Neurotic disorders

1
Neurotic disorders

• vudhichai boonyanaruthee, MD

2
PSYCHOSIS VS NEUROSIS
3
PSYCHOSIS

• OUT OF REALITY
• DISORGANIZED BEHAVIOR
• DISORGANIZED SPEECH
• THOUGHT DISORDER
• IMPAIRED INSIGHT JUDGMENT

4
NEUROSIS

• INTRAPSYCHIC CONFLICTS SEX AGGRESSION
  DEPENDENCY NEED
• DEFENSE MECHANISM

5
NEUROSIS

• ANXIETY NEUROSIS
• PHOBIC NEUROSIS
• OBSESSIVE-COMPULSIVE NEUROSIS
• HYSTERICAL NEUROSIS CONVERSION TYPE,
  DISSOCIATIVE TYPE
• DEPRESSIVE NEUROSIS
• etc.

6
NEUROSES V DSM - IV

• ANXIETY NEUROSIS V GENERALIZED ANXIETY DISORDER
• PHOBIC NEUROSIS V PHOBIC DISORDER
• OBSESSIVE-COMPULSIVE NEUROSIS V OCD
• HYSTERICAL NEUROSIS V CONVERSION DISORDER,
• DISSOCIATIVE DISORDER
• DEPRESSIVE NEUROSIS V DYSTHYMIC DISORDER
• etc.

7
NEUROTIC DISORDERS

• ANXIETY DISORDERS
• SOMATOFORM DISORDERS
• DISSOCIATIVE DISORDERS

8
ANXIETY DISORDERS

• ANXIETY ???????????(anticipation)???
• ???????????(danger)???? ??????????????? ?????????
• ?????????????(feeling of dysphoria) ????
• ???????????(somatic symptoms)

9
ANXIETY V FEAR

• UNKNOWN
• INTERNAL
• VAGUE

• KNOWN
• EXTERNAL
• DEFINITE

10
ANXIETY DISORDERS

• LIFETIME PREVERENCE 24.9
• MCM SOCIAL PHOBIA, SIMPLE PHOBIA AGORAPHOBIA
  WITHOUT PANIC DISORDER, GEBERALIZED ANXIETY
  DISORDER AND PANIC DISORDER
• ( SUBSTANCE USE DISORDERS 26.6, MOOD DISORDERS
  19.3)

11
DSM IV Classification of Anxiety Disorders

• Panic disorder without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without history of panic disorder
• Specific phobia
• Social phobia
• Obsessive-compulsive disorder

12

• Posttraumatic stress disorder
• Acute stress disorder
• Generalized anxiety disorder
• Anxiety due to a general medical condition
• Substance-induced anxiety disorder
• Anxiety disorder NOS

13
Panic disorder and Agoraphobia

• Panic disorder without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without history of panic disorder

14
Panic disorder

• A. 12
• 1. recurrent unexpected panic attacks
• 2. ????????? 1 panic attack ????? ?????????
  1????????????? ?????????????????????? 1 ?????
• a. ???????????? panic attack ???
• b. ??????????????????? ????????????????
• c. ?????????????????????????????????????? PA

15
Panic attack sudden intense fear or discomfort,
at least 4 S/S, peak in 10 min

• a. palpitation, pounding or accelerated heart
• b. sweating
• c. trembling or shaking
• d. shortness of breath or smothering
• e. feeling of choking
• f. chest pain or discomfort

16
Panic attack

• g. nuasea or abdominal distress
• h. feeling dizzy, unsteady, lightheaded or faint
• I. derealization or depersonalization
• j. fear of losing control or going crazy
• k. fear of dying
• l. paresthesia
• m. chills or hotflushes

17
Panic disorder

• B. ?? agoraphobia????????? ?? PD with AP ???? PD
  without AP

18
Agoraphobia

• A. ??????????????????????? ???????????????????????
  ??????? ???? ???????????????????????? ?????????
  ?????????????????? ????????panic
  attack??????????????????????????panic ????
  ????????????????? ??????????? ??????? ???????
  ????????
• B. ?????????? ???? ?????? ?????????????????
  ?????????????????????????????

19
Agoraphobia

• C. anxiety and phobic avoidance
  ?????????????????????????????????????? ????
  social phobia, OCD, PTSD, separation anxiety
  disorder

20
Panic disorder

• C. panic attacks ????????????? substance or
  general medical condition
• D. ????????????????????????????? ???? major
  depressive disorder, schizophrenia, paranoid
  personality disorder, avoidance personality
  disorder, dependent personality disorder etc.

21
Treatment of Panic disorder

• ?????????????? (Drug Treatment)
• ???? Imipramine ??? Alprazolam
• ?????? clonazepam, fluoxetine, fluvoxamine,
  clomipramine

22
Impramine(Troflanil, Minapine 10, 25, 50 mg)

• - 1.5 mg/kg/d ?? panic disorder without
  agoraphobia
• - 2.25 mg/kg/d ?? panic disorder with
  agoraphobia
• - ???????????????????????? (???? 10 mg/d) ???????
• - ??????????? ?????? ? ???????????????????????????
  7-10 ??? ( ???????????????????????????
  ? 4-6 ???????????????????????)
• - ??????????????????????????????????????????????
  8-12 ?????
• - ????????????? ? ??????

23
Alprazolam

• - ???????????????? 0.25-0.5 mg ????? 4 ????? (2-6
  mg/day)
• - ????????????????? 8-12 ?????
• - ???? ? ?????? ???????? ? (25/week)

24
??????????????????? (Psychosocial Treatment)

• ??????????????? ???
• cognitive therapy
• ????????????????? (relaxation training)
• ???????????? (exposure)
• ???? ? ???? ?????????????? (respiratory
  training), ????????????? (family therapy),
  ???????????????????????????? (insight-oriented
  psychotherapy) ???????

25
Cognitive therapy??????????


????????????????????????????? (fears of physical
symptoms) ???????? 3 ??????? ???

• a. identify the fears ?????????????
• b. explain ?????????????????????????????
• c. demonstration ??????????????????? appearance
  of the symptoms, fearful response ??????????
  panic attack

26
c. demonstration

• - ????????????????????????????????????????????????
  ??? ?????????????????????????? panic attack
  ?????????????????????????
• - ??????????????????????????????????????????????
  ???????????????????????????????????? panic attack
  ???????????????

27
Relaxation training?????????????????????????????
? panic attacks

• ?????????????????????? (muscle relaxation)
• ??????????????????????????????????? (relaxing
  situation) ???????????????????????
• ???????????????????????????????

