Abnormal Psych. textbook

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Chapter 1

Abnormal B/h: maladaptive b/h: interference w/ daily functioning/growth, or if it is self-defeating

• painful syndrome ()
• disability of functioning
• risk of death/pain/injury

2 Value assumptions:

1. survival/actualization is worth striving for, on ind./group level
2. b/h can be evaluated for its consequences or for its objectives

treatment: for maladaptive b/f: teaching ind. how to deal w/ reality despite it being hard

abnormal psychology/psychotherapy: the field of psych that deals w/ understanding/treatment/presentation of abnormal b/h

• clinical psych: applied subpart of abnormal b/h
• psychiatry: correspondent field of medicine. Focus is on medicine and not b/h
• social work: analysis of environment/family

3 categories of studies of abnormal b/h

1. nature of abnormal b/h
2. factors that cause/infl. it
3. methods to reduce\eliminate it

clinical picture: defining the abnormality’s nature

i.e. classification

DSM: classification of mental disorders

3 approaches to classify b/h:

1. categorical approach: 2 assumptions
   1. all b/h could be sharply labeled as either normal or abnormal
   2. discrete, non-overlapping types of abnormal b/h, called mental illness

2. dimensional approach: different strengths of discrete dimensions of b/h, i.e. mood/extraversion/communication

i.e. axes 4/5 of the DSM

3. prototype approach: idealized formulation of b/h which goes together

though not everything fits together

DSM

-first 3 axes= present conditionsin #1, 3, more than 1 issue could be the prob.

-last 2 = broader axes

1. particular maladaptive symptoms/psychiatric syndrome
2. personality or dev. prob.
3. medical prob.
4. severity of psychological stressors
5. level of adaptive functioning

Examples of #1, 2

1. organic mental disorders

i.e. destruction of brain tissue, i.e. Alzheimer

2. Disorders usually arising during childhood: mental retardation/infantile autism
3. Substance abuse disorders: i.e. drug/alcohol abuse
4. Disorders of psychological or sociocultural origin: where origin is not brain pathology

functional psychosis: an organic basis has not been demonstrated

Acute: short duration of disease – i.e. under 6 months

Chronic long standing, usually permanent.

Could also be used for low intensity disease, since long term is usually low intensity

Mild/moderate/severe: describe severity of the disorder

Episodic: recurring – go up and down. I.e. in schizophrenia/mood disorders

Recurrent: come and go (i.e. episodic)

Axes 4/5

-range b/w none and catastrophic

90 point scale for functioning

• 90 = good uncollerousno noticeable prob.
• 80 = slight impairment
• 70 = some difficulty
• 60 = moderate difficulty
• 50 = serious difficulty
• 40 = major impairment
• 30 = unable to function
• 20 = some danger
• 10 = persistent danger

Scale of severity of stressors

1. none
2. mildi.e. breakup w/ GF
3. moderate
4. severe –i.e. divorce/birth of a child/unemployment
5. extreme: death of a spouse
6. catastrophic: death of a child/suicide of spouse

comorbidity: appearance of 2 or more identified disorders in the same psychologically disordered person

Retrospective research: studying the root of the presentlook at earlier event of the subject’s life

Prospective research: studying the future from the present: i.e. studying the person who is more likely to get the disease, b/f the fact.

Study of abnormal b/h should be based on:

1. scientific approach
2. awareness of common human goals: i.e. insights into things such as love can’t be obtained in a lab, and thus must find other means, i.e. autobiographical works/drama/etc…
3. respect of integrity/dignity/growth potential of individual.

Case study (N=1 experiment) = hard to generalize

Sign: objective observations of patient’s physical or mental disorder

Syndrome: patient’s subjective description of a physical or mental disorder.

1. particular maladaptive symptoms/psychiatric syndrome
2. personality or dev. prob.
3. Medical problem
4. Psychosocial and environment problems
5. global assessment of functioning

Epidemiology: study of the distribution of [mental] illness/b/h in a given population

Prevalence: during a set time, how many cases were identified w/I a population

• Lifetime prevalence: how many people up to a certain point had the illness
• Point prevalence: estimated active cases

Incidence: occurrences (onset) rate of a given disorder in a given population.

History:

Mass madness: in middle ages: groups b/h disordersapparent mass hysteria

Asylums: institutions only for mentally ill

Moral managements: wide –ranging treatment w/ focus on social/ind./occupational needs

Mental hygiene movement: almost exclusive focus on physical well-being of patient

Medical model: disordered b/h: medical and not cognitive/learnt basis.

Mesmerism: treatment based on animal magnetism (hypnosis)

Nancy school: thought hysteria was a type of a self-hypnosis

Psychoanalysts: use dream analysis

Chapter 2

Etiology: causal patterns underlying abnormal b/h

same rather speak of risk factors instead of instead of cause (i.e. correlates of the abnormal b/h outcome

diathesis-stress model: views of abnormal b/has a result of stress operating on an ind. w/ a bio/psychosocial/sociocultural predisposition t/w de a specific disorder

i.e. predispositions triggerabnormal b/h

predisposition: vulnerability

trigger: stressor =exceeding ind.’s resources

protective factors: factors modifying ind’s resources to environmental stressors making it less likely that he will experience the aversive consequences of the stressor: (i.e. SE/good attachment)

those factors lead to resilience

resilience: the ability to adopt successfully even to difficult circumstances

note: girls seem less vulnerable to many psychosocial stressors, (such as parental conflicts)

-sometimes, bad experiences could act as a protective factor:

i.e. prior experience w/ something makes next time easier

-diathesis-stress models must be looked at in a broad framework of multicausal development models

developmental psychopathy: seeing an abnormal point of dev. by comparing it to normal/expected changes that occur in dev. process

paradigm shift: shift/reorganization of how people think of an entire field of science:

i.e. Freud: shifted psych. from bio/moral science to unconscious process

biopsychosocial viewpoint

biopsychosocial viewpoint: integration of bio/psychosocial and sociocultural factors in psychopathy/treatment

biological factors:

• genes
• biochemical
• biological processes

-brain tissue break-down = first bio to be discovered

but not all abnormal b/h is b/c of neurological damage@

and neurological damage does not lead to abnormal b/h

5 factors of bio causes of maladaptive b/h:

1. neurotransmitters/hormonal imbalance in brain
2. genetic vulnerability
3. constitutional liabilities
4. brain dysfunction/neural plasticity
5. physical deprivation/disruption

Neurotransmitters/hormonal imbalance in brain

-synaptic cleft = gull of fluid

trans-synaptic transmission = chemicals

called neurotransmitters

-some activate/others inhibit post-synaptic cell

imbalance of neurotransmitters

1. too much/little
2. reuptake problems
3. intersynapse deactivation dysfunction
4. postsynapse reception problems (i.e. altered sensitivity)

medication: changes in amount of neurotransmitter released/reuptaken

i.e. Prozac: slows down serotonin reuptake

monoamines = 1mono acid

1. norepinephrine
2. dopamine
3. serotonin
4. GABA

-dopamine/norepinephrine = calecholaminesb/c both are synthesized from amino acid: imp. for emergency reaction!

Dopamine: = schizophrenia

Serotonin: info-processemotional/mood disorders

GABA: anxiety

Hormonal imbalance

-hormones: chemical messengers in blood

released by endocrine glands in our blood

-hypothalamus effects pituitary glands, which then in turn controls all the endocrine glands

important set of interactions: hypothalamic-pituitary-adrenal cortical axis:

-adrenal – top of kidney

produces adrenaline (epinephrine)/hormonal cortisol

-sex hormonesalso infl. maladaptive b/h

androgens (i.e. testosterone) = male sex gormones

produced by gonadal glands

Genetic vulnerabilities

DNA: located in the chromosomes

abnormalities in the structure/# of chromosomescould lead to abnormal b/h

i.e. downs syndrome = trisomy (3 chromosomes in #21)

-depression/alcohol/schizophrenic = genetic base?

Note: genes are not the causers but rather the disposition (i.e. vulnerability), which w/ environmental stressors case the pathology

• Genotype = all genes in a person
• Phenotype = resulting structural/characteristics as a result of combination of genes/environment

-Genotype might shape environment. It might not manifest until later in life

Genotype-environment correlation: when genotype shapes environment, i.e. aggressive (genotype) kidb/c rejected in early grades, later he learns to b/c delinquent

the genes act on environment

Genotype-environment interaction: diff. sensitivity/susceptibility to environment b/w people w/ diff. genotypes

-i.e. people who are vulnerable to depression will react more to stressors w/ depression than those w/o this vulnerability

h. genes are expresses b/v environments

abnormal b/h= polygenetic (i.e. many genes acting together!)

faults could be b/c: CNS structure

• reactivity on nervous system
• biochemical imbalance
  • usually b/c genetic infl. on neurology

ways to study genetic infl.

1. family history method: study 1^st/2^nd order family members to see possible genetic infl.

proband/index case: the ind. carrying the studied gene

control group: general populations: see if the family has more than the general populations

genetics?

Prob: family has some environmental elements!

2. Twin method: identical (monozygotic) twins

Concordance rate: % of identical twins having the trait: if all twins have itconcordance rate = 100%then the issue is all genetic

no such thing is reality, but when higher than dizotic twins, then genetic infl, is higher!

General idea: higher concurrence rate = more genetic infl.

3. adoption method

-comparing biological vs. adopted relatives of the person who has disorder – to compare genetics vs. environmental infl.

variations:

• see bio relatives if the adopted kids w/ disorder
• see adopted kids of adults w/ disorder

-if you use all 3 methodsleast pitfalls

-shared vs. non-shared environments

i.e. family economic situation i.e. experience @ school

misconceptions of genetics infl.

1. if strong genetic influence, then environment is unimportant

disadvantaged kids who are adopted into good homesIQ goes up

2. genetic infl. is limit of potential!

No!!! see IQ story!

3. Genetic infl. diminish w/ age

-not true, since monozygotic twins =w/ time b/c more similar than dizygotic twins

shows the continual genetic infl.

-Huntington’s disease = genetics!!! Yet only comes later in life

4. those disorders in families = genetic, while those which don’t run in families, non-genetic
   • no!!! juvenile delinquency = runs in families yet is environmental
   • autism = don’t run in families yet seems like strong genetic infl.

Constitutional liabilities

-innate/early acquired things that might infl. b/h

1. physical handicap
   1. low birth weight [even when not premature]–associated w/ mental disorders/emotional/b/h disorders

early intervention helps

2. temperament:
   1. reactivity
   2. self-regulation

kagen: those things are beyond genetics: pre/postnatal infl.!

personality dev. from temperament: i.e. conditions for certain things/avoiding other things

• w/o fear no morals
• too much: fear of everything

brain dysfunction/neural plasticity

-major brain lesions – higher risk for psychotherapy

-->though specific brain lesions rarely primary causer of psychiatric diseases

exception: Alzheimer’s, but that is b/c aging (primary cause)

developmental systems approach: genetic activity inf. Neural activitiesinfl. b/hinfl. Environment. These influences are by directional

experience can infl. neural plasticity and even genes!!!

Physical deprivation/disruption

• sleep deprivation
  • leads to b/h/cognitive probs. i.e. time/place disorientation
• food deprivationextreme weight loss = cognitive probs./many yrs. Of binging
• malnutrition in kids:
  • attention deficit disorder: distractibility/lower school achievements/lower attention
    • ADD =more common when mom is passiveneed to teach mom how to be more active
• kid also needs environmental stimulation for physical dev. of brain

Impact of biological view:

-many drugs helped many thing: people think that it will eventually bring a magical, instant cure

common errors:

1. people over-label bio diff. there are bio diff. even b/w intro/extroverts!!! Though this in not a bio prob.!
2. causes are bio: not true: you can only establish that b/f entering the CNS

Imp. to remember: anyone’s probs. isn’t detached from their personalities

Psychological views

1. humanistic: self-actualizing your potential
2. existential: inherent difficulties in self-fulfillments
3. psychodynamic
4. cognitive
5. behavioral-cognitive

humanistic perspective

• individual is a private world of I/Me/Myself
• most basic striving: maintenance/enhancement/actualization of self
• person reacts as how he perceives world/consistent w/ self-concept
• A perceived threat to self = defenses
  • Tightening of perception/b/h
  • Self-defense mechanisms
• individual’s inner tendencies =move to wholeness/healthin normal situations, people b/h rationally/constructively

-humanistic psychopathy: distortion of natural growth

existential perspective

existential issues: quest for values/meaning/self-fulfillment/self-direction/freedom

-difficulties to self-fulfillment/self-meaning-modern/dehumanizing mass

Basic existential themes of Rogers’ self-concept:

• Existence/essence:
• choice/freedom/courage:
• meaning/value/obligation:
• existential anxiety/encounter w/nothingness:

psychodynamic perspective

• consciousness: small part of mind
• unconsciousness: much larger
  • has hurtful motives/forbidden desires/other repressed things
    • tries to seek expression
      • until it is brought to awareness (consciousness)it leads to irrational/maladaptive b/h

structure of personality

• Id: instinctual drives. First personality structure to appear in infancy
  • Life instincts: (libido) sexual drives/basic life energy
    • Primary process thinking: generated by id: mental images/wish-fulfilling fantasies in response to instinctual needs
• Ego: mediates b/w id/reality/superego [when it later develops]: tries to find acceptable/realistic way to express Id urges
  • Secondary process thinking: Reality oriented rational processes used by the ego to deal w/ reality/external demands
• Superego: conscience: moral/ethical embedded here
  • Dev. later: internalizing of outside morals/values

Interpsychic conflicts: conflicts b/w diff. personality structures: Id/Ego/Superego

Anxiety: Freud: b/c of impending imagined/real danger

when threat is unconscious intrapsychic conflict: ego uses ego-defense mechanisms

sometimes, this is adaptive, at other times it is not

Psychosexual stages of development

Psychosexual stages of development: 5 periods, from infancy to puberty: characterized by dominant way to achieve sexual pleasure

• Oral stage: at 1^st 2 years of life:
• Anal stage: 2-3 yrs. anus b/c major stimulation both urges for retention/elimination. Toilet training often takes place here
• Phallic stage: 3-5yrs: self-ma
• Latency stage: 6-12 years: sexual motivation recede, focus on skills
• Genital stage: after puberty: greatest pleasure: sexual relations

Oedipus Complex/Electra complex

Oedipus complex: in phallic stage. Oedipus accidentally killed dad and married mom

boy goes through this symbolization: loves mom, rivals dad. Kid fears that dad will try to castrate him (castration anxiety)thus represses both sexual love for mom and hate for dad.

healthy solution: nonsexual love for mom/identify w/ dad

Electra complex: girl loves dad:

penis envy: b/c/ she thinks that she’s lacking

compromise: identify w/ mom/wait to get married to a man of her own and have a baby (penis substitute)

-solution to conflict: satisfactory heterosexuality

Freud: deterministic/conflict

Newer psychodynamic perspectives

-Sigmund Freud focused on Id

-2nd generation psychodynamic approaches (vs. Freud: psychoanalytical)

1. ego psychology

Anna Freud: focused more on ego, its defenses and how it organizes personality

2. mother child relationship
3. interpersonal approach

Object-relation theory

emphasis: pre-oedipal part of personality dev.

• which obj. the person directed the impulses t/w
• which obj. the person internalized (introjection)
  • inner representation of an object infl. B/h

Mahler: at first, kids don’t distinguish b/w self and other obj.

only later does self differentiate from other objects which are represented

separation-individuation process

• internalized objects have could have conflicting properties: exciting vs. hostile
• obj. can split off from central ego and maintain independent existences
  • leads to inner conflicts
    • one is servant of many masters – no order/integration in life

Kernberg (obj. relations)

Borderline: instability (mostly in personal relations)

can’t integrate/reconcile pathological objects into a full/stable personal identity (i.e. self)

Interpersonal approach

-relationships w/ others (past/present)

• Adler: people motivated to participate in a group
• Erich Fromm: orientation of social interaction (i.e. exploitative)
  • Those orientations could lead to psychopathy
• Karen Horney: agreed w/ Fromm/social learning of femininity/deplored Freud’s description of women/penis envy
• Erik Erikson: elaborated of Psychosexual stages to 8 social stageseach stage w/ its conflict –could be solves healthily or unhealthily
  • Freud: oral / Erikson: ‘Basic Trust’
• Sullivan: purely ‘interpersonal’: first we through interpersonal stages (in a health/unhealthy way): parents/peers/intimate relationsmarriage
  • Anxiety=aroused b/c aspects of interpersonal elements
    • Anxiety about anxiety = psychopathological
  • Security = freedom from anxiety
• Interpersonal accommodation: the way 2 people dev. communication/interaction =goals/mutual needs/build a satisfying relationship
  • If communication/interpersonal accommodation fail =conflicts/dissention/dissolution
• Attachment theory: early attachment style to mom affects later relationships

Impact of Psychodynamic Perspective

• Freud – first to organize human b/h and pathology into a structure

2^nd generation:

• Improvement of scientific method/measurement/assessment

Behavioral perspective

-behaviorism – reaction to unscientific method of psychoanalytical school

need directly observable b/h!!!

• Pavlov: classical conditioning
• Thorndike: instrumental conditioning
• Skinner: called it operant conditioning

mostly in labs

Theme of behaviorism

Learning: modification of b/h through experience

Classical conditioning

Classical conditioning: stimulus elicits a response: associating a neutral stimuli w/ that response

not automatic: animals/humans gain info about CS to know when to expect the UCS

i.e. if UCS sometimes not accompanied by CSanimal won’t expect UCS from the CSno CR!!!

-A learning process where a neutral stimulus get associated w/ another stimuli b/c of repeated pairing of stimuli

i.e. Pavlov study

-attached a fistula (tube) to dog, to saliva gland (to measure saliva flow)

-->light comes on, then food comes. (UCS) Eventually, dog salivates to only light (CR)

Unconditioned stimulus: (UCS) a stimulus that automatically gets a response, usually w/ no prior conditioning

Unconditioned Response (UCR): the response originally given to a previously unconditioned stimulus

used as a basis for a previously unconditioned stimulus

Conditioned stimulus (CS) a previous neutral stimulus that comes to evoke a conditioned response through association w/ the unconditioned response

Conditioned responses (CR): a learned/acquired response to a stimulus that did not evoke that response, originally.

Dog experiment

Food =UC

Salivation =UCR

Light =CS

Salivation to the light =CR

-Dog has been 'conditioned' to associate food w/ light

Extinction: gradual disappearance of a conditioned response that is no longer being reinforced

not unlearning!!! Re: spontaneous recovery

Spontaneous recovery: the return of a learned response a while after extinction occurred

Instrumental conditioning

Instrumental (operant) conditioning: learning of a response through reinforcement of a response by either rewarding or giving something unpleasant.

Reinforcement: the delivery if a reward or pleasant stimulus or escape from aversive stimulus

Conditioned avoidance response: to aversive events -avoiding the stimulus (i.e. nearly drowning= will avoid the swimming pool

could also learn from observe others get rewardthey don’t need reward to get conditioned

• Generalization: similar stimulus elicits response that was conditioned to that original stimulus.
• Discrimination: distinguish and respond differently to diff. stimulus

Impact of behavioral perspective

1. failure to learn adaptive b/h
2. learning of maladaptive/inefficient b/h

cognitive-behavioral approach

-criticized behaviorism for ignoring mental processes

‘thought can also be observed and measured empirically!!!!’

cognitive-behavioral perspective: how thought/info-processing brings to distorted/faulty emotions and b/h:

i.e. ‘I never get anything right!’

mechanisms of maintenance of disorders: i.e. depressed: biases to maintain bad vs. good memories

Bendura:

-People are motivated by internal symbols = thoughts

we can for see us getting stuck in the snow w/ the car, even though it never happened to us, so we go to the garage in the fall

• self-directing
• self-efficacy: achieving one’s goals

Attributions/attribution style/psychopathology

• internal vs. external
• stable (i.e. affects flexibility in relationships)
• global

-dysfunctional attribution styles: i.e. depressed: bad things: internal/stable/global

cognitive therapy

Aaron Beck:

Schema: underlying representation of knowledge that guides current processing of information and often leads to distortions in attention/memory/comprehension

maladaptive schemas (based on early learning experiences) cause psychopathy

how we interpret events infl. how we react to them

i.e. hearing a crash could be b/c of burglar or b/c gust of wind

beck shifted the focus to what cognitions produce the overt b/h

negative biases need to be altered

psychosocial causal factors

psychosocial causal factors: those experiences factors which possibly handicap a person, psychologically, making him less resourceful.

1. early trauma/deprivation
2. inadequate parenting styles
3. marital discord/divorce
4. maladaptive peer relations

Schemas/self-schemas: our views of the world and of ourselves

-cognitive frameworks to fill in gaps in experiences/observations

schemas infl.:

• our expectations of ourselves/others
• social roles
• events

-self-schema: our views of what we are and what we might b/c

-schemas shape out daily b/h/decisions

schemas are unconscious so we are not aware of all its assumptions

despite them possibly being in reality distorted, they are real to us

• assimilation: process of working new experiences into existing cognitive frameworks (schemas) even if this new information needs to be distorted/reinterpreted to make it fit [top-down]
• accommodation: changing existing cognitive frameworks to make possible the incorporation of discrepant information [bottom-up]

Predictability/Controllability

-when things are traumatic/harsh family conditionsless predictable/controllable

predictability/controllability = securityworld is save/unthreatening

too much is of course not too goodneed to also learn to deal w/ stressors

-many uncontrollable/unpredictable things = anxiety

schemas might include possibility that terrible things could occur which are unpredictable and uncontrollable

might even have a fragmented/incoherent self-schema

-kids form schemas diff, dep. on experiences/abilitymight shape future skill, based on the motivation level it causes.

