最新Comer, Fundamentals of Abnormal Psychology, 3e：来的，异常的心理学基础，3E课件PPT.ppt 117页

'Comer,FundamentalsofAbnormalPsychology,3e：来的，异常的心理学基础，3E SomatoformandDissociativeDisordersInadditiontodisorderscoveredearlier,twootherkindsofdisordersarecommonlyassociatedwithstressandanxiety:SomatoformdisordersDissociativedisorders2Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e SomatoformandDissociativeDisordersSomatoformdisordersareproblemsthatappeartobemedicalbutareduetopsychosocialfactorsUnlikepsychophysiologicaldisorders,inwhichpsychosocialfactorsinteractwithphysicalailments,somatoformdisordersarepsychologicaldisordersmasqueradingasphysicalproblems3Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?PeoplewithhystericalsomatoformdisorderssufferactualchangesintheirphysicalfunctioningThesedisordersareoftenhardtodistinguishfromgenuinemedicalproblemsItisalwayspossiblethatadiagnosisofhystericaldisorderisamistakeandthatthepatient’sproblemhasanundetectedorganiccause7Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?DSM-IV-TRliststhreehystericalsomatoformdisorders:ConversiondisorderSomatizationdisorderPaindisorderassociatedwithpsychologicalfactors8Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e 9Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?ConversiondisorderInthisdisorder,apsychosocialconflictorneedisconvertedintodramaticphysicalsymptomsthataffectvoluntaryorsensoryfunctioningSymptomsoftenseemneurological,suchasparalysis,blindness,orlossoffeelingMostconversiondisordersbeginbetweenlatechildhoodandyoungadulthoodTheyarediagnosedinwomentwiceasoftenasinmenTheyusuallyappearsuddenlyandarethoughttoberare10Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?SomatizationdisorderPeoplewithsomatizationdisorderhavemanylong-lastingphysicalailmentsthathavelittleornoorganicbasisAlsoknownasBriquet’ssyndromeToreceiveadiagnosis,apatientmusthavearangeofailments,includingseveralpainsymptoms,gastrointestinalsymptoms,asexualsymptom,andaneurologicalsymptomPatientsusuallygofromdoctortodoctorinsearchofrelief11Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?SomatizationdisorderPatientsoftendescribetheirsymptomsindramaticandexaggeratedtermsMostalsofeelanxiousanddepressedBetween0.2%and2%ofallwomenintheU.S.experienceasomatizationdisorderinanygivenyear(comparedwithlessthan0.2%ofmen)Thedisorderoftenrunsinfamiliesandbeginsbetweenadolescenceandyoungadulthood12Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?SomatizationdisorderThisdisorderlastsmuchlongerthanaconversiondisorder,typicallyformanyyearsSymptomsmayfluctuateovertimebutrarelydisappearcompletelywithoutpsychotherapy13Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?PaindisorderassociatedwithpsychologicalfactorsPatientsmayreceivethisdiagnosiswhenpsychosocialfactorsplayacentralroleintheonset,severity,orcontinuationofpainAlthoughthepreciseprevalencehasnotbeendetermined,itappearstobefairlycommonThedisorderoftendevelopsafteranaccidentorillnessthathascausedgenuinepainThedisordermaybeginatanyage,andmorewomenthanmenseemtoexperienceit14Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?Hystericalvs.medicalsymptomsItcanbedifficulttodistinguishhystericaldisordersfrom“true”medicalconditionsStudiesacrosstheworldsuggestthatasmanyasone-fifthofallpatientswhoseekmedicalcaremayactuallysufferfromsomatoformdisordersPhysicianssometimesrelyonodditiesinthepatient’smedicalpicturetohelpdistinguishthetwoForexample,hystericalsymptomsmaybeatoddswiththeknownfunctioningofthenervoussystem,asincasesofgloveanesthesia15Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e 16Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatAreHystericalSomatoformDisorders?Hystericalvs.factitioussymptomsHystericalsomatoformdisordersaredifferentfrompatternsinwhichindividualsarepurposefullyproducingorfakingmedicalsymptomsPatientsmaybemalingering–intentionallyfakingillnesstoachieveexternalgain(e.g.,financialcompensation,militarydeferment)Patientsmaybemanifestingafactitiousdisorder–intentionallyproducingorfakingsymptomssimplyoutofawishtobeapatient17Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e FactitiousDisorderPeoplewithafactitiousdisorderoftengotoextremestocreatetheappearanceofillnessManygivethemselvesmedicationstoproducesymptomsPatientsoftenresearchtheirsupposedailmentsandareimpressivelyknowledgeableaboutmedicine18Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e FactitiousDisorderFactitiousdisorderseemstobemostcommonamongpeoplewho:AschildrenreceivedextensivemedicaltreatmentforatruephysicaldisorderExperiencedfamilydisruptionsorphysicaloremotionalabuseinchildhoodCarryagrudgeagainstthemedicalprofessionHaveworkedasnurses,laboratorytechnicians,ormedicalaidesHaveanunderlyingpersonalityproblemsuchasextremedependence19Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e FactitiousDisorderMunchausensyndromeistheextremeandlong-termformoffactitiousdisorderInMunchausensyndromebyproxy,arelateddisorder,parentsmakeuporproducephysicalillnessesintheirchildren20Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatArePreoccupationSomatoformDisorders?PreoccupationsomatoformdisordersincludehypochondriasisandbodydysmorphicdisorderPeoplewiththeseproblemsmisinterpretandoverreacttobodilysymptomsorfeaturesAlthoughthesedisordersalsocausegreatdistress,theirimpactonone’slifediffersfromthatofhystericaldisorders21Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e 22Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatArePreoccupationSomatoformDisorders?HypochondriasisPeoplewithhypochondriasisunrealisticallyinterpretbodilysymptomsassignsofseriousillnessOftentheirsymptomsaremerelynormalbodilychanges,suchasoccasionalcoughing,sores,orsweatingAlthoughsomepatientsrecognizethattheirconcernsareexcessive,manydonot23Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatArePreoccupationSomatoformDisorders?HypochondriasisPatientswiththisdisordercanpresentapictureverysimilartothatofsomatizationdisorderIftheanxietyisgreatandthebodilysymptomsarerelativelyminor,adiagnosisofhypochondriasisisprobablyinorderIfthesymptomsovershadowtheanxiety,theymayindicatesomatizationdisorder24Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatArePreoccupationSomatoformDisorders?HypochondriasisAlthoughthisdisordercanbeginatanyage,itstartsmostofteninearlyadulthood,amongmenandwomeninequalnumbersBetween1%and5%ofallpeopleexperiencethedisorderFormostpatients,symptomsriseandfallovertheyears25Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatArePreoccupationSomatoformDisorders?Bodydysmorphicdisorder(BDD)Peoplewiththisdisorder,alsoknownasdysmorphophobia,becomedeeplyconcernedoversomeimaginedorminordefectintheirappearanceMostoftentheyfocusonwrinkles,spots,facialhair,swelling,ormisshapenfacialfeatures(nose,jaw,oreyebrows)MostcasesofthedisorderbegininadolescencebutareoftennotrevealeduntiladulthoodUpto5%ofpeopleintheU.S.experienceBDD,anditappearstobeequallycommonamongwomenandmen26Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?Theoriststypicallyexplainthepreoccupationsomatoformdisordersmuchastheydotheanxietydisorders:Behaviorists:classicalconditioningormodelingCognitivetheorists:oversensitivitytobodilycuesIncontrast,thehystericalsomatoformdisordersarewidelyconsidereduniqueandinneedofspecialexplanationNoexplanationhasreceivedmuchresearchsupport,andthedisordersarestillpoorlyunderstood27Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThepsychodynamicviewFreudbelievedthathystericaldisordersrepresentedaconversionofunderlyingemotionalconflictsintophysicalsymptomsBecausemostofhispatientswerewomen,Freudcenteredhisexplanationonthepsychosexualdevelopmentofgirlsandfocusedonthephallicstage(ages3to5)…28Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThepsychodynamicviewDuringthisstage,girlsdevelopapatternofsexualdesiresfortheirfathers(theElectracomplex)andrecognizethattheymustcompetewiththeirmothersforhisattentionBecauseofthemother’smorepowerfulposition,however,girlsrepressthesesexualfeelingsFreudbelievedthatifparentsoverreacttosuchfeelings,theElectracomplexwouldremainunresolvedandthechildmightre-experiencesexualanxietythroughoutherlifeFreudconcludedthatsomewomenhidetheirsexualfeelingsinadulthoodbyconvertingthemintophysicalsymptoms29Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThepsychodynamicviewToday’spsychodynamictheoriststakeissueswithFreud’sexplanationoftheElectraconflictTheycontinuetobelievethatsufferersofthesedisordershaveunconsciousconflictscarriedfromchildhood30Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThepsychodynamicviewPsychodynamictheoristsproposethattwomechanismsareatworkinthehystericaldisorders:Primarygain:hystericalsymptomskeepinternalconflictsoutofconsciousawarenessSecondarygain:hystericalsymptomsfurtherenablepeopletoavoidunpleasantactivitiesorreceivesympathyfromothers31Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThebehavioralviewBehavioraltheoristsproposethatthephysicalsymptomsofhystericaldisordersbringrewardstosufferersMayremoveindividualfromanunpleasantsituationMaybringattentionfromotherpeopleInresponsetosuchrewards,peoplelearntodisplaysymptomsmoreandmoreThisfocusonrewardsissimilartothepsychodynamicideaofsecondarygain,butbehavioristsviewthegainsastheprimarycauseofthedevelopmentofthedisorder32Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThecognitiveviewSomecognitivetheoristsproposethathystericaldisordersareaformofcommunication,providingameansforpeopletoexpressdifficultemotionsLikepsychodynamictheorists,cognitivetheoristsholdthatemotionsarebeingconvertedintophysicalsymptomsThisconversionisnottodefendagainstanxietybuttocommunicateextremefeelings33Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ThemulticulturalviewSometheoristsbelievethatWesterncliniciansholdabiasthatseessomaticsymptomsasaninferiorwayofdealingwithemotionsThetransformationofpersonaldistressintosomaticcomplaintsisthenormismanynon-WesternculturesAswesawinChapter6,reactionstolife’sstressorsareofteninfluencedbyone’sculture34Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e WhatCausesSomatoformDisorders?ApossibleroleforbiologyTheimpactofbiologicalprocessesonsomatoformdisorderscanbeunderstoodthroughresearchonplacebosandtheplaceboeffectPlacebos:substanceswithnoknownmedicinalvalueTreatmentwithplaceboshasbeenshowntobringimprovementtomany–possiblythroughthepowerofsuggestionorthroughthereleaseofendogenouschemicalsPerhapstraumaticeventsandrelatedconcernsorneedscanalsotriggerour“innerpharmacies”andsetinmotionthebodilysymptomsofhystericalsomatoformdisorders35Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreSomatoformDisordersTreated?PeoplewithsomatoformdisordersusuallyseekpsychotherapyonlyasalastresortIndividualswithpreoccupationdisorderstypicallyreceivethekindsoftreatmentsappliedtoanxietydisorders,particularlyOCD:AntidepressantmedicationExposureandresponseprevention(ERP)36Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreSomatoformDisordersTreated?TreatmentsforhystericaldisordersoftenfocusonthecauseofthedisorderandapplythesamekindoftechniquesusedincasesofPTSD,particularly:Insight–oftenpsychodynamicallyorientedExposure–clientthinksabouttraumaticevent(s)thattriggeredthephysicalsymptomsDrugtherapy–especiallyantidepressantmedication37Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreSomatoformDisordersTreated?Othertherapiststrytoaddressthephysicalsymptomsofthehystericaldisorders,applyingtechniquessuchas:Suggestion–usuallyanofferingofemotionalsupportthatmayincludehypnosisReinforcement–abehavioralattempttochangerewardstructuresConfrontation–anovertattempttoforcepatientsoutofthesickroleResearchershavenotfullyevaluatedtheeffectsoftheseparticularapproachesonhystericaldisorders38Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeDisordersThekeytoone’sidentity–thesenseofwhoweareandwherewefitinourenvironment–ismemoryOurrecallofthepasthelpsustoreacttopresenteventsandguidesusinmakingdecisionsaboutthefuturePeoplesometimesexperienceamajordisruptionoftheirmemory,identity,orconsciousness:TheymaynotremembernewinformationTheymaynotrememberoldinformation39Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeDisordersWhensuchchangesinmemorylackaclearphysicalcause,theyarecalled“dissociative”disordersInsuchdisorders,onepartoftheperson’smemorytypicallyseemstobedissociated,orseparated,fromtherest40Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeDisordersThereareseveralkindsofdissociativedisorders,including:DissociativeamnesiaDissociativefugueDissociativeidentitydisorder(multiplepersonalitydisorder)Thesedisordersareoftenmemorablyportrayedinbooks,movies,andtelevisionprogramsDSM-IV-TRalsolistsdepersonalizationdisorderasadissociativedisorder41Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e 42Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeDisordersKeepinmindthatdissociativesymptomsareoftenfoundincasesofacuteorposttraumaticstressdisordersWhensuchsymptomsoccuraspartofastressdisorder,theydonotnecessarilyindicateadissociativedisorder(apatterninwhichdissociativesymptomsdominate)Ontheotherhand,researchsuggeststhatpeoplewithoneofthesedisordersalsodeveloptheotheraswell43Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeAmnesiaPeoplewithdissociativeamnesiaareunabletorecallimportantinformation,usuallyofanupsettingnature,abouttheirlivesThelossofmemoryismuchmoreextensivethannormalforgettingandisnotcausedbyorganicfactorsOftenanepisodeofamnesiaisdirectlytriggeredbyaspecificupsettingevent44Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeAmnesiaDissociativeamnesiamaybe:Localized(circumscribed)–mostcommontype;lossofallmemoryofeventsoccurringwithinalimitedperiodSelective–lossofmemoryforsome,butnotall,eventsoccurringwithinaperiodGeneralized–lossofmemorybeginningwithanevent,butextendingbackintime;maylosesenseofidentity;mayfailtorecognizefamilyandfriendsContinuous–forgettingofbotholdandnewinformationandevents;quiterareincasesofdissociativeamnesia45Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeAmnesiaAllformsofthedisorderaresimilarinthattheamnesiainterferesprimarilywithepisodicmemory(one’sautobiographicalmemoryofpersonalmaterial)Semanticmemory–memoryforabstractorencyclopedicinformation–usuallyremainsintactCliniciansdonotknownhowcommondissociativeamnesiais,butmanycasesseemtobeginduringtimesofseriousthreattohealthandsafety46Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeFuguePeoplewithdissociativefuguenotonlyforgettheirpersonalidentitiesanddetailsoftheirpast,butalsofleetoanentirelydifferentlocationForsome,thefugueisbrief–amatterofhoursordays–andendssuddenlyForothers,thefugueismoresevere:peoplemaytravelfarfromhome,takeanewnameandestablishnewrelationships,andevenanewlineofwork;somedisplaynewpersonalitycharacteristics47Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeFugue~0.2%ofthepopulationexperiencedissociativefugueItusuallyfollowsaseverelystressfuleventFuguestendtoendabruptlyWhenpeoplearefoundbeforetheirfuguehasended,therapistsmayfinditnecessarytocontinuallyremindthemoftheirownidentityThemajorityofpeopleregainmostoralloftheirmemoriesandneverhavearecurrence48Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e Apersonwithdissociativeidentitydisorder(DID;formerlymultiplepersonalitydisorder)developstwoormoredistinctpersonalities(subpersonalities)eachwithauniquesetofmemories,behaviors,thoughts,andemotionsDissociativeIdentityDisorder(MultiplePersonalityDisorder)49Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DissociativeIdentityDisorder(MultiplePersonalityDisorder)Atanygiventime,oneofthesubpersonalitiesdominatestheperson’sfunctioningUsuallyoneofthesesubpersonalities–calledtheprimary,orhost,personality–appearsmoreoftenthantheothersThetransitionfromonesubpersonalitytothenext(“switching”)isusuallysuddenandmaybedramatic50Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e CasesofthisdisorderwerefirstreportedalmostthreecenturiesagoManycliniciansconsiderthedisordertoberare,butsomereportssuggestthatitmaybemorecommonthanoncethoughtDissociativeIdentityDisorder(MultiplePersonalityDisorder)51Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e MostcasesarefirstdiagnosedinlateadolescenceorearlyadulthoodSymptomsgenerallybegininchildhoodafterepisodesofabuseTypicalonsetisbeforeage5WomenreceivethediagnosisthreetimesasoftenasmenDissociativeIdentityDisorder(MultiplePersonalityDisorder)52Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e Howdosubpersonalitiesinteract?TherelationshipbetweenoramongsubpersonalitiesvariesfromcasetocaseGenerallytherearethreekindsofrelationships:Mutuallyamnesicrelationships–subpersonalitieshavenoawarenessofoneanotherMutuallycognizantpatterns–eachsubpersonalityiswellawareoftherestOne-wayamnesicrelationships–mostcommonpattern;somepersonalitiesareawareofothers,buttheawarenessisnotmutualThosewhoareaware(“co-conscioussubpersonalities”)are“quietobservers”DissociativeIdentityDisorder(MultiplePersonalityDisorder)53Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e Howdosubpersonalitiesinteract?InvestigatorsusedtobelievethatmostcasesofthedisorderinvolvedtwoorthreesubpersonalitiesStudiesnowsuggestthattheaveragenumberismuchhigher–15forwomen,8formenTherehavebeencasesofmorethan100!DissociativeIdentityDisorder(MultiplePersonalityDisorder)54Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e Howdosubpersonalitiesdiffer?Subpersonalitiesoftendisplaydramaticallydifferentcharacteristics,including:VitalstatisticsSubpersonalitiesmaydifferinfeaturesasbasicasage,sex,race,andfamilyhistoryAbilitiesandpreferencesAlthoughencyclopedicknowledgeisunaffectedbydissociativeamnesiaorfugue,inDIDitisoftendisturbedItisnotuncommonfordifferentsubpersonalitiestohavedifferentabilities,includingbeingabletodrive,speakaforeignlanguage,orplayaninstrumentDissociativeIdentityDisorder(MultiplePersonalityDisorder)55Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e