Schizophrenia and Dissociative Disorders: Crash Course Psychology #32


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It’s perhaps the most stigmatized and misunderstood psychological disorder of them all, even among
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psychologists. Maybe because it’s pretty rare, affecting about 1% of the population, schizophrenia
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causes more anxiety in the media, in the public, and even in doctors’ offices than any other mental illness.
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As a result, its sufferers have often been shunned, abused, or locked up. And among the
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many fallacies that surround the disorder is simply what it means. The word “schizophrenia”
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literally means “split mind” but contrary to popular belief, the condition has nothing
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to do with a split in personality or multiple personalities.
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The term refers instead to what’s sometimes called a “split from reality.” Multiple Personality
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Disorder, now known as Dissociative Identity Disorder, is a totally different type of condition,
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a kind of dissociative disorder. And these too, are shrouded in misconceptions, partly
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because they were the subject of, probably, the greatest psychological hoax of all time.
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While many of us can relate on some level to the emotional swings, nervousness, and
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compulsions that come with mood and anxiety disorders, it can be a lot harder for those
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without direct experience to relate to the symptoms of schizophrenia and dissociation.
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Unfortunately we tend to fear and avoid what we don’t understand in each other, whether
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it’s a friend of family member or just some stranger on the bus. But thankfully part of
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the psychologist’s job is to demystify the things that can happen in our heads, and as is
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often the case, understanding may be the key to compassion.
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Schizophrenia is a chronic condition that usually surfaces for men in their early to
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mid-20s, and for women in their late 20s. For some the disorder comes on gradually,
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but for others it could arise more suddenly, perhaps triggered by stress or trauma, although
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no event can actually cause the disorder.
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Once thought of as a single discrete condition, schizophrenia is now included in the DSM-5
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as a point on a spectrum of disorders that vary in how they’re expressed and how long
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they last, but they share similar symptoms.
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Schizophrenia Spectrum Disorders are currently thought of as characterized by disorganized
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thinking; emotions and behaviors that are often incongruent with their situations; and
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disturbed perceptions, including delusions and hallucinations.
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They all involve a kind of loss of contact with reality on some level. The resulting
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behaviors and mental states associated with this break from reality are generally called
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“psychotic symptoms” and they usually impair the ability to function.
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When someone’s experiencing psychotic symptoms, their thinking and speech can become disorganized,
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rambling and fragmented. This tendency to pick up one train of thought and suddenly
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switch to another and then another can make communication painfully difficult.
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People exhibiting these symptoms can also suffer a breakdown in selective attention,
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losing the ability to focus on one thing while filtering others out.
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In extreme cases, speech may become so fragmented it becomes little more than a string of meaningless
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words, a condition given a name that sounds like its own kind of non sequitur, “word salad.”
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Classic schizophrenia is also often marked by delusions or false beliefs not based in
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reality. These delusions can be rooted in ideas of grandeur like “I’m the queen of England!”
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or “I won an Olympic gold medal for the luge!” Or they can become narratives of persecution
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and paranoia, believing your thoughts and actions are being controlled by an outside
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force or that you’re being spied on or followed or that you’re on the verge of a major catastrophe.
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And there are some complicated variations on these delusions, like feeling that you’ve
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died or don’t exist anymore or that someone is madly in love with you or that you’re infested with parasites.
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Delusions of one kind of another strike as many as four out of five people with schizophrenia.
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While some delusions can seem fairly logical, they can also be severe and bizarre and frightening.
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Unfortunately maybe the most memorable examples of people suffering from severe delusions
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come from serial killers and yeah, while Son of Sam did claim that he was taking orders
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from his neighbor’s dog, that kind of stuff is in the tiny, tiny, tiny minority.
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Brian Wilson of The Beach Boys and Syd Barrett of Pink Floyd both suffered psychotic symptoms.
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And then of course there’s John Nash, the Nobel Prize winning American mathematician
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and subject of the movie “A Beautiful Mind.”
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Through proper treatment, some people with schizophrenia have not only learned to live
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with their illness but also made fantastic creative contributions to the world.
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Maybe people with schizophrenia also suffer from perceptual disturbances, or sensory experiences
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that come without any apparent sensory stimulation, like hallucinations. This is when a person
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sees or hears something that isn’t there, often lacking the ability to understand what is real and what isn’t.
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Auditory hallucinations, or hearing voices, are the most common form, and these voices
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are often abusive. It’s as if you’re inner monologue, that conversation that you have
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with yourself or the random things that float through your head, were somehow coming from
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outside of you. It’s as if you couldn’t sort out whether the voices in your mind were internal
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and self-generated, or external and other-generated.
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To me, it sounds terrifying.
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Other common symptoms include disorganized, abnormal, or incongruent behavior and emotions.
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This could mean laughing when recalling a loved one’s death or crying while others are
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laughing. Acting like a goofy child one minute, then becoming unpredictably angry or agitated the next.
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Movements may become inappropriate and compulsive, like continually rocking back and forth or
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remaining motionless for hours.
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Broadly, most psychotic symptoms fall into three general categories traditionally used
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by psychologists: positive, negative, and disorganized symptoms.
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Positive symptoms are not what they sound like. They’re the type that add something
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to the experience of the patient. Like, for example, hallucinations or inappropriate laughter
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or tears or delusional thoughts.
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Negative symptoms refer to those that subtract from normal behavior, like a reduced ability
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to function, neglect of personal hygiene, lack of emotion, toneless voice, expressionless
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face, or withdrawal from family and friends.
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Finally, disorganized symptoms are those jumbles of thought or speech that could include word
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salad and other problems with attention and organization.
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Symptoms like these are useful in diagnosing a disorder on the schizophrenia spectrum,
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but there’s a physiological component too. Like many of the disorders we’ve talked about,
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schizophrenia has been associated with a number of brain abnormalities.
