herself lacking in inspiration. Poets and also creative musicians (Schumann, Wolf, Rachmaninov, Tchaikovsky, etc. In the same way that depression may occur without suicide or suicidal ideas, suicide may be carried out without predisposing pathological depressive mood. Depression is regarded as the fnal common pathway leading to suicide (Van Heeringen et al.

This is a complex disorder characterized by excessive androgen production by the ovaries and/or adrenal cortex which interferes with ovarian follicular ripening yolk cholesterol in eggs from various avian species discount 2.5mg prazosin overnight delivery. Hirsutism can be treated by combined oestrogen/progestogen oral contraception (to induce sex hormone-binding globulin and thus mop up excess unbound testosterone) and by the anti-androgen cholesterol test las vegas order 5 mg prazosin with visa, cyproterone acetate heart healthy cholesterol lowering foods purchase prazosin discount. Dietary advice should be given to reduce obesity which otherwise helps maintain the condition cholesterol readings chart australia purchase prazosin 2.5mg without prescription. She will need social and psychological support to return to her studies and social life cholesterol zelf test kit prazosin 2.5mg with visa. She is a non-smoker cholesterol test machine walgreens cheap prazosin online master card, and says that she does not drink alcohol or take recreational drugs and she is taking no regular medication. Examination of her cardiovascular, respiratory and abdominal systems is otherwise normal. Her peripheral nervous system examination is normal apart from impaired co-ordination and a staggering gait. The most likely explanation is that this patient has taken a phenytoin overdose, tablets which her father uses to control his epilepsy. Excessive ingestion of barbiturates, alcohol and phenytoin all cause acute neurotoxicity manifested by vertigo, dysarthria, ataxia and nystagmus. Vertigo is an awareness of disordered orientation of the body in space and takes the form of a sensation of rotation of the body or its surroundings. Vestibular neuronitis does not recur but lasts several days, whereas vertigo due to ototoxic drugs is usually permanent. Brainstem ischaemic attacks occur in patients with evidence of diffuse vascular disease, and long tract signs may be present. Posterior fossa tumours usually have symptoms and signs of space-occupying lesions. Temporal lobe epilepsy may also produce rotational vertigo, often associated with auditory and visual hallucinations. Gastric lavage should be carried out if it is within 12 h of ingestion of the tablets. Before discharge she should have counselling and treatment by adolescent psychiatrists. The pain is often present in bed at night and may be precipitated by bending down. Occasionally, the pain comes on after eating and on some occasions it appears to have been precipitated by exercise. Her husband has angina and on one occasion she took one of his glyceryl trinitrate tablets. She thinks that this probably helped her pain since it seemed to go off a little faster than usual. She has also bought some indigestion tablets from a local pharmacy and thinks that these probably helped also. The character and position of the pain and the relation to lying flat and to bending mean reflux is more likely. The improvement with glyceryl trinitrate and with proprietary antacids is inconclusive. In view of the long history and the features suggesting oesophageal reflux, it would be reasonable to initiate a trial of therapy for oesophageal reflux with regular antacid therapy, H2-receptor blockers or a proton pump inhibitor (omeprazole or lansoprazole). If the pain responds to this form of therapy, then additional actions such as weight loss (she is well above ideal body weight) and raising the head of the bed at night should be added. If doubt remains, a barium swallow should show the tendency to reflux and a gastroscopy would show evidence of oesophagitis. There is a broad association between the presence of oesophageal reflux, evidence of oesophagitis at endoscopy and biopsy, and the symptoms of heart burn. Recording of pH in the oesophagus over 24 h can provide additional useful information. It is achieved by passing a small pH-sensitive electrode into the oesophagus through the nose. This provides an objective measure of the amount of acid reaching the oesophagus and the times when this occurs. This woman had an endoscopy which showed oesophagitis, and treatment with omeprazole and an alginate relieved her symptoms. These headaches have been present in previous years but have now become more intense. She also complains of loss of appetite and difficulty sleeping, with early morning waking. She has had eczema and irritable bowel syndrome diagnosed in the past but these are not giving her problems