Psychopathology (PSYC 4240) Test 3 Guide
Psychopathology (PSYC 4240) Test 3 Guide PSYC 4240
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Date Created: 06/06/16
6/1/16 Other Disorders with Psychotic Features Schizophreniform Disorders -Schizophrenic symptoms for a few months (less than 6; more than 1) -Impaired functioning is not required; functioning may lag behind symptoms -Some never progress on to schizophrenia or schizoaffective disorder, but many do Schizoaffective Disorder -Symptoms of schizophrenia and a mood disorder; not a mood disorder with psychotic features Must have psychotic symptoms for a few weeks even in the absence of mood symptoms -Both disorders are independent of one another -Prognosis is similar with schizophrenia -These people usually do not get better on their own -Needs to have delusions or hallucinations for at least 2 weeks in the absence of mood disorder Bipolar type: if mania is part of presentation Depressive Type: if only major depressive episodes are part of the presentation Delusional Disorder -Presence of one or more delusions that persist for at least 1 month -Lack the positive and negative symptoms of schizophrenia Types include: Erotomanic – someone else is in love with person Grandiose Jealous – spouse/partner is unfaithful Persecutory Somatic – involves bodily functions or sensations Bizarre content; clearly implausible; not understandable -rare (0.2%) -Better prognosis than schizophrenia Brief Psychotic Disorder -One or more positive symptom of schizophrenia Delusions, hallucinations, disorganized behavior/speech Lasts at least 1 day but not longer than 1 month Many of these people will not go onto schizophrenia/schizoaffective -Not due to substance use -Usually caused by extreme stress or trauma -Can go away on its own Schizotypal Personality Disorder -May reflect a less severe form of schizophrenia -Phenotypical type of a less severe form of schizophrenia Classification Systems and Their Relation to Schizophrenia Process vs. Reactive Distinction Process: insidious onset, biologically based, negative symptoms, poor prognosis Reactive: acute onset (extreme stress), notable behavioral activity, best prognosis Good vs. Poor Premorbid Functioning in Schizophrenia -Focus on functioning prior to development of schizophrenia -No longer widely used Type I vs. Type II Distinction -Type I: positive symptoms which response well to medication, optimistic prognosis, and absence of intellectual impairment -Type II: negative symptoms, poor response to medication, pessimistic prognosis, and intellectual impairments (Defunct) Subtypes of Schizophrenia Paranoid Type -Presence of prominent hallucinations and delusions (usually persecutory or grandeur) but have relatively intact cognitive skills and affect; organized around coherent theme -Does not show disorganized behavior, speech, thought, or affect -Later onset shows better prognosis -The best prognosis of all types of schizophrenia Disorganized Type (hebephrenic) -Marked disruptions in speech and behavior -Flat or inappropriate affect -Hallucination and delusions, if present, tent to be fragmented (unlike paranoid type) -Develops early, tends to be chronic, associated with a continuous course without remissions Catatonic Type -Shows unusual motor responses and odd mannerisms -Immobility -Motor negativism (resistance to instructions or attempts to be moved) -Waxy flexibility -Examples include echolalia (mimic or repeat words) and echopraxia (mimic movements) -Tends to be sever and quite rare; less and less catatonic people are presenting but they don’t know why Undifferentiated Type -Wastebasket category -Has major symptoms of schizophrenia but doesn’t fit into above categories Residual Type -Past diagnosis of schizophrenia -Absence of prominent delusions, hallucinations, disorganized speech and behavior -Continue to display less extreme residual symptoms Presence of negative symptoms common: affective flattening, alogia, avolition or attenuated positive symptoms Facts and Stats Onset and prevalence worldwide -About 0.3-0.7% -Often develops in early adulthood Onset of first psychotic episodes is early to mid-20s for men; late 20s for women; bimodal distribution for women (second onset in 40s) Many have shown “prodromal” signs earlier Better prognosis: good premorbid adjustment, acute onset, later age of onset, being female, precipitating events, immediate treatment, treatment compliance, family history of mood problems, inter-episode functioning 5-6% die from suicide; 20% make suicide attempt Schizophrenia is generally Chronic (although 20% do okay) -Most suffer with moderate-to-severe lifetime impairment Positive symptoms more treatable than negative symptoms -Life expectancy is slightly less than average Affects males and females equally; slightly higher prevalence in men -women have better long-term prognosis b/c they usually get help faster and are less threatening seeming than men -High