Psychopathology (PSYC 4240) Test 2 Guide
Psychopathology (PSYC 4240) Test 2 Guide PSYC 4240
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Date Created: 05/27/16
Psychopathology (PSYC 4240) Test Guide 2 Anxiety Disorders, Mood Disorders, and Eating and Sleep Disorders Read An Unquiet Mind by Kay Redfield Jamison Anxiety Disorders (Anxiety, OCD, trauma-and-stressor-related disorders) Nature of Anxiety and Fear Anxiety -Future oriented mood state (“How is this date going to go?”) -Described with a negative affect; takes away from good experience -Somatic symptoms of tensions like sweating and heavy breathing -Worried about future and bad things that can come from it Fear -Present oriented mood state (“There’s a snake here”) -Described with a negative affect as well -Immediate flight or fight response -Fear makes you develop avoidance behaviors -Activation of the sympathetic nervous system (happens instantly) Anxiety and Fear are normal emotions we experience Characteristics of Anxiety Disorders Psychological disorders: excessive and persistent symptoms of anxiety and fear -avoidance and escapist tendencies start adding dysfunction into your life -there is clinically significant distress in your life Phenomenology of Panic Attacks What’s a panic attack? -A rapid onset of intense fear with physiological and psychological symptoms -Physiological: heartrate, sweating, nausea (feels like you’re dying or having a heart attack) DSM-5 types of Panic Attacks -Expected: you’re expecting that certain stimuli will cause an attack (“obvious cue or trigger”) connected more to phobias -Unexpected: happens in a situation where you’re not expecting and stimuli (“devoid of clear cue or trigger”) *Both occur in Panic Disorder DSM-5 includes specifiers for diagnosis -i.e Depression with panic attacks -Common condition: 11% of population has panic attacks Biological Contributions to Anxiety and Panic Diathesis – Stress -Some people are more vulnerable for anxiety and panic, but it’s not a disorder -Stress and life events can activate the disorder Biological causes and inherent vulnerabilities -Anxiety and brain circuits: GABA, noradrenergic and serotonergic systems -Lower levels of GABA and serotonin leads to more anxiety -higher levels of noradrenaline leads to more anxiety Behavioral Inhibition System -Activated by brain signals which draw our attention to unexpected events like changes in body function which signals danger -i.e. rabbits have high BIS levels while criminals may have low levels -We have a “freeze” reaction and have anxiety which forces us to reevaluate the environment we’re in for signs of danger -BIS is different from the panic system Fight or Flight system -Exciting the system produces an immediate “alarm and escape” response Environmental factors can change sensitivity of the brain Psychological Contributions to Anxiety and Panic Freud -Anxiety is a psychological reaction to danger tied to early childhood fears like castration or penis envy Behaviorist views -Anxiety results from classical and operant conditioning and modeling which is vicarious learning Psychological views -Learned from early experience with a trait of uncontrollability or unpredictability -Parents can pass on this neurotic behavior OR teach their children that they CAN cope with the world and they can influence their environment (these people are not helpless in their environment) Social Contributions -Stressful life events (many from familial or interpersonal events) trigger our vulnerabilities Toward and integrated model of anxiety Integrative view -Triple vulnerability model 1. Generalized biological vulnerability: tendency to be uptight, nervous and high strung is heritable (neurotic) -doesn’t necessarily lead to a disorder, but it may make you more susceptible to one day developing them. 2. Generalized psychological vulnerability: have the belief that the world is dangerous and unpredictable and we can’t cope with that reality 3. Specific psychological vulnerability: this is learned through early experiences; some experiences are surrounded by danger Comorbidity of Anxiety Disorders Very common with anxiety disorders; you’re likely to have multiple anxieties and phobias -About 50% of patients with anxiety disorders have a secondary diagnosis like major depression -Comorbidity suggests there are common factors across anxiety disorders - and maybe mood disorders – and that all of these conditions are not actually unique -Strong correlation between anxiety and depressed (Most depressed people are anxious, but not most anxious people are depressed) Generalized Anxiety Disorder (GAD) Overview and Defining Features -Excessive, uncontrollable anxious worrying about multiple events and activities; worry and anxiety interfere with ability to function and causes distress -Persists for 6 months or more that occurs most days than not -3 or more of following symptoms: restlessness, easily fatigued, difficulty concentrating/mind going blank, irritability, muscle tensions, sleep disturbance -This is different from a “normal” worry which is more distressing and lasts longer -Occurs without triggers -Comes with physical symptoms like G.I distress and exaggerated startle response Facts and Statistics -Affects 3% of general populations -Females suffer from it twice as much as men -Onset is often insidious -Median age of onset: 30, but has a lot of variability -Prevalence peaks during the middle age, and declines in later life -Symptoms wax and wane throughout life and full remission is rare; there’s no real cure and stressors can always bring it back -Earlier onset causes a more intense disorder and higher comorbidity rate Causes of GAD Genetic factors -Genetic factors account for 30% Temperamental factors -High behavioral inhibition; neuroticism Environmental factors -Not really clear; overprotection? Childhood adversities? Cognitive factors -Highly sensitive to threat, especially If it’s personal. They allocate more attention to cues automatically. Treatment of GAD Both drugs and psychological interventions help symptoms get better Medications -Benzodiazepines (i.e. valium, Xanax) can provide immediate relief, but these drugs are very addictive and have many side effects -Impairs cognitive and motor functioning with high abuse potential - Anti depressants work best for GAD since they have less side effects Psychological -Best for long-term effects -Cognitive-Behavioral Therapy: evokes and helps confront anxiety provoking images and thoughts. This is to challenge automatic, “irrational” thoughts