at the moment. Examination of the cardiovascular, respiratory and gastrointestinal systems, breasts and reticuloendothelial system is normal. The headache is usually bilateral, often with diffuse radiation over the vertex of the skull, although it may be more localized. Patients may show symptoms of depression (this woman has biological symptoms of loss of appetite and disturbed sleep pattern). Sufferers may reveal sources of stress such as bereavement or difficulty with work. There may be an element of suggestion as in this case, with concern that she may have inherited a brain tumour from her mother. The onset is usually in early adult life and a positive family history may be present. There will often be other signs, including personality change and focal neurological signs. The question of depression needs to be explored further and may need treating with antidepressants. Two months earlier he had been admitted with a productive cough and acid-fast bacilli had been found in the sputum on direct smear. He was found a place in a local hostel for the homeless and sent out after 1 week in hospital on antituberculous treatment with rifampicin, isoniazid, ethambutol and pyrazinamide together with pyridoxine. His chest X-ray at the time was reported as showing probable infiltration in the right upper lobe. This might have occurred because he had a resistant organism or, more likely, because he had not taken his treatment as prescribed. Other possibilities would be liver damage from the antituberculous drugs and the alcohol, although clinical jaundice would be expected, or electrolyte imbalance. If these are not present a lumbar puncture would be indicated, provided that there is no sign to suggest raised intracranial pressure. It is now 2 months since the initial finding of acid-fast bacilli in the sputum and the cultures and sensitivities of the organism should now be available. These should be checked to be sure that the organism was Mycobacterium tuberculosis and that it was sensitive to the four antituberculous drugs which he was given. The urine will be coloured orangy-red by metabolites of rifampicin taken in the last 8 h or so. Comparison with his old chest X-rays showed extension of the right upper-lobe shadowing. It is difficult to be sure about activity from a chest X-ray but extension of shadowing is obviously suspicious. A direct smear of the sputum showed that acid-fast bacilli were still present on direct smear. The breathlessness persisted over the 4 h from its onset to her arrival in the emergency department. There is no relevant previous medical history except asthma controlled on salbutamol and beclometasone. She works as a driving instructor and had returned from a 3-week holiday in Australia 3 weeks previously. The physical signs of tachypnoea, tachycardia, raised jugular venous pressure and pleural rub would fit with a diagnosis of a pulmonary embolus. The peak flow of 410 L/min indicates that asthma does not explain her breathlessness. The differential diagnosis would include pneumonia, pneumothorax and pulmonary embolism. Possible predisposing factors for pulmonary embolism are the history of a long aeroplane journey 3 weeks earlier, oral contraception and her work involving sitting for prolonged periods. Other signs such as transient right ventricular hypertrophy features, P pulmonale and T-wave changes may also occur. In cases with a normal chest X-ray and no history of chronic lung disease, equivocal results are less common and it is not usually necessary to go further than the lung scan. This showed a filling defect typical of an embolus in the right lower lobe pulmonary artery. A search for a source of emboli with a Doppler of the leg veins may help in some cases, and the finding of negative D-dimers in the blood makes intravascular thrombosis and embolism unlikely. The anticoagulation can then transfer to warfarin, continued in a case like this for 6 months. Alternative modes of contraception should be discussed and advice given on alternating walking or other leg movements with her seated periods at work. Thrombolysis should be considered when there is haemodynamic compromise by a large embolus. The pain is in the centre of the chest and has lasted for 3 h by the time of his arrival in the emergency department. He has been treated with aspirin and with beta-blockers regularly for the last 2 years and has been given a glyceryl trinitrate spray to use as needed. His father died of a myocardial infarction aged 66 years and his 65-year-old brother had a coronary artery bypass graft 4 years ago. Examination He was sweaty and in pain but had no abnormalities in the cardiovascular or respiratory systems. He was given analgesia and thrombolysis intravenously and his aspirin and beta-blocker were continued. On examination, now his jugular venous