28
???????????? (Exposure)

• ??????????????????????????????????????????????????
  ????????????? (phobic targets) ???????????????????
  ???????? 2 ???????

29
???? ?

• ?????????????? (respiratory training)
• ????????????? (family therapy)
• ???????????????????????????? (insight-oriented
  psychotherapy)
• ??????????????????????????????? ????
  ??????????????????????????????????????????????????
  ? panic attack ???? ????, ???? ???????????????????
  ??????????????????? ???? ?????????????????????????
  ? ???????

30
Specific Phobia ??? Social Phobia

• Social phobia ?????????????????????? ???
  ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  (social or performance situations)
  ???????????????????????????????????????
  (avoidance) ?????

31

• Specific phobia ?????????????????????? ???
  ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  (specific feared object or situation)
  ???????????????????????????????????????
  (avoidance) ?????

32
??????????????????? Social Phobia

• A. ???? (fear) ???????????????????????????????????
  ?????????????????????? (social or performance
  situations) ??????????????????????????????????????
  ?????????????? ??????????????????????????????????
  (??????????????????????) ?????????????????????????
  (humiliating or embarrassing)
• B. ??????????????????????????????? (feared
  social situation) ?????????????????????????????
  (anxiety) ????????????? panic attack
• C. ?????????????????????????????? (excessive)
  ????????????????? (unreasonable)

33
??????????????????? Social Phobia

• D. ?????????? ???????????????????????????????????
  ??????????????????????????? (anxiety)
  ??????????????????????? (distress) ???????????
• E. ??????????????????, ????????????????????
  ??????????????????????????????????????????????????
  ??????????????????????????????????????????,
  ?????? (????????), ???????????????,
  ?????????????????????? ???????????????????????????
  ???????????????????????????????????
• F. ?????????????????????????? 18 ??,
  ???????????????? 6 ?????

34
??????????????????? Social Phobia

• G. ???????? (fear) ????????????????? (avoidance)
  ??????????????????????????????????????????????????
  ??????????? ??????????????????????????????????????
  ??? ? ???? panic disorder with or without
  agoraphobia, separation anxiety disorder, body
  dysmorphic disorder, a pervasive developmental
  disorder, schizoid personality disorder ???????
• H. ?????????????????????????????????????????????
  ? ?????????????? 1 ???????????????????????????????
  ???????

35
??????????????????? Specific Phobia

• A. ???? (fear) ??????????????????????????????????
  ????????? (excessive) ???????????????
  (unreasonable) ???????????????????????????????????
  ??????? (object) ????????????? (situation)
  ??????????????????????? ???? ?????????????????
  (flying), ??????? (heights), ????? (animals),
  ??????????? (receiving an injection),
  ???????????? (seeing blood)
• B. ??????????????????????????????????????????????
  ??????????? (anxiety) ????????????????????????????
  panic attack
• C. ?????????????????????????????? (excessive)
  ????????????????? (unreasonable)

36
??????????????????? Specific Phobia

• D. ??????????????????????????????????????????????
  ?????? (anxiety) ???????????????????????
  (distress) ???????????
• E. ??????????????????, ????????????????????
  ??????????????????????????????????????????????????
  ????????????????????, ?????? (????????),
  ???????????????, ??????????????????????
  ??????????????????????????????????????????????????
  ????????????
• F. ?????????????????????? 18 ??,
  ???????????????????? 6 ?????

37
??????????????????? Specific Phobia

• G. ????????????? (anxiety), panic attack,
  ????????????????????????????????? (phobic
  avoidance) ???????????????? (object)
  ????????????? (situation) ???????????????????????
  ????????????????????????????? ? ????
  obsessive-compulsive disorder, posttraumatic
  stress disorder, separation anxiety disorder,
  social phobia, panic disorder with agoraphobia,
  agoraphobia without panic disorder ???????

38
?????????????? (Drug Treatment)

• ?? specific phobia ???????????????????????
  (adjuctive treatment) ?????? adrenergic
  antagonists ???? propanolol ??????????????????????
  ?????? autonomic hyperactivity
• social phobia monoamine oxidase inhibitors
  (????????????????????????????), reversible
  inhibitors of MAO-A (RIMAs), benzodiazepines
  (???? clonazepam, alprazolam) ??? beta-blockers
  (???? atenolol, propanolol)

39
??????????????????? (Psychosocial Treatment)

• specific phobia exposure therapy
  ???????????????????????? (desensitization)
  ???????????????????? ? ???????????????????????????
  ???????????(hierarchy) ???????????????????????????
  ????????????????????????????????????????????
  relaxation ???? breathing control
  ??????????????????????????????????????????????????
  ?????????????????????? ? (????????????????????????
  ??) Systematic Desensitization
• social phobia cognitive therapy, behavioral
  therapy ??? exposure therapy

40
Obsessive-Compulsive Disorder

• ???????????????????? (obsessions)
  (?????????????????????????????????????????????????
  ?????????????????)
• ???/???????????? (compulsions)
  (?????????????????????????????????????) ???????
  OCD ??????????????????????????????????????????????
  ???????????????????

41
??????????????????? Obsessive-Compulsive Disorder

• A. ??????????? (obsessions) ????????????
  (compulsions)
• ????????? (obsessions) ????????????????????
  a., b., c. ??? d.
• a. ??????? (thoughts), ?????????? (impulses)
  ???????????? (imaging) ???????? ??? ? ???????
  ??????????????????????????? (intrusive)
  ??????????????????????????? (inappropriate)
  ???????????????????????? (anxiety)
  ??????????????????????? (distress)

42
b. ???????, ?????????? ???????????????? ?
????????????????????????????????????????????
(excessive worries) ??????????????????????????????
??? (real-life problems)
c. ???????????????????? (ignore)
?????????? (suppress) ???????, ??????????
???????????????? ? ???????????????????????????????
??????? (thoughts) ???????????? (actions) ????d.
?????????????????????, ??????????
???????????????????????????????????????????
(mind) ?????
43
???????? (compulsions) ????????????????????????
a. ??? b.

• a. ??????????? ? (repetitive behavior)
  (??????????????, ?????????, ??????????) ????
  ????????????????????????? (mental actions) (????
  ??????????, ??????, ??????????? ? ??? ?)
  ??????????????????????????????????????????????????
  ??????????? ???? ?????????????????????????????

44
???????? (compulsions)

• b. ??????????????????????????????????????????????
  ????????????????????????????????????????
  (distress) ???? ??????????????????????????????????
  ???????????????? ?????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????????, ????????????
  ??????????????????????????