comorbidity, especially with tobacco use disorder and anxiety disorders -Major cognitive deficits (esp. in working memory) are common and partially explain significant functional impairment Findings from Genetic Research Schizophrenia has a strong genetic component Family Studies -Inherit a tendency for schizophrenia -Do not inherit specific forms of schizophrenia: different subtypes or forms of psychotic disorders -Risk increased with genetic relatedness Twin Studies -Monozygotic twins: risk for schizophrenia if 1 twin has: 48% -Fraternal (dizygotic) twins: risk for schizophrenia if 1 twin has: 17% -Both parents: 46% -One parents: 17% Adoption studies: risk for schizophrenia remains high in cases where a biological parents has schizophrenia -Appears to be significant overlap in the genes that contribute to SZ, schizoaffective disorder, and manic syndromes Summary of Genetic Research -Risk for schizophrenia increases with genetic relatedness -Risk is transmitted independently of diagnosis -Strong genetic component doesn’t explain everything -Can be a “carrier” of schizophrenic genes without displaying disorder (i.e. a stressor never “activated” the disorder) Neurotransmitter Influences The Dopamine Hypothesis -among most prominent theories of schizophrenia -Drugs that increase dopamine (agonists; amphetamines; L-Dopa) result in SZ-like behavior -Drugs that decrease dopamine (antagonists) reduce schizophrenic-like behavior Produces side effects that look like Parkinson’s disease which is related to too little dopamine ***-Dopamine hypothesis is problematic: 1) didn’t find excess dopamine metabolites in fluid form SZ patients; 2) some not helped by dopamine antagonists; 3) do not impact negative symptoms very much; 4) new “atypical antipsychotic” work with some SZ not helped by other drugs and are not powerful dopamine antagonists Current theories: emphasize many neurotransmitters -higher density of dopamine receptors -may make and release more dopamine -excessive stimulation of Dopamine D2 receptors in the striatum (positive symptoms?) -deficient stimulation of prefrontal Dopamine D1 receptors (negative symptoms?) Structural and Functional Abnormalities in the Brain Enlarged later ventricles (50 studies) -real problems is that the areas next to the ventricles may never have developed fully or atrophies -Not found in all SZ (men; older individuals; duration of SZ) -Found in “healthy” siblings of SZ patients Less active frontal and temporal lobes Less frontal, temporal and whole-brain volume -small hippocampus: most reliable difference ***Brain dysfunction appears before onset of SZ Dysfunction in general appears before onset of SZ Children -lower intelligence and achievement scores than healthy siblings as children -abnormalities in social behaviors, less socially response, show less positive emotions, poorer social adjustment -delays and abnormalities in motor development (i.e. crawling or walking) Adolescents -subclinical signs of psychosis (unusual ideas and sensory experiences); eccentric behavior – signs of Schizotypal Personality Disorder) Viral infections during early prenatal development -Mothers exposed to influenza in second trimester may have children more predisposed for SZ -Other prenatal problems: toxemia/preeclampsia; birth complications associated with hypoxia. Cognitive dysfunctions are substantial and are linked with functional impairment -episodic memory -executive functioning: deficits may appear before onset of psychosis and found in non-SZ relative (i.e. planning, sticking to a task…) *** No abnormality shown to be specific to SZ, AND no abnormality to characterize all SZ patients Abnormalities in neural density, structure, and interconnections. No signs of postnatal injury. Benes: mis-wiring in circuits within certain brain regions (microcircuitry) and between two or more regions within a network (macrocircuitry) Psychological and Social Influences The Role of Stress -may activate underlying vulnerability -may also increase risk of relapse Family interactions -Mothers originally blamed (i.e. being cold, dominant, rigid; schizophrenogenic or giving mixed messages – called “double bind”) -High expressed emotion: associated with relapse Family members being critical, hostile, or emotionally over-involved Medical Treatment of SZ Historical Precursors -wrap in wet sheets; electric shock; insulin comas; frontal lobotomies -Institutionalized: what are the rules now? What should they be? Development of Antipsychotic (Neuroleptic) Medications -Usually the first line treatment for SZ -Began in 1950s: Thorazine (early 1950s), Haldol (1957) A-typical, new antipsychotics: Risperdal; Zyprexa; Seroquel; Clozaril; Abilify -Most reduce or eliminate positive symptoms The newer drugs don’t really treat better, they just have fewer side effects -Compliance with medication is often a problem (3/4 of patients stop taking meds for at least 1 week in a two-year span) Acute and