Howdosubpersonalitiesdiffer?Subpersonalitiesoftendisplaydramaticallydifferentcharacteristics,including:PhysiologicalresponsesResearchershavediscoveredthatsubpersonalitiesmayhavephysiologicaldifferences,suchasdifferencesinautonomicnervoussystemactivity,bloodpressurelevels,andallergiesDissociativeIdentityDisorder(MultiplePersonalityDisorder)56Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowcommonisDID?Traditionally,DIDwasbelievedtoberareSomeresearchersevenarguethatmanyorallcasesareiatrogenic;thatis,unintentionallyproducedbypractitionersTheseargumentsaresupportedbythefactthatmanycasesofDIDfirstcometoattentiononlyafterapersonisalreadyintreatmentNottrueofallcasesDissociativeIdentityDisorder(MultiplePersonalityDisorder)57Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowcommonisDID?ThenumberofpeoplediagnosedwiththedisorderhasbeenincreasingAlthoughthedisorderisstilluncommon,thousandsofcaseshavebeendocumentedintheU.S.andCanadaaloneTwofactorsmayaccountforthisincrease:AgrowingnumberofcliniciansbelievethatthedisorderdoesexistandarewillingtodiagnoseitDiagnosticprocedureshavebecomemoreaccurateDespitechanges,manyclinicianscontinuetoquestionthelegitimacyofthecategoryDissociativeIdentityDisorder(MultiplePersonalityDisorder)58Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?AvarietyoftheorieshavebeenproposedtoexplaindissociativedisordersOlderexplanationshavenotreceivedmuchinvestigationNewerviewpoints,whichcombinecognitive,behavioral,andbiologicalprinciples,havecapturedtheinterestofclinicalscientists59Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?ThepsychodynamicviewPsychodynamictheoristsbelievethatdissociativedisordersarecausedbyrepression,themostbasicegodefensemechanismPeoplefightoffanxietybyunconsciouslypreventingpainfulmemories,thoughts,orimpulsesfromreachingawareness60Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?ThepsychodynamicviewInthisview,dissociativeamnesiaandfuguearesingleepisodesofmassiverepressionDIDisthoughttoresultfromalifetimeofexcessiverepression,motivatedbyverytraumaticchildhoodevents61Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?ThepsychodynamicviewMostofthesupportforthismodelisdrawnfromcasehistories,whichreportbrutalchildhoodexperiences,yet:SomeindividualswithDIDdonotseemtohavetheseexperiencesofabuseWhymightonlyasmallfractionofabusedchildrendevelopthisdisorder?62Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?ThebehavioralviewBehavioristsbelievethatdissociationgrowsfromnormalmemoryprocessesandisaresponselearnedthroughoperantconditioning:Momentaryforgettingoftraumaleadstoadropinanxiety,whichincreasesthelikelihoodoffutureforgettingLikepsychodynamictheorists,behavioristsseedissociationasescapebehaviorAlsolikepsychodynamictheorists,behavioristsrelylargelyoncasehistoriestosupporttheirviewofdissociativedisordersWhilethecasehistoriessupportthismodel,theyarealsoconsistentwithotherexplanations…63Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?State-dependentlearningIfpeoplelearnsomethingwhentheyareinaparticularstateofmind,theyarelikelytorememberitbestwhentheyareinthesameconditionThislinkbetweenstateandrecalliscalledstate-dependentlearningThismodelhasbeendemonstratedwithsubstancesandmoodandmaybelinkedtoarousallevelsIthasbeentheorizedthatpeoplewhoarepronetodevelopdissociativedisordershavestate-to-memorylinksthatareunusuallyrigidandnarrow;eachthought,memory,andskillistiedexclusivelytoaparticularstateofarousal,sothattheyrecallagiveneventonlywhentheyexperienceanarousalstatealmostidenticaltothestateinwhichthememorywasfirstacquired64Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowDoTheoristsExplainDissociativeDisorders?Self-hypnosisAlthoughhypnosiscanhelppeopleremembereventsthatoccurredandwereforgottenyearsago,itcanalsohelppeopleforgetfacts,events,andtheirpersonalidentityCalled“hypnoticamnesia,”thisphenomenonhasbeendemonstratedinresearchstudieswithwordlistsTheparallelsbetweenhypnoticamnesiaanddissociativedisordersarestrikingandhaveledresearcherstoconcludethatdissociativedisordersmaybeaformofself-hypnosis65Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreDissociativeDisordersTreated?PeoplewithdissociativeamnesiaandfugueoftenrecoverontheirownOnlysometimesdotheirmemoryproblemslingerandrequiretreatmentIncontrast,peoplewithDIDusuallyrequiretreatmenttoregaintheirlostmemoriesanddevelopanintegratedpersonalityTreatmentfordissociativeamnesiaandfuguetendstobemoresuccessfulthantreatmentforDID66Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreDissociativeDisordersTreated?Howdotherapistshelppeoplewithdissociativeamnesiaandfugue?Theleadingtreatmentsforthesedisordersarepsychodynamictherapy,hypnotictherapy,anddrugtherapyPsychodynamictherapistsguidepatientstosearchtheirunconsciousandbringforgottenexperiencesintoconsciousnessInhypnotictherapy,patientsarehypnotizedandguidedtorecallforgotteneventsSometimesintravenousinjectionsofbarbituratesareusedtohelppatientsregainlostmemoriesOftencalled“truthserums,”thekeytothedrugs’successistheirabilitytosedatepeopleandfreetheirinhibitions67Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreDissociativeDisordersTreated?HowdotherapistshelpindividualswithDID?Unlikevictimsofdissociativeamnesiaorfugue,peoplewithDIDdonottypicallyrecoverwithouttreatmentTreatmentforthispattern,likethedisorderitself,iscomplexanddifficult68Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreDissociativeDisordersTreated?HowdotherapistshelpindividualswithDID?Therapistsusuallytrytohelptheclientby:RecognizingthedisorderOnceadiagnosisofDIDhasbeenmade,therapiststrytobondwiththeprimarypersonalityandwitheachofthesubpersonalitiesAsbondsareforged,therapiststrytoeducatethepatientsandhelpthemrecognizethenatureofthedisorderSomeusehypnosisorvideoasameansofpresentingothersubpersonalitiesManytherapistsrecommendgrouptherapy69Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreDissociativeDisordersTreated?HowdotherapistshelpindividualswithDID?Therapistsusuallytrytohelptheclientby:RecoveringmemoriesTohelppatientsrecovermissingmemories,therapistsusemanyoftheapproachesappliedinotherdissociativedisorders,includingpsychodynamictherapy,hypnotherapy,anddrugtreatmentThesetechniquestendtoworkslowlyincasesofDID70Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e HowAreDissociativeDisordersTreated?HowdotherapistshelpindividualswithDID?Therapistsusuallytrytohelptheclientby:IntegratingthesubpersonalitiesThefinalgoaloftherapyistomergethedifferentsubpersonalitiesintoasingle,integratedentityIntegrationisacontinuousprocess;fusionisthefinalmergingManypatientsdistrustthisfinaltreatmentgoalandmanysubpersonalitiesseeintegrationasaformofdeathOncethesubpersonalitiesareintegrated,furthertherapyistypicallyneededtomaintainthecompletepersonalityandtoteachsocialandcopingskillstopreventlaterdissociations71Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DepersonalizationDisorderDSM-IV-TRcategorizesdepersonalizationdisorderasadissociativedisorder,eventhoughitisdifferentfromtheotherdissociativepatternsThecentralsymptomispersistentandrecurrentepisodesofdepersonalization,whichisachangeinone’sexperienceoftheselfinwhichone’smentalfunctioningorbodyfeelsunrealorforeign72Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DepersonalizationDisorderPeoplewithdepersonalizationdisorderfeelasthoughtheyhavebecomeseparatedfromtheirbodyandareobservingthemselvesfromoutsideThissenseofunrealitycanextendtoothersensoryexperiencesandbehaviorDepersonalizationisoftenaccompaniedbyderealization–thefeelingthattheexternalworld,too,isunrealandstrange73Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DepersonalizationDisorderDepersonalizationexperiencesbythemselvesdonotindicateadepersonalizationdisorderTransientdepersonalizationreactionsarefairlycommonThesymptomsofadepersonalizationdisorder,incontrast,arepersistentorrecurrent,causeconsiderabledistress,andinterferewithsocialrelationshipsandjobperformance74Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e