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Post mortem research on schizophrenia patients has found that many have extra receptors for
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dopamine, a neurotransmitter involved in emotion regulation and the brain’s pleasure and reward centers.
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Some researchers think that overly responsive dopamine systems might magnify brain activity
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in some way, perhaps creating hallucinations and other so-called positive symptoms as the
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brain loses its capacity to tell the difference between internal and external stimuli.
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For this reason, dopamine blocking drugs are often used as anti-psychotic medications in
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treatment. Modern neuroimaging studies also show that some people with schizophrenia have
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abnormal brain activity in several different parts of the brain.
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One study noted that when patients were hallucinating, for example, there was unusually high activity
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in the thalamus, which is involved in filtering incoming sensory signals. Another study noted
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that patients with paranoid symptoms showed over-activity in the fear processing amygdala.
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So, schizophrenia seems to involve not just problems with one part of the brain, but abnormalities
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in several areas and their interconnections.
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But what might be causing these abnormalities?
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Earlier I mentioned how a stressful event might trigger psychotic symptoms for the first
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time, even though it can’t actually create the disorder. Psychologists call this the
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“diathesis-stress model.”
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This way of thinking involves a combination of biological and genetic vulnerabilities
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— diathesis — and environmental stressors — stress — that both contribute to the onset
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of schizophrenia. This model helps explain why some people with genetic vulnerability
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might not always develop schizophrenia and why the rates of schizophrenia tend to be
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higher with some degree of poverty or socioeconomic stress.
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And it seems too that there is some kind of genetic predisposition for the disorder. The
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one-in-a-hundred odds of developing schizophrenia jumped to nearly one in ten if you have a
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parent or sibling with the disorder, with about 50/50 odds if that sibling is an identical
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twin, even if those twins were raised apart.
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One recent landmark seven year study looked at genetic samples across 35 countries, examining
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more than 35,000 people with schizophrenia, and another 110,000 without the disorder.
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The study identified more than 100 genes that may increase the risk of schizophrenia. As
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expected, some of these genes involve dopamine regulation, but others are related to immune
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system functioning. Researchers continue to tease out what is exactly going on here, but
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many are hopeful that these new findings will lead to better treatment.
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Clearly, schizophrenia is a challenging disorder to live with and one that’s hard for outsiders
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to understand, but maybe even more rare and more elusive are the dissociative disorders.
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These are disorders of consciousness, called dissociative because they’re marked by an
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interruption in conscious awareness. Patients can become separated from the thoughts or
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feelings that they used to have, which can result in a sudden loss of memory or even
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change in identity.
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Now, we might all experience minor dissociation at times, like maybe the sense that you’re
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watching yourself from above, as in a movie, or like you’re driving home and get so zoned
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out that suddenly you find yourself in front of Taco Bell thinking, like, “How did I get here?”
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Those things would generally fall into the normal range of dissociation, but most of
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us don’t develop different personalities.
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Dissociative disorders come in several different forms, but the most infamous of the bunch
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is probably Dissociative Identity Disorder. This has long been known as Multiple Personality
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Disorder and, yes, it is a thing. It’s a rare and flashy disorder in which a person exhibits
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two or more distinct and alternating identities and the best known case was that of Shirley
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Mason, whose story was famously rendered in the 1973 best seller “Sybil” and later in
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a popular mini-series.
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The book was marketed as the true story of a woman who suffered great childhood trauma
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and ended up with 16 different personalities, ranging from Vicky, a selfish French Woman,
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to handyman Syd, to the religious and critical Clara.
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The book became a craze and within a few years reported cases of multiple personality skyrocketed
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from scarcely 100 to nearly 40,000.
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Many believe the book was essentially responsible for creating a new psychiatric
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diagnosis. It turns out though, Sybil’s story was a big fat lie.
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Yes, Shirley Mason was a real person and one with a troubled, traumatic past and a number
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of psychological issues. As a student in New York in the 1950s she started seeing a therapist
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named Connie Wilbur and taking some heavy medications. And somewhere in there, maybe
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because she was coaxed, or maybe because she wanted more attention, Shirley started expressing
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different personalities.
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Dr. Wilbur built a career and a book deal out of her star patient, even after Shirley
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confessed that her split personality was a ruse.
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The Sybil case is a powerful reminder that we really don’t understand dissociative disorders
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very well or even know if they’re always real. Indeed, some people question if Dissociative
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Identity Disorder is an actual disorder at all.
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But some studies have shown distinct body and brain states that seem to appear in different
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identities, things like one personality being right handed while the other is left handed,
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or different personalities having variations in their eye sight that ophthalmologists could actually detect.
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In these cases, dissociations of identity may be in response to stress or anxiety, a
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sort of extreme coping mechanism.
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Either way, the debate and the research continue.
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Today we talked about the major symptoms associated with the schizophrenia spectrum disorders, including
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disorganized thinking, inappropriate emotions and behaviors, and disturbed perceptions.
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We also discussed brain activity associated with these disorders and talked about their
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possible origins including the diathesis stress model.
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You also learned about dissociative disorders, and Dissociative Identity Disorder in particular,
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and the scandal that was the Sybil case.
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Thanks for watching, especially to all of our Subbable subscribers who make Crash Course
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possible. To find out how you can become a supporter, just go to subbable.com.
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This episode was written by Kathleen Yale, edited by Blake de Pastino, and our consultant
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is Dr. Ranjit Bhagwat. Our director and editor is Nicholas Jenkins, the script supervisor
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is Michael Aranda. He is also our sound designer and the graphics team at Thought Cafe.


This post was previously published on YouTube.

Photo credit: Screenshot from video.

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