permanent side effects are common Extrapyramidal Side Effects: movement problems -Parkinsonian symptoms: expressionless face, slow motor activity, shuffling gait) -Akathisia: feeling restless and a need to move -Dystonia: abnormal muscle tone; muscle spasms -Tardive dyskinesia: involuntary movement of the tongue, face, mouth and jaw (i.e. tongue sticking out, chewing motions); usually irreversible Caused by “typical” antipsychotics Atypical: less EPS but more weight gain and some can cause life-threatening problems -agranulocytosis: severe reduction in white blood cells caused by Clozaril New methods for reducing noncompliance -injections -psychosocial interventions Psychosocial Treatment of Schizophrenia Historical Precursors -Psychanalytic/dynamic approaches: address early experiences with parents or other traumas -No evidence of efficacy Psychosocial Approaches: Overview and Goals -Behavioral (i.e. token economies) on inpatient units; operant conditioning (response are met with reinforcement or punishment) -Community care programs -Social and living skills training -Behavioral family therapy; reduce EE, supportiveness, didactics -Vocational rehabilitation *Necessary part of medication therapy Documentary: Full documentary on how schizophrenia effects individuals and relationships 6/2/16 Personality and Personality Disorders -Can’t really talk about personality disorders with talking about personality Funder: personality is “an individual’s characteristic patterns of thought, emotional, and behavior.” Millon: A personality trait is “a long-stranding pattern of behavior expressed across time and in many different situations.” Five Factor Model: Openness to Experience (not applicable to all cultures) Conscientiousness Extraversion Agreeableness Neuroticism A personality trait is a long-standing pattern of behavior expressed across time and in many different situations Personality disorders are composed of personality traits that are -Inflexible (adaptive personality is flexible but not unstable) -Maladaptive -Causes significant functional impairment or subjective distress The Nature of Personality and Personality Disorders -Enduring and relatively stable predispositions (i.e. ways of relating and thinking) -Predispositions are inflexible and maladaptive, causing distress and/or impairment -Coded on Axis II of the DSM-IV and DSM-IV-TR Problems: PD’s “neighbor” and reputation Consequences of Personality Disorders Various personality disorders are associated with: -Decreased social functioning -Decreased occupational functioning -Increased risk of substance abuse -Increased risk of depression and anxiety -Increased risk of schizophrenia -Increased risk of suicide -Increased risk of imprisonment or hospitalization The DSM-IV/5 gives these general criteria for all personality disorders An enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture. This pattern is manifested in two (or more) of the following areas: -Cognition: ways of perceiving and interpreting self, other people, and events (i.e. believing you’re worse or better than you actually are) -Affectivity: range, intensity, lability, and appropriateness of emotional response (i.e. having a big range or smaller range of emotions that may have too much or too little intensity) -Interpersonal functioning -Impulse control The enduring pattern is inflexible and pervasive across a broad range of personal and social situations The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood Theoretical Issues Dimensional versus Categorical -Borderline PD: 5 of 9 symptoms for diagnosis; 4 of 9 no diagnosis -Once someone is diagnosed, homogeneity is assumed; most patients look alike 125 ways to have 5 Borderline PD symptoms -Not meeting criteria (i.e. 3 or 4 symptoms) is not the same of being asymptomatic -Dichotomizing dimensional variables always result in loss of information -Cut-off are not empirically derived; don’t look different and don’t functioning differently -Causes problems with stability and inter-rater reliability (i.e. 5 symptoms in past, 4 symptoms now; dimensionally stable but categorically not) -Almost unanimous consensus that PDs should be NOT used in a categorical manner Frances (1993): “Not whether, but then and which [dimensions will be considered and when the change will happen].” Comorbidity -If diagnosed with a PD, you’re likely to have more than 1 (usually 4 or 5) Gender Differences Certain PDs believed to be more common in men vs. women -Med: Paranoid, Schizoid, Schizotypal (Cluster A), Antisocial, Narcissistic, OCPD -Women: Histrionic, Borderline, Dependent Coverage: Most common PD diagnosis in clinical practice is PD NOS (Verheul & Widiger, 2004) -Have a PD not recognized by the DSM -Have features of more than one PD but don’t meet criteria for any specific PD but features cause distress/impairment 10 DSM-5 Personality Disorders: Cluster A “The Weird” Paranoid PD: a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent Schizoid PD: is a pattern of detachment from social relationships and a restricted range of emotional expression Schizotypal PD: is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities or behavior 10 DSM-5 Personality Disorders: Cluster B “The Wild” Antisocial PD: is a pattern of disregard for and violation of the rights of others (i.e. psychopathic criminals) Borderline PD: is a pattern of instability in interpersonal relationships, self-image, and affects and marks impulsivity Histrionic PD: is a pattern of excessive emotionality and attention seeking Narcissistic PD: is a pattern of grandiosity, need for admiration, and lack of empathy 10 DSM-5 Personality Disorders: Cluster C “The Worried” Avoidant PD: is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation Dependent PD: is a pattern of submissive and clinging behavior related to the excessive need to be taken care of OCPD: is a pattern of preoccupation with orderliness, perfectionism and control Assessment Issues Self-report vs. other report -problems with both Gold standard? -Use semi-structured interviews Fundamental Questions: Can psychopathy be captured by the Five Factor Model? Psychopathy: glib and superficial charm, grandiose sense of self-worth, pathological lying, conning/manipulative, lack of remorse or guilty, callous/lack of empathy, impulsivity, irresponsibility, early behavior problems, parasitic lifestyle, failure to accept responsibility for own actions Theoretical Implications Dimensional vs. Categorical: using a general model of personality is very clearly a dimensional approach, no attempt to delineate normal from “disordered” Comorbidity: # of PD diagnoses patients typically receive varies: 2.4 to 4.6 -Trait approach to comorbidity: comorbidity is expected to the extent that the same board domains and/or specific traits underline the varies PDs -Narcissism and Antisocial should be comorbid given the strong shared component of Antagonism Gender Differences -Gender differences in prevalence rates of PDs should be consistent with gender differences in general personality functioning -Meta analyses of gender differences in personality support: Men lower in Agreeableness – Antisocial, Narcissistic; Women higher in Neuroticism – Borderline, Dependent Coverage: Most common PD diagnosis in clinical practice – PD NOS -Use of general trait models provides substantial breadth to understand personality pathology DSM-5 was set to use a radical new approach, reflecting the type of FFM-like work described -Viewed as too untested at the last moment and put in Section III for further study -DSM-IV PDs imported unchanged into the main portion of the DSM-5 DSM-5 Section III approach -Moderate or greater impairment in personality (self/interpersonal) functioning -One or more pathological traits -Inflexible/pervasive -Longstanding Impairment Self -Identity: experience oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity/ability to regulate emotional experience -Self-direction: pursuit of coherent and meaningful short and long-term goals; use of constructive and prosocial internal standards of behavior ability to self-reflect Interpersonal -Empathy: comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding the effects of one’s own behavior on others -Intimacy: depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior DSM-5 trait model 5 domains (25 specific traits) -Negative Affectivity -Detachment -Antagonism -Disinhibition -Psychoticism Only 6 disorders would remain: schizotypal, antisocial, borderline, narcissistic, avoidant, and OCPD DSM-5 Section III: Antisocial PD Impairment: egocentrism; goal setting based on personal gratification; lack of concern for other; exploit, deceive, dominant, coercive) Traits: (6 of 7) Manipulative, callousness, deceitfulness, hostility, risk taking, impulsivity, irresponsibility Personality Disorders: Statistics Prevalence of PD -About 0.5-2.5% of the general population -10-30% in inpatient settings -up to 15% in outpatient settings Origins and Course of Personality Disorders -Thought to begin in childhood: predicted by childhood sexual, physical and emotional abuse; neglect. -Childhood psychopathology predicts later PD status -Pretty chronic, but not as chronic or untreatable as people thought -Comorbidity rates are high Gender Distribution and Gender Bias -Men: Cluster A, APD, Narcissistic, OCPD -Women: Borderline, Histrionic (?), Dependent (?) -Do these differences come from a bias? Maybe? -Gender bias exists in diagnosis (given the same symptoms description, diagnosis changes based on male/female) -Criterion vs. assessment gender bias Cluster A: Paranoid PD (supposed to be dropped in DSM-5) Overview and Clinical Features -Pervasive and unjustified mistrust and suspicion Causes -Biological and psychological contributions are unclear -Early learning that world is a dangerous place -Living in an unsafe environment, lower SES -Evidence unclear whether