45
??????????????????? Obsessive-Compulsive Disorder

• B. ??????????????????????????????????????????????
  ????? (excessive) ??????????????? (unreasonable)
  (??????????????)
• C. ????????? (obsessions) ????????????
  (compulsions) ????????????????????????????????????
  ??????? (marked distress), ????????,
  ????????????????????????, ??????????????,
  ???????????????????? ????????????????????????????

46
??????????????????? Obsessive-Compulsive Disorder

• D. ??????????????????????? 1 (Axis I) ????????
  ??????????????????? (obsessions) ????????????
  (compulsions) ????????????????????????????????????
  ????? ? ???? eating disorder, trichotillomania,
  body dysmorphic disorder, hypochrondriasis,
  paraphilia, major depressive disorder)
• E. ??????????????????????????????????????????????
  ?????????????????????????????????????

47
???????? OCD ????????????????????????????

• 1. ?????????????????????????????? (Obsession of
  contamination) ??????????????????????????? ?,
  ??????????????????? ???? ???????, ???????, ????,
  ???????? ???????
• 2. ?????????????????????????? (Obsession of
  doubt) ??????????????????????????? ?
  ?????????????????????????? ???? ???????????,
  ???????????? ???????

48
???????? OCD ????????????????????????????

• 3. ?????????????????????????????????????
  (Obsessional thoughts without a compulsion)
  ??????????????????????????????????????????????????
  ???????????????????? (sexual or aggressive act)
• 4. ????????????????????????????????????? (Need
  for symmetry or precision) ???????????????????????
  ??????????? (compulsion of slowness) ????
  ????????????????????????????????????????

49
??????????????????? OCD ???? poor prognosis ???

• 1. ???????????????????????????? (compulsions)
• 2. ????????????????????????
• 3. ????????????????? ?
• 4. ?????????????????????????????
• 5. ?? overvalued ideas ??? ????????????????? ?
  ????????????????????????? (delusions)
• 6. ??????????? (delusions) ????????
• 7. ?? personality disorder ???????? ????
  schizotypal personality disorder ???????

50
?????????????? (Drug Treatment)

• clomipramine 25-50 mg. ???????
  ??????????????????????????????? 25 mg/d ??? 2-3
  ??? ?????????????????? 250 mg/d
  ???????????????????????? (side effects) ??????
• SSRIs 80 mg/d ??? fluoxetine, 300 mg/d ???
  fluvoxamine ???? 60 mg/d ??? paroxetine
• ???????????? 10 ??????????????????????????????????
  ????????????????? ?????????????????????? SSRIs
  ?????????????????? ??? clonazepam, pimozide ????
  buspirone ????????????????????????????????????????
  ???????????????????????????? cingulotomy

51
??????????????????? (Psychosocial Treatment)

• behavioral therapy ??????????????????????????????
  ?????????????????????????????????????????
  exposure, response prevention ????????????
  desensitization, thought stopping ??? flooding
• ???????????????? ? ???????????????????????????????
  ???????????????????? ??? ?????????????????????????
  ??? (insight-oriented therapy),
  ???????????????????????? (supportive
  psychotherapy), ????????????? (family therapy)
  ???????????????? (group psychotherapy)

52
Posttraumatic Stress Disorder Acute Stress
Disorder

• Posttraumatic stress disorder (PTSD) ???
  ???????????????????????? ??? ?????????????????????
  ?????????????????????????????????????????????????
  (extremely traumatic event) ?????????????????
  (reexperiencing) ?????????????????????????????????
  ??? (increased arousal) ??????????????????????????
  ???? (stimuli) ?????????????????????
• Acute stress disorder (ASD) ??????????????????????
  ??? ??????????????????????????? posttraumatic
  stress disorder ??????????????????????????????????
  ?????????????? (extremely traumatic event)

53
??????????????????? Posttraumatic Ttress Disorder
(PTSD)

• A. ???????????????????????????????? (traumatic
  event) ????????????????????????????????
• a. ????? (experienced), ?????????????
  (witnessed) ????????? (confronted)
  ???????????????????????????????? (actual death),
  ??????????? (threatened death), ?????????????
  (serious injury) ???????????????????????????
  (threat to the physical integrity)
  ????????????????
• b. ??????????????????????????????????? (intense
  fear), ??????????????????????????????
  (helplessness), ??????????????? (horror)

54
??????????????????? Posttraumatic Ttress Disorder

• B. ????????????? (reexperienced)
  ?????????????????? (traumatic event)
  ?????????????????????????????????????????
• a. ???????????????? (recollections)
  ????????????? ? ??????????????????????????????????
  ???????? (distressing) ??????????????????????
  (images), ??????? (thoughts) ???????????????
  (perceptions)
• b. ??????????????????????????????? (distressing
  dreams) ???? ?
• c. ???????????? (acting) ?????????? (feeling)
  ???????????????????????????????????????????

55
??????????????????? Posttraumatic Ttress Disorder

• d. ???????????????????????????? (intense
  psychological distress) ??????????????????????????
  ??????????????????????????????????????????????????
  ????????????? (symbolize) ????????? (resemble)
  ?????????????????????
• e. ?????????????????????? (physiological
  reactivity) ??????????????????????????????????????
  ??????????????????????????????????????????????????
  ? (symbolize) ????????? (resemble)
  ?????????????????????

56
??????????????????? Posttraumatic Ttress Disorder

• C. ??????????????? (avoidance) ????????
  (stimuli) ???????????????????????????? (trauma)
  ??? ???????????????????????? (general
  responsiveness) ??????????????????? 3
  ?????????????????
• a. ?????????????????????????, ??????
  ??????????????????????????? (trauma)
• b. ???????????????????????, ???????
  ?????????????????????????????????????????????
  (trauma)
• c. ????????????? (recall) ???????????????????????
  ?????? (trauma)

57
??????????????????? Posttraumatic Ttress Disorder

• d. ?????????? (interest) ????????????????
  (participation) ??????????????????????
• e. ?????????????? ( feeling of detachment)
  ????????????????? (enstrangement) ??????????
• f. ??????????????????? (restricted range of
  affect) ????????????????????????
• g. ??????????????????? (foreshortened future)
  ???? ????????????????? ? ????????????????,
  ???????, ???? ???? ?????????????????