pressure is raised to 6 cm above the manubriosternal angle. On auscultation of the heart, there is a loud systolic murmur heard all over the praecordium. In the respiratory system, there are late inspiratory crackles at the lung bases and heard up to the mid-zones. The late inspiratory crackles are typical of pulmonary oedema and the chest X-ray confirms this showing hilar flare with some alveolar filling, Kerley B lines at the lung bases and blunting of the costophrenic angles with small pleural effusions. The problems likely to occur at this time and produce shortness of breath are a further myocardial infarction, arrhythmias, rupture of the chordae tendinae of the mitral valve, perforation of the intraventricular septum or even the free wall of the ventricle, and pulmonary emboli. The first four of these could produce pulmonary oedema and a raised jugular venous pressure as in this man. Pulmonary embolism would be compatible with a raised jugular venous pressure but not the findings of pulmonary oedema on examination and X-ray. Acute mitral regurgitation from chordal rupture and ischaemic perforation of the interventricular septum both produce a loud pansystolic murmur. The site of maximum intensity of the murmur may differ being apical with chordal rupture and at the lower left sternal edge with ventricular septal defect, but this differentiation may not be possible with a loud murmur. The management of acute ventricular septal defect or chordal rupture would be similar and should involve consultation with the cardiac surgeons. When these lesions produce haemodynamic problems, as in this case, surgical repair is needed, either acutely if the problem is very severe, or after stabilization with antifailure treatment or even counterpulsation with an aortic balloon pump. Milder degrees of failure with a pansystolic murmur may occur when there is ischaemia of the papillary muscles of the mitral valve. This is managed with antifailure treatment, not surgical intervention, and can be differentiated by echocardiography. He has complained of general pains in the muscles and he also has some pains in the joints, particularly the elbows, wrists and knees. Three weeks earlier, he fell and hit his leg and has some local pain related to this. He is a non-smoker who does not drink any alcohol and has not been on any medication. Twelve years ago he had a myocardial infarction and was put on a beta-blocker but he has not had a prescription for this in the last 6 years. Examination He is tender over the muscles around his limb girdles and there is a little tenderness over the elbows, wrists and knees. There are no other abnormalities to find in the cardiovascular, respiratory or alimentary systems. There are some larger areas of bruising on the arms and the legs which he says have not been associated with any trauma.

After this experience cholesterol lowering diet in spanish generic 5 mg prazosin fast delivery, she offered her services as a healer and solver of domestic diffculties to her village cholesterol levels hdl order prazosin visa, and several people consulted her each day at home cholesterol control foods eat best purchase for prazosin, where she had devoted one tiny room to a sanctuary and another to a waiting room cholesterol steroid prazosin 2.5 mg amex. With her husband blowing a buffalo horn repeatedly and herself chanting hdl cholesterol in quail eggs generic prazosin 2.5mg, she induced a trance in herself in which she spoke with different voices as either one of two female deities giving advice to her clients can cholesterol medication cause vertigo generic prazosin 2.5mg visa, which her husband interpreted. A different case, with psychiatric disorder present, was that of a 37-year-old Sri Lankan housewife who believed herself to be possessed by her long-dead grandmother; on three occasions she had gone into a trance, lost contact with the outside world and seen the image of her grandmother coming close to her and trying to squeeze her neck. She showed symptoms of depressive illness, with poor sleep, early morning wakening, loss of appetite and weight, anergia, fatigue and feeling low in mood; she had been abandoned by her mother when 7 years old. Episodes, often lasting about 30 minutes, were usually precipitated either by emotional stress or culture-bound stimuli such as witnessing an exorcism ceremony. During trance, subjects were most often restless with rhythmic trembling of the trunk and exaggerated gesturing, speech was aggressive and commanding and, typically, mood was angry; most often, the possessing spirit was that of a close but dead relative. In females especially, as the condition continued they were increasingly likely to become permanent adepts. These authors regarded only one of their subjects as suffering from schizophrenia, although 17 of 37 