Early Deprivation

• fixation in oral stage (freud)
• Basic mistrust (Erikson)
• Stunt in child’s capacity for anxious-free exchanges of tenderness/intimacy (Sullivan)
• Lack of reinforcement to acquire basic skill (Skinner)
• Self-Schema of unstable/untrustworthy/w/o affection (Beck)

Institutionalization

-When kids grow up in institutions, often less warmth/physical contact

missing much intellectual/social/emotional stimulation

Protective factors:

• those who later enter harmonious family: better than those who enter discordant family
• kid who has secure attachment and enters institution in later childhood = better
• success in school, whether in sports/achievements/social relationships/supportive marital partner later in life
  • helps SE and Self-efficacy

Deprivation/abuse in home

-could run from inattention/neglect of kids cruel and abusive treatment

possible result of neglect: failure to strive syndrome

‘failure to strive ’syndrome:

• b/h prob.
• delay in developmentcould compromise health

• parents find them bad
• could start when kid is depressed

could be b/c of prenatal stuff/low birth weight

-some studies show that downright abuse might be better than infant neglect

outright parental abuse

• depression
• anxiety
• impaired emotional functioning
• impaired social relationships (tend to be rejected)
• aggression linguistic dev. probs.
• disorganized attachment

disorganized attachment

• confused pattern of relating to mom at least until age 13
• predicts:
  • violence in family/non-familyespecially in males
  • suicide
  • depression
  • anxiety
  • personality disorders
  • lower IQ/reasoning ability
  • physiological disturbances

-intergeneration transmission of violence – 30% chance, since many parents internalize the roles-schema of violent parents

protective factors incl

• good adult role-model
• positive school experience
• higher IQ
• more attractive

Other childhood traumas, that could :

-i.e.:

• prolonged hospitalization of parentcould infl. attachment

could be downplayed w/ support of other parent

• being made fun of by step-brothers

poor parental styles

-parents make the most significant social interaction in the first few yrs. Of the kids’ lives

-bi-directional= hard kids = bad parenting, while bad parenting = bad kids

-parental psychopathy infl. kids (beyond genes)

1. depressed parent = inattentiveness = depressed kids
2. alcoholic parents = depressed/anxious/lower SE kids

types of parental styles

• Parental warmth
• Parental control

1. Authoritative parenting: A parenting style in which parents are nurturing/responsive/supportive, yet set firm limits for their kids

best parenting style

-high on control/warmth

2. Permissive-indulgent parenting: A parenting style in which parents fail to set firm limits or to require appropriately mature behavior of their children, yet spoil them

high on warmth/low on control

kid learn aggression impulsivity

the kid jumps into social relationships but usually for manipulatingjust like he manipulated his parents

has ‘entitled’ self-schema

3. Authoritarian Parenting: A parenting style in which parents are unresponsive/inflexible/harsh in controlling behavior
   • poor social and cognitive tools

-high on control/low on warmth

Severe discipline: physical punishment and other poor parenting tools used (vs. privileges withdrawn

kid uses this as a model for his self-schema

4. neglectful-uninvolved parenting:

disruptions in attachment/moodiness/low SE/poor peer relations/poor academic performance

communication:

Inadequate/irrational/angry communications

Inadequate:

• parents too busy
  • don’t give child opportunity to express issues
    • thus parents fail to give proper support/assistence

irrational

i.e. distorting speaker’s intent

Anger

i.e. b/c of marital discord/abuseleads to psych probs.

marital discord/divorce:

marital discord:

often leads to:

• child abuse
• child neglect
• parent w/ serious mental disorder
• authoritarian/neglect-uninvolved parenting

protective factors: when parent is:

• Warmness
• Prone to giving praise/approval
• Inhibit of rejecting b/h

Divorce/separation

Effects of divorce on parents:

• divorce of a difficult marriage is also hard!!!
  • Divorced people = over-represented in psychiatric patients

• divorce = major source of psychopathology/physical illness/death/suicide/homicide

Effect of Divorce on kids

• feeling of insecurity/rejection
• conflicting loyalties (i.e. one parent spoils the kids
• some dev. maladaptive responses
• temperament could help or make harder the adjustment
• delinquency is more common in divorced families

• long-term effect of kids
  • lower income/even welfare
  • academic attainment
  • lower life satisfaction
  • children out of wedlock
  • divorce themselves

many kids adjust well: negative effects of parental divorce = modest

since 50’s (especially 70s) negative effects are decreasing = less stigma to divorce?

better to divorce than to be in torn house

remarriage could help, in favorable rearing conditions

usually not so, especially for girls

Maladaptive peer relationships

-in preschoolers: not so refines: immediate satisfaction means that they will try to reject a kid when another, favorable kid comes

-peer prob.= linked w/ school drop out/depression/delinquency

sometimes reflects a heritable diathesis

on the other hand, peer interaction could be a learning experience(give-and-take)

social skill = social competence

practice/experience w/ intimate communication =possible transition from sexual curiosity to genuine love

Sociocultural/cross-cultural studies

some things are universal

• schizophrenia
• some symptoms of the MMPI (Minnisota Multiphasic Personality Inventory)

cultural difference:

• stress:
  • westerners: depression
  • china: physical symptoms: fatigue/weakness/other complaints

note: -depression = dysphoria

Diff soc. experience depression diff.:

-guilt as part of the westerner’s depression is not seen in nonwestern cultures.

• buddist: social relations = base of all suffering: avoid social contact as part of salvation
• Iran: grief = religious experience of living justly in an unjust world

Culture and overcontrolled vs. undercontrolled b/h

-in Thailand = culture supports only overcontrolled b/g: politeness//inhibit any anger

apparently: seen less disobedience as compared to US where undercontrolled b/h is more tolerated

question: does that mean that there is more shyness/depression in Thailand?

answer: yes!!! But you also se subtle overcontrolled b/ht/w animals/prob. concentrating

-Thai parents bring their kids less for treatment:

• too shy?
• Buddist religion of transiency of problems/optimism that b/h will improve

Causal factors w/I sociacultural environment

-social/sex roles /subgroup roles/norms get passed down:

is nonviolence is sanctioned, then the kids will learn to settle conflicts in non-violent ways

-many times, conflicting beliefs in a society. Yet there are some core values

-expected roles exist also for specific things like students/officer/nurse etc…

person has many roles through life, and at any moment

-conflicting/unclear/uncomfortable roles or when one can’t achieve satisfactory role in a group = personality dev. could be impaired

sex roles

-today, androgyny (combo of both sex roles) seems to be the ideal for both genders

many still keep traditional sex roles

Acceptance of sex-roles imp!!!

-low masculinity =tends to be associated

b/c masculinity is associated w/ SE

-high femininity/low masculinity = failure to accept leadership in problem-solving cases

similar to learnt-helplessness

causal factors in depression/anxiety

could explain why more women experience depressive/anxiety disorders

Other pathogenic social influences

Low socioeconomic status/unemployment

-inverse correlation b/w socioeconomic status and abnormal b/h

stronger correlation for some disorders over others, for example antisocial.

• antisocial 3 times more in lowest vs. highest status
• depressive only 50% more

possible other factors that lead to socioeconomic’ status infl. the poor more than the rich:

• often, those people don’t have $ to climb back up!!!
• More stressors in life
• Less cognitive stimulation in youth
• this pop. also shows other prob.: low birth weight/prenatal complications/health prob.

poverty and other correlates:

• lower IQat least up to age 5
• more child abuse by fatheralso adverse effects on his wife (who consequently shows also more hostility/anxiety/depression)
• more punitive (especially in single moms)leads to cognitive distress/depression

Unemployment

-not only mentally ill lose job!

-beyond the financials, it is demoralizing/self-devaluation/emotional distress

unemployment: increase in depression/marital stress/somatic complaints which usually stop when reemployed

-resilience in school/peers/familyhelps upwards social mobility

Disorder-endangering social roles

-for example: the role of a commander in army allows him to tell soldiers to maim/kill othersas seen in Vietnam = those horrors make people vulnerable to disorders/guilt/etc

Prejudice/discrimination based on race/ethnicity/gender

-many more women suffer from depression/anxiety disorders

passivity/dependence of traditional roles

stressors incl: being both a full time mother and full time worker

studies show that in some cases: working outside home helps

Social change/uncertainty

-Education/jobs/families/leisure pursuits –constant change!!!

constant readjustments cause uncertainty

• despair
• demoralization
• sense of helplessness
  • pre-establish abnormal reaction to stressful event

Impact of sociocultural viewpoint

a disorder could have many causers: genetic/socioculture!!!

Chapter 3

Clinical assessment

Clinical assessment: try to understand client’s symptoms/probsin order to understand nature/extent

use psych test/observations/interviews

Dynamic formulation: integrated evaluation of ind.’s personality traits/b/h patterns/environmental demands/etc… intended to describe the person’s current situation, and to hypothesize what is driving person to b/h in maladaptive ways

Assessment of Physical Organism

Neurological examination

1. Electroencephalogram (EEG): brain wave impulse patterns in diff areas, by electrodes

if it shows dysrythmia: use diff. ways to find prob: perhaps lesions/tumor?

2. CAT scan (computerized axial tomography): X-rays of brain: helps see structural abnormalities of brain
3. MRI (magnetic resonance imaging): sharper than CAT: differentiates soft tissues betterless radiation/ionized radiation
4. PET (positron emission tomography): metabolic activity of diff. areas (radioactive glucose)sees functioning
5. fMRI (functional MRI): maps oxidation/blood-flow in brain -->less invasive and much clearer: can measure ongoing thoughts/sensations!!!

Neurophysical examination

Neuropsychologival assessment: use of psycholofical tests that measure a person’s cognitive

-i.e. cognitive/motor skills measured: i.e. measures of memory/dementia

• halstead category test: measures ability to learn./remembermeasures impulsivity/judgment
• rhythm test: sustained concentration/attention through audio-perception test
• tactual performance test: motor speedresponse to the unfamiliarability to use tactile/kinesthetic cues
• speech sounds perception test: can identify words?
• finger oscillation test: measures the speed at which the subject can depress a lever w/index finder

Assessment interviews

• unstructured interview: no preexisting plan w/ respect to content sequence
  • more unique and specific to the ind.
• structured interview: patient is being asked in a highly controlled way
  • usually more reliable

Clinical Observations

-overt o/h or emotions/hygiene/symptoms (i.e. depression/hallucinations/ect…)

• self-monitoring: observing/recording own’s b/h/thoughts/feelings that occur in natural setting
• rating scale: i.e. rate h.m. of something takes placemeasure its predominance

Intelligene tests

• wais III (wechler adult intelligence scale revised
• WISC-II wechler intelligent scale for children revised
• Stanford-binet

Projective personality tests

-ambiguous stimuli which ind. is encouraged to interpret/unstructured

-->get a population range of responses to know deviant responses

• Rorschach Test: projective personality test, consisting of 10 inkblot pictures to which the individual responds w/ associations that come to mind. Analysis of those responses allow inferring of personality characteristics
• Thematic Apperception Test: projective personality test consisting of a series of simple pictures, that ind. is asked to make up stories: analysis of those stories gives clues to person’s conflicts/traits/personality dynamics/etc…
• Sentence-completion test: projective personality tests utilizing incomplete sentences that person is to complete: analysis of the responses enable clinician to infer personality dynamics.

Objective personality tests

-Structured personality tests such as questionnaires/self-inventories/rating scales used in psychological assessment

• MMPI (Minnesota multiphasic personality inventory) [ -A] =adolescents
• Regardless of the content of item, you are measured in comparison to h.m. answered that way that were ill in some specific disease. Each pathology has a constellation of answers

Electrocunvolsive therapy(ECT): electro shock used to alleviate mostly severe depression/mania

Neurosurgery:

Prefrontal lobotomy: in 30’s was done to treat various pronblems

** - drugs – p. 95-104

classical psychoanalysis

main idea: insight into repressed thoughts –frees ind. from need to keep wasting energies of defense mechanisms

4 basic techniques

1. free association: saying whatever comes to mind regardless of h. personal/painful/seemingly irrelevant it might seembrings forth the preconscious
2. analysis of dreams: i.e. its manifest content vs. its latent content
   1. manifest content of a dream: the storyline of the dream
   2. latent content of the dream: the unacceptable motives of then dream that seek expression through desquising themselves in the manifest content of the dream
3. analysis of resistance: analyze why a person resists speaking about certain [threatening] things
4. analysis of transference: analyze the attitudes/feelings [of past relationships w/ a sig. Person] onto the therapist

-counter-transference: when analyst b/h in accord w/ transference of the patientcould ruin the treatment

modern psychoanalytical schools:

• object relations
• attachment/self psychology: -emphasis is on interpersonal i.e. transference.

-i.e. Sullivan

the key is the transference, since the therapy activates a maladaptive early schema of how to relate to people (i.e. to be rejected by everyone)ignore the drive elements of the psychodynamic theory

behavior therapies

behavior therapies: use of therapeutic procedures based originally on the principles of classical/operant conditioning

directly modifying problem b/h: i.e. counter-conditioning/extinguishing maladaptive reactions

guided exposure

main idea: unlearning of a maladaptive response to a certain stimuli

Example:

systematic desensitization: behavior therapy technique aimed at teaching a person to relax or b/h in some other way that is inconsistent w/ anxiety while in the presence of (real or imagined) anxiety-producing stimuli

-‘systematic’ = gradually increasing levels of exposure to the aversively conditioned stimuli

counter-conditioning this now-aversive stimuli

• in-vivo exposure: real stimuli [much more efficient than in- vitro]
• in- vitro: imagined stimuli

modeling: learning the skills at hand by imitating another person doing the b/h to be acquired

aversive therapy: punishment for undesired b/h: i.e. smoking/overeating/drug abuse/bizarre psychotic b/h

systematic use of reinforcement:

contingency management: using a systematic program fir the reinforcement to suppress/illicit a learnt response

response shaping: behavior therapy technique using a positive reinforcement to establish by gradual approximations a response that is actively resisted or is not initially in a person’s behavioral repertoire

token economics: a b/h modification program, often used in hospitals/institutions where the rewarding reinforcement is in a form of a token which could be exchanged for privileges

behavioral contracting: positive reinforcement technique that uses a contract (usually b/w a couple or family) that identifies b/h to be changed and specified the rewards or privileges to follow

biofeedback: behavioral treatment technique in which a person is taught to influence his or own physiological processes.

Cognitive/cognitive-behavioral therapies

Cognitive-behavioral therapy: any therapy based on altering dysfunctional thoughts and cognitive distortions

Cognitive therapy: another term for cognitive-behavioral therapy

assumption: cognitions infl. emotion/motivation/behaviors

3 approaches:

1. Rational-emotive behavior therapy (Albert Ellis)
2. Stress-inoculation therapy of Donald Meichenbaum
3. Cognitive therapy of Aaron Beck

Rational-emotive behavior therapy – Albert Ellis

-irrational b/hbased on irrational emotionsbased on irrational beliefs

change irrational beliefs changes the emotions and thus the b/h to more adjustive

Stress-inoculation therapy Donald Meichenbaum

-change self-statements that are made in stressful situations

Cognitive therapy of Aaron Beck

Change negative view of:

• self
• world
• future

Humanism:

Client-oriented therapy: client is not dependant but a responsible client

therapy just helps clear obstacles for self-actualization [re: humanism]

Existentialism

Existentialism: concern w/ existence (‘human predicament’)– the person in the human condition

some things are basic/fundamental to the human existence

look for meaning in life

1. Experience is taken seriously
2. Ind. is unique/irreplaceable/singular

Existential focus on:

1. Freedom/consciousness/self-reflection
2. Responsibility (for action/choices/being authentic)
3. Fear of deathloneliness
4. Phenomenology = focus on ind.’s experiences

Gestalt therapy: ‘wholeness’: resolve unresolved conflicts: integrate all the hidden thoughts/feelings/actions should integrate into self-awareness

if not, then we tend to act out our past unresolved conflicts/traumas in present relationships. Therapist tries to help obstacles so problem could come into awareness and person could deal w/ the trauma and not have it be expressed in other ways:

i.e. by acting out fantasies

at certain point, patient comes to impase, and has to deal w/ his true inner feelings

criticism of humanist/existential/gestalt therapies: lack of systemized models of human b/h and its specific aberrations

marital therapies

couples therapy: form of interpersonal therapy involving sessions with both members of the couple present. Emphasis is on mutual gratification/social role expectations/communication patterns/similar interpersonal factors

marital therapy: another name for couples counseling

• Family system approach: treatment approach that makes the assumption that the within-family b/h of a particular family is largely infl. by b/h and communication patterns of other family members
• Conjoint family therapy: approach to family therapy that focuses on improving communication, interactions and relationships among family members and on fostering a family system that better meets needs of each member
• Structural family therapy: Approach to family therapy that focuses on analyzing and altering the patterns of interaction among family members to help them b/h in more supportive and less pathogenic way to each other

Chapter 4 – stress-related disorders

stressor: adjustment demands placed on ind. or group

Stress: effort of the stressor on organism =: it taxes body’s resources

Coping strategies: ways to cope w/ stress

Interdependent: stress infl coping techniques and coping techniques infl. stress

Stress

• eustress: positive stress
• distress: negative stress associated w/ pain/anxiety/

crisis: stressful situation that approaches/exceeds the adaptive capabilities of ind. (or group)

factors predisposing person to stress:

1. nature of stress
   • significance
   • intensity immediate
   • cumulative effect
   • duration
2. perceptionof stressor: i.e. if stressor is perceived to be less manageable = more stress
3. ind’s stress tolerence: stress tolerance = the ability to eithstand stress w/o being impaired
4. lackof external resources/social support

responding to stress

3 interacting levels

1. bio –i.e.: immune system/damage repair mechanism
2. psychological/interpersonal level
3. socioeconomic level: i.e. group resources/labor unions/law enforcement groups/religion groups
   1. group can malfunction and inf. The ind.

response to stress

1. meet the requirements of the stress
2. protect the self from psych damage/disorganization

task-oriented response: b/h to deal w/ requirements of stressor.

appraises situationconsider alternative solutionsdecide on best solution

defense-oriented response: moight be less productive/more self-defeating

2 kinds:

1. psych damage: repair = crying/talking
2. ego-defense mechanism: only maladaptive when w/ primary means of coming

effects of severe stress:

• lower efficiency
• depletion of adaptive resources
• bio wear

psychological/personality decomposition: lowering of adaptive psychologicaql functioning in face of sustained/severe stressors

bio effects of stress

general adaptation syndrome (GAS): 3 stage model that helps exmplain course that bio decomposition takes under extreme stress:

alarm reaction stage of resistence exhaustion

after decompositionbody tries to return to homeostasis

if extreme Damage: need to teach people to reorganize adaptive b/h /defenses

adjustment disorder

adjustment disorder: maladjusted way to respond to common stressor, i.e. childbirth

must occur w/I 3 month of the stressor

maladaptive response

1. unable to function
2. reaction in extreme

stressor subsides

1. stressor subsides
2. learn to deal w/ stressor

-if more than 6 months = mental disorder

Adjustment disorder: a disorder where person’s response to a common stressor is maladaptive and occurs w/I 3 months of stressor

2 kinds of adjustment disorder

1. acute stress disorder (ASD): after a traumatic event:
   • 3 or more dissociative episodes
   • numbness
   • detachment
   • derealization
   • depersonalization
2. PTSD: same as ASDthe symptoms just last more than 4 weeks

Disaster syndrome: the common reactions of many victims to major catastrophe during/after/long-run

• replays trauma, even thought attempt to avoid stimuli
• anxiety
• impairment

symptoms:

acute: w/I 6 moths

delay: onset is after 6 months

stages:

1. shock: stunned/dazed/apathenic
2. suggestablke stage: passive/suggestable/willing to take directions
3. recovery stage: tense/apprehensive: general anxiety

gradual regaining psychological equilibrium

psychological effects of long term stress

-personality decomposition: certain cource

1. Alarm/mobilization: resources for coping w/ traume is alerted/mobilized
   1. emotional arousal
   2. sensitivity
   3. greater alertness (vigilance)
   4. attempt @ self-control

-anxiety/gastrointestinal upset/lowered efficiency/signal that mobilizes of adaptive responses is inadequate

2. resistance: if trauma continues – same means for dealing w/ trauma

–temporary concerted task-orienting response

-ego mechanisms =intensified

-cling to old [mal]adaptive waysno reevaluation of responses

3. Exhaustion: adoptive responses are depleted/coping strategies b/g to fail

inappropriate way to deal w/ realityi.e. disorganized thought/delusions/hallucinations

-->try to salvage psych integration -->tries to reintegrate reality

-->i.e. studies of hostages

PTSD – main symptoms

• high arousability
• low frustration/stress tolerance
• irritability
• emotional instability/numbness

rape – 5 areas of disruption of functioning

1. Physical disturbance
   • hyper-arousal
   • anxiousness

2. Emotional problems
   • low SE
   • Depression
   • Anxiety

3. Cognitive problems
   • Low concentration
   • Intrusive thoughts

4. Atypical behaviors
   • Aggression
   • Antisocial acts
   • Substance abuse

5. Social problems
   • intimacy problems
   • sexual dysfunction
   • self-victimization (in further sexual relations)

-greater identification w/

• goals of war
• combat unit
• quality of leaderships

psychological protective barrier

Psychological preparedness: protective factor for lessening the psychological effect of torture

-prior experience w/. anxiety = could lessen war PTSD

2 elements of stressors

• controllability
• predictability

less controllability/predictability = more stress

Treatment/prevention

Stress inoculation: train people to tolerate/anticipate stressors

change the things that they say to themselves

3 stages:

1. info about stress situations and h. person deals w/ it
2. self-statements, i.e. don’t worry, pain is part of the treatment
3. practice those statements in pain-threatening or ego-threatening situation

medication

-usually antidepressants

Crisis interventions:

-emotional support – usually right after trauma

Direct therapeutic exposure

-exposure to feared stimuliw/ relaxation techniques

chapter 5

Anxiety: general apprehension about possible dangermuch more diffuse than fear

Historically thought to be part of neurotic b/h

Nerutotic b/h: exaggerated use of avoidance b/g or defence mechanisms in response to anxiety

Neurosis: term used historically to characterize maladaptive b/h resulting from intrapsychic conflict and marked by prominent use of defense mechanisms

Freud: the anxiety that causes the neurosis is often masked: i.e. anxiety about sexuality/aggression might be masked/deflected

many disorders that Freud classified as neurosis, which did not incl. observed anxiety were later reclassified

fear/anxiety response patterns

fear/panic: a basic emotion which incl. activation of the ‘fight-or-flight’ response of the sympathetic nervous system

3 parts:

1. Cognitive/subjective
2. physiological
3. behavioral

Anxiety: a whole mix of emotions/cognitions: general apprehension about possible dangermuch more diffuse than fear

1. Cognitive: negativity/worry about future danger/threatpreucupation w/ unpredictable or uncontrollable

No fight-or-flight activationjust preparation for it!