that lead to anxiety -Looks at past experiences to collect “data” to help predict future occurrences Panic Disorder Overview and Defining Features -Recurrent unexpected panic attacks with our or more symptoms (choking, dizzy, nausea, fear of dying, heat/chills, numbness, chest pain, sweating, shortness of breath, trembling) -1 attack must be followed by at least a month of one or more of: 1. Persistent worry about having more attacks or worrying about their consequences (social concerns; physical illness) 2. Significant maladaptive change in behavior related to attacks (i.e. avoidance of situations where you think you’ll be triggered) Facts and Statistics -12 month prevalence: 2-3% -2/3 of patients are female -Onset is acute, beginning between ages 20-24 -Symptoms wax and wane but is a chronic disorder if left untreated Associated Features -Nocturnal panic attacks: waking up from sleep with physical symptoms of panic attacks – not related to having bad dreams -Many have general physical or health concerns -Sensitive to medication side effects -Substance use is a common way to control their panic -They avoid any activity that can lead to cues like exercise or sex increasing heart rate Biological predisposition to overreact to life events. Some people may have an “emergency alarm reaction” as a response to a stressor (i.e. heart racing, sweating, breathing heavily) -Fearful of physiological changes -Develops anxiety about having panic attacks and they end up making catastrophic misinterpretations about their symptoms (i.e. “I’m dying” “This will be so embarrassing, I can never leave the house again”) -Intense focus on internal cues leads to misinterpretations which makes the internal symptoms even worse (A cycle or worrying) Treatment of Panic Disorder Medication Treatment -Target serotonergic, noradrenergic, and benzodiazepine GABA systems -SSRIs (i.e. Prozac and Paxil) are the preferred drugs -Relapse rates are high when medication is discontinued Psychological and Combined Treatments of Panic Disorder -Cognitive-behavior therapies are highly effective -Exposures to Agoraphobia (sometimes paired with relaxation strategies) -Panic: create mini-panic attacks in sessions with the hope that the exposure paired with cognitive-therapy treatment changes the way they think about their symptoms (i.e. spinning in chair, exercise, hyperventilation, breathing through a straw) Stop taking anti-anxiety medication during therapy process -No long-term advantage from combining medicine and therapy -Cognitive-behavior therapy works best from long-term outcomes Agoraphobia – fear of the market place -Fear or anxiety of 2 or more of: public transportation, open spaces, enclosed spaces, standing in line or being in a crowd, being outside of home alone -Fear or avoid situations because they believe escape will be difficult or they can’t find help -Situations will almost always cause fear or anxiety -Situations are avoided or need someone to be with them; this causes a great deal of stress -This fear is considered over the top and not normal to the situation -Fear, anxiety and avoidance must last for 6 months or longer 12 month prevalence < 2% Females 2:1 ratio Treatment is exposure therapy, SSRIs and benzodiazepines Specific Phobias Overview and Defining Features -Extreme and irrational fear of a specific object or situation -The object or situations always causes intense fear and anxiety -Fear is over the top and not normal in regards to the situation -Causes life-altering distress and impairment -Avoidance and “escapeism” is a central part to all anxiety disorders; avoids triggering objects or suffers from great distress Facts and Stats -12-month prevalence: 7-9% -Females 2:1 ratio -Chronic disease with early onset in childhood Associated Features and Subtypes of Specific Phobia -Blood-inury-injection phobia: different physiological response; instead of fight or flight, your blood pressure and heart rates drop and causes you to faint -Can be strongly heritability; very evolutionary -Uniquely causes fainting -Situational phobias: public transportation or enclosed places -Natural environment phobia: events occurring in nature like heights or storms or darkness -Animal phobia: animals and insects -Other phobias: cannot really fit in a category (i.e. fear of clowns) Causes of Phobia -Direct conditioning (i.e. dog biting child) -Experiencing a panic attack in situations and your brain focuses on whatever is around -Observing (vicarious learning) of someone else’s fears -Being told about a danger (information transmission) -Biological and evolutionary vulnerability: more likely to develop fear for certain object as in inherited tendency to fear things that are dangerous to humans -But we’re not scared of guns, cars or fast-food because evolution hasn’t caught up to our society yet -Many patients don’t know the cause but it doesn’t really matter for treatment *Phobias are often comorbid; you have more than one phobia Treatment Psychological Treatments of Specific Phobias -Cognitive-behavior therapies work very well -Exposure therapy -Build anxiety hierarchy: Subjective Units of Distress (SUDs) -Start with least threatening and move onto most threatening -Starting at a too high of a level lowers treatment compliance -Use counter-conditioning like muscle relaxation, visualization, deep breathing Social Anxiety Disorder Overview and Defining Features -Mark fear/anxiety about a social situation in which individuals are exposed to scrutiny/judgment of others Social Performance situations: speaking; eating; using bathroom; writing -Fears he/she will act in a way that shows their anxiety symptoms and people will negatively judge them -Social situations always provoke fear or anxiety -Situations avoided or endured with intense distress -Fear is not proportional to situation -Causes distress and impairment that lasts for 6 months or more Facts and Statistics -12 month prevalence: 7% -Females slightly more presented than males (close to 2:1) -Onset is usually during adolescence (median age = 13) with majority of onset between 8 and 15 Causes -Evolutionary vulnerability: evolved to fear disapproving faces -Biological vulnerability: some people are just born shy. Introverted people are chronically more aroused and need less stimulation. Social/performance experiences may cause over-arousal. -Psychological factors: taught that social evaluation is important or dangerous -Direct conditioning -Observational learning -Information transmission Medication Treatment -Beta blockers and ineffective -Tricyclic antidepressants reduce social anxiety -Mono oxidase inhibitors reduce anxiety -SSRI Paxil was the first drug FDA approved for social anxiety disorder -High relapse rates once medication is discontinued Psychological Treatment of Social Anxiety -Cognitive-behavioral treatment: exposure, rehearsal, role-play in a group setting Therapists challenge automatic thought regarding phobic activities (i.e. “If I mispronounce a word, everyone will laugh at me”) -Cognitive-behavior treatments are very effective with the exposure component being the most important Obsessive-Compulsive Disorder (OCD) Obsessions- persistent, recurrent and intrusive thoughts, images or urges that someone tries to resists (“Did I turn my stove off, did I turn my stove off…”) Common worries – contamination, doubts about safety, order, aggressive or sexual imagery Ego-dystonic – feel intrusive and out of one’s own control; not consistent with “regular” thought content Compulsions- repetitive thoughts or actions that someone feels like they have to do according to rigid rules -Goals of compulsion is to prevent or reduce distress associated with the obsessions. Compulsions are either not realistic or aren’t even connected to their actual fear. Obviously excessive and can even be useless (i.e. not stepping on sidewalk cracks) *Obsessions and compulsions are time consuming or cause significant distress or impairment (i.e. showing for 2 hours a day; checking stove dozens of times) Classifier: good to fair insight (recognizes that OCD beliefs aren’t true); poor insight (thinks that their OCD beliefs are probably true); absent insight/delusions (convinced OCD beliefs are true) Facts and Statistics -12 month prevalence: 1.2% -Females are more affected (but more male children have OCD) -OCD is chronic, especially if it’s untreated -Onset is typically in early adolescence or adulthood (mean age = 20) High morbidity with tic disorders like hoarding or skin picking Causes of OCD -Genetic factors -Greater neuroticism; internalizing symptoms -Early life experiences and learning that some thoughts are dangerous or unacceptable (i.e. thoughts about sex and how that relates to religious upbringing) -Focusing too much about thoughts leads to thought-action fusion: having the thought becomes equated with the action “I thought about hitting that women with my car I did hit that woman with my car” -Linked to excessive sense of responsibility and results in guilty, Belief that some thoughts are unacceptable and must be suppressed -Difficulty dealing with uncertainty Medication Treatment of OCD -Clomipramine and other SSRIs help about 60% -Psychosurgery is used in very extreme cases: cause lesions in parts of the brain that cause obsessions -Relapse is common once medicine is discontinued Psychological Treatment of OCD -Cognitive-behavioral therapy is most effective for OCD -CBT involves exposure and response prevention (Make them do an action and then not letting them perform OCD actions) -Combined treatments are not really better than CBT alone (Reality is that very sever OCD cases treat with combined treatments) Body Dysmorphic Disorder -Preoccupation with one or more perceived defects or flaws in appearance that are not observable to other or appear slight to others -Individual has/does perform repetitive behaviors or mental acts in response to concerns (checking or avoiding mirrors) -Causes distress or impairment -Specifier: with muscle dysmorphia – believe that muscles are too small or insufficiently muscular (mostly in men) -Insight specifier: good to fair; poor insight; absent/delusional -Prevalence: 2.4%; higher among dermatology patients, cosmetic surgery patients, orthodonture patients -Slightly more common in women -Very serious disorder which can lead to suicide Treatment -Similar to OCD treatment: SSRIs and CBT Posttraumatic Stress Disorder (PTSD) -Requires exposure to actual or threated death, serious injury, or sexual violence: directly experiencing events; witnessing, in person, events; learning of events that occurred to your family or friends; experiencing repeated or extreme exposure to aversive details of traumatic events Symptoms -Intrusive: recurrent, intrusive, involuntary memories; distressing dreams’ flashbacks; intense distress at cues of events whether they be internal or external; physiological reactions to cues -Avoidance of stimuli associated with events: memories, thoughts, feelings associated with events -Negative alterations in thoughts or mood: unable to remember important details; exaggerated negative beliefs about oneself or others or the world; distorted cognitions about cause; negative emotional stress; diminished interest in participation in significant activities or detachment or estrangement from others; anhedonia (inability to feel pleasure) -Alterations in arousal/reactivity associate with traumatic events: irritability/angers; recklessness or self-destructive behavior; hypervigilance; exaggerated startle; sleep and concentration problems Facts and Stats Disturbance lasts 1 month or more Specifier: with dissociative symptoms -Depersonalization: feels detached from oneself and one’s thought/feelings or behaviors -Derealization: sense of unreality; experience of world as distorted, surreal or dreamlike Lifetime prevalence = 8.7%; 12 month = 3.5% Higher rates among veterans and certain jobs like first responders or victims of rape, combat, captivity, etc. Symptoms usually begin within 3 months of trauma but delayed expression can happen (DSM-IV; delayed onset of 6 months) Risk factors -Prior to trauma: childhood emotional problems, other mental disorders, lower education, lower SES, prior trauma, lower intelligence, female gender and younger age -During trauma: severity of trauma, perceived life threat, personal injury, dissociation. For veterans: killing enemy, witnessing or participating in atrocities Most common trauma: sexual assault, accidents, combat, natural disasters Psychological Treatment of PTSD -CBT involves graduated or massed imaginal exposure (re-experience event in a safe, controlled environment) Remember what happened in great detail and try to work through it -Can challenge thoughts and emotions attached to event; goal is to reduce negative emotions like shame, guilt or anger -Increase positive coping skills and social support -CBT is more effective than medication, but patients will usually use anti- depressants too Medications -SSRIs may help reduce anxiety and panic Eating Disorder Three Major Types of DSM-5 Eating Disorders -Anorexia