58
??????????????????? Posttraumatic Ttress Disorder

• D. ????????????????????????????????????????
  (symptoms of increased arousal)
  (?????????????????????????????????)
  ???????????????????? 2 ????????????
• a. ???????????????????????????? (difficulty
  falling or staying sleep)
• b. ???????????????????? (irritability)
  ???????????????????? (outbursts of anger)
• c. ?????????? (difficulty concentrating)
• d. ?????????? (hypervigilance)
• e. ???????????????? (exaggerated startle
  response)

59
??????????????????? Posttraumatic Ttress Disorder

• E. ??????????????????? (????? 2, 3 ??? 4)
  ????????????? 1 ?????
• F. ??????????????????????????????????????????????
  ??????? (significant distress) ???????????????????
  ????????????????????? (functioning) ????????,
  ?????????????? ?????????? ????????? ?

60
???????????????? Acute Stress Disorder (ASD)

• ???????? PTSD ???????????????????????? ???
• ???????????????????????? ASD ??????????????? 4
  ??????? ????????????????????????? (traumatic
  events)
• ????????????????????????????????? 2
  ????????????? 4 ???????
• ????????????????????? 4 ????????????????????????
  ?????????? ASD ???? PTSD

61
?????????????? (Drug Treatment)

• ?????????????? ???????????????????????????????
  ??? imipramine ??? amitriptyline 50-300 mg/d
  ?????????????????? (intrusion) ????????????????
  (avoidance) ??? ??????????????????????????????? 8
  ??????? ??????????????????????????????????????????
  ??????????? 1 ??
• ?????????? ? ?????????????????????? ?
  ?????????????????????? (aggression)
  ?????????????? (agitation) ??? SSRIs, MAOIs,
  anticonvulsants, clonidine, propanolol.
  alprazolam ??????????????? (antipsychotics)

62
??????????????????? (Psychosocial Treatment)

• ??????????????????? ??? ??????????????????? PTSD
  ??????????????????????????? (traumatic events)
  ??????????????????????????????????????????????????
  ? (crisis intervention)
• Gelder ?????? (1994) ????????????????? ???

63

• 1. ??????????????????????????????????????????????
  ??????????????????????(sympathetic)
  ????????????????????????????? ?
  ??????????????????????
• 2. ??????????????????????????????????????????????
  ??? (working through) ????????????????????????????
  ????????? (avoidance) ?????????? (denial)
  ?????????????????????????????????????????
• 3. ???????????????????????????? (coping)
  ???????????? ? ???????????????
• 4. ???????????????????????? ???? ?????????????,
  ???????????? ???????

64
?????????????????????????? PTSD
??????????????????????????????????????????????????
?????

• ??????????????????????????? (exposure)
  ????????????????????????????????? (systemic
  desensitization) ?????????????????????????????????
  ?? (relaxation technique) ?????????????????????
  (cognitive therapy)
• ?????????????????? ? ???????????? ???
  ????????????? (group psychotherapy),
  ????????????? (family therapy)

65
Generalized Anxiety Disorder(GAD)

• ???????????????????? ??? ?????????????????????
  ??? (anxiety) ???????????? (worry)
  ?????????????????????????????????? 6 ?????

66
??????????????????? generalized anxiety disorder
(GAD)

• A. ??????????????? (anxiety) ?????????????
  (worry) ?????????????????????????? (events)
  ??????????? (activities) ????????? ????
  ???????????????????? ????????????????????
  ????????????????? 6 ?????
• B. ??????????????????????????????? (worry)
  ?????????????????

67

• C. ????????????? (anxiety) ????????????? (worry)
  ????????????????????????? 3 ?? 6
  ?????????????????
• a. ??????????? (restlessness) ???????????????????
  (feeling keyed up) ????????????? (on edge)
• b. ????????????? (being easily fatigued)
• c. ?????????? (difficulty concentrating)
  ????????? (mind going blank)
• d. ???????? (irritability)
• e. ??????????????????? (muscle tension)
• f. ????????????? (sleep disturbance) ??????????,
  ??????????????????? ??????????????????

68

• D. ??????????????????????????????????????????????
  ??????????????????????????? 1 (Axis I)
• E. ?????????????, ?????????????
  ??????????????????????????????????????????????????
  ??????? (significant distress) ???????????????????
  ?????????????????????, ??????????????
  ?????????????? ? ????????
• F. ??????????????????????????????????????????????
  ????????????? (substances) ???????????????????
  (general medical condition) ??????????????????????
  ????????????? mood disorders, psychotic disorder
  ???? pervasive developmental disorder

69
?????????????? (Drug Treatment)

• benzodiazepines ??? buspirone
• ????????????????????????????????????????????????
  ??? ?????????????? (diagnosis), ?????????????
  (target symptoms) ????????????????????? (duration
  of treatment) ????????????????????????????????????
  ?????? 2-6 ????????????????? ???1-2
  ???????????????? ? ??????

70
Benzodiazepines

• intermediate half-life, 8-15 hrs???? lorazepam,
  alprazolam ???????????????????????????????????????
  ???????????????????????????????????????
  benzodiazepines ????????????????????? (long
  half-life, gt100 hrs) ?????????????????????????????
  ??
• ?????????????????????????????? 25-30
  ???????????????????????????? (tolerance)
  ????????????? (dependence) ??? benzodiazepines ???

71
Buspirone

• ????????????????????????? GAD ???????????????????
  60-80 ????????????????? ????????
  ???????????????, ????????????????????????????????,
  ??????????????????????????????????????
  ???????????????????? alcohol ???????
  ?????????????? 2-3 ???????????????????????????????
  ??????????????????????????????????????
  benzodiazepines ?????????????????????????????????
• ?????????????????? ??? ??????????????
  (antidepressants) ??? B-adrenergic antagonist

72
??????????????????? (Psychosocial Treatment)

• 1. ???????????????????????? (Supportive
  psychotherapy) ???????????????????????????????????
  ????????????????
• 2. ????????????????????????????
  (Insight-oriented psychotherapy)
  ????????????????????????????????????????????
  (unconscious conflict)
• 3. ???????????????????? (Cognitive
  psychotherapy) ???????????????????????????????????
  ????????
• 4. ???????????????????? (Behavioral
  psychotherapy) ???????????????????????????????????
  ? GAD

73
Anxiety Disorder due to a General Medical
Condition
and

Substance-Induced Anxiety
Disorder
74
Anxiety Disorder due to a General Medical
Condition

• Endocrine conditions hyperthyroidism,
  hypothyroidism, pheochromocytoma, hypoglycemia,
  hyperadrenocorticism
• Cardiovascular conditions congestive heart
  failure, pulmonary embolism, arrhythmia
• Respiratory conditions chronic obstructive
  pulmonary disease, pneumonia, hyperventilation
• Metabolic conditions vitamin B12 deficiency,
  porphyria
• Neurological conditions neoplasms, vestibular
  dysfunction, encephalitis

75
Substance-Induced Anxiety Disorder

• intoxication alcohol, amphetamine
  ?????????????????, caffeine, cannabis, cocaine,
  hallucinogens, inhalants, phencyclidine
  ????????????????? ???????
• withdrawal ???? alcohol, cocaine, sedatives,
  hypnotics ??? anxiolytics

76
?????????????????????