DepersonalizationDisorderThedisorderoccursmostfrequentlyinadolescentsandyoungadults,hardlyeverinpeopleolderthan40Thedisordercomesonsuddenlyandtendstobelong-lastingRelativelyfewtheorieshavebeenofferedtoexplaindepersonalizationdisorderandlittleresearchhasbeenconductedontheproblem75Comer,FundamentalsofAbnormalPsychology,3eAbnormalPsychology,7e 术前肺功能测定及其临床意义复旦大学附属中山医院呼吸病研究所蔡映云 术前肺功能测定的意义估计手术的风险制订术前准备术后并发症预测和预防手术方案的设计和修改术后处理和监测的预案术后肺功能和活动能力的预计 常见的PPCs感染：肺炎、支气管炎肺不张支气管痉挛心原性或非心原性肺水肿肺栓塞长时间留置气管导管呼吸衰竭 一.PPCs的病理生理机制肺容量减少气体交换障碍呼吸中枢驱动削弱膈肌功能受损肺防御机制削弱 引起PPCs的因素患者因素手术因素麻醉因素 1.患者因素老龄　换气功能肥胖动脉血气营养不良病变分布吸烟史伴发症：心功能、贫血通气功能 2.手术因素手术类型（急诊、择期）手术部位手术范围手术方法手术时间输血量 3.麻醉因素（1）椎管内麻醉和全身麻醉不如局部麻醉和神经阻滞安全。（2）椎管内麻醉中硬膜外麻醉比脊麻可控性强，更安全。（3）全身麻醉可抑制呼吸中枢，减少肺活量致小气道陷闭，引起V/Q失调，抑制粘膜上皮细胞纤毛功能。（4）合并使用阿片类、镇静剂、肌松剂可抑制呼吸中枢或神经肌肉功能。 可以增加PPCs的因素手术部位胸腔或靠近膈肌手术时机急诊手术或限期手术手术时间>3小时病员一般情况年龄、肥胖、营养心脏情况近期内心梗、慢性心衰和肺心病肺部情况有阻塞性或限制性肺病吸烟史戒烟时间<8周 二.肺功能评估方法病史现病史既往史、个人史：伴发症、住院、手术、用药情况、麻醉史、围术期情况、吸烟史体检可发现异常体征胸部平片呼吸功能检查 肺功能测定的项目肺容量通气功能换气功能动脉血气心肺运动试验 术前肺功能检查的适应证年龄>65岁肥胖病人胸部手术上腹部手术吸烟史心肺疾病史 肺容量 FourCapacitiesFourvolumes肺总量TLC潮气量TV肺活量VC补吸气量IRV深吸气量IC补呼气量ERV功能残气量FRC残气量RV 2.通气功能用力肺活量测定 利用肺量计可以测定的肺通气指标用力肺活量（FVC）第一秒用力呼气量（FEV1）一秒率（FEV1/FVC%）最大呼气中期流速（MMEF）分钟最大通气量（MVV）上述参数通常以占预计值的百分数表示预计值则以年龄、性别、身高、体重校正后得出 用力肺活量（FVC）及第一秒用力呼气量（FEV1）对开胸手术及肺叶切除术的预测价值最大比较使用支气管舒张剂前后的FVC及FEV1，能有效地反映肺功能可逆程度 分钟最大通气量（MVV）是阻塞性、限制性通气功能障碍、肌力、营养状况等因素的综合反映 术前FEV1>2L安全1-2L有一定风险<0.8L风险极大缺点：没有考虑病人身高、体重、年龄、性别没有考虑手术切除范围 VC>50%预计值FEV1>50%预计值RV/TLC>50%预计值DLco>50%预计值缺点：没有考虑手术部位、手术范围安全手术的术前肺功能要求 预测开胸术后并发症最有意义的单项指标是术后预计FEV1%(PPO-FEV1%)其计算公式如下：PPO-FEV1%=术前FEV1%(1-切除的功能性肺组织所占的百分数)要求PPO-FEV1至少大于800ml或大于预计值的33%术后预测肺功能 切除的功能性肺组织所占百分数的估计方法分侧肺功能侧位肺功能同位素扫描 目前为大家所接受的保证肺叶切除术后长期存活的最低标准为FEV1%50%，PaCO250mmHgPPO-FEV1%40% 一氧化碳弥散DLCO计算肺切除术后的预计值，计算方法同ppoFEV1%ppoDLCO<40%预计值通常预示着较高的术后心肺系统并发症3.换气功能 4.动脉血气分析通常把不吸氧时PaO2<60mmHg或PaCO2>45mmHg作为禁忌肺切除术的界值但目前仍有低于该条件下成功进行手术的报道若手术能解除PaCO2升高或PaO2降低的原因，则PaCO2升高或PaO2降低不能成为预测PPCs的指标不同部位不同范围手术，标准应有所不同 5.心肺联合功能试验可精确控制患者的工作功率可进行多个生命体征监测，包括：心率、心电图、呼吸频率、作功量、氧耗量（VO2）、二氧化碳产生量（VCO2）、氧通气当量（VE/VO2）、二氧化碳通气当量（VE/VCO2）、动脉血乳酸、无氧阈等 登车运动方案（1）增量运动，空负荷登车，随后每隔1分钟运动负荷增加，直至运动极限（2）恒量运动固定运动负荷下登车，直至运动极限 无氧阈（AT）是出现由无氧代谢补充有氧代谢供能的位点，通常以此时的氧耗量表示 最大氧耗量（VO2max）是指患者运动-摄氧曲线进入平台期（即氧耗量不随运动功率的增加而上升）时的耗氧量。＞20ml/kg/min并发症0-10%＜10ml/kg/min并发症43-100% 心肺联合运动试验的绝对禁忌证近期内静息心电图出现明显的改变，提示心肌梗死或其它急性心脏事件近期内并发急性心肌梗死或不稳定心绞痛尚未控制的室性心律失常房性心律失常尚未得到控制，且引起心功能异常Ⅲ度房室传导阻滞，未安装起搏器 心肺联合运动试验的绝对禁忌证急性充血性心衰严重主动脉瓣狭窄可疑或已有主动脉夹层分离活动性或可疑的心肌炎和心包炎血栓性静脉炎或心内血栓形成近期内体循环或肺循环栓塞急性感染明显的精神萎靡，抑制 （1）肺动脉阻断试验阻断拟切除肺叶的肺动脉，如患者能耐受由此产生的肺动脉高压和低氧血症，则可胜任手术阻断后PaO2应不低于45mmHg，肺动脉压不高于35mmHg。（2）支气管扩张试验6.其它检查 术后发生PPCs危险的指标FVC<预计值的50%FEV1<预计值50%RV/TLC>预计值的50%DLco<预计值的50%MVV<预计值的50%或50L/min 戒烟药物治疗体疗减肥改善营养NPPV治疗三.术前准备措施 1.戒烟戒烟后12~24h血中CO及尼古丁水平下降48h后碳氧血红蛋白水平恢复正常48~72h后支气管粘膜纤毛功能提高1~2w后痰液分泌减少4~6w后肺功能有所改善6~8w后免疫功能恢复8~12w后吸烟对PPCs的近期影响解除 2.药物治疗舒张支气管、祛痰、分泌物引流抗感染掌握雾化吸入技术 训练咳嗽锻炼腹式呼吸呼吸肌锻炼3.术前体疗 一般在术前5-7天开始进行无创正压通气训练，呼吸模式多数采用PSV加或不加PEEP。每天2次，每次1-2小时4.无创正压通气（NPPV） 尽可能采用局部麻醉尽可能缩短外科手术时间尽可能减少肌松剂腹腔镜或胸腔镜手术并发症少四.术中措施 五.术后主要防治措施1.密切观察患者神志，呼吸2.监测PetCO2、SpO23.拮抗残余麻醉药物，对有呼吸中枢抑制者可用机械通气支持翻身拍背鼓励咳嗽5.早期活动和下床 6.疼痛治疗硬膜外镇痛静脉镇痛7.预防深静脉血栓形成8.营养支持9.雾化吸入五.术后主要防治措施 10.NPPV(1)患者临床上出现呼吸困难的征象，在明确无禁忌证之后即可应用。(2)具有高危因素的肺切除术患者，术后当天拔除气管导管后就可以开始间断无创正压通气支持采用PSV模式，压力支持水平8-10cmH2O，加或不加PEEP支持的时间和间隔应根据病人的治疗效果而定：少则一天2次，每次2小时；多则夜间全程支持，白天每间隔2小时支持2小时。五.术后主要防治措施'