manifested active psychiatric disorder, mostly neurotic in nature. Possession and trance states straddle the boundary between normative behaviour and abnormal behaviour indicative of a disorder. Moreira-Almeida and Cardena (2011) argue that lack of personal suffering, absence of social or functional impairment, absence of psychiatric comorbidity, self-control over the experience and personal growth all point in the direction of a non-pathological spiritual experience. It is clear though that possession and trance states can occur in the setting of indubitable neurological disease such as lesions in the basal ganglia and fronto-parietal lobes (Basu et al, 2002), hence the need to have an integrative model that is grounded in neuroscience but admits sociocultural processes informed by aspects of how the self is socially constructed (Seligman and Kirmayer, 2008). Jaspers (1959), in writing about disorders of self-awareness, concerned himself with disorder of content as well as of form. In discussing states of possession, he commented on the rare condition of lycanthropy, the patient believing that he has been transformed into an animal, literally a wolf. Lyncathropy has a long history in Western societies and identical beliefs of transformation into other feared animals such as the fox in Japan, the tiger, hyena and crocodile in China, Malaysia and India are documented (Fahy, 1989). In antiquity there was belief in the possibility of radical physical transformation of the human body into that of a wolf. However, recent case reports have adopted a robust phenomenological approach and identify the belief of transformation as a delusion of non-specifc value but principally associated with mood disorders, schizophrenia, and occasionally organic brain disease (Keck et al, 1988; Fahy, 1989; Kulick et al, 1990). Lyncathropy is usually a transient belief but occasionally the belief can be enduring, lasting for many years (Keck et al, 1988). This emphasizes the importance for psychiatric diagnosis in assessing psychopathological form. One subject put this as: I was being disorganized the world around was looking very distorted indeed things were pretty rocky so I decided to sit back quietly for a moment and reassure myself by returning to my own private inner world. The central core of the personality, the ego, the sense of personal identity, was itself fuctuating and, for want of a better phrase, dissolving. Boundaries of Self in Schizophrenia In schizophrenia, the sense of invasion of self appears to be fundamental to the nature of the condition as it is experienced; many but not all frst-rank symptoms have in common permeability of the barrier between the individual and his environment, loss of ego boundaries (Sims, 1993). There is a merging between self and not self; this is clearly portrayed in Figure 12. The external observer fnds a blurring or loss of the boundaries of self that is not apparent to the patient himself. All passivity experiences falsely attribute functions to not self infuences from outside, which are actually coming from inside the self. This is also true for disorders of the possession of thought, such as thought insertion and thought withdrawal. Thought broadcasting obviously involves private thoughts becoming public without the consent or action of the patient. This is another example of a breakdown in the normal boundaries of what is self and non-self. Other experiences, such as auditory hallucinations, rely on the patient ascribing internally generated activity, that is, internal speech, to external agencies. The subjective experience of passivity is a disorder of the distinction between what is and what is not self. Sensations, emotions, impulses and actions that in objective reality come from inside the self are ascribed to not self. Other Alterations to Boundaries In states of ecstasy, there are also disturbances in the boundaries of self (Chapter 16). Ecstasy states occur in normal people and in those with personality disorder, as well as in sufferers from psychoses and in epilepsy. In epilepsy it is part of the aura and is characterized by intense feelings of well-being and heightened self-awareness. It is thought to emanate from hyperactivation of the anterior insula rather than the temporal lobe (Picard and Craig, 2009). This alteration in awareness of the boundaries of self is different from that of schizophrenia described above. The phenomenon described by Jung in himself with which this chapter begins is a lack of defnition of the boundaries of self. However, there was no loss of reality judgement; it was a game, and Jung did in fact know what was himself and what was the stone. Another patient believed that while he was in a hospital ward he was helping other patients because he permeated the medical staff and thereby assisted them in their work. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn, revised. Anzellotti F, Onofri V, Maruotti V, Ricciardi L, Franciotti R, Bonanni L, Thomas A and Onofrj M (2011) Autoscopic phenomena: case report and review of literature. Blanke O and Arzy S (2005) the out-of-body experience: disturbed self-processing at the temporo-parietal junction. Blanke O, Landis T, Spinelli L and Seeck M (2004) Out-of-body experience and autoscopy of neurological origin. Dewhurst K and Pearson J (1955) Visual hallucinations of the self in organic disease. Heydrich L and Blanke O (2013) Distinct illusory own-body perceptions caused by damage to posterior insula and extrastriate cortex. Koehler K, Ebel H and Vartzopoulos D (1990) Lycanthropy and demonomania: some psychopathological issues. Scharfetter C (1995) the Self-experience of Schizophrenics: Empirical Studies of the Ego/Self in Schizophrenia, Borderline Disorders and Depression. Schilder P (1935) the Image and Appearance of the Human Body: Studies in the Constructive Energies of the Psyche. Todd J and Dewhurst K (1962) the signifcance of the Doppelganger (hallucinatory double) in folk-lore and neuropsychiatry. This page intentionally left blank C H A P T E R 13 Depersonalization Summary Depersonalization is a subjective state of unreality in which there is a feeling of estrangement, either from a sense of self or from the external environment. Frequently, it is accompanied by the symptom of derealization, a term denoting a similar feeling of unreality with regard to awareness of the external world. The localization of this feeling of unreality to a selected part of the body is called desomatization. There may be experience of changes of size or quality, for example appearing large or tiny, or empty, or detached or flled with water or foam. Deaffectualization has been used to describe the consistent loss of the capacity to feel emotion, so that the person seems unable to cry, love or hate. These experiences are associated with anxiety and mood disorders, organic disease such as epilepsy and traumatic brain injury. Depersonalization can also be triggered by the use of cannabis, hallucinogens, ecstasy and alcohol. It is best to reserve the use of the word to this as if feeling rather than the experience of unreality that occurs in psychosis. It has been considered that, after depression and anxiety, depersonalization is the most frequent symptom to occur in psychiatry (Stewart, 1964) and 12 month prevalence estimates for depersonalization and derealization in a rural population are put at 19. Patients characterize their imagery as pale, colourless and some complain that they have altogether lost the power of imagination. Patients complain they are capable of experiencing neither pain nor pleasure; love and hate have perished with them. They experience a fundamental change in their personality, and the climax is reached with their complaints that they have become strangers to themselves. Depersonalization has been defned by Fewtrell (1986) as a subjective state of unreality in which there is a feeling of estrangement, either from a sense of self or from the external environment. Defnitive features are: depersonalization is always subjective; it is a disorder of experience the experience is that of an internal or external change characterized by a feeling of strangeness or unreality the experience is unpleasant any mental functions may be the subject of this change, but affect is invariably involved insight is preserved. Excluded from depersonalization are: the experience of unreality of self when there is delusional elaboration the ego boundary disorders of schizophrenia the loss or attenuation of personal identity. Mellor comments on the frequency of the condition and the variety of different psychiatric illnesses with which it may be associated. It may occur with organic psychosyndromes including traumatic brain damage (Grigsby and Kaye, 1993), epilepsy and migraine (Lambert et al. It is associated with mood disorders and anxiety disorders including social anxiety (Simeon et al. The depth of depression is positively correlated with depersonalization and in depressed patients with anhedonia, depersonalization was present in 75% of cases (Zikic et al. Although the symptom has been described for longer, the term was used by Heymans (1904) and by Dugas and Moutier in 1911. The earliest theories implicate the sensory system, but loss of mood and loss of feelings were also prominent in early descriptions (Sierra and Berrios, 1997). Frequently, depersonalization is accompanied by the symptom of derealization, a term used by Mapother (1935) to denote a similar change in the awareness of the external world. Depersonalization and derealization often go together, because the ego and its environment are experienced as one continuous whole. The