nervosa, bulimia nervosa, and binge eating disorders -Severe disruptions in eating behavior -Extreme fear or apprehension about gaining weight -Strong sociocultural origins – Westernized views Increased in 45 years 90% of cases are young females from wealthy families Are these culturally bound? -Anorexia: No, has been seen in every non-western culture throughout large periods of history -Bulimia: Yes, significant increase in last 50 years and doesn’t exist in non- western cultures that lack Western influence (ergo…exists in other cultures, but those cultures involve non-western influences) Bulimia Nervosa Overview Binge eating: most identifying factor of bulimia -Binge: eating excess amount of food -Eating is perceived as uncontrollable Compensatory Behaviors -Purging: self-induced vomiting diuretics, laxatives (not very successful) -Some exercise excessively while others fast Bing eating and compensatory behaviors occur at least once a week for 3 months -Mild: 1-3 episodes a week; Moderate: 4-7; Severe: 8-13; Extreme: 14+ Self-evaluation is influenced by weight/body shape Associated Medical Features Most are within 10% of normal body weight Purging can result in sever medical problems: teeth decay, electrolyte imbalance, kidney failure, cardia arrhythmia, seizures, intestinal problems, permanent colon damage Associated Psychological Features Most are overly concerned with body shape Fear of gaining weight Between binges, patients restrict valorizes and avoid high fat foods and “trigger” foods High comorbidity with anxiety, mood disorders and substance abuse Stice’s Dual Pathway model of Bulimic pathology pressure to be thin Dieting Body Dissatisfaction Bulimic symptoms Thin-ideal internalization Negative affect Anorexia Nervosa Overview Successful Weight Loss: most identifying factor of anorexia -Restriction of energy intake relative to requirement that leads to significantly low body weight according to age, sex, development and health (15% below expected weight (DSM-IV)) -Often begins with dieting -Intense fear of obesity -Disturbance in way one’s body shape is perceived; denial of seriousness of the problem; large impact on self-evaluation DSM-IV Subtypes of Anorexia -Restrictive subtype: limit calories, fast, excessive exercise -Binge-eating-purging subtype: like bulimia but with significant weight loss Associated Features Marked disturbance in body image High comorbidity with other psychological disorders Weight loss methods have life threatening consequences Never satisfied with weight – needs to continuously lose weight o feel better Medical consequences Amenorrhea (stops menstruating), dry skin, brittle nails and hair, sensitivity to cold temps, lanugo (downy hair on limbs and cheeks), cardiovascular problems, and death Psychological consequences Depression, withdrawal, anxiety, irritability, reduced sex drive -Secondary to starvation Binge-Eating Disorder In the Appendix of DSM-IV; became a full diagnosis in DSM-V -Engage in food binges without compensatory behaviors -Perceived loss of control during binges -Bingeing associated with: eating fast; eating until uncomfortably full; eating when not hungry’ feeling embarrassed about intake; feeling disgusted/guilty after eating -Distress about their eating behaviors Episodes last once a week for at least 3 months Associated Features -Many are normal weight/overweight or obese -Often older than bulimics and anorexics -More psychopathology vs. non-bingeing obese people -Concerned about shape and weight -Bingeing is used as a coping mechanism -No major differences across gender or cultural/racial groups unlike anorexia/bulimia Bulimia and Anorexia: Facts and Stats Bulimia -90% female -Onset around 16 to 19 years -Lifetime prevalence is about 1.1% for females, 0.1% for males -6-8% of college women suffer from bulimia -Tends to be chronic if left untreated -Childhood obesity and early pubertal onset are risk factors Anorexia -Majority are female and white from middle-to-upper-middle class families -Usually develops around age 13 or early adolescence -More chronic and resistant to treatment than bulimia *Both bulimia and anorexia are found in westernized cultures -immigrants from other countries develop symptoms to adhere to cultural expectations -Lower rates in Black and Asian females Causes of Bulimia and Anorexia: Toward and Integrative Model Media and Cultural Consideration -Being thin is seen as successful and happiness -Cultural imperative for thinness translates into dieting -Media standards of the ideal are difficult to achieve Models, or peer groups may act as a transmission path for body image concerns and coping behaviors (i.e. dieting and exercise) -Cultural differences can serve as protective factors (i.e. rap lyrics promoting “thick” women) -Male variations are on the rise (“reverse anorexia”) where men are obsessed with gaining muscle Biological Considerations -50% due to genetic factors, but we don’t know which genes are being inherited Psychological and Behavioral Consideration -Need for control -Perfectionistic attitudes; inflexible thinking -Low self-esteem (bulimia) -Restrained emotional expression (anorexia) -Excessive physical activity -Distorted body image -Preoccupation with food and appearance -Mood intolerance: uses food-related coping strategies to regulate mood Medical and Psychological Treatment of Bulimia Nervosa Medical Treatment -Antidepressants: helps reduce bingeing and purging -Not effective in long-run Psychological Treatment -Cognitive-behavior therapy Didactics: consequences of binges and purging and talking about its ineffectiveness Scheduled eating (5-6 meals; short interval between meals) Challenge automatic and dysfunctional thoughts Monitoring purges and graduated plan for decreasing them; use new coping skills or distraction to handle urges to purge -Interpersonal psychotherapy: advantages similar to CBT but doesn’t work as quickly Medical and Psychological Treatment of Binge-Eating Disorder Medical Treatment -Sibutramine (Meridia): used to control hunger Psychological Treatment -CBT for bulimia appears efficacious -Interpersonal psychotherapy is seen as just as effective as CBT -Self-help techniques are also effective (not true for anorexia or bulimia) Medical and Psychological and Treatment of Anorexia Nervosa Medical Treatment -None… Psychological Treatment -First goal is weight restoration If below 70% of normal weight, inpatient treatment is preferred -Weight gain is usually easiest part: Convince them they are not going to be overweight Eating numerous, small