• analgesics, sympathomimetics ????
  bronchodilators, anticholinergics, insulin,
  thyroid preparations, oral contraceptives,
  antihistamines, antiparkinsonian medications,
  corticosteroids, antihypertensives ???
  cardiovascular medications, anticonvulsants,
  lithium carbonate, antipsychotic medications,
  antidepressant medications ???????

77
???????? (Treatment)

• ???????????????????????????????
• ??????????????? ???? ????????????????????????????
  ????????????????
• ??????????????????????????????????????????????????
  ???????????????????????????????????????????? ????
  ?????? anxiolytics, serotonergic antidepressants,
  behavioral therapy ???????
• 
  

78
Somatoform Disorders

• ??????????????????????????????????????????????????
  ???????????? ?????????????????????????????????????
  ???????? ??????????????????????????????
• 1) ???????????????????????????????????????????????
  ???????????????????????????????????
• 2) ??????????????????? ??? ???????????(conflicts)
  ????????????????????????(initiating),?????????????
  ???????????????????????(exacerbation) ???
  ?????????????(maintenance)

79
Somatoform Disorders
V

Psychological Factors affecting medical
conditions

• Asthma
• Migraine
• Tension Headace
• Rheumatoid Arthritis
• Ulcerative Colitis
• etc.

80
Somatoform Disorders

• 1. Somatization Disorder
• 2. Conversion Disorder
• 3. Hypochondriasis
• 4. Body Dysmorphic Disorder
• 5. Pain Disorder
• 6. Residual diagnostic categories ????
  Undifferentiated Somatoform Disorder, Somatoform
  Disorder NOS

81
Somatization Disorder

• monosymptomatic syndrome - conversion disorder
  polysymptomatic syndrome -
  somatization disorder
• ????????? 17 Thomas Sydenham ?????? psychological
  disturbance??????????? Antecedent
  sorrow(??????????????????????????)
  ????????????????????????? hysteria
  Sydenham????????????????? hysteria????????

82

• 1970 ????? multisymptomatic hysteria ???
  Briquets syndrome ???? Briquets disease
• ?? DSM-III ?????? Briquets syndrome??????????????
  ????????????????? somatoform disorder

83
??????????????????? Somatization Disorder

• A. ???????????????????????????????? ????????????
  30 ???????????????????????????????????????????????
  ??????????????????????? ?????? ???????????????????
  ????????

84

• B. ??????????????????????????????????????????
• . 4 pain symptoms ?????????? ???????????????????
  ??? ???????????( ??????? ?????, ????, ????, ???,
  ?????, ??, ???????? ???????
  ???????????????????, ??????????????,
  ??????????????)

85

• . 2 gastrointestinal symptoms
  ?????????????????????????? ???????????????????
  ??? ???? ????????, ???????, ????????????????????
  ??????????????????, ???????? ????
  ???????????????????????????????????????????
• . 1 sexual symptoms ??????????????? ????
  ??????????????????? ??????????????????? ???
  ???? ??????????????????????????????
  ????????????????????,?????????????????,
  ?????????????????????, ????????????????????????,
  ???????????????????????????????

86

• . 1 pseudoneurological symptoms ????????? ????
  ???????????(deficit)??????????????????????????????
  ??????????????????????????? ??? ???? ????
  coordination ???? balance, paralysis ????
  localized weakness, ???????? ???? ?????????,
  ??????????, urinary retention , hallucination,
  ?????????????????????????? ??????????,
  ???????????, ???????, ???, dissociative symptoms
  ???? ????????(amnesia), ??????????????????????????
  ????????????????????(loss of consciousness other
  than fainting)

87

• C. ???????????? 1. ???? 2.
• 1. ????????????????????? ??????? B.
  ????????????????????????????????????? ????
  ????????(???????? ???? ??)
• 2. ????????????????????? ??????????
  ?????????????????? ??????????????????????????????
  ???????, ?????????????? ???? Lab
  
• D. ?????????????????????????????(???? ??
  factitious disorder ???? malingering)

88
???????? (Treatment)

• ???????????(management)??????????????
• ????????(treatment)
• ????????????????????????????????(doctor-patient
  relationship)?????????????????????????????

89
Helpful management strategies for Somatoform
Disorder

• - ????????????????(primary care
  doctor)??????????????????(????????????)
  ???????????????????????????????????
• - ??????????????????????????????? ??? ??? ??? ??
  ???????
• - ?????????????????????????????????????
• - ???????????????????????? ??????????????????????
  ??????????????????????????????????????????

90

• - ????????????????????????????????????????????????
  ??? ????????????????????????????
• - ???????????(signs)?????? ???????????????????????
  ???????
• - ?????????????????????????????????(diagnosis
  test) ????????????????????????(laboratory
  evaluations) ???? ?????????(operative procedure)
  ??????????????????????????
• - ???????????????????????????????????????????????
  ?????????????????????????

91

• ??????????????????????????????????????????????????
  ?????????????? ? ?????????
• ???????? ???????????????????????????????????
  Somatization Disorder ???????????? ???
  ????????????????????????????????? ?
  ??????????????????????????? ??????????????????????
  ????????????
• ??????????????????????????????????????????????????
  ??????????drug abuse

92
Conversion Disorder

• ?????? ????????????? Conversion Disorder ???
  Somatization Disorder ??????????? hysteria ,
  conversion reaction ???? dissociative reaction
• ???????????? Briquet ??? Jean-Martin Charcot
  ????????????? conversion ??????????????????????
  ????????????????????????????????????????????
  (traumatic event)
• Sigmund Freud ??????????????????? ?????
  conversion ???????????????????????????????
  (unconscious conflict)

93
??????????????????? Conversion Disorder

• A. ?? 1 ???? ??????? 1????????????????????(symptom
  s or deficit) ??? voluntary motor ???? sensory
  function ?????????????? ????????????????
  ???????????????
• B. ?????????????????????????????????????????
  ????????????(initiation) ??????????????????????(ex
  acerbation)???????? ??????????????????????(conflic
  ts) ???? ??????????(stressors)
• C. ?????????????????????????????(????
  ??factitious disorders ???? malingering)

94

• D.????????????????????? ??????????????????????????
  ???????????????? ???? ?????????????? ????
  ???????????????????????????????????????????????(cu
  lturally sanctioned behavior or experience)
• E. ??????????????????? ???????????????????????????
  ????????????????????
• F. ??????????????????????? ????????
  ????????????????????? ????????????????????????????
  ???? Somatization Disorder ???????????????????????
  ?????????