less a patient takes himself for granted, the more unfamiliar and alien does the world around him become (Scharfetter, 1980). I saw it and it upset me and I went to pieces I felt I did not want to be alive because I was not related to anything. It is important to realize that depersonalization, the experience, like other non-psychotic phenomena, occurs in healthy, normal people. Others may have such experiences at times of powerful emotional stimuli or life crisis of any valence: extreme happiness, falling in love, the loss of bereavement or intense fear or anger. The actual self-description of depersonalization is similar irrespective of context. There is one particular feature described by patients and not occurring in the depersonalization that healthy people, especially children, may experience spontaneously in states of fatigue, after prolonged sleep deprivation or under sensory deprivation. There is virtually always other evidence of disturbance of mood present: depression or anxiety or both. At this point, it is important to emphasize the distinction between depersonalization as a symptom, occurring associated with many psychiatric conditions or no disorder at all, and depersonalization as a syndrome. In their detailed description of the symptoms of depersonalization disorder, based on classic descriptions from authors in the nineteenth and early twentieth centuries, Sierra and Berrios (2001) have listed the following four symptoms as most prevalent for diagnosis: emotional numbing, changes in visual perception, changes in the experience of the body and loss of feelings of agency. In a more recent study, Simeon et al (2008) demonstrated that the Cambridge Depersonalization Scale (Sierra and Berrios, 2000) yielded fve factors: numbing, unreality of self, perceptual alterations, unreality of surroundings, and temporal disintegration. In addition patients with depersonalization appear to have impaired ability to generate visual imagery compared to normal controls. However in these individuals with impaired imagery there was no associated abnormality of perceptual processes as measured by a battery of visual perception tests (Lambert et al. These symptoms are sometimes included with a description of depersonalization but, for the sake of clarity, should be separated and regarded as different psychopathological phenomena.

Behavior therapy stresses changing behavior rather than identifying unconscious motivations or root causes of problems (Wolpe cholesterol test numbers purchase prazosin canada, 1997) cholesterol test near me buy generic prazosin on-line. In some cases cholesterol levels ldl purchase prazosin online, a behavior itself may not be immediately maladaptive cholesterol and foods to eat purchase prazosin with amex, but it may be followed by unwanted consequences at a later point in time foods lowering cholesterol levels effortlessly cheap generic prazosin uk. The ultimate goal is for the the form of treatment that rests on the ideas patient to replace problematic behaviors with more adaptive ones; the patient acthat (1) maladaptive behaviors cholesterol medication and vitamin d 5 mg prazosin with visa, cognitions, and emotions stem from previous learning and quires new behaviors through classical and operant conditioning (and, to a lesser (2) new learning can allow patients to develop extent, modeling). The antecedents the form of treatment that combines methods might include his (irrational) thoughts about what will happen if he goes into a from cognitive and behavior therapies. The consequences of his avoidant behavior include relief from the anticipatory anxiety. The therapist assigns homework, important tasks that the patient completes between therapy sessions. Homework for Leon, for instance, might consist of his making eye contact with a coworker during the week, or even striking up a brief conversation about the weather. To prepare for this task, Leon might spend part of a therapy session practicing making eye contact or making small talk with his therapist. The success of behavior therapy is measured in terms of the change in frequency and intensity of the maladaptive behavior and the increase in adaptive behaviors. The Role of Classical Conditioning in Behavior Therapy As we saw with Little Albert in Chapter 2, classical conditioning can give rise to fears and phobias and, more generally, conditioned emotional responses. To treat the conditioned emotional responses that are associated with a variety of symptoms and disorders and to create new, more adaptive learning, behavioral therapists may employ classical conditioning principles. Treating Anxiety and Avoidance A common treatment for anxiety disorders, particularly phobias, is based on the principle of habituation: the emotional response to a stimulus that elicits fear or anxiety is reduced by