05-10-2020

Psychopathology – Disorders of Self

We’ll not be going over specific diseases, but rather go over the general aspects and elements of
“disorders of self”.

Self, terms, ego and self, self-awareness, levels of self awareness, self concept and body image,
theories, formal characteristics of self, disorders.

Self-representation allow you to say who I am and why do I differ from other human beings.
This is crucial for social interactions and relationships, by regulating our behaviour. This is an
unconscious process.

The personal expression became more important with the invention and spread of mirrors,
which encouraged greater self-inspection and introspection. This led to a self-psychology
theory, conceived by Heinz Kohut in the 1960s.

In psychology, self is defined as the way a person thinks about and views his or her traits,
beliefs, and purpose within the world. It is also defined as a collection of cognitively helf beliefs
about oneself, or evaleuation of one’s worth.

The self concept is a fully conscious and abstract awareness of oneself “about who we are”. This
is true from a physical, emotional, social and spiritual POV. This is different from body image,
which is unconscious and physical matters, which is the experiaential aspect of body awareness

Body scema and cathexis

Self awareness – object of one’s own attention.

Neisser’s levels of self-awareness. Ecological self awareness of internal and external stimuli:
self in the embodied form that can b physically identified in tme and space
Interpersonal self: awareness with others, including the interactions such as social relations in
your interaction with the others.

The extended self  awareness of time, past and future, self which is in our memory, both
personal and private
The private self  awareness of one’s own thoughts, feelings, intentions
Conceptual slef abstract idea of self that a person holds

Freud talked about self, and he called the self ego. He made a quite definite distinction between
id, super-ego and ego. Anything that is conscious is normally clear to ourself, anything just
below the surface is the preconscious, made by ego and superego, and the unconscious is the id,
which is the primitive and instinctual part of the mind that contains sexual and aggressive
drives and hidden memories.

Self-Esteem
Self esteem refers to the positive or negative feelings that we have of ourselves. Self-esteem is in
part a trait that is stable over time, with some people having relatively highself-esteem and
others having lower self-esteem. But self-esteem is also a state that varies day to day and even
hour to hour. Rosenberg Self-Esteem Scale might be used to measure it.

Ideal Self
Is what you’d like to be. It is a concept that has to do with an image that yo’d want to aspire to.It
might be a mismatch between how you see yourseflf. If the ideal self is not consistent with what
happens in life, you talk about incongrunce; whereas you have ideal and actual experience
aggree,ng, then you have congruence.

Biological Aspects
Major neurotransmitter in psychiatry is serotonin. Studies suggest fluctuations in this NT which
may play an important role in regulating our self-esteem. High serotonin levels may be
correlated with a high self esteem and social status.

Instead, when we talk about neuroimaging studies, we know that there are certain areas that
are involved, including the medial prefrontal xortex, cingulate gyrus and *****

Temporoparietal junction and extratriate body area are two portions of the brain found to have
a large importance on a person’s perception of self. If these regions don’t talk to each other,
you’ll have d****

Moral decisions have neural correlates, in the anterior and medial prefrontal cortex, and
superior temporal sulcus, which are actvated when guilt, compassion or embarrassment are felt.

Mesolimbic pathway  guilt and passion

Amygdala  indignation and disgust

Jasper is one of the fathers of psychiatry and he has categorized the characteristics of self in a
way that can be used to define the pathologies of self. Distinguish I from what is not I.
1- Ego activity
2- Ego consistency and coherence
 3- Ego identity
4- Ego demarcation
5- Ego vitality – added by Scharfetter

VITALITY – feeling of awareness of being or existing: fundamental to awareness of self

ACTIVITY – awareness of any action as self
CONSISTENCY – the awreness of unity – at any given moment you know who yo are
IDENTITY – awareness of who you are, continuous in biography, gender, geneaological origin
DEMARCATION – awareness of boundaries of self – I is different from others.

When a part breaks down, you get a psychopathological picture

These aspects of self-experience may be disturbed. Awareness of existence and activity; and of
separation

CLASSIFICATION
Disorders of:
1- Vitality
2- Activity
3- Consistency
4- Identity
5- Demarcation

VITALITY DISORDER
Being: the patient’s experience of his very exitence may be altered
I don’t exist
There’s nothing here
I am rotting
I am not alive any more

This is the core experience of nihilistic delusions.

ACTIVITY DISORDER
All events that can be brought into consciousness are associated with a sense of personal
possession. This I quality hhas been called personalization and may be disturbed in
psychological disorders
Memorizing and imagining: may be changed in depressioin
Moving: may show abnormality, such as in the passivity experience ofr delusions of control of
patients with schizophrenia
Willing: may be altered – schizophrenia pts no longer experience their will as being their own.
Commonly, neurotic patients describe an inability to initiate activity

CONSISTENCY DISORDER
In health a person is integrated in his thing.