95

• ???? ??????????????????????????
• . with motor symptom or deficit
• . with sensory symptom or deficit
• . with seizure or convulsion
• . with mixed presentation

96

• ??????????????????????? ?????? ????? ?????????
• ???????????????????????????????????? ??? passive
  aggressive , dependent , antisocial ???
  histrionic
• ?????????????????????????????????????????????
  Depressive ??? Anxiety disorders ???????

97
???????????????????????????????????????????? ???

• 1. Sensory symptoms ????????????????????????????
  ? ???? stocking and glove anethesia
  ????????????????????????????????????????????
  ??????????? ????? Tunnel vision
  ???????????????????? ???????
• 2. Motor symptoms ????????? ???
  ???????????????????????????, ??????????
  ???????????????? ????????? ? ???????????? ????
  tremor, choreiform, tics, jerk ???????

98

• 3. ???????? (Seizure symptom)
  ??????????????????? (pseudoseizure) ?????????
  (seizure) ??????????????????? ????????????????????
  1 ?? 3 ????????????????????????????????????????
• 4. ?????????? ? ????????????? (Other associated
  features)
• 4.1 Primary gain
• 4.2 Secondary gain
• 4.3 La belle indifference
• 4.4 Identification

99
???????? (Treatment)

• ?????????????????????????????????
• ??????????????????????????????????????????????????
  ????????????

100
Hypochondriasis

• ?????????????????????????????????????????????
  ?????? ???????????????????????????????????
• ?????????????????????????????????????????????
  ? ???????????????????? ?
• ?????????????????????????????????
  ????????????????????????????????????? ?
  ??????????????

101
??????????????????? Hypochondriasis

• A. ???????(preoccupation)?????????????????????????
  ???????????????????? ?????????????????????????????
  ??????????
• B. ??????????????????????? ???????????????????????
  ??????????????????????????
• C. ?????????????? A. ???????????????? (???? ??
  Delusional Disorder, Somatic Type)
  ?????????????????????????????????????????????(????
  ?? Body Dysmorphic Disorder)

102

• D. ??????????????????????? ????? ????
  ?????????????????
• E. ???????????????? 6 ?????
• F. ????????????? generalized anxiety disorder,
  obsessive compulsive disorder, panic disorder,
  major depressive episode, separation anxiety ????
  somatoform disorder ????
• ???? ???
• with poor insight ??????????????????????
  ??????????????????????????????????????????????????
  ???????????????????????? ???? ???????????

103
????????(Treatment)

• ??????????????????????????????????
  ????????????????????????????????????????????????
• ??????????????????????????????????????
  ??????????????????????????????????????
• ????????????????????????? ????????????????????????
  ??? ????? Social support ??? Interaction
  ??????????????????????
• ????????? Insight - oriented psychotherapy
  ???????????????

104

• ??????????????????????????? ??????????????????????
  ?????????????? ???????????????????????????????????
  ?????????
• ??????? ??? ???????????????????????????????????
  ?????? ???????????????????????

105

• ??????????????????????????????????????????????????
  ????????????????????????????????? Underlying
  ???????? Major depressive disorder ???? Anxiety
  disorder
• ??????????????????????? Hypochodriacal
  ???????????????????????????????????????? (
  Transient situational reactoin )
  ??????????????????????????????????????????????????
  ????????????? ?????????????????????????????

106
Body Dysmorphic Disorder

• ???????????????? Body Dysmorphic Disorder
• A. ??????????????????????????????????????(imagined
  defect)??????????(appearance) ???????????????????
  ????????? ???????????????????????????????????????
• B. ??????????????????????? ????? ????
  ??????????????????????
• C. ???????????????????????????????????????????????
  ? ???? Anorexia Nervosa

107
????????

• ???????????????????????????????????????
  ??????????? ??????? ????????? ????????
  ????????????????????????????
• ?????? Serotonergic drug ???? Fluoxetine ????
  Clomipramine??????????? 50
• ???????????????????????????????????????

108
Pain Disorder

• ???????????????????????????????????????????????
  ???????????????????????????????????????
• ???????????????????????????????????????????????
  ???????????

109
??????????????????? Pain Disorder

• A. ????????????????? 1 ????????????????????????
  ?????????????????????????????????? ???
  ??????????????????????????????????????????
• B. ????????????? ???? ?????????
  ??????????????????????
• C. ????????????????? ????????????
  ??????????????(onset) ??????????(severity)
  ??????????(exacerbation) ???? ?????????(maintenanc
  e) ???????????

110

• D. ????????????? ???????????( ?????? Factitious
  Disorder ???? Malingering)
• E. ????????????????????? Mood, Anxiety ????
  Psychotic Disorder ??? ??????????? ????????
  Dyspareunia
• ???? Pain Disorder Associated with Psychological
  Factors
• Pain Disorder Associated with Both
  Psychological Factors and a General Medical
  Condition
• Pain Disorder Associated with a General
  Medical Condition
• ???? Acute ??????????????? 6 ?????
• Chronic ?????????????? 6 ?????

111
????????(Treatment)

• Pharmacotherapy
• ?????????????????? ???? Psychotropic medication
  ??????????????????????????????????????????????????
  ???
• Antidepressant ???? Amitriptylline , Imipramine
  ???? Doxipine ????????????? ???? Serotonergic -
  antidepressant ???? Clomipramine ???? Fluoxetine
  ????????????????? ???????????????????????????
  Serotonin ????????????????????????

112

• Behavioral therapy
• Biofeedback ???????????? Migraine ,
  Myofacial pain ???? Muscle tension
• Psychothehrapy
• ????? Psychodynamic psychotherapy ?????
  ??????????????????????????????????????????????????
  ?? ???????????????????????????????????????????????
  ???? ? ????????????????????????????????
  ??????????????????????????????????????????????????
  ?????( Physical) ??? ????????(Psychological)
  ???????????????????????????????

113

• Pain control program
• ????????????????????????????????????????????
  ?????????????????????? ??????????????????? Pain
  unit ???????????????????????????? ???? Cognitive
  - Behavioral therapy , Group psychotherapy ,
  Physical ??? Rehabilitation ???
  ????????????????????????????