meals under supervision Use reinforcements like giving movies or music Confront self-defeating behaviors -Psychoeducation about food, weight, nutrition, health -Behavioral and cognitive interventions *Treatment is going to be unsuccessful without cognitive restructuring -Treatment often involves family -Long-term prognosis is poorer than bulimia Obesity Not a formal DSM disorder Concern arises because of related medical complications and social and occupational impairments Statistics -In 2000, 20% of adults in US were obese -Mortality rates are close to those of smoking -Increasing more rapidly for teens and young children -Obesity is growing rapidly in developing nations -Highly stigmatized: impacts occupational, school and social functioning Causes -Obesity is related to technological advancement Advertisement/availability of cheap, fatty foods Increasing sedentary lifestyle including occupations -Genetics account for about 70% of variance in BMI; Waist Circumference Impacts # of fat cells Likelihood of fat storage Location of fat storage Activity level -Biological and psychosocial factors Impulse control; learned patterns of how to “use” food Treatment -Moderate success with adults -Greater success with children and adolescents Treatment Progression -From least to most intrusive options -First step: self-directed weight loss program -Last step: bariatric surgery Limits food intake and caloric absorption Surgery has significant mortality rate Usually must undergo psychological evaluation before surgery Sleep Disorders Two Major Types of DSM-IV Sleep Disorders Dyssomnias: difficulties in getting enough sleep, problems in timing of sleep and complaints about quality of sleep -Insomnia -Hyper somnolence Disorder -Narcolepsy -Breathing related sleep disorder -Circadian rhythm sleep disorder Parasomnias: abnormal behavioral and physiological events during sleep -Nightmare disorder -Sleep terror disorder -Sleep walking disorder Assessment: Polysomnographic (PSG) Evaluation Spend 1+ night in sleep lab -Electroencephalography (EEG): Brain wave activity -Electrooculograph (EOG): eye movement -Electromyography (EMG): muscle movements Includes detailed history and assessment of sleep hygiene and sleep efficiency (Amount of time asleep/amount of time in bed) -Some degree of subjectivity in whether one has a sleep problem or not Insomnia Disorder Problems initiating and maintaining sleep, and/or nonrestorative sleep; early morning awakenings -3 nights a week for at least 3 months Facts and Stats Most prevalent of sleep disorder (6-10%) Affects more females than males (1.5x more) Comorbid with other disorders Associated Features Unrealistic expectations about sleep Believe lack of sleep will be more disruptive than it is Anxiety: neurotic personality styles; poor environmental conditions to sleep (noise; light) Some genetic contribution Hypersomnia and Primary Hypersomnia Excessive sleepiness despite sleeping 7+ hours -One of 3: recurrent periods of sleep or lapses into sleep during the day; main sleep episode of 9 or more that in nonrestorative; difficulty being fully awake after abrupt awakening -3 times a week for 3 months Facts and Stats Rare Symptoms get worse over time (some people sleep 20 or more hours) Likely a genetic component Associated Features Complaints of feeling sleepy throughout the day even though they can sleep throughout the night Narcolepsy Recurrent periods of irrepressible need for sleep, sleep lapses or need for naps -3 times a week for 3 months Cataplexy: brief episodes of muscle control loss triggered by laughing/joking where muscle loses its tone and can lead to falling Hypocretin (1 and 2) deficiency is found is most cases with cataplexy; hormone associated with promoting wakefulness Short latency to REM sleep Facts and Stats Rare: 0.2-0.4% of population Affects males and females relatively equally Onset in early childhood or adolescence 20-60% experience hypnagogic hallucinations (before or upon falling asleep) or hypnopompic hallucinations (just after waking up) 20-60% experience sleep paralysis Breathing Related Sleep Disorders Sleepiness during the day or disrupted sleep at night Sleep apnea: restricted air flow and/or brief cessations of breathing Subtype of Sleep Apnea Obstructive sleep apnea (OSA): airflow stops, but respiratory system works -symptoms: breathing disturbances like snoring or snorting; daytime sleepiness/fatigue Central sleep apnea (CSA): respiratory system stops for brief periods -related to central nervous system disorders and much more severe Mixed sleep apnea: combination of OSA and CSA Facts and Stats More common in males (2 to 4:1 ratio) Occurs in 10-20% of population Associated with obesity and increasing age Associated Features Persons are usually minimally aware of apnea problems Often snore or sweat during sleep and wakeup frequently May suffer morning headaches Experience episodes of sleep during the day Circadian Rhythm Disorders Sleep-Wake Disorders -Persistent sleep disruption due to alteration of circadian rhythms or misalignment between internal system and sleep-wake schedule of patients -Causes excessive sleepiness or insomnia Types of Circadian Rhythm Disorders Delayed sleep phase types: going to bed and waking up later than ideal Advances sleep phase types: going to bed and getting up earlier than ideal Shift work type: problems due to working at night Medical Interventions for Dyssomnias Insomnia -Benzodiazepines and over-the-counter sleep medication (short acting preferred) -Prolonged use can cause rebound insomnia or dependence -Best as a short-term solution Hypersomnia and Narcolepsy -Stimulants like Ritalin -Cataplexy is usually treated with antidepressants which reduce REM sleep Breathing-Related Sleep Disorders -Include medication, weight loss and mechanical devices like Continuous Positive Air Pressure Machine Environmental Interventions for Dyssomnias Circadian Rhythm Sleep Disorders -Phase delays: moving bedtime later (best approach) -Phase advanced: moving bedtime earlier (more difficult to work into peoples’ schedules) -Use of very bright light: trick brain’s biological clock Psychological Interventions for Dyssomnias Relaxation and Stress Reduction -Reduces stress and assists with sleep (use of diaphragmatic breathing, PMR, guided imagery) -Modify unrealistic expectations about sleep Stimulus Control Procedures Improve Sleep hygiene: bedroom is place for sleep, address substance use, limit exercise before sleep, reduce caffeine 6 hours before bedtime, regular sleep schedule, reduce