exposing the patient to the stimulus repeatedly. The technique of exposure involves such repeated contact with the (feared or arousing) stimulus in a controlled setting, and usually in a gradual way. The patient first creates a hierarchy of feared events, arranging them from least to most feared (see Table 4. Over multiple sessions, this process is repeated with items higher in the hierarchy until all items no longer elicit significant symptoms. Although Leon avoids almost all the situations on the completed form, some situations arouse more fear than others. Situation Fear Avoidance Give a 1-hour formal lecture to 30 coworkers 100 100 Go out on a date 98 100 Ask a colleague to go out on a date 97 100 Attend a retirement party for a coworker who is retiring 85 100 Habituation Have a conversation with the person sitting next to me on the bus 70 100 the process by which the emotional response Ask someone for directions or the time 60 99 to a stimulus that elicits fear or anxiety is reduced by exposing the patient to the Walk around at a crowded mall 50 98 stimulus repeatedly. Virtual reality exposure has been used to treat a variety of psychological disorders, including posttraumatic stress disorder (Ready et al. Patients are less likely to refuse treatment with virtual reality exposure than with in vivo exposure (Garcia-Palacios et al. Whereas exposure relies on habituation, systematic desensitization relies on (Krijn et al. Systematic desensitization is used less frequently than exposure because it is usually not as efficient or effective; however, it may be used to treat a fear or phobia when a patient chooses not to try exposure or has tried it but was disappointed by the results. The first step of systematic desensitization is learning to become physically relaxed through progressive muscle relaxation, relaxing the muscles of the body in sequence from feet to head. Once the patient has mastered this ability, the therapist helps the patient construct a hierarchy of possible experiences relating to the feared stimulus, ordering them from least to most feared, just as is done for exposure (see Figure 4. Over multiple therapy sessions, the patient practices becoming relaxed and then continuing to remain relaxed while imagining increasingly feared experiences. Although systematic desensitization and biofeedback both involve relaxation, systematic desensitization uses relaxation as the first step in reducing anxiety in response to feared stimuli and does not utilize any equipment. In contrast, the goal of biofeedback is learning to control what are generally involuntary responses. Treating Compulsive Behaviors In some cases, avoidance or fear of a specific stimulus is not the primary maladaptive behavior. After grocery shopping, for example, a person may feel compelled to reorganize all the canned goods in the cupboard so that the contents remain in alphabetical order. Similarly, some people with bulimia nervosa feel compelled to make themselves throw up after eating even a bite of a dessert. These Systematic desensitization compulsive behaviors temporarily serve to decrease anxiety that has become part of the behavioral technique of learning to relax a conditioned emotional response to a particular stimulus. Foundations of Treatment 125 To treat compulsive behaviors, behavior therapists may use a variant of exposure called exposure with response prevention, whereby the patient is carefully prevented from engaging in the usual maladaptive response after being exposed to the stimulus (Foa & Goldstein, 1978). Using this technique with someone who compulsively alphabetizes his or her canned goods, for instance, involves exposing the person to a cupboard full of canned goods arranged randomly and then, as agreed, preventing the typical maladaptive response of alphabetizing the cans. Similarly, someone with bulimia might eat a bite or two of a dessert and, as planned, not throw up. Once she is out of the habit of purging, she may use exposure with response stimulus). Others may binge (habitual maladaptive behavior) when they eat dessert prevention to learn to eat cookies without (the stimulus). This technique, called stimulus control, involves changing the frequency of a maladaptive conditioned response by controlling the frequency or intensity of exposure to the stimulus that elicits the response. For example, the person who drinks too much in bars would refrain from going to bars; the person who binges after eating even a bit of dessert might avoid buying desserts or going into bakeries. Stimulus control will be described more fully when we discuss treatment for substance abuse (Chapter 9). The Role of Operant Conditioning in Behavior Therapy Whereas classical conditioning methods can be used to decrease maladaptive behaviors related to conditioned emotional responses, operant