2. Physiological: over arousal of autonomous system
3. behavioral: avoidance

-Anxiety is adaptive when mildwhen chronic = prob.!

-Anxiety and fear are highly conditionablei.e. traumas: kid seeing dad beat up mom = anxiety at dad’s car arrive

overview of anxiety disorders

anxiety disorders: any mental disorder characterized by unrealistic/irrational fear or anxiety of disabling intensity. DSM-IV-TR = 7 types:

• phobic disorders (specific/social)
• panic disorders (w/ or w/o agoraphobia)
• generalized anxiety disorder
• OCD
• PTSD

Phobia: persistent and disproportionate fear of some specific obj./situation that represents little/no actual danger to a person

3 types of phobia:

1. specific
2. social
3. agoraphobia

Specific phobias: persistent or disproportionate fear of other species (i.e. snakes/spiders), aspects of the environment (high places/water) or situations (airplanes/elevators)

Social phobia: fear of social situations in which a person might be exposed to a scrutiny of others and might act in humiliating or embarrassing ways

Agoraphobia: fear of having a panic attack in places you can’t escape or might be embarrassed (fear of either/both [?] open/closed spaces)

Specific phobias

-presence or anticipation of stimuli causes strong/persistent fear

when stimuli is presentimmediate reaction that looks like a panic attack (just that here, there is an external cause)

subcategories:

1. animal (snakes/spider)
2. natural environment (height/water)
3. blood-injection-injury
4. situational (airplane/elevators
5. atypical (vomiting/choking)

-some phobias are exaggerated fear to specific things that we all fear to some extent

imp: avoidance is key to phobias: since the phobic response is also unpleasant (i.e., climbing up 100 floors instead of elevator

-sometimes phobias are maintained for secondary-gain purposes: i.e. attention/avoidance of several responsibilities

Blood-injection-injury

-fear at sight of blood/injury/injection

-instead of only initial acceleration of heart rate/blood-pressure

also 2^nd stage of lowered heart rate/blood-pressure/dizziness/nausea/fainting

characteristics

• familial patterns
• the people who show this phobia show the typical patterns for the rest of the phobias that they have

age/gender

-more women than mendiff %, depending on specific phobia

-some at childhood/others, such as claustrophobiaadolescents

psychosocial causal factors:

psychoanalytical causes:

-anxiety is displaces onto an external object

behaviorism

-b/c of trauma (i.e. dental/accident phobia)

-could also be vicarious/observational classical conditioning

TV/mass-mediai.e. lab monkeys conditioned to be scared of snakes through a television

question: why don’t everyone who experience a trauma undergo phobia conditioning?

Answer:

1. diff. in life experiences: i.e. positive experiences w/ friendly dogsno dog phobia after a bite
2. conditioning experience: if the trauma is inescapable/uncontrollable: much stronger phobia conditioning
3. experiences after the conditioning: i.e. even if you’re verbally told ‘you’re lucky to be alive!’ you maintain the phobia in a stronger way.

shows the strength of cognitive element of conditioning: i.e. always looking out for the aversive stimulus!

Biological causal factors

Genetic/temperamental causal factors

• genetic
• personality
• temperament (i.e. Kagan: inhibited kids =more phobias)

Evolutionary Causal factors

-b/c of our evolutionary past, we’re more easily conditioned to fearing things like water/height/snakes, than bikes/cars/guns, though they might be more traumatic

-->Called preparedness

Therapy

-exposure: stimuli/situation that elicit the phobia is gradually given to the client

could be in-vivo or imagined

-participant modeling: the psychologist shows the client the b/h that illicit the b/h

social phobia

-specific social phobias = a specific social situation i.e. public speech

-generalized social phobia: any social situation

-->in feared situation –might have a panic attack

-->soc. phobia, unlike other phobias start at childhood

psychosocial/biological causal factors

social phobia as a learned b/h

direct/vicarious classical conditioning: witnessing/experiencing a perceived social defeat or humiliation i.e. having isolating parents: many chances at vicarious social fears

social fears/phobias in evolutionary context

dominance hierarchies: aggressive encounters w/ other members of group over dominance -->there is fear, but note that no one tries to leave situation completely!!! Soc. phobia won’t run away!!! Starts in adolescence where there is a dominance conflict

genetic/temperamental factors

• some genetic involvement
• temperamental predictor: Soc. inhibited!

Perceptions of uncontrollability

-uncontrollable stressful events: leads to submissive/unassertive b/h

-->typical of soc. phobia

-you tend to see in soc. phobia a diminished sense of control

cognitive variables

-expectation of rejection/negative evaluation

-senses vulnerable in presence of others

-->the ‘danger schema’ of the soc. phobics:

• Hypervigilant of hints of rejection/negative evaluations
• Expectations to fail –interferes w/ability to interact in socially skilled way

-->b/c less friendly, confirming their expectation

treatment

-Inderal (High Blood pressure drugs) = inhibits the peripherals of autonomic system:

-i.e. the trembling hands

-for full-blown attacks: antidepressants/anti-anxiety

-->behavioral/cognitive = best treatment: i.e. recognize the irrational thoughts, such as ‘no one understands me’

Panic disorders

Panic disorder: a mental disorder characterized by the occurrence of repeated, unexpected panic attacks, often accompanied by intense anxiety about having another suck attack --> must worry for at least a month

-4x more in women than in men

4 of 13, incl.:

• shortness of breath
• heart palpations
• sweating
• dizziness
• dear of dying
• dear of losing control
• depersonalization (detachment from body)
• derealization (external world is unreal)

-->10 of 13 are somatic!

-such attacks are unpredicted-->unprovoked by identifiable cues

-sometimes, situationally predisposed, i.e. nocturnal panic attack

Panic vs. anxiety

-panic: sudden/brief/intense

-anxiety: chronic

Agoraphobia

Agoraphobia: fear of being in places/situations which would be physicAllt difficult/psychologically embarrassing or in which immideate heko would be unavailable in the event that something would happen

-->fear developed from the initial [anic attack sin those places

agoraphobia w/o panic

-not linked w/ panic attacks

-->very rare -->called limited symptoms attack- less than 4 symptoms

comorbidity

• depression
• suicide

drugs

• antidepressants (i.e. tricyclic)

-serotonin drugs

-sometimes, panic attacks associated w/ preaqueductal gray

-->locus coeruleus: in brain stem, and/or preaqueductal gray

-->autonomic storm: panic attack!!!

-->causes anticipatory anxiety in limbic system -->remembered in the prefrontal cortex

Cognitive/behavioral causal factors

Interoceptive cognitive model

Interoceptive fears: fears focused on various internal bodily sensation

-->i.e. sense heart palpations and then the anxiety produces the panic attack

recent model: we sense the internal/external cues and then we get panicked-->eventually they b/c conditioned to provoke a panic attack

-some people are genetically/temperamentally prone to panic attacks

-->main idea: ‘fear of fear’

cognitive model

-some people are hypersensitive to bodily sensations and then catastophize it [interpretation problem!!!] -->panic attack-->reinforcement of bodily sensations

Diff. b/w cognitive model and interoceptive cognitive model

-in cognitive model, more emphasis on the meaning that people place on the stimuli

-->also gives importance to the person seeing how drs. and others treat the situation!

Perceived control/anxiety sensations

-more [sense of] control over a situation: less panic

-->the fact that panic attacks are unpredictable/uncontrollable, actually helps to maintain them

-some people have higher anxiety sensitivity: a high level of belief that certain bodily sensations have bad consequences

-anxiety sensitivity is often a precursor to panic attacks

medication reduces symptoms but not the underlying problem!

-benzodiazephine (or example Xanax)

-anxiolytics (anti-anxiety)

-antidepressants

behavioral/cognitive based therapies

-based on exposure

-some treatments are based on interoceptive expose: expose the person to the bodily symptoms that lead to the panic attack

-some therapies (more cognitive oriented) based on automatic catastrophic thoughts

modern way:

• teach about the panic cycle
• then teach to identify the panic cycle arousal and lower it.
• teach to decatastophize the thing

generalized anxiety disorder (GAS)

generalized anxiety disorder: a mental disorder characterized by chronic excessive worry about a number of events or activities w/ no specific threats present and is accompanied by at least 3 of the symptoms of:

• restlessness
• fatigue
• difficulty concentration/going blank
• irritability
• muscle tension
• sleep disturbance

-must occur at least ½ the days for at least 6 months

-some don’t come for treatment b/c they learn to lie w/ it

general characteristics:

• constant state of tension/worry/diffuse uneasiness
  • anxious apprehension

• chronic negative affect
• lack of sense of control
• worry about making mistakes, and causing catastrophes
  • review real/made-up mistakes of the past and anticipate future mistakes

comorbidity - usually other axis 1 disorders:

• anxiety disorder
• social phobia
• panic attacks

prevalence/age of onset:

-at any yr: 3% of pop

-lifetime: 5%

-X2 more in women (less than other, more specific phobias)

onset:

-hard to determine onset -->some think that it was there all their lives, while others remember a slow and insidious onset

Psychosocial causal factors of General Anxiety Disorder (GAD):

psychoanalytic

-unconscious conflict b/w id and ego [Freud: sexual or aggressive impulse]

-->defense mechanisms not functioning well.

-in phobias, repression and displacement a re working. Here, non are!!!

Behaviorist

-conditioning to many environmental cues (vs. phobias: 1 cue is negatively conditioned)

-->today, behaviorists speak more about anxiety apprehension

role of predictability/controllability

-more controllability/predictability = the stressor is less stressful.

-->i.e. Mondays, the boss is always angry

-->i.e. if having prior experience w/ uncontrollable events (i.e. parent who yells at you for no good reason) = more likely to have GAD

-more early experience w/ control and mastery = less GAD

-hypervigilence = might be exactly b/c of those lack of safety signs in their environment (no predictability!!!)

cognitive:

-automatic thoughts based on maladjusted thought/schemas

-->i.e. everyone will laugh at me

-->key maladaptive assumption: ‘any strange situation is dangerous’

Advantages that GAD people think that they have

1. superstitious avoidance of catastrophe: (‘less likely...’)
2. actual avoidance of catastrophe (‘wont happen that …’)
3. avoidance of deeper emotional things
4. coping and preparation
5. motivation divide

paradox: attempt to lower anxiety actually brings more!

GAD worry is self-sustaining

cognitive biases

schemas developed early in life might infl. automatic thought

Cognitive bias: GAD people = take the threatening part of the situation and concentrate on it. Non-GAD people concentrate on the non-threatening part of the situation (reversed bias)

Example:

• they discussed the priest’s conviction
• the dr. examined her growth

Bio basis for GAD

genetics

-genes not directly involved in GAD, but linked to the personality trait neurotism, which then is often linked w/ anxiety

Neurotransmitters

-deficiency in GABA (inhibitor neurotransmitter) - especially in limbic system, is know to be associated w/ GAD

-serotonin/norepinephrine – also involved in modulating anxiety

Neurological basis of diff b/w anxiety and panic

-beyond anxiety just being from an unknown source of fear:

• anxiety: limbic system: more prolonged/chronic state
• panic: locus coeruleus/preaqueductal gray: ready for fight-or-flight

medication

• buspirone – no side effects, that bemnxodiazephine has, though might take longed than benzo. To work
• benzodiazephine – i.e. Valium
• antidepressants

cognitive-behavioral treatment: inc. relaxation treatment as well as cognitive work on the automatic thoughts

obsessive-compulsive disorder

Obsessive-compulsive disorder: an anxiety disorder that combines one or both obsessions/compulsions

Obsessions: persistent intrusion of unwelcome thoughts/images/impulses that elicit anxiety. Attempts are made to suppress them, are unsuccessful, so they try to neutralize them w/ other actions

Compulsions: irresistible urges to carry out certain rituals/acts to reduce anxiety, usually in response to the obsessive thoughts.

• often, rigid rules for the compulsive act
• the person knows that it is a product of his own mind

important elements

• must cause distress
• consume a lot of time (over an hour a day
• interfere w/ social/occupational functioning

-obsessive thoughts are often associated w/ the compulsive acts

-->regardless of whether the repetition is a thought or act, the point is the subjective sense of loss of control

-->only b/c a problem when it interferes w/ daily life

-those people: able to see that their acts are irrational, but are unable to resist them

>feel a release of tension once the act is preformed

comorbility

• depression
• social phobias
• panic disorders
• specific phobias
• avoidant/dependant personality disorder (PD)

body dimorphoic disorder (DD)

body dismorphic disorder: obsessive thoughts about perceived flaw/defect kn person’s appearance ->not like once thought: somatoform prob!

obsessed w/ look: always look at mirror/plastic surgery

psychochoanalytical viewpoint

oedipal stage fixation: shame for trying to satisfy id (i.e. soiling)and ego says not to defense mechanisms lead to OCD

behavioral viewpoint

2 procedss theory of avoisdance learning

-Anxiety= associated w/ 1 stimuli, and reduced by anotherleads to avoidence conditioning

common types of obsessive thoughts

• symmetry
• sexual obsessions
• religion
• aggressive

5 primary times of OCD

• cleaning
• checking
• repeating
• ordering/arranging
• counting

examples:

• washing hands
• checking intersection for hours about an imagined accident

Consistent themes:

1. Anxiety =affective symptoms
2. All OCD people fear a catastrophe (if they don’t deal w/ ‘prob.’)
3. Compulsion reduces this anxiety (in the short run)

OCD’s Memory

-OCD = less/lower non verbal memory

can’t remember if they did the act

preparedness

looking at OCD in evolutionary ways:

1. Overrepresentative: dirt/contamination

evolutionary reasons!?!

2. also other animals have obsessive grooming after anxiety/distress!!!

Suppression paradox:

Paradox: the more you try to surpress the more that the obsessive thoughts come

Similar to GAD: people tyr to surpress the anxiety (in this case, the obsessive thoughts), but it really increases it!!!

Bio causal factors

• genetics
• serotonin
• brain structure: i.e. in orbital prefrontal cortex/cingulated cortex/basal ganglia

treatment:

medication: antidepressants (re serotonin reuptake inhibitors)

behaviorist: exposure/preventation of compulsive acts

brain surgery: in extreme cases

chapter 6 – mood disorders/suicides

Mood disorders: mental disorders characterized by disturbances of mood that are intense and persistent enough to be clearly maladaptive

Mania: emotional state characterized by intense/unrealistic feelings of excitement/euphoria

Depressions: emotional state characterized by feelings of extraordinarily sad/dejections

Unipolar disorders: only depressive episodes

Bipolar disorders: both manic/depressive episodes

Hypomanic: mild form of mania

Note: depression often goes w/ anxiety

Subtypes of major depression:

1. Melancholic type: subtype of major depression, which beyond the major depressive symptoms, the person has also lost all interest/pleasure in all activitiesdoes not respond to any pleasure!!!

Other symptoms including:

1. early morning awakening
2. depression being worse in morning
3. marked psychomotor agitation/retardation
4. sig. Loss of appetite/weight
5. excessive/inappropriate guilt
6. depressed mood that is qualitatively diff. from non-melancholic depression

this depression is more infl. genetics than other depressions

most likely to be helped by electoconvulsive treatment

2. severe major depressive episode w/ psychotic features

major depression w/ psychotic episodeslack of contact w/ realitydelusions/hallucinations b/c of the depressions

1. mood-congruent psychotic features: i.e. I am worthless/my body organs are deteriorating
2. mood-incongruent features: a divine sent me on a mission

3. postpartum onset: w/I 4 weeks after birth of a baby. Usually an adjustment disorder.

Distinguishing major depression:

-Sometimes hard, since there are some people who have ‘double depression’:

-chronic dysthemia w/ episodes of major depression

recovery form the major depression episodes is more common than the recovery from the chronic dysthemia

Seasonal affective disorder: mood disorder involving at least 2 episodes of depression in the last 2 year, occurring at the same time of year (usually fall/winter) w/ full remission from each of those episodes occurring at certain time of year, (usually, spring)

seems more common in northerly altitudes

Depression as a recurrent disorder

-diagnose differentiates b/w single (initial?) and recurrent episode (had already been depressed b/f)

• recurrence: a new occurrence of disorder after a period of remission of symptoms lasting for at least 2 months

recurring depression = more severe/more symptoms

• relapse: return of symptoms w/I short period of time

probably b/c the run of depression has not finished its run in that episode

Biological Causal Factors

• hereditary: some genetic infl. on unipolar disorders
  • less genetic causality for milder things, like dysthemia
• biochemical: monoamine acids are most important biochemical factors in depression (monoamine hypothesis)
  • dopamine
  • serotonin
  • norepinephrine

prob.!!! unclear hypothesis, since there seems to be a decrease in long term, of serotonin/norepinephrine

• neuroendocrine/neurophysiological factors

neuroendocrine/neurophysical

hypothalamic-pituitary-adrenal axis: releases cortisol: 50-60% more in depressed people

hypothalamic-pituitary-thyroid axis: too little thyroid level (hypothyroidism) is associated w/ expression

Left anterior prefrontal cortex:

• lesion(but nor right) is associated w/ depression
• low activity level in l. anterior prefrontal cortex

disturbances in sleep/other bio rhythms:

-sleep disturbances seen in depressed people is seen much b/f the depression onset!

Sleep symptoms: especially melancholic depressed

• difficulty falling asleep
• early morning awakening
• poor sleep maintenance: often waking up
• rhythms:
  • too little deep sleep/too much REM
  • REM starts earlier (60 min instead of 80 minutes) at expense of deep sleep)

-sleep problems exist also w/ depression remission

-another causal problem: circadian rhythm abnormalities: also affects thyroid/melatoning

sunlight/seasons: seasonal affective disorder might be linked to total amount of light available in the northerly climates

Psychosocial causal factors

• stressful life events:
  • being fires/failing exam
  • thwarting of imp. goal
  • several sressors in row: i.e. breakup w/ GF and then failing on exam
  • insidious stressors unrecognized as such by the affected person, i.e. living w/ depressed/physically handicapped person
  • disease/abnormality that gives a sense of deterioration

chronic strain: i.e. poverty: leads to increase in depressive symptoms but not necessarily to major depression

individual differences in response to stressors:

-beyond genetics/experiences, some people seem more sensitive to the stressors that lead to depression

if a series of misfortunes, then everyone will b/c depressed, since this will be beyond everyone’s sensitivity

Some think that stressors act to cause depression by altering the hormonal/biochemical balance

Types of diathesis-stress models for unipolar depression

Personality/cognitive diathesis:

• neuroticism: hereditary personality trait associated w/ negative affect which could lead to depression
  • usually low levels of extraversion/positive affect
  • also associated w/ guilt/anxiety/hostility
    • makes for a poorer prognosis for the depressed.
• early parental loss: thought good parental after loss could avoid the depression vulnerability
• early childhood problems i.e. poor parenting/parental psychopathology

psychodynamic theories

Freud: finds parallel b/w depression and morning

Karl Abraham: regression to oral stage: (feeling t/w self what he felt to lost person). This usually also means hostile fealsing (since the other person had some control over you.

deresison could be b/c of ‘symbolic loss’

i.e. failure in school/w/ GF = same as loss of parent

• depression = grief!

Klein/Jacob: emphasis on quality of mother/child relationship in establishing vulnerability to depression

Bowlby: emphasis on attachment: secure attachment = less depression

Main idea: parallel b/w loss and depression, possibly b/c of the symbolic loss

Diathesis-stress factors

Personality/cognitive diathesis

1. neuroticism = primary personality trait leading to depression

temperamental sensitivity to negative stimuli

negative emotions associated w/ neuroticism

• guilt
• anxiety
• hostility
• sadness

2. low in extraversion/positive affectivity

feeling dull = depressions

3. negative thinking pattern (cognitive)

Early parental loss diathesis

-early parental loss =depression diathesis

unless remaining parental care is good

-Sometimes, it is not parental loss, but poor parenting, i.e. abuse or family turmoil

several known paths

• geneticsneuroticismpessimismdepression
• parental lossnegative cognitive processesdepression

5 theories of depression

• psychodynamic
• behavioral
• beck’s cognitive theory
• helplessness/hopelessness theory of depression
• interpersonal effects of mood disorder

psychodynamic theories

Freud: finds parallel b/w depression and morning

Karl Abraham: regression to oral stage: (feeling t/w self what he felt to lost person). This usually also means hostile fealsing (since the other person had some control over you.

deresison could be b/c of ‘symbolic loss’

i.e. failure in school/w/ GF = same as loss of parent

• depression = grief!