noise and light in bedroom, increase exposure to natural light during the day Set a regular bedtime routine for children Combined Treatments -Insomnia: short-term medicine plus psychotherapy Parasomnias Nature of Parasomnias -Problem is not with sleep itself -Abnormal events during sleep, or shortly after waking -Mixtures of wakefulness and sleep Two Types of Parasomnias -Those that occur during REM -Those that occur during non-REM Nightmare Disorder Occurs during REM sleep Involves distressing and disturbing dreams; usually remembered usually involve escape from harm or threat Dreams interfere with daily life functioning Facts and Associated Features Dreams often awaken the sleeper and disrupt sleep Dreamer is alert upon awakening Problems more common in children than adults Treatment Involved antidepressants and/or relaxation techniques Rapid Eye Movement Sleep Behavior Disorder Repeated episodes of arousal during sleep with vocalization of complex behaviors Happened during REM sleep Upon awakening, individual is alert and aware -Engaging in dream enacting behavior (punching; vocalizations are loud and profane) Restless Leg Syndrome Urge to move legs due to uncomfortable sensation in legs Non-REM Sleep Arousal Disorders Recurrent episodes of incomplete awakening from sleep accompanied by either (usually happens in first 1/3 of sleep) -Sleep walking: hard to communicate with or awakening; can be involved in eating or sexual behavior -Sleep terrors: abrupt arousal from sleep and begins with scream; accompanied by symptoms of intense fear and arousal (sweating, rapid breathing, rapid heart rate) Usually little to no dream imagery present; amnesia is present for these episodes Facts and Associated Features Problem is more common in children than adults; many have few episodes but the disorder is uncommon Difficult but not dangerous to awaken sleep walker Genetic component: 80% of patients have family members with history of behaviors Problem usually goes away on its own Treatment Often involves wait-and-see approach Severe cases are treated with antidepressants or benzo Scheduled awakenings prior to sleep terror Overview of Mood Disorder Depressive Disorder -Major Depressive Disorder -Persistent Depressive Disorder (Dysthymia) -Premenstrual Dysphoric Disorder -Disruptive Mood Dysregulation Disorder (childhood diagnosis) Bipolar and Related Disorders -Bipolar I Disorder -Bipolar II Disorder -Cyclothymic Disorder Major Depressive Disorder 5 or more symptoms present during same 2-week period and represent a change from previous functioning. At least one must be depressed mood or loss of interest/pleasure (anhedonia) -Depressed mood most of day nearly every day -Marked diminished interest or pleasure in all or most activities -Significant weight loss when not dieting or gain or decrease/increase in activity -Insomnia or hypersomnia nearly every day -Psychomotor agitation or retardation -Fatigue or loss of energy -Feelings or worthlessness or excessive/inappropriate guilt -Diminished ability to think clearly or concentrate; indecisive -Recurrent thoughts of death, suicidal ideation, or attempt Having a signal episode is unusual -Reoccurrence is higher in younger people, whose last episode was severe, and people who already had multiple episodes -Most people begin to recover in 1 year. Recurrent episodes are separated by two months during which criteria for depression is not met (otherwise it’s probably just the same episode) Dysthymia Overview Depressed mood most of day, more days than not, for at least 2 years (1 for children/adolescents) Milder or fewer symptoms -2 of following: poor appetite or overeating; insomnia or hypersomnia; low energy/fatigue; low self-esteem; poor concentration/difficulty making decisions; feelings of hopelessness Can persist unchanged over long periods…even up to 20 years Facts and Stats Late onset: 21 or older Early onset: before 21 -More chronic with poorer prognosis and has more comorbid diagnoses (i.e substance use, personality disorder) Premenstrual Dysphoric Disorder Major of cycles with 5 symptoms in final week before onset of menstruation; start to improve after onset on menstruation; minimal or absent in week post menstruation -Affective lability (mood swings) -Irritability; anger; interpersonal conflict -Depressed mood; hopelessness -Anxiety; tension -Decreased interest in activities -Poorer concentration -Lethargy; lack of energy -Change in appetite and sleep -Feel overwhelmed or out of control -Physical symptoms (bloating; tenderness) Facts and Stats Prevalence: 2-6% over 12 months 1.3% for those with functional impairment associated with PDD Symptoms may worsen with age up until menopause Found cross-culturally with significant heritability (30-50%) Treatment SSRIs (used even only a couple weeks a month); CBT; Birth control pills Bipolar I Disorder Overview Essential features: occurrence of one or more manic episodes or mixed episodes (depression and mania) Individuals will usually experience a major depressive episode Mania Distinct period of elevated, expansive or irritable mood and abnormally increased goal directed activity or energy for 1 week and has 3 or more symptoms: -Inflated self-esteem or grandiosity -Decreased need for sleep -More talkative; pressured speech -Flight of ideas; racing thoughts -Distractibility -Increase in goal-directed behavior -Excessive involvement in pleasurable activities Facts and Stats Average age onset: 18 years 90% or more of individuals with 1 manic episode have recurrent mood episodes Is usually chronic; functional recovery lags behind symptoms recovery Has one of the highest risks for suicide; even higher than MDD (15x higher than general population) Bipolar II Disorder Overview Must meet criteria for current or past hypomanic episode (less chronic than mania) and meets criteria for current or past depressive episode Hypomania: main different from mania is severity of symptoms and whether or not these symptoms cause serious impairment or hospitalization Usually comes to treatment because of depression, learns of hypomania later on from other informants. BP-II diagnosis doesn’t usually come until multiple depressive episodes Facts and Stats Average onset age is mid-20s Can begin in childhood, but psychologists are weary of diagnosing children 5 to 15% of BP-II progress to full Bipolar I disorder Chronic and impairing: don’t view it as a “milder version of BP-I” Suicide risk is just as high as BP-I (32% to 36% report lifetime suicide attempt) Cyclothymic Disorder Overview More