it is a variant of a psychotic disorder; research suggests yes Treatment Options -Few seek professional help on their own -Treatment focuses on development of trust -Cognitive therapy to counter negativistic thinking -Lack good outcome studies Cluster A: Schizoid PD (supposed to be dropped in DSM-5) Overview and Clinical Features Pervasive pattern of detachment form social relationships -Not interested in close relationships -Little interest in sexual experiences -No close friends -Indifferent to praise or criticism Very limited range of emotions in interpersonal situations -Takes pleasure in few things -Flattened affectivity; appears cold and detached Causes -Etiology is unclear -Preference for social isolation resembles autism; extreme variant of shyness/introversion? Treatment Options -Few seek professional help on their own -Focus on the value of interpersonal relationships -Building empathy and social skills -Lack good outcome studies Cluster A: Schizotypal PD (almost moved to Schizophrenia subtypes) Overview and Clinical Features -Odd and unusual behavior, appearance, and cognition -Most are socially isolated, highly suspicious -Magical thinking, ideas of reference, and illusions -Unusual perceptual experiences -Many meet criteria for major depression Causes -A phenotype of a schizophrenia genotype? -Diagnosis came as a result of research on family members of people with SZ; higher rates of schizotypal PD in family members of patients with SZ -Generalized cognitive deficits Treatment Options -Main focus is on developing social skills -Treatment also addresses comorbid depression -Medical treatment similar to SZ: use of antipsychotics but not very effective -Treatment prognosis is poor but not as bad as SZ (***usually, SZ patients want to get to this schizotypal level during treatment) Cluster B: Antisocial PD Overview and Clinical Features -Noncompliance with social norms -Violate rights of others -Irresponsible, impulsive, and deceitful -Lack empathy and remorse -Lack concern for safety of self or others -Must be evidence of Conduct Disorder before age 15 Psychopathy and Antisocial Personal Disorder (APD) have similar constructs but operationalized differently (personality traits vs. behavior) -Asymmetrical: 90% of criminal psychopaths meet the criteria for APD; 20- 30% of inmates with APD also meet criteria for psychopathy (probably b/c cutoff from psychopathy is stringent) Relation with Conduct Disorder and Early Behavior Problems -Early histories of behavioral problems -Families with inconsistent parental discipline and support (i.e. inconsistent discipline, harsh punishment like physical abuse) -Families have histories of criminal and violent behavior (evidence of genetic impact on criminality and APD) -ADHD and conduct disorder may be a “recipe” for later psychopathy Neurobiological Contributions and Treatment of Antisocial Personality Prevailing Neurobiological Theories -Brain damage: little support for this view -Under arousal hypothesis: cortical arousal is too low Future criminals have lower skin conductance activity, lower resting heart rate, and more slow frequency brain activity -Cortical immaturity hypothesis: cortex is not fully developed Based on evidence that Theta waves are correlated with psychopathy; theta waves uncommon in adults; could be due to lack of anxiety -Fearlessness hypothesis: fail to responds to danger cues -Gray’s model of “behavioral inhibition system” paired with an overactive “behavioral activation system” -Response modulation difficulties Treatment -Few seek treatment on their own; tend to externalize blame -Antisocial behavior is predictive of poor prognosis -Emphasis is placed on prevention and rehabilitation -Often incarceration is the only viable alternative 6/3/16 Video: “I, Psychopath” Borderline PD (Cluster B) A pervasive pattern of instability in interpersonal relationships, self-image, and affects. Marked impulsivity beginning by early adulthood and present in a variety of contexts Indicated by 5 or more of the following: -Frantic efforts to avoid real or imagined abandonment -A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation -Identity disturbance: marked and persistently unstable self-image or sense of self -Impulsivity in at least two areas that are self-damaging (i.e. spending a lot of money, sex, substance abuse, reckless driving, binge eating) -Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior (***Associated with behaviors of self-harm, without always the goal of suicide) -Emotional instability due to marked reactivity of mood (i.e. extreme irritability, anxiety, vulnerability, anger, which lasted only a few hours or at most a few days) -Chronic feelings of emptiness -Inappropriate, intense anger or difficulty controlling anger (i.e. frequent displays of temper, constant anger, recurrent physical fights) -Transient, stress-related paranoid ideation or severe dissociative symptoms Most common of the