Klein/Jacob: emphasis on quality of mother/child relationship in establishing vulnerability to depression

Bowlby: emphasis on attachment: secure attachment = less depression

behavioral theory

-less reinforcement for what was reinforced to = depression

less positive reinforcement for stimuli-response contingence

i.e. poor social skills = less reinforcement

depressed people do seem to get less positive reinforcements

beck’s cognitive theory

-negative cognition precede depression

-underlying depression: depressogenic schemes/dysfunctional beliefs

Depressogenic schemas: dysfunctional beliefs that are rigid/extreme/counterproductive

person b/c susceptible of depression in times of stress

Dysfunctional beliefs: negative beliefs that are rigid/extreme/counterproductive

• if everyone doesn’t love me, then I am worthless

he will think that he’s being rejected

• if I don’t succeed 100% than I am failure

person doesn’t have to be aware of those schemas

-they are thought to dev. for poor childhood experience w/ parents

gets activated during stressors, which then create a pattern of negative automatic thoughts

negative automatic thoughts: thoughts just below consciousness which involve unpleasant pessimistic predictions, usually centering around negative cognitive triad

Negative cognitive triad: negative thoughts which center on self/world/future

• Self: I am worthless
• World: no one likes me
• Future: its hopeless: it will always be this way

Cognitive biases/distortions

1. Dichotomic reasoning: all-or-nothing!
2. Selective abstraction: exaggerating some elements while ignoring other part s of a situation
3. overgeneralization

-those distortions maintasn the negative triad

depression model of beck

Early experience

Formation of dysfunctional beliefs

Critical incident(s)

Beliefs activated

Negative automatic thoughts

Symptoms of depression

Behavioral motivational affective cognitive Somatic

-Depressed people – negative info-processing bias

as seen in

• memory recall
• attitudes about world

creates a vicious cycle of depression: you’re depressed and you see the world negatively, so you b/c depressed more

-no scientific proof yet of beck’s claim of depressogenic thoughts causing depression.

Helplessness/Hopelessness theories of depression

Leaned helplessness: cognitive/motivational deficits exhibited when humans/animals learn that they don’t have control over aversive events.

seligman’s animals showed symptoms of human depression, such as lower aggression levels and weight/appetite loss

role of attributional style and hopelessness

-people might think things are pretty helpless since the attribute wrongly:

Attribution: process of assigning causes to things that happen: 3 axis:

1. Internal/external
2. Global/specific
3. Stable/unstable

-Depressogenic attribution for failure (i.e. failure on exam)= Internal.global/stable

‘I am stupid’

-more optimistic view: external/specific/unstable

‘teacher was in a bad mood’

-external = teacher

-specific: only that teacher

-unstable: not always in a bad mood’

-people have a stable attribution style

some have a depressogenic: pessimistic attribution style

--

hopelessness theory: the theory that a sense of hopelessness about the future following a negative life event is sufficient to cause depression

those people have an hopeless expectancy: they always expect things that they have no control over

women = more depression = b/w discrimination shows that they have no control over events (i.e. less pay for same job)

Interpersonal effects of mood disorders

**

chapter 7 – somatoform/dissociative

-often dissociative disorders go w/ somatoform

Somatoform: conditions involving physical complaints or disabilities that occur w/o any evidence of physical pathology to account for them

Dissociative disorder: conditions involving a disruption ina person’s sense of personal identity

Somatoform disorder

• Somatization disorder
• Hypochondriasis
• Pain disorder
• Conversion disorder

Somatization disorder

Somatization disorder: a somatoform disorder characterized by multiple complaints of physical ailment that extend for long periods beginning b/f age 30, that are inadequately explained by independent findings of physical illness or injury and lead to medical treatment or to significant life impairments

-claimed illnesses don’t have to be real. Mere reporting of them is sufficient

at least minimally in 4 areas:

1. 4 pain symptoms: in areas or functions, i.e. joints/rectum/menstruation/sexual intercourse/urination
2. 2 gastrointestinal symptoms: i.e. vomiting when no pregnancy/diarrhea
3. 1 sexual symptom sexual indifference/dysfunction/menstrual irregularities
4. 1 psydoneurological: involuntary muscle/sensory impairments: i.e. involuntary muscle contractions/abnormalities of consciousness/memory (i.e. dissociative amnesia)

Comorbility: somatization in women often equals antisocial in men

Hypochondriasis

Hypochondria: a somatoform disorder, characterized by preoccupation w/ the fear of having a serious illness, based on misinterpreting bodily symptoms.

sometimes, w/ no physiologically coherent symptom patterns

• hard to communicate exactly
• hard to describe the feeling ‘not exactly pain, but…’
• no impairment of visual/motor/sensory system, as in conversion disorder
• often carry medications w/ them
• no delusional problems, i.e. lungs drying up
• hypochondriacs do not malinger

malingering: consciously faking to get a specific non-medical result, i.e. ‘sick benefits’/paid leave.

factitious disorder: a disorder where a person fakes disability in order to gain personal goal of attention

-->the diff. is in the goal. Factitious disorder is merely for the attention

2 psychodynamic reasoning:

1. to get more attention
2. to reduce responsibilities of life

a ‘disease’ as a form of communication

history: trauma:

1. violence
2. sexual abuse

3. child sickness: early onset of trying to communicate the attention seeking/distress signals

pain disorder

pain disorder: a somatoform disorder characterized by reported pain of significant duration and severity to cause significant life disruptions in absence of medical pathology to explain the cause of the experiences pain

2 subtypes

1. psychological origin
2. both psychological and medical factors

the medical element is coded in Axis III

but pain is out of proportion

-psychogenic pain disorders often adopt a invalid lifestyle

go from dr. to dr. in hope of finding medication

sometimes even mutilating surgery!!!

Conversion disorder

Conversion disorder: A somatoform disorder where symptoms of some physical malfunction or loss of control appear w/o any underlying pathology. It was originally called hysteria

-Freud: repressed sexual energy =hysteria

-->i.e. guilt from masturbation = paralyzed hand

modern view: to escape some [external] sort of stimuli/responsibility

-->called secondarey gain in psychoanalytic schools

-decrease in modernity, since more sophisticated sciences allow us to discover that there is nothing wrong

1. Sensory symptoms: often related to the issue that wants to be escaped
   • Blur of vision
   • Blindness
   • Tactile

2. motor symptoms
   1. paralysis conversion: i.e. writer’s cramp: yet can use same muscles for piano/playing cards. Usually 1 limb
   2. contractures: usually of joints
   3. aphonia: a speech related conversion disorder: can only speak in a whisper -->usually after trauma
   4. mutism: can’t speak at all
3. visceral symptoms: i.e. lump in the throat

common criteria:

1. unconcern in describing what is wrong: matter-of-factly-->whereas describing a paralyzed arm should really use anxiety.
2. Failure to conform to any particular disease
3. Selectiveness of disorder: only disabled under those conditions where person need not escape anything/conversion blindness people don’t bump into each other
4. Under hypnosis/narcosis (sleep-inducing drug), the hysteria could be ignored/removed/shifted

Chain of developmental events:

1. desire to escape from situation
2. desire to be sick in order to avoid those situations
3. beginning of ‘medical’ symptoms to avoid such situations

-you can tell that they are not malingering b/c they are naively willing to discuss their ‘disease’ symptoms in detail

Biology of conversion disorders

-disorder tends to be in left side of body more often

-->nonverbal right side of brain (?!?)

psychosocial causal factors

• often accompanied by other psychiatric problems such as depression/anxiety disorder
• emotional vulnerability of neuroticism is often seen in somatoform disorders
• child abuse: often seen in somatoform -->often w/ some sort of dissociative disorder

Sociocultural causal factors

-in cultures where expression of emotional distress is unacceptable =more somatoform disorders -->they call it ‘neurathenia’ = ‘weak nerves’

-->possibly undifferentiated somatoform disorder

-->not same thing a chronic fatigue symptoms

Treatment of somatoform disorders

-best not to give anything (even thought that they are convinced that they have a real disease), yet sometimes, it is necessary to give anti-anxiety/antidepressants

-->Best treatment: reassurances/non-threatening explanation of the causes

note: no good prognosis for full recovery of somatoform diseases, except pain/conversion disorder

dissociative disorders

-nothing wrong w/ dissociation

i.e. in the automatism of doing a task, while thinking about something else

after all, many things we do are automatic and not subject to conscious self-awareness

normal preconscious processes:

Implicit memory: memory occurring below conscious level

Implicit perception: perception occurring below conscious level

Dissociative disorders: loss of integration: inability to maintain preconscious processes b/c of severe psych. threat

-like somatoform: avoiding stressful event/anxiety fof saily functions that are threatening

must avoid it!

Pathological dissociation:

• dissociative amnesia
• fugue
• dissociative identity disorder
• depersonalization disorder

dissociative amnesia/fuge
amnesia: inability to remember past experience

could be b/c neurotic/psychotic episodes or brain damage

prob. in permanent amnesia is usually in the encoding or in the retrieval stages

type of dissociative amnesia:

• psychogenic (dissociative) amnesia: a dissociative disorder characterized by inability to recall personal info, which is still known in the unconscious level
  • localized: forgets nothing for the period of a few hours after traumatic event
  • generalized: forgets entire life history
  • continuous: forgets nothing b/y a certain point

symptoms:

-forgetting of name/age/won’t recognize relatives/friends

habits usually remain intact, such as semantics/skills

autobiographical and episodic memory is usually affected and not semantic/procedural/perceptual representation/STM

• fugue: an amnesic state that entails loss of memory accompanied by actual flight from one’s present life situation to new environment or previous, less threatening one.

assumes new home/identity/work/new life

after days/years, they might find themselves in this strange situation [that they created], and not know how they got there. They will have amnesia of their fugue period

-in dissociative periods, person still seems normalyet diff. ‘person’ that previously

Note: in both conversion disorder and dissociative, person leaves threatening situation

Dissociative identity disorder (DID)

-formerly called multiple personality disorder

dissociative identity disorder: b/c of a sterssor, person manifests at least 2 more or less complete systems of identity:

split personalities: stable personalities w/ their own emotions/thought processes

host personality: original personality of person w/ DID

usually, the personalities are strikingly dif. From one another

Alter identities: identities other than the host identity in the person w/ the DID

cases of non-human alters!!!

Nature of alters

-alters are not usually full personalities but usually fragmented, in order to deal w/ an unmanageable psych. distress.

alters play out inter conflicts

• child
• protector
• persecutor
• opposite sex alter

-sometimes, 1 alter knows everyone and cooperates w/ therapist

-host identity might not know of other alters or that that ‘others’ really accompany his body/time/space

more diagnosis: more acceptance of the diagnosis

-some think that is induced through highly susceptible hypnotable people

brain scans: show diff. activity of brain for diff. alters!!!

Depersonalization disorder:

Depersonalization: a dissociative in which there is a loss of as sense of self

that their bodies are diff. –i.e. their bodies have changed, i.e. b/c grotesque

related to realization

i.e. mind leaves/travels for a while

visits other plants/people in other cities

Derealization: experience in which the external world is perceived as distorted in various ways: it may accompany depersonalization disorder

i.e. people look like zomby/dream-like

depersonalization often occurs w/ acute stress of an infectious illness

cormobility:

• avoidant personality disorder
• OC Personality disorder
• Borderline

childhood trauma is a common experience but not as hard as DID disorders

-mild forms happen to everyone!

might be the early manifestation of decomposition in schizophreniform type psychotic states

Pathways to DID

1. child abuse pathway: child attempts to deal w/ powerless/hopeless reality of child abuse. Child thus tries to create stable internal persons who will be available for nurture/security/sadfety/attachment
2. childhood neglect pathway: if child neglected (usually by psychiatrically impaired parents) b/c psychiatrically impaired themselves. (i.e. if kid locked in closet for longtime)
3. factitious pathway: person tries to ‘scams’ the health systemusually more severe than the abuse pathway. Here, the person usually has a long history of psychiatric probs.
4. iatrogenic pathway: iatrogenic = medicine-inducedusually poorly guided treatment for bipolar/PTSD/mixed syndromes, usually revolving around dissociative disorder.

-generally, DID is not genetic.

Psychosocial causal factors

-DID is kind of a post-traumatic ‘dissociative’ disorder

usually happens after a trauma

i.e. after repeated trauma of abuse, the child dev. partly independent alters each w/ his own coping techniques

studies found connection b/w murders and past experiences:

• neglect/abandonment
• physical abuse
• sexual abuse
• incest

Things that are highly associated w/ DID

• high hypnotability
• high capacity for personal absorption (inwards focus of attention)
• fantasy

-in some societies, DID-like phenomenon are adaptive

i.e. spirit possession

why it is hard to find causality in dissociative disorders

-in depersonalization –many don’t come for treatment

in dissociative amnesia/fugue = also, very few cases to study

-diversity for treatment incl. integrating the alters/making them less controlling of the host

popular, 3 staged approach:

1. stabilization: i.e. establishing the nature of the therapy: i.e. all the alters can’t threaten the therapist or his family
2. working through trauma/resolution of the dissociative defenses:
   1. deal effectively w/ amnesia/propensity to switch b/w alters
   2. face and deal w/ dissociative memories, reconnecting them to real life memories
   3. reestablish connection w/ seemingly separate identity states
3. post-integration therapy: learning to deal w/ the childhood deficits/traumas.

Chapter 9 personality disorders

Personality disorder: mental disorders stemming from gradual dev. of inflexible/distorted personality and b/h pattern that results in persistent maladaptive ways of perceiving/thinking about/relating to the world

usually seen in Axis II

Odd cluster (Custer A)

• Paranoid PD
• Schizoid
• schizotypal

Dramatic cluster (Cluster B)

• Histerionic
• Borderline
• Narcissist
• Antisocial

more impulsivity

b/h that leads to contact w/ health system/legalauthorities

Fearful anxious cluster (Custer C)

• avoidant PD
• OC PD
• Dependent personality disorder

Paranoid personality disorder: pervasive suspiciousness/distrust of others

Chapter 6- Mood Disorders & Suicide

Mood disorders- mental disorders characterized by disturbances of mood that are intense & persistent enough to be clearly maladaptive.

2 key moods involved in mood disorders:

Mania- emotional state characterized by intense & unrealistic feelings of excitement & euphoria.

Depression- emotional state characterized by feelings of extraordinary sadness & dejection.

Difference b/w unipolar disorders & bipolar & their prevalence:

Unipolar disorders- mood disorders in which a person experiences only depressive episodes. More common.

Bipolar disorders- mood disorders in which a person experiences both manic & depressive episodes

Depression Throughout the Life Cycle

1. Most cases of mood disorder occur during early & middle adulthood.
2. Infants may experience a form of depression (anaclitic depression or despair) when separated from an attachment figure.
3. Incidence of depression rises sharply during adolescence & sex differences in rates of depression begin to emerge.

Unipolar Mood Disorders

Dysthymia:

Dysthymia- moderately severe mood disorder characterized by a persistently depressed mood (more days than not) lasting for at least 2 years (1 yr. for children & adolescents). One must also have at least 2/6 additional symptoms:

1. Poor appetite (or overeating)
2. Sleep disturbance
3. Low energy level
4. Low self-esteem
5. Difficulty in concentration/decision making
6. Feelings of hopelessness.

1. Individuals w/ dysthymia don’t show less severe symptoms than major depressives; the difference is simply that they don’t necessarily show the symptoms every day.
2. Average duration of dysthymia is 5 years, but can persist for more than 20 years.
3. Normal moods may intercede, but last at most a few days/weeks.
4. No identifiable precipitating event/condition need be present.

Adjustment Disorder w/ Depressed Mood:

Adjustment disorder w/ depressed mood- moderately severe mood disorder similar to dysthymia but not exceeding 6 months in duration & having an identifiable psychosocial stressor w/in 3 months before the onset of depression.

1. Differs from dysthymia in that it doesn’t exceed 6 months & requires the existence of an identifiable psychosocial stressor w/in 3 months before onset.
2. There should be either impaired social or occupational functioning or the stressor shouldn’t be severe enough to account for the depression.
3. Chronic cases that do not remit need to be diagnosed as dysthymia.

Major Depressive Disorder:

Major depressive disorder- severe mood disorder in which only depressive episodes occur most of every day for at least 2 weeks & person experiences other symptoms such as fatigue, sleep disturbance, loss of appetite & weight, psychomotor agitation or retardation, difficulty in concentrating, self-denunciation, guilt & recurrent thoughts of death or suicide.

1. Must exhibit more symptoms than required for dysthymia & they need to be more persistent (not interwoven w/ periods of normal mood).
2. Sad mood & loss of interest/pleasure & at least 5/7 symptoms must be present all day nearly every day for 2 consecutive weeks before diagnosis is applicable.

Symptoms:

1. Fatigue/loss of energy
2. Insomnia/hypersomnia
3. Decreased appetite & significant weight loss w/o dieting
4. Psychomotor agitation or retardation
5. Diminished ability to think or concentrate
6. Self-denunciation to the point of claiming worthlessness or guilt out of proportion to any past indiscretion
7. Recurrent thoughts of death or thoughts of suicide

Cognitive & motivational symptoms: cognitive distortions, thinking one is a failure & that everybody thinks that as well, self-blame, self-hatred, anger & lack of trust of family & friends. Hoplessness about the future, but no motivation to try to improve the situation.

Subtypes of Major Depression:

Melancholic type- subtype of major depression that involves loss of interest or pleasure in almost all activities & other symptoms, including early morning awakenings, worsening of depression in the morning, psychomotor agitation or retardation, loss of appetite & weight, inappropriate or excessive guilt, & sadness that is qualitatively different from the sadness usually experienced after a loss.

1. This subtype is influenced more by genetic factors than other forms of depression.
2. May be more responsive to electroconvulsive treatment or to tri-cyclic antidepressant medications than to SSRIs.

Severe major depression w/ psychotic features- major depression involving loss of contact w/ reality, often in the form of delusion or hallucinations.

Mood-congruent psychotic features- delusional thinking that is consistent w/ a person’s predominant mood.

Mood incongruent psychotic features- delusional thinking that is inconsistent w/ a person’s predominant mood.

Postpartum onset- beginning w/in 4 weeks of the birth of a baby. Typically best understood as an adjustment disorder b/c it tends to be relatively mild & is resolved rather quickly.

“Double depression”- major depression coexists w/ dysthymia. Double depressives are moderately depressed on a chronic basis & who undergo increased problems from time to time, periods during which they manifest “major” depressive symptoms.

Depression as a Recurrent Disorder:

Recurrence- a new occurrence of a disorder after a period of remission of symptoms lasting for at least 2 months.

Relapse- return of symptoms of a disorder w/in a fairly short period of time.

Seasonal Affective Disorder:

Seasonal affective disorder- mood disorder involving at least 2 episodes of depression in the past 2 years, occurring at the same time of year (most commonly, fall or winter) & w/ full remission from each episode occurring at a certain time of year (most commonly spring).

Biological Causal Factors

-Strong case for some hereditary contribution to the causal factors for unipolar major depression, but not so much for milder forms. Liability for unipolar depression & generalized anxiety disorder actually come from the same genetic factor.

Biochemical Factors:

-Associated w/ the monoamine class (neurotransmitters) norepinephrine, dopamine, & serotonin, there is either a depletion or a net increase of

Neuroendocrine & Neurophysiological Factors:

1. The feedback loop in regulation of the thalamic-pituitary-adrenal axis, doesn’t operate properly in ½ of seriously depressed patients.
2. Disturbances in the hypothalamic-pituitary thyroid axis is linked to depression.
3. Low thyroid levels lead to depression.
4. Decreased metabolism (brain activity) in the anterior (prefrontal region of the cerebral hemisphere), especially on the left side is linked w/ depression.

Disturbances in Sleep & Other Biological Rhythms:

1. Depressed patients, especially those w/ melancholic features show sleep problems: early morning awakening, poor sleep maintenance difficulties falling asleep- linked to disturbances in the overall sleep-wake cycle & the REM-sleep rhythm (receive less deep sleep).
2. Circadian Rhythms: Alterations in the neurotransmitters occurring as a secondary consequence to the disturbed rhythms. Seasonal affective disorder patients show disturbances in their circadian cycles, showing weaker 24-hour patterns than normal individuals- they are affected by lack of light (in fall & winter). They display increased appetite & hypersomnia as opposed to other depressions.

Psychosocial Causal Factors

1. Stressful life events may precipitate unipolar depression
2. Depression may also generate stress (depression can lead to poor interpersonal problem solving)
3. Minor stressful events aren’t associated w/ clinical depression, but may increase depressive symptoms.
4. Series of misfortunes (3 or more)
5. Psychosocial stressors may cause long-term changes in the brain functioning & these changes may play a role in the development of mood disorders.

Diathesis-Stress Model:

-People who eventually develop a disorder differ in some underlying way from those who do not, & this underlying difference is known as the diathesis (predisposition). Among those w/ the diathesis, only those who experience stress will actually develop the disorder.

1. Genetic/constitutional diathesis
2. Personality diathesis: neuroticism or negative affectivity is a stable & heritable personality trait involving a temperamental sensitivity to negative stimuli. People who are high on this trait are prone to mood disorders.
3. Cognitive diathesis: pessimism or dysfunctional beliefs, provide the diathesis, which in interaction w/ negative life events can produce depression.
4. Parental loss or poor parental care: especially in early childhood.