chronic version of BI-II (2 years or more; 1 if child) Numerous periods of hypomanic symptoms and depressive symptoms that don’t meet criteria for hypomania or major depression Manic or depressive mood states are present for at least half the time without the absences of these symptoms for more than 2 months ***Treatment for all 3 is pretty much the same…mood stabilizing drugs Facts and Stats Average age of onset is adolescence or early adulthood Cyclothymia tends to be chronic and lifelong General population doesn’t favor either gender, but more women are seen in clinics 15-50% eventually develop BP-I or BP-II Major depression, BP-I and BP-II are more common in relative of people with Cycothymia than those without the disorder Additional Defining Criteria for Mood Disorders: Symptom Specifier Symptom Specifiers Anxious distress: tense, restless, worry, catastrophic thoughts, concerns that one will lose control Mixed features: symptoms of mania or hypomania during depressive episodes (i.e. grandiosity; more talkative; increased energy) Atypical: mood reactivity, weight gain/appetite increase, hypersomnia, sensitivity to rejection Melancholic: near absence of pleasures, not reaction to pleasurable stimuli, profound despair, symptoms worse in the mornings, anorexia or weight loss, guilty, early morning awakenings Catatonic: absence or abnormal movement – very serious Psychotic: mood congruent or incongruent hallucinations/delusions Peripartum: depressive episodes during pregnancy or within 4 weeks of childbirth (people with depressive episodes in past are more susceptible) Seasonal pattern: pattern of relationships between onset of depressive episodes and seasons Mood Disorders: Additional Facts and Statistics Worldwide Lifetime Prevalence -16.1% for MDD (7% for 12 month prevalence) -3.6% for Dysthymia -1.3% for Bipolar (0.6% for 12-month; 0.8% for BP-II) - <1% for Cyclothymia Sex Differences -Females are most likely to have MDD (rate changes following puberty) -Difference in depression disappear at age 65 -Bipolar disorders equal amongst sexes Prevalence of Depression Does Not Vary across Subcultures Relation Between Anxiety and Depression -Most depressed people are anxious -Not all anxious people are depressed Familiar and Genetic Influences Family Studies -Rate is high in relatives -Rate of mood disorders is 2 to 3 times higher in family members of a mood disordered person Twin Studies -Concordance rates are high in identical twins -Severe cases have a stronger genetic contribution -Heritability rates are almost equal for men and women (0.40) -Vulnerability for unipolar or bipolar disorder Appears to be inherited separately Genetic contribution appear to be higher for Bipolar (0.70-0.80) Neurobiological Influences Neurotransmitters -Serotonin regulates other neurotransmitters -Mood disorders are related to low levels of serotonin??? Maybe ??? -The “permissive” hypothesis Lower serotonin allows other neurotransmitter to vary more substantially and thus become dysregulated which can lead to mood dysregulation Balance between neurotransmitter probably more important than absolute levels Endocrine System -Elevated cortisol “stress hormone” which increases energy, attention and lowered pain sensitivity -May impact depression by reducing the ability to develop new neurons (esp in hippocampus which deals with emotions and memories) Sleep Disturbance -Found is most mood disorders -Relationship between depression and sleep: people enter REM sleep more quickly, experience less slow wave, “deep” sleep Psychological Influences (Stress) Role of Stress in Mood Disorders -Stress is strongly related to mood disorders Poorer response to treatment Longer time before remission Better predictor of initial episodes than later recurrences -The relation between context of life events and mood What’s good for you is not good for others -Reciprocal-gene environment model Not just stress depression relation Genetically predisposed to putting ourselves in situations that result in “stress” and thus increase our chance of depression Depressed people can create stressors in their lives by their social situations -Stress alone is not necessarily enough to make us depressed; stress interacts with psychological characteristics to affect the outcome (but it is possible) Psychological Influences (Learned Helplessness) Learned Helplessness Theory of Depression -Based on animal research -Related to lack of perceived control over life events Depressive Attributional Style -Internal attributions: Negative attributions are one’s own fault -Stable attributions: Believing there is little room for change -Global attribution: Believing negative vents will have wide-ranging effects All three domains contribute to a sense of hopelessness and it is the hopelessness that leads to depression Psychological Influences (Cognitive Theory) Aaron T. Beck’s Cognitive Theory of Depression -Depressed persons engage in cognitive errors -A tendency to interpret life events negatively Types of Cognitive Errors -Arbitrary inference: overemphasize the negative -Overgeneralization: negatives apple to all situations -Dichotomous thinking: black or white; can’t see things in a dimensional way -Personalization: believing that other’s behavior is directed at you. Cognitive Errors and the Depressive Cognitive Triad -Think negatively about oneself think negatively about the world think negatively about the future *This thought process may lead to depression, or it may come out of being depressed Social and Cultural Dimensions Marriage and Interpersonal Relationships -Marital dissatisfaction is strongly related to depression: high conflict and low supports is linked with depression -Relation works other way too (depression marital conflict) For men, depression leads to marital programs; for women, marital problems lead to depression Gender Imbalances -Females have twice as many cases as men -Found in all mood disorder except bipolar disorders -Found cross-culturally -Gender imbalance could be because of socialization and gender roles (women are encouraged to be expressive and emotional while men aren’t) or because of biological factors Social Support -Related to depression: lack of support predict depression -Substantial support predicts recovery from depression Integrative Model of Mood Disorders Shared Biological Vulnerability Overactive neurobiological response to stress Exposure to Stress -Activates hormones that affect neurotransmitter systems -Turns of certain genes -Affects circadian rhythms -Activates dormant