One of the most important characteristics of delusion si that the thought is not shared in the
community that the patient lives. In ecstacy, the patient may experience certain symptoms that
can be assessed as a disturbance to the boundaries of self, but this is determined by the
community.
26-10-2020
Major Depressive Disorder, Bipolar Disorder and Schizophrenia should be known “to the word”,
also with the clinical presentation. There’s a textbook he suggests for those that are willing to go
into psychiatry  Kaplan and Sadock’s.
Movies with oldani, songs with Brambilla and pictures with zaytseva
Trainspotting.
Other clips on OCD and general anxiety (panic) disorder.

Substance Related Disorders

Substance use disorders (not necessarily connected to a clinical symptom with a psychiatric
disorder) and Substance-induced disorders

Intoxication
Injecting a substance is quicker than inhaling it.
Withdrawal occurs only when you have a prolonged use.
Centro Anti-Veleni

Prognosis is worse if the substance use starts at an earlier age.

Remember the DSM-5 criteria for Major Depressive Disorder

Anxiety Disorder, PTSD and OCD

Anxiety can be an adaptive physiological mechanism, but when it starts impairing functioning,
then it becomes pathological. GABA and serotonin are the two most relevant neurotransmitters
involved in the genesis of anxiety. Low levels of GABA contribute to anxiety, as it reduces the
activity of CNS.

GABAA is more ionotrophic (ligand-gated ion channel), whereas GABAB is metabotropic (G-
protein). When GABA A binds, it causes hyperpolarization and inhibits the neurotransmission.

Amygdala
There are some brain areas that are strictly connected to anxiety, mostly the phylogenetically
most ancient areas of the brain, among which amygdala stands out. It is central to the
processing of fear and anxiety and its function might be disrupted in anxiety disorders. The
sensory information enters the amygdala through the nuclei of the basolateral complex which is
related to fear, memory etc.

All the areas around the amygdala are strictly connected to and involved in the circuit that is
related to anxiety. Specifically, the adjacent central nucleus is very specific for fear responses via
connections to the brainstem, hypothalamus and cerebellum areas.

Environmental Factors
There are environmental factors, as well as the biological factors, that take part in the genesis of
anxiety. Anxiety can be worsened by a number of external substances that can contribute in the
regulation of mechanisms regarding anxiety.
Consider the comorbid diagnoses, as you’d also need to treat them too.

There are different anxiety disorders, some of which are as common as 10% in prevalence,
whereas there are others (such as OCD and Panic Disorder) which aren’t diagnosed as often, 2-
3%.

But in general, the prevalence is quite high, and they are quite common in the general
population. Anxiety is very commonly found and develops into a disorder very easily.

Generalized Anxiety Disorder

Excessive worry more days than not for at least 6 months about a number of events and they
find it difficult to control the worry (you’d also want to wait 6 months for the diagnosis of
schizophrenia, as the diagnosis carries implications that should not be lightly taken).

Axis I disorder??

Benzodiazepine + alcohol when given together (to treat an alcoholic patient with anxiety), the
patient may die due to respiratory failure.

Flumazenil is a competitive benzodiazepine antagonist that reverses the effects of

benzodiazepines.

If you give dopamine to depressed patients, you could develop side effects as delusions
(nihilistic) leading to the Cotard syndrome when you’re convinced that your organs turn into
stone, and that your blood is not there anymore.

Panic Disorder Etiology

Drug/alcohol, genetics, social learning, cognitive theories, neurobiology/conditioned fear,
psychosocial stressors. To treat eliminate all the drugs etc. that may be strictly connected to the
symptoms (even caffeine, or nicotine).

Agoraphobia
Marked fear or anxiety for more than 6 months about 2 or more of the following situations:

The patient fears or avoids such situations, because escape from there might be difficult.

Obsessive-Compulsive Disorder
Anxiety disorder. Characterized by anxiety-provoking ideas, images or impulses (obsessions)
and by urges (compulsions) to do something that will lessen their anxiety.

The experience that these patients have can be seen as a glucose consumption study CT in the
brain. The prefrontal area of the frontal cortex is particularly activated. There are a number of
causes. 80% of cases occur before 18, seen more in males than in females. More common in latin
America, Africa and Europe.

There are psychological, biological, genetic and stress causes (bio-psycho-social genesis of these
disorders).

Then he did OCD and PTSD but whatever.