Five major psychological theories of depression:

1. Psychodynamic: Freud: depression parallels process of mourning loss of loved one. Mourner/depressed regresses to the oral stage (can’t distinguish himself from others) & introjects/incorporates the lost person, introjects feelings of anger & hostility. Depression may also result from symbolic loss in addition to real loss (ex. failing exam). Klein & Jacobson: importance of mother-infant relationships in establishing resistance /vulnerability to depression. Bowlby Attachment Theory: Child needs secure attachment to a parental figure to be resistant to depression.
2. Behavioral: Reduction in positive reinforcement (verbal or otherwise) or increase of aversive experiences. Reduction in motivation & activity. Less efficient coping w/ conditions.
3. Beck’s Cognitive Theory: Cognitive symptoms of depression precede & cause the affective or mood symptoms. Childhood & adolescence experiences w/ one’s parents & significant others may lead to: Depressogenic schemas- dysfunctional beliefs that are rigid, extreme, & counterproductive & are thought to leave one susceptible to depression at times of stress. Dysfunctional beliefs- negative beliefs that are rigid, extreme, & counterproductive. Negative automatic thoughts- thoughts that are just below the surface of awareness & that involve unpleasant pessimistic predications. Negative cognitive triad- negative thoughts centered on the self, world, & future. -Along w/ the dysfunctional beliefs that fuel the negative cognitive triad, a variety of cognitive distortions act to maintain the negative cognitive triad: (1) Dichotomous/all-or-none reasoning, (2) selective abstraction (tendency to focus on negative detail of a situation), (3) overgeneralization.
4. The Helplessness & Hopelessness Theories of Depression (Seligman): Learned Helplessness- cognitive & motivational deficits exhibited when animals or humans learn that they have no control over aversive events. Abramson & colleagues reformulated the theory by focusing on the kinds of attributions (process of assigning causes to things that happen) people make about uncontrollable events: internal/external, global/specific, stable/unstable. A depressogenic/pessimistic attribution = internal, global, stable for negative events. Optimistic attribution for negative events = external, specific, unstable. Hopelessness theory- the theory that a sense of hopelessness about the future following a negative life even is sufficient to cause depression.

Interpersonal Effects of Mood Disorders:

1. Lack of social networks. Can trigger negative affect in those close to the depressed person thus distancing them.
2. Mother who is less playful & interacts less w. her kids can put them at greater risk.

Sociocultural Factors

1. In some cultures there is no comparable concept to depression in “developed” countries.
2. Some “underdeveloped” cultures lack the components of guilt, self-recrimination, attempted or actual suicide. In such cultures impulses may be more outwardly directed (hostility).
3. Behavior in these cultures is largely group-determined & individuals aren’t confronted w/ problems of self-sufficiency, choice, & responsibility (such cultures may reveal more manic disorders, but less depressive).
4. Primitive tribe recompenses loss which prevents loss from becoming hopelessness & prevents sadness from becoming despair, thus breaking up the process of depression.
5. Single & divorced people tend to have higher depression rates, but marital distress is highly associated w/ depression.

Bipolar Disorders

Cyclothymia

Hypomania- mild form of mania

Cyclothymia- mild mood disorder characterized by cyclical periods of hypomanic & depressive symptoms that aren’t disabling.

1. Lacks symptoms of full-blown manic &/or major depressive symptoms.
2. During depressive episode: lack of interest in pleasurable activities, sleep irregularity, decreased cognitive sharpness, social withdrawal, tearfulness, low energy levels, feelings of inadequacy, decreased efficiency, productivity, talkativeness.
3. Hypomanic episode: esentially opposite symptoms of dysthemia, except often decreased need for sleep.
4. For a diagnosis, there must be at least a 2-year span during which there are numerous periods w/ both hypomanic & depressed symptoms (one year for adolescents & kids).

Bipolar Disorder

Bipolar disorder- severe mood disorder in which a person experiences both manic & depressive episodes

1. Any given episode is depressive, manic, or mixed.
2. Mixed episode is characterized by symptoms of both manic & major depressive episodes- they are either intermixed or alternate rapidly every few days.
3. Like unipolar, it is also typically recurrent. Bipolar disorder w/ a seasonal pattern- bipolar disorder in which recurrences are seasonal in nature
4. 2/3 of cases: manic episode either immediately precedes or follows a depressive one, In other cases manic & depressive episodes are separated by intervals of relatively normal functioning.
5. Bipolar II disorder (doesn’t experience full-blown manic episodes) may evolve into Bipolar I disorder.
6. Manic symptoms: markedly elevated, euphoric, expansive mood, often interrupted by occasional outbursts of irritability/violence (especially when others don’t go along w/ persons schemes).
7. Must persist for at least 1 week to be diagnosed.
8. Also noticed is increase in goal-directed activity, unrelievable restlessness, & sped up mental activity- “flight of ideas” distractibility, high levels of verbal output in speech/writing, severely decreased need for sleep, inflated self-esteem, feelings of grandeur/power, loosened inhibitions, foolish business ventures, major spending sprees, sexual indiscretions. Some patients will have intermixed feelings w/ depressive mood, guilt, anxiety, suicidal thoughts.

Rapid cycling- a pattern of bipolar disorder involving at least 4 manic or depressive episodes per year.

Schizoaffective Disorder

Schizoaffective disorder- severe mood disorder accompanied by at least 2 major symptoms of schizophrenia, such as hallucinations & delusions.

1. During at least 2 weeks of the illness, the person must experience schizophrenic symptoms & he must meet criteria for mood disorders for a substantial portion of the period of illness.
2. Has better prognosis for recovery than schizophrenia, but worse than other mood disorders.

Biological Causal Factors

Hereditary Factors:

1. Genes account for over 80% of the variance in the tendency to develop bipolar disorders.
2. Transmission is likely polygenic.

Biochemical Factors:

1. Disturbances in balance of monoamines.
2. Norepinephrine, serotonin & dopamine associated w/ bipolar disorder.
3. In mania, neuroepinephrine & dopamine seem to be elevated.

Other Biological Causal Factors:

1. Dysregulation of the hypothalamic pituitary-adrenal axis. Significant abnormalities in functioning of hypothalamic-pituitary-thyroid (administration of thyroid hormone makes antidepressants work better). Thyroid hormone may precipitate manic episodes.
2. Disturbances in biological rhythms
3. Unbalanced blood flow (brain glucose metabolic rates) b/w prefrontal cortex & right frontal & temporal regions.
4. Depression: reduced blood flow to left prefrontal cortex
5. Mania: reduced blood flow to right frontal & temporal regions
6. Normal mood: blood flow across 2 hemispheres approx. equal

Psychosocial Causal Factors

-High levels of stress are associated w/ the experience of mania, hypomanic or depressive episodes.

Sociocultural Factors

-Bipolar disorder is more common in higher than lower socioecononic classes. Patients w/ bipolar disorder also tend to have more education than those w/ unipolar depression. This may be because hypomanic phases may lead to increased achievement & accomplishment.

Stress & Bipolar Disorder:

1. Stressful events may have a destabilizing effect on critical biological rhythms which may be a factor for the development of bipolar disorder.
2. Personality & cognitive variables may interact w/ stress in determining the likelihood of relapse. Bipolar individuals who were highly introverted or obsessional, were especially responsive to stress. Pessimistic attributional style & negative life events lead to an increase in depressive symptoms whether bipolar or unipolar.
3. Psychodynamic view: Manic & depressive disorders = defense-oriented strategies for dealing w/ severe stress. Mania is avoiding pain of inner-life through out-world distractions. Manic tries to deny helplessness & hopelessness via exaggerated competence. The emotional exhaustion of mania eventually leads to an admission of defeat & inevitable depression. When depressed person feels devalued & guilt-ridden by inactivity & inability to cope, finally feels compelled to attempt some countermeasure so goes into manic stage.

Treatments & Outcomes for Mood Disorders

Majority of manics & depressed patients will recover (at least temporarily) w/in a year. The natural course of a depressive episode if left untreated is 6-9 months.

Pharmacotherapy & Electroconvulsive Therapy

1. Tricyclics- antidepressants- treats seriously unipolar depressed to dystemia. Often have unpleasant side effects (dry mouth, weight gain, constipation, etc.).
2. In a patient w/ bipolar antidepressants can sometimes precipitate a manic episode or rapid-cycling form of bipolar disorder.
3. SSRI’s: New antidepressants w/ less negative side effects than tricyclics (Ex. Prozac & Zoloft). Negative side effects of orgasmic problems & lowered interest in sex. Drug treatment shouldn’t cease once outward symptoms reside, b/c underlying symptoms may still exist. These drugs are also effective for prevention of recurrent episodes. (Antidepressants take 3-4 weeks to show significant improvements).
4. Lithium: mood stabilizer in treatment of both depressive & manic episodes of bipolar disorder. Negative side effects: lethargy, decreased motor coordination, gastrointestinal problems, kidney problems. Anticonvulsants also used.
5. Bipolar & unipolar patients w/ psychotic symptoms may also receive antipsychotic medication.

Psychotherapy

1. Cognitive-Behavioral Therapy: Highly-structured, systematic, empirical approach. Challenges negative automatic thought.
2. Interpersonal Therapy (IPT)
3. Family & Marital Therapy: Important for preventing relapse- improving life situation. Better increases marital satisfaction than does cognitive-behavioral.

Depression & Marital Violence:

1. Mood-disordered persons have more of risk for engaging in violence. Men who violently attack their partners tend to be highly emotionally dependant on the partner, their male role status has been devalued & they feel the need to “control” situation.
2. Men tend to turn to alcohol & drugs to deal.

Comorbidity of Anxiety & Mood Disorders: People w/ high anxiety are also more often high in a scale of depression. They are both high in negative affect, but not anxious individuals.

Suicide

Suicide- taking one’s own life.

Suicide Attempts:

1. Risk is significant factor in all depressive states, 50% of the people do so in recovery phase.
2. Usually young people attempt suicide.
3. Suicide attempts higher in separated/divorced people
4. Most attempts occur in context of interpersonal discord or other severe life stress.
5. Mood disorders common among the attempters.

Completed Suicide:

1. More men die by suicide in US
2. Highest rate among elderly (1/2 or more suffer from a chronic disease)
3. Women use drugs
4. Men: lethal/gunshot
5. In addition to mood disorders, psychopathology & schizophrenia are most commonly associated w/ suicide
6. Children who lost parent are at increased risk
7. Depression, antisocial behavior & impulsivity also a risk
8. Conduct disorder, substance abusers are common among completers
9. 2+ disorders risk for completion increases.

Psychosocial Causal Factors

1. Events leading to loss of sense of meaning to life &/or hopelessness about the future. (Ex. Success suicides, interpersonal crises, imprisonment)
2. Baumeister views suicide as escape from the self, self-awareness, intolerable experience, “cognitive deconstruction”.
3. Negative cognitive functioning/cognitive deficits that stem from early negative experiences (family psychopathology, alcoholism, depression, suicidal behavior), child maltreatment &/or family instability that lead to low self esteem, hopelessness, & poor problem-solving skills in the child & later the adult.

Biological Causal Factors

1. Possible genetic factors
2. Reduced serotonergic activity

Sociocultural Causal Factors

1. Religious taboos may decrease suicide rates.
2. Involvement/identity w/ others (being married, having kids) tends to protect from suicide.
3. Absence of strong ties leads to suicide.
4. Unemployment, downward mobility, alienation

Suicidal Ambivalence

-Whether direct or indirect, communication of suicidal intent usually represents a warning & cry for help. Failing to receive the support, they go in to suicide.

Suicide Prevention & Intervention

-Helping distressed regain their ability to cope w/ their immediate problems & do so as quickly as possible. Emphasis is usually placed on:

1. Maintaining contact w/ person over shot period of time (1-6 contacts)
2. Help person realize acute distress is impairing his ability to assess the situation accurately
3. Help person see other ways of dealing w/ the problem
4. Take a highly directive & supportive role
5. Help person see that the present distress & emotional turmoil won’t be endless.

-Such programs haven’t revealed real impact.

Warning Signs for Student Suicide:

1. Depressed mood
2. Withdrawn
3. Marked decline in self-esteem
4. Deterioration in personal hygiene
5. Tend to expect a great deal of themselves in terms of academic achievement & academic competition ca be a precipitating stressor also a break up of a romance.

Chapter 7- Somatoform & Dissociative Disorders

Somatoform disorders- Conditions involving physical complaints or disabilities that occur w/o any evidence of physical pathology to account for them.

-All somatoform disorders share the key feature of being expressions of psychological difficulties in the “body language” of medical problems that on careful examination cannot be documented to exist. They are not faking the symptoms, they genuinely believe that something is wrong w/ their bodies.

-These individuals are typically preoccupied w/ their state of health & w/ various disorders or diseases of bodily organs.

1. Somatozation disorder
2. Hypochondriasis
3. Pain disorder
4. Conversion disorder
5. Undifferentiated somatoform disorder- persistent (at least 6 mos.) & unfounded complaints of insufficient clarity or intensity to meet criteria for a more specific somatoform disorder.
6. Body dysmorphic disorder- preoccupation w/ imagined defect in one’s physical appearance (considered a variant of OCD).

-They all involve “neurotic” development, but causation & treatment may differ.

Somatization Disorder

Somatization disorder- a somatoform disorder characterized by multiple complaints of physical ailments that extend over a long period, beginning before age 30, that are inadequately explained by independent findings of physical illness or injury & that lead to medial treatment or to significant life impairment.

DSM Symptoms (must be present to at least minimal degree):

1. 4 pain symptoms: Patient must report history of pain experienced w/ respect to at least 4 different sites or functions. Ex. Head, abdomen, back, joints, or rectum, or during menstruation, sexual intercourse, or urination.
2. 2 gastrointestinal symptoms: Must be other than pain. Ex. Nausea, diarrhea, bloating, vomiting when not pregnant.
3. 1 sexual symptom: 1 reproductive system symptom other than pain. Ex. Sexual indifference/dysfunction, menstrual irregularity, vomiting throughout pregnancy.
4. 1 pseudoneurological symptom: Ex. Symptoms that mimic sensory or motor impairments, abnormalities of consciousness of memory.

-10 times more common among women. Lifetime prevalence of 2%. There is evidence of a familial linkage w/ antisocial personality disorder & that common underlying predisposition leads to antisocial behavior in men & somatization in women. More prevalent among lower socioeconomic status. This may just be linked to gross family disorganization & not to genetics.

Hypochondriasis

Hypochondriasis- a somatoform disorder characterized by the person’s preoccupation w/ the fear that he has a serious disease, based on misinterpretations of bodily symptoms.

Differences b/w Hypochondriasis & Somatization disorder:

1. Hypochondriasis may onset after 30 unlike somatization disorder.
2. Abnormal health concerns in hypochondriasis don’t need to focus on any particular set of symptoms.
3. Don’t need to be a lot of different symptom complaints as w/ hypochondriasis as in somatization. Hypochondriacs usually focus on 1 serious disease.

-Hypochondriasis is one of most frequent somatoform disorders w/ 4-9% prevalence. Frequently they are disappointed when no physical illness is found.

Major characteristics:

1. Usually have trouble giving a precise description of their symptoms.
2. Constantly on alert for new symptoms.
3. Read a lot on medical topics- think they are suffering from every new disease they read about.
4. Major consumers of over-the-counter drugs.
5. Self-diagnose themselves w/ serious illnesses.
6. They don’t show intense fear/anxiety of those who truly suffer from these illnesses.
7. They aren’t malingering- consciously faking symptoms of illness or disability to achieve some specific nonmedical goal.
8. Often preoccupied w/ digestive/excretory functions.
9. Most also meet criteria for Axis-I psychiatric diagnoses
10. Often experienced childhood psychological trauma (violence, sexual abuse)

More Than Meets the Eye?

Hypochondriac is saying:

1. I deserve more of your attention & concern.
2. You may no legitimately expect me to perform as a well person would.

Pain Disorder

Pain disorder- a somatoform disorder characterized by reported pain of sufficient duration & severity to case significant life disruption & the absence of medical pathology that would explain the experienced pain.

DSM Subdiagnoses:

1. Pain disorder associated w/ psychological factors (any coexisting medical condition is of minimal causal significance in the pain complaint)
2. Pain disorder associated w/ both psychological factors & a general medical condition (here the pain experienced is out of proportion to the medical condition that might cause the pain).

The Subjectivity of Pain:

1. Women are diagnosed w/ pain disorder more than men.
2. The experienced pain is a function of patient’s stress level.
3. Reported pain could be vaguely located in the heart area or other vital organs or could be in lower back & limbs (headaches & migraines don’t count here).

-Somatoform patients often end up disabled through medication addiction or surgery.

Conversion Disorder

Conversion disorder- A somatoform disorder in which symptoms of some physical malfunction or loss of control appear w/o any underlying organic pathology; originally called hysteria.

-Symptoms often mimic neurological disorders.

Escape & Secondary Gain:

-The physical symptoms are now seen as serving the function of providing a plausible excuse to escape or avoid a stressful situation w/o having to take responsibility for doing so.

Secondary gain- Any external circumstance that tends to reinforce the maintenance of disability.

Decreasing Incidence:

-Used to be common among soldiers (Ex. Paralysis of leg gets them out of battle & being called coward). Constitutes 1-3% of mental health disorders.

DSM recognizes subtypes of conversion disorder according to symptoms:

1. Sensory
2. Motor
3. Seizure or convulsion
4. Mixed

-Often visceral symptoms are present.

Sensory Symptoms:

-Research of airmen in WWII w/ conversion disorder revealed that symptoms of each pilot were closely related to his performance duties. Ex. Night pilots were more likely to have night blindness, etc.

-Sensory conversion disorder sufferers while under hypnosis didn’t endanger themselves. Ex. “Blind” person didn’t walk into object in his path.

Motor Symptoms:

1. Paralysis conversion reactions: Usually only single limb & selective loss of function. Ex. Writer’s cramp- person who can’t write, but can shuffle cards.
2. Tremors & tics
3. Aphonia: Only able to talk in a whisper, however they can cough normally (common after emotional shock).
4. Mutism (rare)
5. Convulsions (don’t have to symptoms of true epileptic & only have the “seizures” when people are around)

Visceral Symptoms:

1. Often show symptoms w/ no actual organic disease (Ex. Tuberculosis, appendicitis, etc.)
2. Pseudopregnancy- period stops, breast enlarge, morning sickness.

Diagnosis of Conversion Disorders:

Criteria to distinguish conversion disorders from organic disorders:

1. Unconcern, little anxiety in describing symptoms (someone really sick would be concerned, anxious).
2. The “dysfunction” not showing the symptoms of the actual disease.
3. Selective nature of dysfunction (Ex. Being blind, but not walking into things.)
4. Symptoms can be removed under hypnosis.

Precipitating Circumstances:

1. Desire to escape from some unpleasant situation.
2. Fleeting wish to be sick in order to avoid the situation.
3. Under continued stress, begins to show appearance of symptoms of some physical ailment.
4. Person sees no relation b/w symptoms & stress.
5. Symptoms of previous illness or one copied from other source usually occur.

Distinguish Conversion Disorder from Malingering/Factitious Disorder:

Malingering disorder- Faking being “sick” seeking a specific outcome such (Ex. Award of money or avoidance of an unwanted duty or obligation).

Factitious disorder- A disorder in which a person feigns disability or illness in order to maintain the personal benefits the “sick role” may provide, including the attention & concern of medical personnel &/or family members. They often alter their own physiology (Ex. by taking drugs) in order to simulate various real illnesses.

-Individuals w/ conversion disorders are usually dramatic & naive & are not concerned when inconsistencies in their behavior are pointed out. On the other hand factitious disorder patients are defensive, evasive & suspicious.

Factitious disorder by proxy- deliberately making your child sick in order to maintain the benefits of the “sick role”

Causal Factors in Somatoform Disorders

Biological Causal Factors:

1. Limited evidence suggest it to be genetic, possibly it being more of a learned behavior passed down.
2. Some suggestions that right cerebral hemisphere which controls left side of body may be involved in these disorders since somatoform disorders often involve nervous system “damage” on left side of body.

Psychosocial Causal Factors:

1. Often accompanied by other psychiatric disorders notably depression & anxiety disorders.
2. Somatizing patients exhibit neuroticism.
3. History of child abuse
4. People unwilling/unable to communicate personal distress in another way

Sociocultural Causal Factors:

Chronic fatigue syndrome: Idea of psychologically caused fatigue is less accepted here than in other parts of world.

Treatment & Outcomes of Somatoform Disorders:

1. Medication: mostly it is not recommended to treat somatoform disorders w/ medication due to risks of drug dependence & the fact that it doesn’t provide sustained relief. However sometimes they absolutely refuse therapy & are given antianxiety or antidepressant medication.
2. Best treatment is often none at all, just support, reassurance, non-threatening explanations of the causes. Frequent medical reexaminations may help this approach.
3. Recovery is not promising, however cognitive-behavioral therapies seem to help. Ex. Eliminating sources of secondary gain could help.

Dissociative disorders

Dissociative disorders- Conditions involving a disruption in a person’s sense of personal identity.

-These people often cannot recall who they are/where they are from, or they may have split themselves into 2 individuals or more having independent “personalities” & autobiographical memories.

1. Inability to access info that is normally in the forefront of consciousness.
2. Normally useful capacity to maintain ongoing mental activity outside of awareness appears to be subverted & misused for the purpose of managing severe psychological threat.
3. Appear to be ways of avoiding anxiety & stress like somatoform disorders. Person avoids stress by pathologically dissociating- escaping from his autobiographical memory.
4. Way to deny personality responsibility for one’s unacceptable wishes or behavior.

Implicit memory- Memory that occurs the conscious level

Implicit perceptions- Perception that occurs below the conscious level

Dissociative Amnesia & Fugue

Amnesia- partial or total inability to recall or identify past experience.

Types of Dissociative Amnesia:

Psychogenic (dissociative) amnesia- A dissociative disorder characterized by the inability to recall personal info, which is still known on an unconscious level.

Types of psychogenic amnesia:

1. Localized- Remembering nothing that happened during a specific period, usually 1^st few hours following a traumatic event.
2. Selective- Forgetting some, but not all of what happened during a given period.
3. Generalized- Forgetting entire life story (rare).
4. Continuous- remembering nothing beyond a certain point in the past (rare).

Typical Symptoms:

-Only episodic memory (pertaining to events experienced) or autobiographical memory is affected. Don’t remember names, age, where they live, don’t recognize family & friends, yet basic habit patterns (talking, reading, skilled work) is in tact.

Fugue States:

Fugue- Amnesic state that entails loss of memory accompanied by actual physical flight from one’s present life situation to a new environment or a less threatening former one (though they can engage in complex activities).

1. Dissociative amnesia pattern is similar to that in conversion disorder except that instead of avoiding some unpleasant situation by becoming physically dysfunctional, a person avoids thoughts about the situation or in an extreme leaves the scene.
2. Threatening info becomes inaccessible (often described as repression)
3. Person may consciously suppress threatening info by avoiding thoughts that lead to its exposure in awareness.

Dissociative Identity Disorder (DID)

Dissociative identity disorder (DID)- a dissociative disorder in which a person manifests at least 2 more or less complete systems of identity; formerly called multiple personality disorder (MPD).

1. When well-developed (alters are often fragmentary), each system of identity has distinctive emotional & thought processes & represents a separate entity having relatively stable characteristics.
2. Identity change may w/in few minutes or up to several years.
3. Alters are usually strikingly different from the host personality & often from one another.

Host personality- the original personality in a person w/ DID.

Alter identities- identities other than the host personality in a person w/ dissociative identity disorder

The Nature of Alters:

1. Alters are pretended, fragmented parts of a single person, not “personalities”.
2. They normally know of each other & the host personality who is not “permitted” explicit knowledge of the alters.
3. Amnesia among the alters is sometimes occurs
4. One alter often knows all & can be of help to therapist.

Common roles in alters include:

1. Child
2. Protector
3. Persecutor
4. Opposite-sex alter who may share one of these other roles

Incidence & Prevalence- Why Are Diagnoses Increasing?

1. DID diagnoses my be increasing due to the fact that this has become more accepted & therapists are less skeptical to diagnose it.
2. More females than males usually (9:1), usually diagnosed in 20’s or 30’s. This is possibly due to higher instances of sexual abuse amongst females.

The DID Diagnosis: Continuing Controversy:

1. Some people are in doubt as to DID’s existence, thinking it’s just acting.
2. Others blame hypnosis as bringing it out in suggestible people (untrue).
3. People have faked DID to get out of crimes.
4. Brain scans may vary from alter to alter.

Depersonalization Disorder

Depersonalization disorder- a dissociative disorder in which there is a loss of the sense of self. More common in adolescents & young adults.

-People feel they are suddenly different, that they are other people or that their bodies have drastically changed.

Derealization- Experience in which the external world is perceived as distorted in various ways (Ex. out-of-body experience); may accompany depersonalization disorder.

1. Depersonalization disorder is often precipitated by acute stress resulting from an infectious illness, accident, or some other traumatic event.
2. It was noted that many had personality disorders alongside depersonalization disorder, especially avoidant, borderline & OCD.
3. Depresonalization disorder is highly treatment-resistant.
4. Seems to happen in unstable, vulnerable individuals, w/ lots of other problems.
5. They usually function normally b/w episodes.
6. Sometimes depersonalization feelings may be beginning of development of psychotic states of schizophreniform type.
7. Reducing anxiety & dealing w/ stress may help.

Causal Factors in Dissociative Disorders

Pathways that may lead to DID (can be more than 1):

1. Childhood abuse pathway: Attempt to cope w/ feelings of hopelessness & powerlessness in face of repeated abuse. The child creates stable internal persons who are always available for attachment, safety, security, nuturing.
2. Childhood neglect pathway
3. Factitious pathway: Way to “scam” to engage the health care system.
4. Iatrogenic pathway: “Treatment-induced”, meaning misguided treatment of disorders (especially bipolar), post-traumatic stress, or mixed syndromes involving some dissociative elements.

Biological Causal Factors:

-No evidence of it.

Psychosocial Causal Factors:

1. There is evidence that DID is a post-traumatic dissociative disorder, that alters help adapt & cope w/ traumas.
2. In some cases reports of abuse may be false memories induced by the therapist

Evidence encouraging development of DID:

1. Ease of being hypnotized
2. High capacity for inward focus of attention
3. Fantasy

-A questionnaire, Dissociative Experiences Scale, measures to see if one has dissociative tendencies.

Sociocultural Causal Factors:

-Whether dissociative disorders are culturally accepted as normal behavior or as legitimate mental disorders has an influence on its prevalence.

Treatment & Outcomes in Dissociative Disorders

-Most therapists try to integrate the alters into the host personality.

3-stage model for treatment of DID (Kluft):

1. Stabilization: Therapist & client establish ground rules for nature of the relationship, develop ways to prevent further fragmenting under stress.
2. Working through the trauma & resolution of dissociative defenses: dealing w/ amnesia, deal w/ & reconnect dissociative memories, reconnect identities.
3. Postinegration therapy: Making up for deficiencies they may have after years of pseudo-adjustment. Hardest stage, b/c patient now feels painful memories they had avoided.

Ch 9- Personality Disorders

Personality disorders- Mental disorders stemming from the gradual development of inflexible & distorted personality & behavioral patterns that result in persistently maladaptive ways of perceiving, thinking about, & relating to the world.

1. Possibly 10-13% of population suffers from personality disorder.
2. Coded on Axis-II, b/c they are not considered standard psychiatric syndromes one finds on Axis-I. Some may be diagnosed on both Axis-I & II. Ex. Personality disorder & major depression.

Clinical Features of Personality Disorders

-Behavioral deviations of these people is persistent & intrinsic to their personalities

DSM Criteria

1. Essential feature of a personality disorder is an enduring pattern of inner experience & behavior that deviates markedly from the norm
2. Needs to be traced back to adolescence & or early adulthood.
3. Needs to include at least 2 of these areas: cognition, affectivity, interpersonal functioning, impulse control.

Difficulties in Diagnosing Personality Disorders

Misdiagnoses occur frequently for these reasons:

1. Personality disorder categories aren’t as sharply defined as most Axis I diagnostic categories.
2. The diagnostic categories are not mutually exclusive. Some may be diagnosed w/ more than 1 or “personality disorder not otherwise specified.”
3. It is hard to draw the line b/w normal & abnormal behavior. Ex. Being conscientious about the details of one’s job doesn’t mean one has OCD.

Categories of Personality Disorders

1. Cluster A: Paranoid, schizoid, schizotypal personality disorders. These people often seem odd & eccentric.
2. Cluster B: Histrionic, narcissistic, antisocial, borderline personality disorders. These people tend to be dramatic, emotional, unstable.
3. Cluster C: Avoidant, dependent, & obsessive compulsive personality disorder. Anxiety & fearfulness are often part of this disorder, making it difficult to distinguish them from anxiety-based disorders. These people are more likely to seek help b/c of their anxiety.

Paranoid Personality Disorder

Paranoid personality disorder- Personality disorder characterized by pervasive suspiciousness & distrust of others.

1. Blame others for their mistakes/failures- even ascribing evil motives to others.
2. Constantly looking for clues to validate their expectations while disregarding evidence to the contrary.
3. Preoccupied w/ doubts about loyalty of friends leading to reluctance to confide in others.
4. Hypersensitive- read threatening meanings into benign remarks.
5. Bear grudges, quick to react w/ anger.
6. Mostly in clear contact w/ reality (not psychotic).

Schizoid Personality Disorder

Schizoid personality disorder- Personality disorder characterized by the inability to form social relationships or express feelings lack of interest in doing so.

1. Do not have good friends, w/ exception possibly of close relatives. Don’t desire or enjoy close relationships.
2. Unable to express feelings, seen as cold & distant.
3. Lack social skills & have solitary interests/occupations.
4. Don’t take pleasure in activities (even not sex)
5. Appear indifferent to praise/criticism

-Once thought that schizoid was precursor to schizophrenia, but this isn’t so. Negative symptoms of schizophrenia (social withdrawal, anhedonia) are however similar schizoid behavior.

Schizotypal Personality Disorder

Schizotypal personality disorder- Personality disorder characterized by excessive introversion, pervasive social & interpersonal deficits, cognitive & perceptual distortions, & eccentricities in communication & behavior.

1. Social withdrawal & isolation (as in schizoid)
2. Oddities of thought, perception or speech
3. Reality contact is usually maintained, rather there is “loosening” from reality
4. Highly personalized & superstitious thinking
5. May experience transient psychotic symptoms under extreme stress
6. Often believe they have magical powers & will engage in magical rituals
7. 3% prevalence in US
8. Attentional & memory deficits common in schizophrenia
9. Genetic & biological association w/ schizophrenia, at high risk for developing schizophrenia.

Histrionic Personality Disorder

Histrionic personality disorder- personality disorder characterized by attention-seeking behavior, emotional instability, & self-dramatization.

1. Feel unappreciated if not center of attention
2. No stable relationships, b/c the partner tires of giving such a high level of attention
3. Theatrical, emotional, sexually provocative, seductive in seeking attention
4. Dramatic speech, but lacking in detail
5. Highly suggestible & consider relationships to be closer than they are
6. Viewed as shallow & insincere by others
7. When attention-seeking tactics (ex. seductive behavior) don’t work they become irritated
8. 2-3% prevalence in US

Narcissistic Personality Disorder

Narcissistic personality disorder- personality disorder characterized by an exaggerated sense of self-importance, a preoccupation w/ being admired, & a lack of empathy for the feelings of others.

1. Grandiosity manifested by strong tendency to overestimate their abilities & accomplishments while often underestimating others.
2. Sense of entitlement- they deserve it.
3. See themselves as so special that only other high-status people can understand him/associate w/ him.
4. Unable to see things in other people’s perspectives.
5. Show lack of empathy.
6. Take advantage of others to achieve their own goals.
7. Envious of others or feel others are envious of them.
8. View themselves as nearly perfect & so don’t seek psychological help.
9. Very sensitive to criticism
10. Researchers believe they have fragile self-esteem underneath.
11. 1% prevalence in US.

-Difference b/w narcissist & histrionic: Both may be promiscuous, but narcissist is more dispassionately exploitative, histrionic is more overtly needy. Exhibitionistic (bragging) for histrionic is to seek attention, narcissist for admiration.

Antisocial Personality Disorder

Antisocial personality disorder (ASPD)- personality disorder characterized by continual violation of & disregard for the rights of others through deceitful, aggressive, or antisocial behavior, typically w/o remorse or loyalty to anyone.

1. Impulsive, irritable & aggressive
2. Pattern of irresponsible behavior that must have occurred since 15
3. Before 15 must have had symptoms of conduct disorder- persistent patterns of aggression towards people/animals, destruction of property, deceitfulness or theft, serious violation of rules at home of in school.
4. More common in men (3%) than women (1%)

-Difference b/w antisocial & narcissist: Narcissist exploits to show domination & superiority, whereas antisocial for personal, material gain.

Borderline Personality Disorder

Borderline personality disorder (BPD)- personality disorder characterized by impulsivity & instability in interpersonal relationships, self-image, & moods.

1. Serious disturbances in basic identity, unstable self-image (key causal factor, never developed coherent identity).
2. Unstable interpersonal relationships- overidealization of friends/lovers ending in disappointment.
3. Unstable mood.
4. Low tolerance for frustration.
5. Chronic feelings of emptiness, intolerance for being alone.
6. Erratic self-destructive behaviors (ex. binge-eating, substance abuse, sex), especially self-mutilation (associated w/ relief from anxiety, possibly analgesia- not feeling pain).
7. Manipulative suicide attempts.
8. Sometimes show transient break from reality
9. Co-occurrence w/ Axis-I disorder (panic, PTSD, substance abuse, eating disorders, however, their depression is more characterized by chronic feeling of loneliness & don’t react as well to antidepressants) & coocurrence w/ other personality disorders (histrionic, dependent, antisocial, schizotypal).
10. 2% of population, mostly women.

-Differences from other personality disorders: Their exploitative use is an angry & impulsive response to disappointment, whereas the antisocial’s is guiltless & for personal gain.

Avoidant Personality Disorder

Avoidant personality disorder- personality disorder characterized by extreme social inhibition & introversion, limited social relationships, hypersensitivity to criticism & rejection & low self-esteem & excessive self-consciousness.

1. Because of their hypersensitivity to criticism they don’t seek out other people though they long for affection.
2. They are lonely & bored.
3. Inability to related comfortably to others causes acute anxiety & is accompanied by low self-esteem & excessive self-consciousness.
4. May see ridicule where none exists.
5. May be biologically based & reinforced by environmental factors.

-Differences: Avoidant & dependant personalities often co-occur, though avoidants don’t initiate relationships to avoid rejection & dependants want to be taken care of. Schizoids are indifferent to criticism, avoidants hypersensitive to it. Similar to generalized social phobia.

Dependant Personality Disorder

Dependant personality disorder- personality disorder characterized by extreme dependence on other s, particularly a need to be taken care of, leading to clinging & submissive behavior.

1. Acute discomfort- even panic- at possibility of separation.
2. Build their lives around other people & subordinate their own views to keep people involved w/ them.
3. Fail to get appropriately angry w/ others b/c of fear of losing their support.
4. Difficulty making simple decisions w/o tons of advice & reassurance & therefore they let others take over the major decisions in their lives.
5. Lack self-confidence, feel helpless even when they have actually developed good work skills or other competencies.
6. They feel selfless & bland sine they feel they have not right to express individuality.
7. Seek out new relationship w/ great urgency when one ends.
8. Often cormorbid diagnosis of anxiety disorder.
9. Dependant personality disorder common among people w/ eating disorders.
10. May function well as long as not on their own.

-Differences: Both borderline & dependant fear abandonment, but borderlines act w/ rage & dependants w/ submissiveness. Both borderlines & histrionics need reassurance/approval borderlines do it actively demanding attention & dependants do it in a more docile, self-effacing way.

Obsessive Compulsive Personality Disorder

Obsessive compulsive personality disorder- personality disorder characterized by perfectionism & an excessive concern w/ maintaining order & control.

1. Careful so as to not make mistakes & often repeatedly check for mistakes.
2. Use their time poorly due to preoccupation w/ trivialities, therefore have trouble finishing projects.
3. Devoted to work to the exclusion of leisure.
4. May have tough time relaxing, doing something for fun.
5. Excessively conscientious (disposition to be deliberate, disciplined, competent, achievement-striving, organized, inflexible on moral issues).
6. Difficulty delegating tasks to others, rigid & stubborn.

-Differences b/w OCPD & OCD: OCD is persistent intrusion of particular undesired thought/images (obsessions) that are source of anxiety/stress that can only be reduced by performance of compulsive rituals, however OCPD’s aren’t not anxious about the compulsiveness itself.

-Other differences: Narcissists believe they have achieved perfection, OCPD’s are self-critical. Narcissists & antisocials aren’t generous, but will indulge, whereas OCPD’s aren’t generous to themselves or others.

An Overview of Personality Disorders

-Beck & colleagues developed scheme that details personality disorder’s overdeveloped & underdeveloped distinct behavior patterns. Sometimes the deficient behavior is somehow a counterpart to the overdeveloped behavior. They also list the core dysfunctional belief of the disorder.

Causal Factors in Personality Disorders

-High level of comorbidity among personality disorders makes difficult to understand which causal factors are associated w/ which disorder.

Biological Causal Factors

1. Infant temperament may predispose one to a certain PD.
2. Borderlines may have low serotonin & disturbances in noradrenergic neurotransmitters.
3. Dopamine deficits may cause transient psychotic symptoms.

Psychosocial Causal Factors

Early Learning Experiences:

-History childhood abuse & neglect (especially w/ borderlines) may lead to PD.

Psychodynamic Views:

Kohut: All kids go through normal stage of grandiosity where they think all revolves around them & parents must do some mirroring of the grandiosity in order for kid to develop normal self-confidence.

Millon: Argues opposite of Kohut, that narcissism develops from parental overvaluation.

Sociocultural Factors

-Maybe more PD’s in US b/c culture encourages impulse gratification, instant solutions, etc.

Treatments & Outcomes For Personality Disorders

-PD’s are pretty resistant to therapy partly b/c their personalities makes it hard for them to have good relationship w/ therapist & also they don’t come in for therapy so much as the people around them. People w/ Axis I disorders as well as PD’s don’t do as well in treatment as those only w/ Axis I.

Adapting Therapeutic Techniques to Specific Personality Disorders

1. W/ dependants, histrionics & borderlines, different therapy methods need to be used so as not to make them even more dependant.
2. W/ Cluster C’s who are sensitive to criticism one need to be super-careful not to come across as critical, by possibly allowing the patient to give feedback.
3. Cognitive approach assumes that the behavior & dysfunctional feelings of PD’s are due to schemas that produce biased judgements & tendencies to make cognitive errors in situations. Changing these schemas

Treating Borderline Personality Disorder

Pharmacotherapy:

1. Low doses of antipsychotic medication may help.
2. SSRIs may help
3. Lithium may be useful in reducing irritability, suicidality & angry behavior.
4. Generally drugs are used as an adjunct to psychological treatment.

Psychological Treatments:

Psychodynamic therapy: Primary goal of strengthening weak egos, particular focus in their primary defense mechanism of splitting which leads them to black & white thinking & rapid shifts in their reactions to others. This is very expensive & time-consuming.

Marsha Linehan’s treatment:

-She believes the inability to tolerate strong states of negative affect is central to the disorder. One goal is to encourage the patients to accept this negative affect w/o engaging in self-destructive or other maladaptive behaviors.

-This dialectical behavioral therapy combines individual & group (skills & training for interpersonal skills, emotion regulation, stress tolerance) components.

-Therapist accepts the person for who s/he is (but not approving of inappropriate behavior).

Hierarchy of goals:

1. Decreasing suicidal behavior (#1, b/c you can’t work w/ a dead patient)
2. Decreasing behaviors that interfere w/ therapy (missing sessions, lying, getting hospitalized)
3. Decreasing escapist behaviors that interfere w/ stable lifestyle (ex. substance abuse)
4. Increasing behavioral skills in order to regulate emotions, increase interpersonal skills & to increase tolerance for distress
5. Other goals the patient chooses

Treating Other Personality Disorders

-Cluster A & B treatment is not very promising. Cluster C treatment seems more promising. Antidepressants & short-term psychotherapy sometimes are useful in avoidant personality disorder.

Antisocial Personality & Psychopathy

-Only individuals 18+ are diagnosed as having antisocial personality

DSM diagnosis:

1. There have been at lease 3 behavioral problems occurring after age 15. (Ex. Acts that are grounds for arrest, disregard for safety, irresponsibility in work/financial matters, lack of remorse).
2. There were at least 3 instances of deviant behavior before age 15 (aggression towards people/animals, destruction of property, theft, serious violation of rules, in other words symptoms of conduct disorder).
3. The antisocial behavior isn’t a symptom of another mental disorder such as schizophrenia or a manic episode.

Psychopathy & ASPD

Psychopathy- a condition involving the defining features of antisocial personality disorder as listed in DSM, as well as such traits as lack of empathy, inflated & arrogant self-appraisal, & glib & superficial charm.

Two Dimensions of Psychopathy:

-Hare & colleagues did research & suggest that ASPD & psychopathy are related but differ in very significant ways. Hare created a 20-item Psychopathy Checklist to aid clinicians in diagnosing it. The list shows there are 2 related, but separable dimensions of psychopathy, w/ each predicting different types of behavior:

1. Affective & interpersonal core of the disorder: traits such as lack of remorse, selfishness, exploitative use of others.
2. Behavior: Aspects of psychopathy making up an antisocial, impulsive, & socially deviant lifestyle. This is the dimension closest to the DSM definition of ASPD (they show the behavior, but not enough selfishness, etc. to be labeled psychopaths).

-Psychopathy seems to predict criminal behavior much more than ASPD.

The Clinical Picture in Antisocial Personality & Psychopathy

-Psychopaths & antisocials are often charming, spontaneous & likeable on 1^st acquaintance, but they are deceitful, manipulative & callously use others to achieve their needs/desires.

-The below traits are typical of psychopaths, but they’re not all usually found. Many w/ ASPD also share at least a subset of these characteristics, though not criteria for DSM ASPD diagnosis.

Inadequate Conscience Development:

1. Severely retarded/nonexistent conscience development: Psychopaths appear unable to understand & accept ethical values except on a verbal level. They claim to adhere to high moral standards that have no connection w/ their behavior. Behave as if social regulations don’t apply to them.
2. Typically normal intellectual development: Intelligence & education even seems to serve as protective factors for adolescents at risk of psychopathy or ASPD.

Irresponsible & Impulsive Behavior:

1. Psychopaths: Callous disregard for the rights, needs & well-being of others.
2. They take rather than earn what they want.
3. Prone to thrill-seeking.
4. Break the law impulsively w/o regard for consequences.
5. Antisocials & perhaps psychopaths have high rates of alcoholism & substance abuse dependence disorders (related to 2^nd, behavioral dimension of psychopathy).

Ability to Impress & Exploit Others:

1. Often charming & likeable & easily win friends, but seldom able to keep close friends.
2. Good sense of humor, positive outlook.
3. Frequent liars that when caught in a lie will promise to make amends & not do so.
4. Adept at exploiting others.
5. Psychopaths cannot understand love in others or give it in return, are irresponsible & unfaithful mates.

Causal Factors in Psychopathy & Antisocial Personality

Genetic Influences:

-Results of adoption & twin studies show modest heritability for antisocial or criminal behavior. Results of at least 1 study found same for psychopathy.

Deficient Aversive Emotional Arousal & Conditioning:

-Research indicates that psychopaths show deficient aversion emotions arousal making them less prone to fear & anxiety in stressful situations & less prone to normal conscience development & socialization (more closely associated w/ egocentric, callous, exploitative dimension of psychopathy than the antisocial behavioral dimension).

Gray’s model & Fowles’s theory:

1. Behavioral inhibition system: Psychopaths’ deficient anxiety conditioning may be b/c they have deficient behavioral inhibition systems. They don’t acquire passive avoidance learning (avoiding punishment by not making the response).
2. Behavioral activation system: This system activates cues for reward (positive reinforcement) & for active avoidance of threatened punishment. (ex. lying, running away to avoid punishment.) & is thought to be overactive in psychopaths.