psychological vulnerabilities -Contributes to sense of uncontrollability -Fosters a sense of helplessness and hopelessness ***Social and Interpersonal Relationships are Moderators Treatment of Mood Disorders: Tricyclic Medications Widely used: Tofranil, Elavil Block reuptake: norepinephrine and Other Neurotransmitters Takes 2 to 8 weeks for effects to be seen Negative side effects are common: blurred vision, dry mouth, constipation, weight gain, sexual dysfunction possible Can be overdosed and lead to death Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors Monoamine Oxidase (MAO): enzyme that breaks down serotonin/norepinephrine Must avoid certain foods with Tyramine -Red wine, beer, cheese… -Reacts poorly with fermented food and other prescriptions MAO inhibitors block Monoamine Oxidase which either blocks effect or enhances effect As or slightly more effective than tricyclics Can interact dangerously with other medications Rarely prescribed Treatment of Mood Disorders: Selective Serotonergic Re-Uptake Inhibitors (SSRIs) Keeps more serotonin in synaptic cleft to regulate reuptake Specifically Block Reuptake of Serotonin -Fluoxetine (Prozac) is a popular SSRI Celexa, Lexapro, Luvox, Paxil, Zoloft SSRIs have no unique risk of suicide or violence (unlike what FDA promotes) Side effects are common: upset stomach, insomnia, physical agitation, sexual dysfunction or lower sexual desire -Usually these symptoms are more tolerable that other anti-depressants and some of them go away in a few weeks Treatment of Mood Disorders: Lithium (mood stabilizer) Lithium is a common salt with is just found in our water and environment -Primary drug of choice for bipolar disorders mostly because it helps reduce risk for suicide -Anti-depressants are often problematic (but you can mix these with a mood stabilizer to make it safer) -Anti-convulsants are also commonly used (Tegretol or Depakote) but less effective at reducing suicide Side effective can be severe -Dosage needs to be carefully monitored with blood tests so it stays effective but not toxic -Patient compliance is a part of BP treatment since people want the high of mania Mechanisms are unclear Electroconvulsive Therapy (ECT) ECT -Involves applying brief electrical current to the brain -Results in temporary seizures -Usually 6 to 10 treatments are required (once every other day) -Not a long-term fix usually…symptoms go away for 3 to 6 months and then return -Can be done bilateral or unilateral (both temples or just one) Effective for cases of severe depression which cannot be treated with medication Side effects: short-term memory loss (or even long-term); short-term confusion Mechanism is unclear (why does it work?) Relapse is common Cognitive Therapy (CBT) Addresses cognitive errors in thinking -With hope of substituting more realistic thoughts Includes behavioral components (i.e. exercise, increased social activities) Collaborative, empirical approach Structures, time-limited; use of homework like thought records Behavioral Activation Involves increased contact with reinforcing events -Exercise -Increased social contact Interpersonal Psychotherapy (IPT) Focuses on problematic interpersonal relationships -Identify precipitant of depression -Problems categorized into 1 of 4 categories (i.e. role transition, role disputes/conflict, grief, interpersonal deficits) Outcomes with Psychological Treatments (CBT and IPT) Comparable results to medications Combined treatment (psychotherapy and medication) may be more useful for chronic depression Mild/moderate depression is treated between with psychotherapy Maintenance treatment is important for the prevention of a relapse -Even if you feel better, don’t stop the medicine or the treatment Psychological Treatment for Bipolar Disorder Can help with medication compliance Help get patient to keep a regular schedule, which may reduce the likelihood of starting a new mood episode -Missing sleep can induce a manic episode Miklowitz emphasizes the role of family tension in relapses (fighting leads to relapse) -Didactics about illness -Works on family communication The Nature of Suicide Facts and Stats 10 leading cause of death in US (201) Overwhelmingly a White and Native American phenomenon -White rate (14 per 100,000); Black rate (5.1 per 100,000) -Why? Because of religious beliefs and families ties States with highest rates of suicide because of gun ownership, rural, weather, less diverse population Suicide rates very high in elderly (85+ 36% higher likelihood of suicide) Higher in those divorced, separated, widowed; lowest in those married Most common method: firearm (50%) Gender Differences Males are most likely to commit suicide (4-5x higher) Females are more likely to attempt suicide (3x higher) Indices of suicidal behavior -Suicidal attempts (1 successful suicide per every 25 attempts) -Suicidal ideations are common, however Risk Factors Psychological Autopsies Mental illness in about 90% of completed suicides Suicide in the family can lead to a 6x higher risk factor in family member committed suicide -Probably a biological connection Low serotonin levels (or comparatively low) -Related to depression, impulsivity and aggression Evidence of preexisting psychological disorders -Hopelessness is a key factors Alcohol use and abuse is implicated in 25-50% of suicides Past suicidal behavior -Attempted suicide is a predictor of future risks Experiencing of a shameful/humiliating stressor (more implicated in men) Publicity about suicide and media coverage Interpersonal-Psychological Theory of Suicide (Joiner) 3 Key Factors 1. Sense of thwarted belongingness: feels socially isolated, alone and unwanted 2. Perception of self as a burden: others would be better off if individual wasn’t alive ***3. Acquired capability for suicide -person must desensitize to thought of death and physical pain -Repeated attempts (the norm) and non-suicidal self-injury can help lead to desensitization Treatment/intervention and suicide Never be afraid to ask about suicide Ask if they have a plan Ask if they have means like guns or medication “No Suicide” contract: specific treatment plan (No real usefulness from this…) Hospitalization (doesn’t really help in the long run unless they get on medication) Risk factors: stressors, hopelessness, helplessness, recent loss, feeling trapped, impulsivity/recklessness, substance abuse, previous attempts, seriousness of past attempts, communication of intent, lack of social support, chronic medical illnesses
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