ten specific DSM-IV personality disorders in a psychiatric setting Comorbidity is high with a lot of disorders: mood, PTSD, substance use, eating disorders, other PDs Causes -Genetic component, esp with families with mood disorders -Early trauma and abuse have some role (but not specific or sufficient to this PD) ***These people are most likely born with intense emotions, and then grow in an environment where they didn’t learn to regulate emotions Major theory: Biosocial theory (Linehan) -Emotionally vulnerable individuals who react strongly to stress; long recovery rate following stress -Invalidating environment which tells patient their emotions or feelings aren’t ok, being told perceptions are wrong, physical or sexual abuse, and invalidates boundaries, privacy, or autonomy Treatment -Few good treatments or cures -Antidepressants give short-term results -Antipsychotics can reduce aggression -Psychotherapy isn’t great either -Dialectical behavior therapy (DBT): most promising treatment developed by Linehan Group therapy that focuses on: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotional regulation and mindfulness Individual Therapy deals with problems of the past week and talks about therapy interfering behaviors (self-harm, suicide threats) and how to handle situations/emotions/outcomes Helps reduce suicide thoughts, self-harm, time spent in in-patient therapy, but doesn’t really reduce distress…just makes them functional Histrionic PD (Cluster B) – was going to be dropped in DSM-5 Overview and Clinical Features -Overly dramatic, sensational and sexually provocative -Impulsive and need to be the center of attention -Thinking and emotions are perceived as shallow -More common in females Causes -Etiology is largely unknown -Sex-typed variant of antisocial personality? Probably sex-typed variant of narcissism? Treatment -A lot of these people don’t come into therapy since it’s not very dysfunctioning (Think: Kardashians, Paris Hilton…) -Focus on attention seeking/long-term consequences -Address problematic interpersonal behaviors -Little evidence that treatment is effective Narcissistic PD (Cluster B) Overview and Clinical Features -Exaggerated/unreasonable sense of self-importance -Preoccupation with receiving attention -Lack sensitivity and compassion for other people -Sensitive to criticism, envious, and arrogant (to maintain their superiority) -Don’t really think they’re nicer; it’s more about power -Mainly causes social impairment; mildly distressing over time but secondary to impairment it causes -***Unique b/c it causes most harm to people around narcissists Causes -Link with early failure to learn empathy as a child because of parents’ failure to effectively “mirror” child (Kohut) Parents never affirmed child’s goals or dreams -Parents are spiteful and cold but find 1 specific quality in the child to reward (i.e. athletic, academic, music) Grandiosity conceals concerns about defectiveness (Kernberg) -Child over-valued and parents provide non-contingent praise, attention and tribute to child, even when child isn’t actually successful (Millon) “Your teacher is stupid, not you.” -Appears that over OR under valuation can cause it: too much/too little attention; pampering or neglect; excessive praise or no praise (But all this is also affected by child’s personality) Treatment -Those who come in for therapy are usually vulnerable, the “secure” narcissists won’t go for therapy -Focuses on grandiosity, lack of empathy -Little evidence that treatment is effective -Really disliked to be treated by psychologists Avoidant PD (Cluster C) Overview and Clinical Features -Extreme sensitivity to the opinions of others -Highly avoidant of most interpersonal relationships -Interpersonally anxious and fearful of rejection -“look like” schizoid individuals but different motivations for similar behavior (want relationships, but are too afraid) Causes -Numerous factors -Difficult temperament and early rejection (possibly witnessing parents’ divorce) -Recall feeling isolated and rejected in childhood -Extreme variant of introversion? Treatment -Several well-controlled treatments -Treatment is similar to that used for social phobia -Treatment targets include socials skills and anxiety taught How to approach people while realizing that rejection isn’t completely catastrophic Dependent PD (Cluster C) – was going to be dropped in DSM-5 Overview and Clinical Features -Reliance on other to make major and minor life decisions -Unreasonable fear of abandonment -Clingy and submissive in interpersonal relationships (but also, may use violence to get what they want which is sometimes observed in dependent men) -Focused on maintenance of supportive/nurturing relationships Causes -Still largely unclear -May be due to feelings of incompetence and low self-efficacy -Linked to early disruptions in learning independence Early disruption of important attachment relationships Temperamental differences