114
Undifferentiated Somatoform Disorder

• ???????????????????
• A. ???????????????????? 1 ???????????(????
  ?????????, ??????????, ???????????????????????????
  ???????????????
• B. ??1) ???? 2)
• 1)????????????????????? ??????????????????????
  ??????????????????????? ????????????????????
• 2)????????????????????? ??????????????????????
  ???????????????????????????????
  ??????????,?????????????? ?????Lab

115

• C. ??????????????????? ???? ??????????????????????
  
• D. ??????????? 6 ?????
• E. ??????????????????????????????????(????
  Somatoform Disorder????, Sexual Dysfunction, Mood
  Disorder, Sleep Disorder ???? Psychotic Disorder)
• F. ????????????????????????(???? ?? Factitious
  Disorder ???? Malingering)

116
Somatoform Disorder NotOtherwiseSpecified(NOS)
????????????????

• ???????????????????????? Somatoform ???
  ?????????????????????? Specific Somatoform
  Disorder ?? ??????

117

• Pseudocyesis ????????????????????????????????????
  ???????????????????????????????????? ????
  ????????, ?????????????????????,
  ?????????????????, ????????, ?????????????????????
  ??, ???????????????????????????????
  ??????????????????????????????????????????????????
  
• Nonpsychotic Hypochondriacal Symptom
  ??????????????? 6 ?????
• Unexplained Physical Complaints (????????? ????
  ??????????????)??????????????? 6 ????? ???
  ?????????????????????????????

118
??????????????????? Factitious Disorder

• A. ??????????? ???? ??????????????? ???????
  ?????????
• B. ?????????????????????????? ??????????????????(s
  ick role)
• C. ??????????????????? ???? ???????,
  ???????????????????????????? ?????????????????????
  ????????????? Malingering
• ????
• With Predominantly Psychological Signs and
  Symptoms
• With Predominantly Physical Signs and Symptoms
• With Combined Psychological and Physical Signs
  and Symptoms

119
Malingering

• Definition ?????????????????????? ???? ?????
  ???????????????????????????????????? ????
  ??????????, ??????????????? ???? ????????

120
Dissociative Disorders

• ??????????????????????????????????????????????????
  ??????(unitary sense of self) ???
  ????????????????? ????????????????????????????????
  ?????(a single basic personality)
• ??????????????????????????????????????????????????
  ???????????(thoughts),??????????(feelings)????????
  ??? (actions) ????????????????????????????????????
  ???(unique personality)
• dissociative disorders ????????????? ???
  ?????????????????????????????????????

121
?????????????? DSM-IV

• 1. Dissoiative Amnesia ????????? Psychogenic
  Amnesia
• 2. Dissociative Fugue ????????? Psychogenic Fugue
• 3. Dissociative Identity Disorder ( Multiple
  Personality Disorder)
• 4. Depersonalization Disorder
• 5. Dissociative Disorder Not Otherwise specified
  (NOS)

122
Dissociative Amnesia

• ??????????(amnesia)??????????????
• ?????????? dissociative amnesia
  ??????????????????????????????????????????????????
  ?????????????????????????stressful or traumatic
  events
• ?????????????????? dissociative amnesia ???
  personal identity ????????????????????????????????
  ??????????

123

• ????????????????????????????????????? dementia
  ??????????????????????????????????????????????
  ???? ???????????????????????? ????????????????????
  ??????????????????????????? ??????????????????????
  ??????????

124
???????????????? Dissociative Amnesia

• A. ??????????????????? ??? ???????????????????????
  ??????????????? ???????????????????????
  ????????????????????????? ???? ???????????????(tra
  umatic or stressful nature) ??????????????????????
  ?????????????????????????????????????(ordinary
  forgetfulness)

125

• B. ???????????????????????????????????????????????
  ???????(course) dissociative disorder,
  dissociative fugue, posttraumatic stress
  disorder, acute stress disorder, ????
  somatization disorder ????????????????????????????
  ??????????????(???? ????????? ???? ??)
  ?????????????????????? ?????????????????(amnestic
  disorder ?????????????????????)

126

• C. ???????????????????????????????????????????????
  ???????? ???? ??????????????????? ?????, ??????,
  ???? ???????????????????

127
????? amnesia ??????

• localized amnesia ???????????????????????
  ???????????????????????????????????????(??????????
  ????????????????)
• generalized amnesia ????????????????????????????
  ??????????(whole lifetime experience)
• selective(systematized) amnesia
  ?????????????????????????????????????????????????

128
????????(Treatment)

• ??????????????????????????????????????
  ?????????????????????????????????????????
  ??????????????????????????????????????????????????
  ???????? ?????????????????????????????????????????
  ?????????????

129

• ??????????????????????????????????????????????????
  ????????????????????????? ?????? intermediate ???
  short acting barbiturate ???? thiopental(Pentothal
  ) ??? sodium amobarbital ????????????
  ??????????????????????????????????????
  (drug-assisted interview)
• ??????????(hypnosis) ?????????????????????????????
  ???????????????????????????
• ?????????????????????????????????
  ???????????????????????????????????????????????(in
  corporate)?????????????

130
Dissociative Fugue

• ??dissociate fugue ???????????????????????????????
  ?????????????????????????????????????????
  dissociative amnesia
• ?????????????????????????? ????????????
  ??????????????????????????????????????(????,
  ????????, ??????)
• ?????????????????????????????????
• ???????????????????????????????????????????????
  dissociative identity disorder

131
???????????????? Dissociative Fugue

• A. ??????????????????? ????????????????????????
  ?????????????????????????????????????????
  ???????????????????????????????????
• B. ?????????????????????????????????? ????
• (assume)?????????????(??????? ???? ???????)

132

• C. ???????????????????????????????????????????????
  ??????? dissociative identity disorder
  ??????????????????????????????????????????(????
  ????????? ???? ??) ???? ????????????????(????
  temporal lobe epilepsy)
• D. ???????????????????????????????????????????????
  ???????? ???? ??????????????????? ?????, ??????,
  ???? ???????????????????

133
????????(Treatment)

• ???????????????? dissociative amnesia
  ????????????????????,???????????????????????(drug-
  assisted interviewing), ?????????????
  ????????????????? ????????????????????????????????
  ????????????
• ??????????????????????????????????????????????????
  ?????????????????? ???????????? treatment of
  choice ??? dissociative fugue ???
  expressive-supportive psychodynamic psychotherapy

134
Dissociative Identity Disorder ( DID)
(Multiple
Personality Disorder)

• ???? dissociative disorder ??????????????????
  ???????????????????????????????????????
  ???????????????????????????????????????
  ???????????????????
• ??????????????????????????????????????????????????
  ????????????????????????????????????????????????
• ???? dissociatice disorder ??????????????????????