conditioning techniques can be used to modify maladaptive behaviors more generally. When operant conditioning principles such as reinforcement and punishment are used to change maladaptive behaviors, the process is called behavior modification. Making Use of Reinforcement and Punishment the key to successful behavior modification is setting appropriate response contingencies, which are the specific consequences that follow maladaptive or desired behaviors. It is these specific consequences (namely, reinforcement or punishment) that modify an undesired behavior. Some behaviors are too complex to learn or perform immediately and must be developed gradually. They may not exposed to a stimulus that usually elicits the be able to go from their daily intake of perhaps a serving of yogurt, a glass of milk, response. Sometimes the desired behavior change (in this case, resumthe behavioral technique for changing the ing normal eating) can only occur gradually, and reinforcement follows small and frequency of a maladaptive conditioned then increasingly larger components of the desired new complex behavior. Thus, a response by controlling the frequency or woman recovering from anorexia nervosa might be reinforced for increasing her intensity of exposure to the stimulus that dinner from only a glass of milk and an apple to also include a small helping of fish. On subsequent meals, she might be expected to eat the fish (without reinforcement) Behavior modification and be reinforced for adding a piece of bread. This process would continue until she the use of operant conditioning principles to ate normal meals. Making Use of Extinction In addition to using reinforcement and punishment, therapists also rely on the principle of extinction, which is the process of eliminating a behavior by not reinforcing it. This man only gets anxious in certain types of social situations, such as going to a party where there will be unfamiliar people. Therapist and patient might decide that the maladaptive behavior to change is his complaining, because it leads his wife to decline the invitation (or to leave him at home). That is, when he complains about parties, she should ignore these comments, and they both then go to the party. The date, day of the week, and time of day can help the patient to identify triggers related to time. Information about the context can help the patient to identify whether particular situations or environments have become conditioned stimuli. Identifying thoughts, feelings, interactions with others, or other stimuli that triggered the problematic behavior (right-hand column in Figure 4. Daily self-monitoring logs are used in treatments for anxiety, poor mood, smoking, compulsive gambling, overeating, and sleep problems, among others. Behavioral techniques that rely on operant conditioning principles are often used in inpatient psychiatric units, where clinicians can intensively monitor and treat patients 24 hours a day, 7 days a week. Under these conditions, caregivers can change the response contingencies for desired and undesired behavior. In order to change behavior, treatment programs for psychiatric patients, mentally retarded children and adults, and prison inmates often employ secondary reinforcers, objects and events that do not directly satisfy a biological need but are desirable nonetheless. Examples of secondary reinforcers are praise or the opportunity to enjoy a favorite activity, such as watching television or using a computer. A treatment program that uses such secondary reinforcers to change behavior is called a token economy. Such dysfunctional thoughts and beliefs, in turn, conchits as secondary reinforcers to change tribute to maladaptive behaviors and poor mood. Treatment might focus on his social anxiety and avoidance at the outset; as those lessen, so should his depression. Leon, for example, has irrational, dysfunctional thoughts about being evaluated, and he expects to feel embarrassed and humiliated. With cognitive therapy, Leon would have an opportunity to reassess whether his automatic thoughts and beliefs are realistic and, if not, learn to substitute more realistic ones that will make social interactions less anxiety-provoking. Leon should then be more likely to participate in social situations, which in turn may reduce his depression. Although there are some differences between the specific positive emotions and adaptive behaviors. Over the years, however, Ellis incorporated behavioral techniques into his therapy. Thus, this therapy also is designed to reduce self-blame (based on faulty beliefs), which is viewed as getting in the way of rational thinking. A successful dispute leads to (E) an effect or an effective new philosophy, a new idea or a new pattern of emotion or behavior.

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