in negative emotions Treatment -Research on treatment efficacy is lacking -Therapy typically progresses gradually -Treatment targets include skills that foster independence -On surface, seem to be a perfect patient; but be weary of patient’s dependence on therapy and therapist Obsessive-Compulsive PD (Cluster C) Overview and Clinical -Excessive and rigid fixation on doing things the right way (i.e. “my way or the highway”) -Frugal -Highly perfectionistic, orderly, and emotionally shallow -True obsessions and compulsions are rare (NOT like OCD) -Really about control -Miss the big picture and focus on the details Causes -Largely unknown -Impairment may be more limited than other PDs Treatment -Data supporting treatment are limited -Addresses fears related to the need for order -Address rumination, procrastination SUBSTANCE ABUSE AND RELATED DISORDERS Perspective on Substance-Related Disorders The Nature of Substance-Related Disorders Use and abuse of psychoactive substances that alter mood and/or behavior -Wide ranging psychophysiological and behavioral effects -Associated with significant impairment and costs Some important terms and distinctions (DSM-IV) Substance abuse vs. dependence -Abuse: impairment -Dependence: impairment and dyscontrol DSM-5 merges these terms Substance Use Disorder only -Can be used for 9 of 10 drug classes described in DSM-5 (except caffeine) ***DSM doesn’t use the phrase “addiction” Substance dependence 2 or more in 12-month period: 1) substance often taken in larger amounts or over a longer period time than intended - dyscontrol 2) persistent desire or unsuccessful effort to cut down or control substance use – dyscontrol 3) a great deal of time is spent in activities necessary to obtain substance, use the substance, or recover from its effects – maladaptive 4) craving or strong desire to use substance – dyscontrol 5) recurrent use resulting in failure to fulfill major role obligation at work, school or home – maladaptive 6) continued use despite persistent or recurrent social or interpersonal problems caused by effects of substance – maladaptive 7) important social, occupation or recreational activities are given up or reduced because of substance – maladaptive and dyscontrol 8) recurrent use in situations in which it is physically hazardous – maladaptive and dyscontrol 9) substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by substance abuse – dyscontrol 10) tolerance: need for markedly increased amounts of the substance to achieve intoxication or desired effect; markedly diminished effect with continued use of same amount 11) withdrawal: characteristic withdrawal syndrome for the substance; same or closely related substance is taken to relieve or avoid symptoms DSM-5: Only Substance Use Disorder -Lots of false-positives? Add severity dimensions: 2-3 = mild; 4-5 = moderate; 6+ = severe Pathological Gambling New to DSM-5 (used to be categorized as “impulse control disorder”) 4 or more (in 12-month period) 1) need to gamble with increasing amounts of money to achieve desired excitement 2) restless or irritable when attempting to cut down or stop gambling 3) made repeated unsuccessful efforts to control, cut back, or stop gambling 4) preoccupied with gambling (i.e. reliving past gambling experiences; thinking of ways to get more money to use for gambling) 5) gambles when distressed 6) after losing money gambling, often returns another day to get even or “chasing losses” 7) lying to conceal extent of involvement in gambling 8) has jeopardized or lost a significant relationship, job or educational/career opportunity because of gambling 9) relies on other to provide money to relieve financial situations caused by gambling Perspective on Substance-Related Disorder Main Categories of Substances -Depressants: results in behavioral sedation -Stimulants: increases alertness and elevates mood -Opiates: primarily produce analgesia and euphoria -Cannabis -Hallucinogens: alter sensory perceptions like time -Other drugs of abuse: inhalants, anabolic steroids, medications 6/6/16 The Depressants: Alcohol Use Disorder Psychological and Physiological Effects of Alcohol -Central Nervous System depressant – reduces physiological arousal -Feels like a stimulant (initially) because it slows down our inhibitory centers -Affects several neurotransmitter systems – more complex than other drugs (GABA, glutamate, serotonin) Effects of Acute/Chronic Use Intoxication: clinically significant maladaptive behavior or psychological changes that develops as a result of alcohol use -1 or more of the following: slurred speech, incoordination, unsteady gait, impairment of memory Withdrawal: autonomic hyperactivity (sweating, fast pulse rate), increased hand tremor, insomnia, nausea or vomiting, hallucinations, agitation, anxiety, seizures Associated conditions: -Dementia: loss of intellectual abilities -Wernicke-Korsakoff syndrome: confusion, loss of coordination, memory loss