More General Emotional Deficits:

-Psychopaths showed less significant physiological reactivity to distress cues than did nonpsychopaths which confirms them having low empathy. They weren’t underresponsive to unconditioned threat cues (slides of sharks, pointed guns).

A Developmental Perspective:

1. Especially for boys, number of antisocial behaviors exhibited in childhood is best predictor of who develops psychopathy or ASPD.
2. Kids w/ early history of oppositional defiant disorder- pattern of hostile & defiant behavior toward authority figures- by age 6 & followed by conduct disorder around 9 are most likely to develop ASPD or psychopathy or other problems as adults. Those who develop conduct disorder in adolescence are limited to problems in teenage years.
3. ADHD is often precursor of ASPD & psychopathy. ADHD occurring together w/ conduct disorder often lead to psychopathy.
4. Poor & ineffective parenting skills due to parent’s own antisocial behavior, divorce, low socioeconomic status, parental stress/depression, etc. lead to antisocial behavior.

Sociocultural Causal Factors & Psychopathy:

-Cultural variations often occur for frequency of aggressive & violent behavior due to socialization forces (Ex. Psychopaths in China may be less likely to engage in violent behavior).

-Individualistic societies like US (emphasize competitiveness, self-confidence & independence) would be expected to be more likely to promote behavioral characteristics that carried to an extreme result in psychopathy, but evidence here is minimal.

Treating Psychopathy & ASPD

1. Therapist must be careful so the psychopath doesn’t manipulate him.
2. Psychotherapy (b/c of not accepting responsibility) & biological treatments (electroconvulsive therapy & drugs) don’t help much.
3. Some evidence that antipsychotic drugs may help to reduce aggressive behavior in psychopaths who also show schizoptypal symptoms may help certain symptoms
4. Drugs used to treat bipolar disorder (lithium) may help treat the aggressive impulsive behavior of criminals.
5. SSRI’s can reduce aggressive impulsive behavior & increase interpersonal skills.
6. None of these have helped the disorder on a whole.

Cognitive-Behavioral Treatments:

Common targets for cognitive-behavioral interventions w/ ASPD & psychopathy:

1. Increasing self-control, self-critical thinking, & social perspective-taking
2. Victim awareness
3. Anger management
4. Changing antisocial attitudes
5. Curing drug addiction
6. Reducing contacts w/ antisocial peers & improving interactions w/ nonantisocials.

-These all require a controlled situation (inpatient or prison setting) in order to succeed.

-Beck & Freeman focus on improving social & moral behavior through examination of self-serving dysfunctional beliefs that psychopaths tend to have (Ex. “Undesirable consequences will not occur or will not matter to me.”). This can also be incorporated w/ ASPD therapy. These programs are more successful in treating young offenders (teenagers).

-Psychopathy is harder to treat than ASPD. Fortunately after age 40 they both improve w/o treatment, possibly b/c of weaker biological drives, better insight into self-defeating behaviors, etc. However, the egocentric, callous & exploitative affective interpersonal dimension doesn’t improve.

Ch. 12- The Schizophrenias

Schizophrenias- severe mental disorders characterized by the breakdown of integrated personality functioning, withdrawal from reality, emotional blunting & distortion, & disturbances in thought & behavior.

Psychosis- a significant loss of contact w/ reality, as when hallucinations or delusions are present.

Delusional disorder- a nonschizophrenic paranoid disorder in which a person nurtures, gives voice to, & sometimes takes action non beliefs that are considered completely false & absurd by others; formerly called paranoia.

1. But other than that they may behave normally & don’t show the gross disorganization & performance deficiencies characteristic of schizophrenia.
2. Not many cases are reported, b/c unless they become a serious nuisance they are usually able to maintain themselves in the community & don’t recognize their paranoid condition or seek help.

Shared psychotic disorder- a nonschizophrenic paranoid disorder in which 2 or more people, usually in the same family, develop persistent, interlocking delusional ideas; also known as folie deux.

Brief psychotic disorder- a mental disorder characterized by brief episodes (lasting 1 month or less) of otherwise uncomplicated delusional thinking.

The Schizophrenias

-Considered the most serious of all mental disorders.

-No evidence that there is progressive brain deterioration in schizophrenia & where it has occurred it is usually treatment-induced (antipsychotic medication).

-Usually onset is in adolescence or early adulthood.

Prevalence & Onset

-In some cultures certain beliefs are acceptable, but in our culture would be considered crazy. Allen claims schizophrenia is rarer in traditional, small-scale societies than in modern.

Point prevalence of schizophrenia: 0.2-2%

Lifetime prevalence: 0.7% among those not currently institutionalized

Incidence (cumulative occurrence rate of new cases): Could be as high as 0.2%

State & county hospitals: 40% of all admissions

Males & females: Same prevalence, men have earlier onset. Males may develop more severe forms of schizophrenia. Late-onset schizophrenia is more common among women.

The Clinical Picture in Schizophrenia

Positive-syndrome schizophrenia- schizophrenia w/ a symptom pattern characterized by additions to normal behavior & experience, such as marked emotional turmoil, motor agitation, &/or delusions & hallucinations.

Negative-syndrome schizophrenia- schizophrenia w/ a symptom pattern characterized by an absence or deficit of normal behaviors, such as emotional expressiveness, communicative speech, &/or reactivity to environmental events.

Type I schizophrenia- form of schizophrenia similar to the positive-syndrome type & thought to involve chiefly temporolimbic brain structures.

Type II schizophrenia- form of schizophrenia similar to the negative syndrome type & thought to involve chiefly frontal brain structures.

-Most patients exhibit both positive & negative symptoms. However, patients who exhibit more negative symptoms have a more unfavorable prognosis than those who exhibit more positive symptoms. The polar terms of positive & negative would be better conceived as end points of an uninterrupted continuum or even has 2 independent continua, both which are for some reason involved in manifest schizophrenic behavior.

DSM:

1. Characteristic symptoms: At least 2 of following, each present for significant portion of time during a 1-month period (or less if successfully treated): 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms *Only one criterion A symptom required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts or 2 or more voices conversing w/ each other.
2. Social/occupational dysfunction
3. Duration: Continuous signs of disturbance persist for at least 6 months & must include at least 1 month of symptoms (or less if successfully treated).
4. Schizoaffective & Mood Disorder exclusion: ruled out b/c either (1) No major Depressive, Manic, or Mixed Episodes have occurred concurrently w/ active-phase symptoms; or (2) If mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active & residual periods.
5. Substance/general medical condition exclusion
6. Relationship to a Pervasive Developmental Disorder: If there is a hisotry of Autism or other PDD, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Disturbance of Associative Linking

Formal thought disorder (associative disturbance)- failing to make sense, despite seeming to conform to semantic & syntactic rules of verbal communication. Prime indicator of a schizophrenic disorder.

Disturbance of Thought Content

Delusions- false beliefs about reality that are maintained in spite of strong evidence to the contrary. Ex. One’s thoughts/action are being controlled by external agents. Or a neutral environmental event (TV program) has intended personal meaning (ideas of reference).

Disruption of Perception

-Patient is unable to sort out & process the great mass of sensory info to which all of us are constantly exposed.

Hallucinations- false perceptions, such as seeing or hearing things that aren’t real or present. Most often auditory, typically a voice that keeps up a running commentary on the person’s behaviors or thoughts.

-Some claim this is due to malfunctioning neural feedback connections b/w brain regions.

Emotional Dysfunction

-They display clearly inappropriate emotion & emotional shallowness. However, evidence suggests that the deficit is only one of expressiveness, not feeling.

Anhedonia- inability to experience joy/pleasure

-Other times, especially during acute phases, the person may show strong affect, but the emotion clashes w/ the situation or w/ the content of his thoughts.

Confused Sense of Self

-May feel confused about identity, often delusional assumption they’re someone else.

Disrupted Volition

-Deterioration of performance in everyday tasks, possibly due to impairment of prefrontal region of the cerebral cortex.

Retreat to Inner World

-Withdrawal from reality that often seems deliberate. Elaboration of an inner world.

Disturbed Motor Behavior

-Peculiarities of movement (hyperactivity, clumsiness, rigid posturing).

Continuing Problems in Defining Schizophrenia

Disorganized schizophrenia- 3^rd symptom pattern of chaotic & seemingly directionless speech & behavior. Recognized as one of classic subtypes of schizophrenia (hebephrenia).

Dolphus & colleagues suggested 4 discriminable patterns of schizophrenia signs:

1. Positive
2. Negative
3. Disorganized (once considered negative)
4. Mixed

-Most patients display mixed.

The Classic Subtypes of Schizophrenia

Schizophrenia, residual type- subtype of schizophrenia used as a diagnostic category for people who have experienced a schizophrenic episode from which they have recovered sufficiently so as to not show prominent symptoms, but who still manifest some mild signs of their past disorder.

Undifferentiated Type

Schizophrenia, undifferentiated type- subtype of schizophrenia in which a person meets the usual criteria for schizophrenia- including (in varying combinations) delusions, hallucinations, disordered thoughts, & bizarre behavior- but doesn’t clearly fit into one of the other types b/c of a mixed symptom pattern.

-People often exhibit undifferentiated symptoms in acute, early phases of schizophrenic breakdown. The episode usually clears up in a matter of weeks, at most months. If the “schizophrenoform” disturbance exceeds 6 months, it may qualify as schizophrenia.

Catatonic Type

Schizophrenia, catatonic type- subtype of schizophrenia in which the central feature is pronounced motor symptoms, either of an excited or stuporous type, which sometimes makes it difficult to differentiate this condition from a psychotic mood disorder.

1. This is often an early manifestation of a disorder that will become chronic unless the underlying process is somehow stopped.
2. Some of these patients are highly suggestible, will mimic actions (echopraxia) or words (echolalia) of others. May stay in uncomfortable position for hours.
3. No attention paid to bowel/bladder control, may drool.
4. Vacant facial expression
5. Waxy skin
6. Threats/painful stimuli have no effect.
7. May suddenly pass from states of stupor to excitement (sometimes violence, suicide attempts, etc.)
8. Some believe this, due to reduced filtering ability & increased vulnerability to stimulation, this is way of providing control over external stimuli

Disorganized Type

Schizophrenia, disorganized type- subtype of schizophrenia that usually begins at an earlier age & represents a more severe disintegration of the personality than seen in the other subtypes.

1. History of oddness, overscrupulousness about trivial things, & preoccupation w/ obscure religious & philosophical issues.
2. Become more seclusive & more preoccupied w/ fantasies.
3. Becomes emotionally indifferent & infantile (Ex. silly smile, inappropriate shallow laughter when inappropriate).
4. Incoherent speech & may include baby talk, repetitious use of similar sounding words, derailing of associated thoughts, neologisms.
5. Hallucinations (esp. auditory- voices may accuse them of immoral practices)
6. Delusions (sexual, religious, hypochondriacal, persecutory), typically changeable, unsystematized.
7. Occasionally aggressive, hostile, outbursts, but not anger connected to anything real, only to the fantasies.
8. Some other odd behaviors (odd facial grimaces, talking & gesturing to themselves, etc.)
9. Obscene behavior
10. Poor prognosis

Paranoid Type

Schizophrenia, paranoid type- subtype of schizophrenia in which a person is increasingly suspicious, has severe difficulties in interpersonal relationships, & experiences absurd, illogical & often changing delusions. (Once made up ½ of hospital admissions, now less & undifferentiated is on rise.)

1. Persecutory delusions
2. Delusions of grandeur (I’m G-d), often accompanied by hallucinations.
3. This pathological “paranoid construction” may provide them w/ sense of identity & importance. Thus there tends to be higher level of adaptive coping & cognitive integrative skills than w/ other types of schizophrenia.
4. Loss of critical judgement, unpredictable behavior, sometimes dangerous.
5. Show less bizarre behavior & less extreme withdrawal

Other Schizophrenic & Psychotic Patterns

Schizoaffective disorder- mental disorder in which a person shows features of both schizophrenia & severe mood disorder.

Schizophreniform disorder- any schizophrenia-like psychosis of less than 6 months duration (most often seen in an undifferentiated form).

-All recent-onset cases of true schizophrenia presumably must 1^st receive a diagnosis of schizophreniform disorder. Better prognosis.

Causal Factors in Schizophrenia

Biological Factors in Schizophrenia

Genetic Influences:

1. Strong correlation b/w closeness of blood relationship & degree for concordance, but this may also be due to shared environments.
2. Current experts believe that schizophrenia has a polygenic involvement.

Twin Studies:

1. Concordance higher among identical twins, however if it were exclusively a genetic disorder, concordance would be 100%. There are also more discordant than concordant identical pairs.
2. In a study by Torry & colleagues, the discordant identical twin showed the risk of schizophrenia. Seems neurological abnormalities play a role.
3. Genetic predisposition may remain unexpressed unless released by unknown environmental factors.

Adoption Studies:

1. Offspring of schizophrenic mothers were more likely to b/c schizophrenic, & to be diagnosed w/ other forms of psychopathology (mentally retarded, neurotic, psychopathic).

2. In the Finnish adoptive study, which considers biology & environment of schizophrenics’ relatives, most psychopathology is in the group of poorly functioning adoptive parents.

3. Most schizophrenics don’t have relatives w/ schizophrenia though they may share the same biological anomalies. Risk of schizophrenia for 1^st degree relatives of schizophrenics is 4.8%.

Biochemical Factors:

1. Attempts to discover the site & nature of CNS effects induced by drugs that diminish behavioral expression of the disorder. Usually drugs that do so are ones that alter the likelihood that a nerve impulse arriving at a synapse will cross the synapse & fire the next neuron in the chain.

2. Dopamine hypothesis: schizophrenia is due to excess dopamine activity. If only excess dopamine activity were the cause, these drugs should have ameliorative effects almost immediately & they usually don’t. The drugs reduce it to abnormally low levels which create additional serious problems (ex. tardive dyskinesia).

3. Several types of dopamine receptor sites exist & they are involved in differing biochemical process & different antipsychotic drugs act in them in varying ways.

Neuropsychological Factors:

1. Imbalance in certain neurophysiological processes & inappropriate autonomic arousal, called “cognitive dysmetria” by Andreasen, Paradiso & O’Leary. This theory in part is correct, b/c schizophrenics have a hard time tracking a moving target (smooth pursuit eye movement- SPEM). Family member of schizophrenics often have SPEM as well.

2. Abnormal brain reaction to stimulation (maybe also in people at risk).

Neuroanatomical Factors:

1. Premature birth could contirbute.
2. Early brain injury only seems to affect persons already genetically predisposed.
3. Abnormal enlargement of brain’s ventricles in minority of chronic cases.
4. Abnormally low frontal lobe activation (hypofrontality).
5. Temperolimbic, especially left side may play role in positive symptoms.

Neurodevelopmental issues:

1. Fetuses/newborns sustaining earlier insult, are at elevated risk for misconnected circuitry arising during cell organization.
2. Maternal influenza during 2^nd trimester (associated w/ enlarged ventricles & sulci).

Psychosocial Factors in Schizophrenia

-Stress may affect social & personality development.

Damaging Parent-Child & Family Interactions:

1. High incidence of emotional disturbances & conflict in families of schizophrenics
2. Destructive parental interactions
3. Double-bind communication (Bateson): giving kid mixed messages (Ex. Kid falls, kiss him, but then shout, “Why’d you fall?!”). This makes the kid anxious.
4. Singer & Wyne: Communication deviance: (1) Amorphous: Failure in differentiation, everything’s loosely organized. (2) Fragmented: lowered integration, disruptive shifts in communication.

The Role of Excessive Life Stress & Expressed Emotion:

1. Marked increase of stress has been found in 10-weeks before schizophrenic breakdown.
2. Expressed emotion (EE)- type of negative communication involving emotional overinvolvement & excessive criticism directed at a patient by family members. Especially involved in relapse.

Sociocultural Factors in Schizophrenia

1. Often the symptom-content has a cultural overlay.
2. Suggestions that low socioeconomic status may be the result of schizophrenia or that low socioeconomic status leads to more stress…

Treatments & Outcomes for Schizophrenia

The Effects of Antipsychotic Medication

1. Phenotiazine drugs were 1^st used & today better antipsychotic drugs are used. This allows patients to be released w/in matter of weeks, however readmission is still high.
2. Social recovery- ability to manage independently as an economically effective & interpersonally connected member of society. This seems to be what even drugs can’t cure in schizophrenics according to Brown.

Psychosocial Approaches in Treating Schizophrenia

-Therapy together w/ medication is often helpful.

Family Therapy:

-This is important due to the relapse hazards due to familial expressed emotion (EE).

Individual Therapy:

-Can enhance social adjustment & social role performance. Learning coping skills for managing stressful/emotional events.

Social-Skills Training & Community Treatment:

-Training in social skills is helpful in overcoming the embarrassment, ineptitude, awkwardness & attentional “cluelesness” these people have shown in social situations.

Assertive community treatment (ACT)- Community-based psychosocial treatment program for helping people w/ schizophrenia manage life problems.

Intensive case management (ICM)- community-based psychosocial treatment program that uses multidisciplinary teams w/ limited caseloads to ensure that discharged mental patients don’t get overlooked & “lost” in the system.

A Problem: Overcoming Inertia:

-People overestimate the power of antipsychotic drugs & underestimate psychosocial therapy. They should be combined.

Ch 13- Brain Disorders & Other Cognitive Impairments

-Some psychological problems are result of damage or defects in the brain tissue. This could disrupt effective thought, feeling & behavior.

-Structural defects in the brain present before birth or at an early age may cause mental retardation.

-Injuries, diseases & toxic substances may cause functional impairment or death of neurons or their connections. This could cause impaired & maladaptive behavior (even psychotic). Starting w/ a deficit of this kind vs. having one later in life is very different. Losing established functioning can add a psychological burden to the organic one. Or these patients could be unaware of their losses & thus be poorly motivated for rehab.

Neuropsychological disorders- Disorders entailing behavioral & mental impairments that occur when there has been significant organic damage to a normal adolescent or adult brain.

Neuropsychological Disorders & Brain Damage

-Prior to DSM-IV, most disorders of this type were called organic mental disorders, however this term failed to distinguish b/w direct neurological consequences of brain injury, including various cognitive deficits & the psychopathological problems sometimes accompanying such injury (ex. depression, paranoid delusions). The majority of people w/ a neuropsychological disorder don’t develop psychopathological symptoms, though many will show at least mild deficits in cognitive processing & self-regulation.

-Psychopathological symptoms that sometimes accompany brain impairment are less predictable than symptoms of a neuropsychological disorder & more likely to show individual nuances consistent w/ prior personality & the total psychological situation the patient is confronted w/.

-Analogy of brain as being hardware & the psychosocial experience as being software

-The brain destruction could only cause limited behavioral deficits or could cause a wide range of psychological impairments depending on:

1. Nature, location & extent of neural damage
2. Premorbid (predisorder) competence & personality of individual
3. Individual’s total life situation
4. Amount of time since the 1^st appearance of the condition

Brain reserve capacity: Intelligent, well-educated, metally active people have enhanced resistance to mental & behavioral deterioration following brain damage, excluding situations where the damage/location is so severe that it can destroy the integrity of the personality.

General Clinical Features of Neuropsychological Disorders

-Mental symptoms associated w/ neuropsychological disorders are the direct product of physical interruption of established neural pathways in brain. Symptoms include:

1. Impairment of memory: Trouble remembering recent events (sometimes even something that happened a few minutes ago), less so w/ past events. Tendency to invent memories to fill in the gaps (confabulation).
2. Impairment of orientation: Inability to locate oneself in time, space & in relation to the personal identities of others.
3. Impairment of learning, comprehension & judgement: Clouded, sluggish, inaccurate thinking. Thought impoverishment.
4. Apathy or emotional blunting: Individual shows little emotion.
5. Impairment in the initiation of behavior: Loss of “executive” function, can no longer get started doing something, needs to be constantly reminded even though they are competent to do the behavior.
6. Impairment over controls over matters of propriety & ethical conduct: Lowering of personal standards in appearance, hygiene, language, etc.
7. Impairment of receptive & expressive communication: Difficulties understanding written/spoken language & expressing himself orally/in writing.
8. Impaired visuospatial ability: Difficulty w/ eye-hand coordination.

Nature & Location of Neural Damage:

-Destruction of cells bodies & neural pathways is permanent. Some functions lost due to actual brain damage can be relearned (usually at a less efficient & compromised level). Rapid recovery is usually due to resolution of temporary conditions (ex. edema- swelling) produced in tissue spared from actual damage.

-Location is important factor in nature of damage. Left hemisphere responsible for serial (order) processing of language, math equation. Right hemisphere specializes in configuration, or gestalt (ex. appreciation of patterns), which we use for grasping new situations, reasoning on a non-verbal, intuitive level & appreciation of spatial relations.

Frontal area damage is associated w/ 1 of the 2:

1. Behavioral inertia, passivity, apathy & inability to give up a given stream of associations or initiate a new one (perservative thought).
2. Impulsiveness, distractibility, & insufficient ethical restraint.

Right parietal lobe damage:

1. Impairment of visual-motor coordination
2. Distortions of body image

Left parietal lobe damage:

1. Language function impairment
2. Reading, writing, arithmetical abilities

Temporal lobe:

1. Impairment to early stage of memory storage
2. No storage of new info into memory
3. Eating, sexuality, emotional disturbances (probably due to damage to the neighboring limbic system responsible for primitive functions)

Occipital damage:

1. Visual impairments

Diagnostic Issues in Neuropsychological Disorders:

-Many basically medical disorders have various kinds of associated mental symptoms are coded on Axis-III (not on Axis-I). The associated mental conditions are then coded on Axis-I, w/ phrase “Due to [a specified General Medical Condition (i.e., the disease process indicated on Axis-III)]”.