135
???????????????? Dissociative Identity Disorder

• A. ?????????????? ???? ???????????????????????????
  ????????????? 2 ?????????(????????????????????????
  ??????????????????, ???????????,
  ????????????????????????????? ????????)
• B. ??????????? 2 ????????? ???? ?????????
  ????????????????????????????????????

136

• C. ????????????????????????????????
  ??????????????????????????????????????????????????
  ??????????
• D. ????????????????????????????
  ??????????????????????????(????
  ????????-blackouts ????????????????????????-chaoti
  c behavior ?????????????? ????????????????????(???
  ? complex partial seizures) ????????
  ?????????????????????????????????
  ????????????????????????????(imaginary playmates)
  ???? ??????????????????????(fantasy play)????

137
???????????????(Clinical Features)

• ??????????????????? 5-10 ??????
  ?????????????????? 20 ?????? ?????????????????????
  ????????? ????? 2-3 ?????? ???????????????????????
  ??????????
• ??????????????????????????????????
  ????????????????????????????????????????????
• ???????????????????????????????????????????? ????
  ??????? ??? ????????????????????????????????(frien
  ds/companions) ???? ???????(adversaries)

138

• ?????????????????????????????????? ?????????????
  ???? the protector
• ????????????????????????????????????????????
• ??????????????? host personality????????????????
  ???????????????
• host personality ?????????? ????? ???? ???
  ????????? masochistic personality traits
  ??????????????????????????????????

139

• ??????????? secondary personality????
  subordinate personality ??????????????????????
  ???? ??????????????????????? ??????? ??????????
  ????????????????????????????? ??????????,
  ?????????, ???? ??????????
• ????????????????????????? ?????????????????????
• ????????????????????????????????????? (childlike
  personality)

140

• ?????????????????????????????????????? ??????
  ???????????????????
• ??????????????? ???? ?????????????????????????????
  ???????
• ?????????????????? diary ?????????????? multiple
  personalities ????????????????? diary
• ?????? 60 ??????????????????????????????????
  ?????? 20????????????????????????
  ???????????????????????????????????

141
????????(Treatment)

• ???????????????????????? ??? insight- oriented
  psychotherapy ????????????? hypnotherapy ????
  drug-assisted interviewing technique??????????????
  ????????????????,???????(identifying)?????????????
  ???????????????, ?????????????????? abreaction
• ????????????????????, ???????????????????
  ???????????????
• ????????????????? ???? Carbamazepine ???????????

142
Depersonalization Disorder

• depersonalization disorder ????????????????
  ????????????????????????(persistent)?????????????(
  recurrent) ????????????(perception)??????????????(
  self) ???????????????????(sense)
  ???????????????????????????????????

143
????????????? Depersonalization Disorder

• A. ??????????????? ????? ???? ????????????????????
  ????? ??????????????, ????????????????????????????
  ??,????????????????(mental process) ????
  ??????????????? (???? ?????????????????????????)
• B. ?????????????? depersonalization
  ???????????????????????????????????

144

• C. ????? depersonalization ???????????????????????
  ?????????????????????? ???? ???????????????????
  ?????, ??????, ???? ???????????????????
• D. ?????depersonalization ??? ????????????????????
  ???????????????????????????????? ????
  schizophrenia, panic disorder, acute stress
  disorder, ?????????????? dissociative disorders
  ????, ??? ????????????? ??????????????????????????
  (???? ?????????, ??) ???? ????????????????(????
  temporal lobe epilepsy)

145
???????????????(Clinical Features)

• ???????????????????????????? ??????
  ??????????????????????????? ??????????????????????
  ??????????? ????????????????????????????
  ??????????????????????????????? ????
  ??????????????? ????????? ???????????????
  ?????????? ???????????????????????????????????????
  ?????

146

• ????????? ?????????????????????????????????????
  ??????????? ???? ???????????????
• ?? hemidepersonalization ???????????????????????
  ????????????????????????????? ???? ?????????????
  ????????????????????????? parietal lobe
  ???????????

147

• ???????????????????????????? doubling
  ???????????????????? ?????????????? I-ness
  ??????????????????? ????????????????? 2-3 ???
• ??????????????????????????????????????????????????
  ????????????? reduplicative paramnesia ????
  double orientation
• ?????????????????????????????????????????????????
  sense of reality

148
????????(Treatment)

• ?????????????? ??????????????????????? ????
  antianxiety ??????????????????? anxiety
• Psychoanalysis ???? insight-oriented
  psychotherapy ???????????????????????????????????
  ?????????, ??????????????????????,
  ???????????????????

149
Dissociative Disorder Not OtherwiseSpecified(NOS)

• ????????????????? dissociative symptoms
  ???????????
• (???? ?????????????(disruption)
  ????????????????????????? ????????????, ??????,
  ????????? , ???? ????????????????????)????????????
  ????????????????dissociative disorder ??? ??????

150

• ??????????????????? DID ?????????????????????????
  DID ???? a) ??????????????????????????????????????
  ??????? 2 ????????? b) ??????????????????????????
  ???????????????
• ???????????? derealization ????????
  depersonalization ????????

151

• ???? dissociation ????????????????????????????????
  ??????????(coercive persuasion)??????????? ???
  ?????? ???? ???????????(brain washing),
  ????????????????(thought reform), ????
  ??????????????????????? (indoctrination)??????????
  ???????

152

• Dissociative trance disorder ???????????????????
  ????????????????, ?????????, ???? ??????
  ????????????????????? ???? ?????????????
  ??????????????????????????????????????????? ????
  ???????? dissocitive trance ?????????????????????
  ??????????????????????????? ????
  ??????????????????????????????????????????????????
  ????

153

• posssesion trance ??????????? ???????????????????
  ???????????????????? ???????????????????? ??????,
  ????, ???????, ???? ?????????, ?????????????????
  ???????????????????????????????? ???? ????????
  ???? amok (Indonesia), piblokto(Arctic), ataque
  de nervios(Latin America), ??? possession(India)
  dissociative ???? trance disorders ??????
  ??????????????????????????????????????????????????
  ????????????????????????????

154

• Loss of consciousness, stupor, ???? coma
  ???????????????? ????????????????
• Ganser syndrome ?????????????????????????????????
  ?? (???? 225) ???????????????????? dissociative
  amnesia ???? dissociative fugue