-Some pathological brain changes that may produce mental symptoms are related to abuse of certain substances (Ex. Long-term excessive alcohol assumption). Here a specific etiological notation is added in Axis-I, Ex. “Substance-Induced Persisting Amnestic Disorder”.

-In cases of dementia the presumed underlying neurological disease process is sometimes included in both Axis-I & Axis-III.

Ex. Axis-I: Vascular dementia, Axis-III: Occlusion, cerebral artery

Ex. Axis-I: Dementia of Alzheimer’s Type, Axis-III: Alzheimer’s disease

Neuropsychological Symptom Syndromes

Syndrome- Group of signs & symptoms that tend to cluster together.

Categories of syndromes:

1. Delirium
2. Dementia
3. Amnestic syndrome
4. Neuropsychological delusion syndrome
5. Neuropsychological mood syndrome
6. Neuropsychological personality syndrome

-More than 1 syndrome may be present in a person at a given time & the patterns of the syndromes may change over disorder’s course of development. Clinicians must always be aware that the brain impairment itself may be directly responsible for the clinical phenomena ovserved.

Delirium- neuropsychogical symptom syndrome characterized by relatively rapid onset of widespread disorganization of the higher mental processes (perception, memory, & info processing) & by abnormal psychomotor activity (wild thrashing about, disturbance of sleep cycle); caused by a generalized disturbance in brain metabolism.

1. Delirium reflects a breakdown in the functional integrity of the brain & may be seen as only one step above a coma & could lead to coma.
2. Delirious states tend to be acute conditions that rarely last more than a week , terminating in recovery or less often in death due to the underlying injury or disease.

Causes of delirium:

1. Head injury
2. Oxygen deprivation
3. Sudden withdrawal from alcohol or other drugs in an addicted person.
4. Toxic/metabolic disturbances
5. Insufficient delivery of blood to brain tissues

Dementia- Neuropsychological disorder characterized by progressive deterioration of brain functioning that occurs after the completion of brain maturation (after about age 15) & that involves deficits in memory, abstract thinking, acquisition of new knowledge or skills, visuospatial comprehension, motor control, problem solving, & judgement.

1. Early in course of the disease, person is fairly alert & well attuned to events, environment.
2. Episodic memory (memory for events), but not necessarily semantic (language, concept) is typically affected in early stages, especially remembering recent events.
3. They show increasingly marked deficits in abstract thinking, etc. (the rest listed above in definition).
4. Personality deterioration & loss of motivation accompany the other deficits.
5. Normally dementia is also accompanied by impairment in emotional control & in moral & ethical sensibilities.
6. Dementia may be progressive or static (usually progressive) & is sometimes irreversible.

Causes of dementia:

1. Head injury
2. Anoxia (lack of oxygen)
3. Intracranial tumors
4. Toxic substances
5. Degenerative processes in older individuals, such as Alzheimers.
6. Repeated strokes
7. AIDS & other infectious diseases
8. Dietary deficiencies

Amnestic Syndrome- Neuropsychological disorder characterized by a striking deficit in the ability to recall ongoing events more than a few minutes after they have taken place.

1. Immediate memory, memory for events that occurred before the disorder & memory for words & concepts may remain intact.
2. Some opinions are that if given clues they can recognize/recollect events from the recent past meaning that the difficulty may involve a defective retrieval mechanism rather than storage.
3. Overall cognitive functioning may remain relatively intact.

Causes of amnestic syndrome:

1. Most commonly caused by alcohol or barbituate addiction & in these cases the damage is usually irreversible.

Neuropsychological Delusional Syndrome- Disorder characterized by false beliefs or belief systems arising from organic brain pathology.

1. Depending on etiology (cause of disease), the delusions may vary in content. Ex. Paranoid, persecutory delusional system is common among abusers of amphetamine drugs.

Causes of neuropsychological delusional syndrome:

1. Head injury
2. Long-term drug abuse (Ex. amphetamines)
3. Intracranial tumors
4. Alzheimer’s
5. Neurosyphylis (now rare)

Neuropsychological mood syndromes- Serious mood disturbances apparently caused by disruptions in the normal physiology of cerebral functioning.

1. Closely resembles symptoms seen in depressive/manic mood disorders.
2. Pseudodementia- Term used for severe depressive syndromes appearing to be dementias upon superficial examination.
3. The mood reaction depends on the nature of the organic pathology.
4. Often the awareness of lost function can make a person depressed, so we have to exercise caution when diagnosing someone.

Causes of neuropsychological mood syndromes:

1. Head injury
2. Intracranial tumors or tumors of hormone-secreting organs
3. Withdrawal of certain drugs
4. Strokes
5. Parkinson’s
6. Excessive use of steroids or other medications.

Neuropsychological personality syndromes- Disorders characterized by notable change in general personality style or personality traits (usually in a socially negative direction) following brain injury of any kind.

1. Course of it depends on etiology.
2. The personality change may be transitory (Ex. As when induced by medication), however it usually deteriorates.

Causes of neuropsychological personality syndromes:

1. Damage to the frontal lobes (maybe especially right frontal lobe).

Neuropsychological Disorder w/ HIV-1 Infection

AIDS dementia complex (ADC)- General loss of cognitive functioning affecting a substantial proportion of AIDS patients.

-ADC damage seems to be concentrated in subcortical regions (b/c of notably delayed reaction time).

Prominent Features:

Neuropsychogical features of AIDS (ADC):

Early stage:

1. Psychomotor slowing
2. Diminished concentration
3. Mild motor difficulties
4. Slight motor clumsiness.

Later stage (rapid):

1. Behavioral regression
2. Confusion
3. Psychotic thinking
4. Apathy
5. Marked withdrawal

Prevalence Studies:

AIDS-related complex (ARC)- Pre-AIDS manifestation of HIV infection, involving minor infections, various nonspecific symptoms (ex. unexplained fever), blood cell count abnormalities & sometimes cognitive difficulties.

Treatment:

-Antiviral therapy is thought to improve cognition & neurological functioning in AIDS patients, although complete restoration is unlikely. However, due to the virus adapting over time to the presence of antiviral agents, its positive effects are viewed as only temporary.

Dementia of the Alzheimer’s Type

Dementia of Alzheimer’s Type (DAT)- Progressive dementia associated w/ Alzheimer’s disease & ultimately terminating in death; onset may occur in middle or old age & symptoms include memory loss, withdrawal, confusion, & impaired judgement.

Senile dementias- Mental disorders that sometimes accompany brain degeneration in old age.

Presenile dementias- Mental disorders resulting from brain degeneration occuring prior to old age

-Senile & presenile dementias have different behavioral manifestations & brain tissue alterations.

The Clinical Picture in DAT:

-Difficult to diagnose DAT b/c it is only possible to distinguish the Alzheimer neuropathology by brain tissue samples, which is only possible after autopsy. Brain structure abnormalities viewed in MRI’s, etc. could be the cause of a number of different disease conditions. They usually diagnose DAT by ruling out other potential causes of dementia.

-DAT in older people, is very gradual, slow mental deterioration making it difficult to determine onset point. Factors such as support, predisorder personality, stress, etc. may change the nature & extent of the brain degeneration.

Signs often begin w/ person’s gradual withdrawal from active engagement w/ life:

1. Narrowing social activities & interests
2. Lessening of mental alertness & adaptability
3. Lowering of tolerance to new ideas & changes in routine
4. Self-centered & childlike thoughts & activities (ex. preoccupation w/ bodily functions of eating, digestion, etc.)

More severe symptoms:

1. Impaired memory for recent events
2. “Empty” speech
3. Messiness
4. Impaired judgment
5. Agitation
6. Periods of confusion

-In some rare cases the symptoms may reverse, but in true DAT this is temporary.

Terminal stages: Patient is reduced to vegetative level & death is usually caused by some disease that overwhelms the person’s limited defensive resources.

Allowing for individual differences, victim is likely to show one of these behavioral manifestations:

1. Simple deterioration (1/2 of all DAT patients): Gradual loss of mental capacities (recent memory), poor judgment, neglect of personal hygiene, loss of contact w/ reality. If delusions occur they are transitory & inconsistent over time.
2. Paranoid orientation to the environment (less frequent). In early phases they show no cognitive deficits (enabling them to build a case against someone to accuse them). Jealousy delusion is common (thinking spouse is cheating). Sometimes, but rarely they physically attack. The paranoid orientation seems to develop in already sensitive & suspicious individuals.
3. DAT as a presenile dementia (develops in 40’s/50’s) usually progresses very rapidly. This is possibly a genetic form of DAT.

Prevalence of DAT:

-DAT accounts for the majority of cases of dementia. Higher ratio for older people.

Causal Factors in DAT:

Neuropathology:

1. Senile plaques- small areas of dark colored matter, partly the debris (beta amyloid) of damaged nerve terminals.
2. Tangling of normally regular patterning of neurofibrils w/in neuronal cell bodies.
3. Granulovacuoles- Abnormal appearance of small holes in neuronal tissue caused by cell degeneration.
4. Generalized brain atrophy
5. Insufficient availability of neurotransmitter acetylcholine (ACh- involved in memory)

Gene-Environment Interaction in DAT:

-DAT may be genetic. It may be related to a genetic connection to Down syndrome. Down syndrome often causes a DAT-like dementia.

-Differing forms of blood protein called ApoE may predict risk for late onset in some cases.

-Monozygotic twin studies showed that they do not match for DAT, meaning that it could be environmental.

Treatments & Outcomes in DAT:

-No cure, however some of the problematic behaviors associated w/ DAT can be somewhat controlled using behavioral approaches.

-Research has tried providing DAT patients w/ drugs that enhance ACh , however the effects are limited & inconsistent.

-Antidepressants are sometimes administered to depressed DAT patients (but we have to be careful giving them medication, b/c in their states they are susceptible to exaggerated responses)

-The best potential treatment would be preventative/deployable at 1^st onset of DAT.

Treating Caregivers:

-The caregiver needs to deal w/ the “social death” of the patient. They are at high risk for depression.

-Most DAT patients are cared for at home for emotional reasons.

-The move into an institution could worsen symptoms. Early rather than later removal to an institution is better.

Vascular Dementia

Vascular dementia (VAD)- Dementia resulting from a series of circumscribed (determined) cerebral infarcts (small strokes) that cumulatively destroy neurons over expanding regions of the brain, leading to brain atrophy & behavioral impairments that ultimately mimic those of DAT.

-The decline is less smooth for several reasons:

1. The discrete character of each small stroke event
2. Variations over time in volume of blood delivered by a seriously clogged artery, producing variations in the functional adequacy of cells that have not yet succumbed to oxygen deprivation.
3. Tendency for vascular dementia to be associated w/ more severe behavioral complications

-VAD is far less common than DAT probably b/c many people die from the stroke. Some patients are discovered to have “mixed” dementia- both DAT & VAD.

-Treatment of VAD offers much more hope. Management measures (not medication) useful for DAT is probably useful for VAD as well since the psychological & behavioral aspects of the 2 are alike.

Disorders Involving Head Injury

Traumatic brain injuries (TBI)- Any brain damage resulting from head trauma, such as in motor vehicle crashes or gunshot wounds.

-Brain injuries having notable, long-standing effects on adaptive functioning are coded on Axis-I using the appropriate syndromal descriptive phrase, “due to head trauma.”

The Clinical Picture in Head Injury Disorders:

-Most neuropsychologically significant head injuries give rise to immediate acute reactions (ex. unconciousness). In cases of unconciousness, the person often experiences retrograde amnesia- inability to recall events immediately preceding the injury.

Anterograde amnesia (post-traumatic amnesia)- inability to effectively store in memory events happening during variable periods the time after the trauma.

Coma- being unconscious for an extended period of time.

-Anterograde amnesia has a negative prognosis & prognosis for improvement is poor after having been in a coma. Coma is sometimes followed by delirium.

-Head injury may cause disruptions of brain function quite often develop into chronic disorders. Most recovery tends to occur in the earliest post-trauma phase.

-Bleeding may occur (intracranial hemorrhage). Enough blood may accumulate w/in the skull & cause pressure on neighboring brain regions (subdural hematoma- one type) if not relieved, this can produce permanent neuronal damage. Petechial hemorrhages is whne there are small spots of bleeding.

Treatments & Outcomes:

-Immediate medical treatment of head injuries often needs to be followed by reeducation & rehab.

After-effects of moderate brain injury:

1. Chronic headaches
2. Anxiety
3. Irritability
4. Dizziness
5. Easy fatigability
6. Impaired memory
7. Concentration.

-Extensive brain damage could cause markedly reduced intellectual level (especially temporal/parietal lobe lesions).

-Various specific neurological & psychological defects may follow localized brain damage. Ex. Epilepsy.

-In a minority of brain injury cases personality changes occur (Ex. Phineas Gage, or passivity, anxiety, depression).

-Most people w/ mild concussions go back to normal shortly. Moderate brain injuries take longer & they suffer from the above symptoms. Severe cases can vary from need to institutionalization to being able to relearn things (intact brain areas taking over). The younger one is at the time of injury, the fewer competencies they have & the harder recovery.

Outcomes of brain injury are most favorable when there is:

1. A short period of unconscious or post-anterograde amnesia.
2. No or minimal cognitive impairment
3. A well functioning pre-injury personality
4. Higher educational attainment
5. A stable pre-injury work history
6. Motivation to recover or make most of residual capacities
7. A favorable life situation to which to return
8. Early intervention
9. An appropriate program of rehab & retraining

-Individuals who are also victims of alcholism, drug dependence, other medical problems are at greater risk.

Mental Retardation

Mental retardation- Significantly subaverage general intellectual functioning that is diagnosed before age 18 & is accompanied by significant limitations in adaptive functioning in skill areas such as self-care & safety.

1. Any functional equivalent of mental retardation is considered dementia.
2. Mental retardation in contrast to other developmental disorders is coded on Axis-II w/ personality disorders. It is treated as a specific type of disorder even though it can occur w/ other disorders on Axis-I or Axis-II. Other psychiatric disorders (especially psychoses) occur much more among retarded.
3. 1% of US population is diagnosed while initial diagnosis is usually around 5/6 years, peak at 15 & then drop.
4. IQs below 70 are usually considered mental retardation, while 70-90 is “borderline” or “dull-normal”. Individuals w/ only mild mental impairment seem normal & is only apparent in when difficulties start w/ schoolwork quite often they learn to adapt & lose the “mentally retarded” identity.

Mild Mental Retardation:

1. Mild mental retardation (IQ of 50-70) makes up the majority of mentally retarded. They are usually considered “educable” & as adults they are comparable w/ 8-11 year-olds intellectually, though their info-processing/speed may not be comparable. On the other hand their life experience may slightly raise their IQs.
2. Social adjustment of mildly mentally retarded often approximates that of adolescents though lack imagination, inventiveness & judgement that adolescents have. Their inability to foresee their actions causes them to need some supervision.
3. “Borderline” IQs may need services to maximize their potentials.
4. Early diagnosis, parental assistance, special education programs can help majority of them adjust & become self-supporting.

Moderate Mental Retardation:

1. Moderately mentally retarded (IQ of 35-55) are often considered trainable- to be able to master certain routine skills if provided specialized instruction.
2. As adults they attain intellectual levels of 4-7 year olds.
3. Very slow learning rate & limited conceptualizing extremely limited
4. Physically they appear clumsy, suffer from bodily deformities & poor motor coordination. A few are hostile & aggressive, but usually unthreatening.

Severe Mental Retardation:

1. Sometimes called “dependant retarded” & they are always dependent.
2. Severely retarded speech & motor development.
3. Can develop limited levels of self-help skills.

Profound Mental Retardation:

1. “Life support retarded”
2. Unable to master even simplest tasks.
3. If speech develops its rudimentary.
4. Severe physical deformities, central nervous system pathology, retarded growth
5. Convulsive seizures, mutism, deafness & other physical anomalies.

-Usually severe & profound can be diagnosed in infancy due to delayed development & physical malformations. They still may have more ability in some areas than in others.

Diagnosis Guidelines:

-American Association on Mental Retardation (AAMR) raised cutoff point for diagnosis of mental retardation to IQ 75 (thus expanding the pool of eligibles). Instead of listing level of severity they listed level of support needed.

Brain Defects in Mental Retardation

-25% of mental retardation cases involve organic brain pathology (almost always at least moderate & profound always).

Genetic-Chromosomal Factors:

1. Particularly mild retardation tends to run in families, but so does poverty, sociocultural deprivation.
2. Genetic-Chromosomal factors play a role in less frequent cases of retardation (ex. Down syndrome). Genetic abnormalities are responsible for metabolic alterations that adversely affects brain development.

Infections & Toxic Agents:

1. Mental retardation can be caused when mother is infected during pregnancy (Ex. Measles, HIV). Brain damage can result either during pregnancy or after birth (Ex. viral encephalitis).
2. Toxic agents (Ex. carbon monoxide) may cause brain damage during fetal development or after birth.
3. Immunological agents may in rare cases lead brain damage.
4. Drugs, alcohol.

Prematurity & Trauma (Physical Injury):

1. Premature born babies & underweight babies are at higher risk.
2. Physical injury at birth, hypoxia- lack of oxygen to brain.

Ionizing Radiation:

1. Radiation may directly cause gene mutations in the sex cells of either or both parent.

Malnutrition & Other Biological Factors:

1. Negative impact of malnutrition may be more indirect than once though. One hypothesis says it alters child’s responsiveness, curiosity & motivation to learn. These losses would than lead to relative retardation of intellectual faculty.

Organic Retardation Syndromes

Down syndrome- A condition resulting for a chromosomal abnormality (trisomy 21) & associated w/ moderate to sever mental retardation, typically accompanied by characteristic physical features.

1. Adaptive abilities seem to decrease w/ age. There seems to be no correlation b/w the severity of physical abnormalities of Downs (almond shaped eyes, stubby fingers, etc.) & the degree of mental retardation.
2. Seem to experience an accelerated aging process.
3. Usually able to learn self-help skills, etc.
4. Severity often depends on support.
5. IQ deficit may not be consistent across various abilities. Ex. Appear to have no impairment in appreciation of spatial relationships & visual-motor coordination (some argue this).
6. Greatest deficits are in verbal & language skills.
7. High risk of Alzheimer’s in their adult life.
8. Seems to be connected to advancing parental age in father or mother (too young also).

Phenylketonuria (PKU):

PKU- An inheritable condition that can result in mental retardation & that involves the lack of a liver enzyme needed to break down phenylalanine, amino acid found in many foods.

1. The genetic error results only when significant amounts of phenylalanine are ingested (which is certain to occur if it remains undiagnosed).
2. Symptoms suck as vomiting can appear during early weeks of life, though usually 1^st symptoms noticed are mental retardation which will vary depending on progress of illness.
3. Lack of motor coordination & other neurological problems are common.
4. Dietary restriction helps, though some still suffer retardation.
5. Both parents must carry PKU recessive genes to inherit it.

Cranial Anomalies:

Macrocephaly (large-headedness)- Rare condition associated w/ mental retardation & characterized by an increase in the size & weight of the brain, enlargement of the skull, visual impairment, convulsions & other neurological symptoms, resulting from abnormal growth of the glial cells that form the supporting structure for brain tissue.

Microcephaly (small-headedness)- Condition characterized by mental retardation resulting from impaired development of the brain & a consequent failure of the cranium to attain normal size.

-Microcephalics range from moderate to profoundly retarded.

-Caused by radiation & infections in uterus.

Hydrocephalus- Relatively rare condition in which the accumulation of an abnormal amount of cerebrospinal fluid w/in the cranium causes damage to the brain tissues & enlargement of the skull, leading to some degree of intellectual impairment.

-Can be congenital, or can develop in infancy/early childhood due to a tumor, etc. (in those cases it’s always caused by a blockage of cerebrospinal pathways).

-Depending on case the damage varies. Can cause convulsions, hearing/vision loss. Early diagnosis/treatment can prevent sever brain damage.

Cultural-Familial Mental Retardation

-Sociocultural conditions, particularly where there is a deprivation of normal environment stimulation, can cause mental retardation (usually only mild). 2 subtypes that may fall into this category:

1. Mental retardation associated w/ extreme sensory & social deprivation (Ex. Isolation during developmental years).
2. Cultural-familial retardation- Mental retardation that is result of an inferior quality of interaction w/ the cultural environment & w/ other people rather than arising form brain pathology. Most mental retardation is of this type.

Treatments, Outcomes, & Prevention

Treatment Facilities & Methods:

-Institutionalization of retarded kids should be a “last resort”. Institutionalized kids fall into 2 groups:

1. Those who in infancy & childhood manifest severe mental retardation & associated physical impairment & who enter institution at an early age. Families of this group come from all socioeconomic levels.
2. Those who have no physical impairments but show relatively mild mental retardation &a failure to adjust socially in adolescence, eventually being institutionalized b/c of delinquency/problem behavior. Families of this group come from lower education/occupations.

-In these cases social incompetence is main factor of the decision.

Education & Mainstreaming:

-Educational & training procedures involve mapping out target areas of improvement. Often step-by-step training can bring retarded individuals repeated experiences of success & lead to substantial progress.

Mainstreaming- Placement of mentally retarded children in regular school classrooms for all or part of the day.

-A disadvantage of mainstreaming is deficits in self-esteem experienced by the retarded child, however this can be reduced if they receive social skills training 1^st.

-Parallel Alternate Curriculum emphasizes specialized instruction in a normal class setting & has shown much promise.

Frontiers in Prevention:

-Programs to prevent mental retardation have focused on reaching high-risk children early w/ the intensive cognitive stimulation believed to underlie sound development of mental ability. It is possible that educational performance of these kids improves because of temporary enhanced motivation & not higher rates of cognitive development, meaning that where the environment continues to be harmful, the gain could be lost upon the end of the short-term program.