and inability to form new memories -Fetal alcohol syndrome – retards growth, cognitive deficits, behavior problems, characteristic appearance Facts sand Stats -12-month prevalence of alcohol use disorder: 9% in 18 or older -23% report binge drinking in the past month College binge drinking: 42%; those living in frats and sororities report highest levels -Rates highest in Caucasians and Native American (cultural and genetic factors) Highest in Native American and Alaskan Natives (12%), Whites (9%), Hispanics (8%), African Americans (7%), and Asians (5%) -Males use and abuse alcohol more than females 12% in men vs. 5% in women -Violence is associated with alcohol -Alcohol alone does not cause aggression Depressants: Sedative, Hypnotic, or Anxiolytic Substance use Disorder Native of Drugs in This Class -Sedatives: calming, very addictive, lethal at high doses -Hypnotic: sleep inducing -Anxiolytic: anxiety reducing (i.e,. benzodiazepines) -None of these should be taken on a long-term basis or from day to day Should not be combined with alcohol -Effects similar to large doses of alcohol; combining forms a synergistic relationship -All of these influence GABA system Stimulants Nature of Stimulants -Most widely consumed drug in US -Such drugs increase alertness and increase energy -Examples: amphetamines, cocaine, nicotine, and caffeine Effects of Amphetamines -Produce elation, vigor, reduce fatigue, reduce appetite -Effects followed by extreme fatigue and depressed -All are lab made -Amphetamines stimulate CNS by enhancing release of norepinephrine and dopamine; reuptake is subsequently blocked by keeping it in the synapse longer. Too much leads to hallucinations and delusions: impacted theories of schizophrenia Signs of intoxication: pupillary dilation, blood pressure change, chills, nausea or vomiting, weight loss, psychomotor agitation, muscle weakness, respiratory depression, chest pain, cardiac arrhythmias Stimulants Cocaine Use Disorder Effects of Cocaine -Short lived (15-30 min) sensations of elation, vigor, alertness, reduces fatigue, causes insomnia and loss of appetite -Individuals often feel more powerful and confident; paranoia is common -Blocks reuptake of dopamine, which is related to reward and pleasure systems -Highly addictive, but addiction develops slowly -Can affect cardiac health like arrhythmia, slow or fast heart rate Cocaine Intoxication is the same as Amphetamines Cocaine Withdrawal (dysphoric mood) and fatigue, vivid, unpleasant dreams, insomnia or hypersomnia, increased appetite Stimulants: Nicotine Use Disorder Effects of Nicotine -Stimulates nicotinic acetylcholine receptors -Results in sensations of relaxation, wellness, pleasure; may diminish negative affect -Nicotine is highly addictive -Relapse rates equal those for alcohol and heroin users DSM-IV-TR Criteria for Nicotine Withdrawal Only -Psychological symptoms (dysphoria, anxiety, irritability, restlessness) -Physiological symptoms (insomnia, difficulty concentrating, decreased heart rate, increased appetite or weight gain) Stimulants: Caffeine Use Disorder Effects of Caffeine – The “Gentle” Stimulant -Found in tea, coffee, cola drinks, and cocoa products -Blocks reuptake of adenosine neurotransmitter -Small doses elevate mood and reduce fatigue -Half-life of 3 to 6 hours 13 for women on oral contraceptives 18 to 20 hours for pregnant women -Used by over 90% of Americans -Regular use can result in tolerance and dependence Opioids: An Overview The Nature of Opiates and Opioids Opiate: narcotic like chemical in the opium poppy -Analgesic and sedative effects Opioids: substances that produce narcotic effects -Includes natural and synthetic variants Often referred to as analgesics (i.e. help relieve pain) Examples: heroin, opium, codeine, and morphine Effects of Opioids: -Activates body’s endorphins -Low doses: euphoria, drowsiness, and slow breathing -High doses can be fatal -Withdrawal symptoms can be lasting and severe: nausea/vomiting, chills, muscle aches, diarrhea, insomnia -Lasts up to a week Opioids: Diagnostic Criteria and Associated Features Mortality rates are high via overdose, suicide, homicide -Many die at young age Users at increased risk for HIV Hallucinogens: An Overview Nature of Hallucinogens -Substances that alter perceptions of the world -Produce delusions, paranoia, hallucinations, and/or altered sensory perception -Examples include LSD, mushrooms, PCP, MDMA, ketamine -Rarest substance use disorder 0.1% 12-month prevalence in adults (0.5% 12-17) Thought to have highest rates of recovery Very rare among older adults (30 or older) -DSM-5 has a “hallucinogen Persisting Perception Disorder” Following cessation of use, re-experience perceptual symptoms associated with intoxication (i.e. flashes of color, trails of moving objects; false perceptions of movement); causes distress and impairment LSD and Other Hallucinogens -LSD is most common form of hallucinogenic drug -Appears to disrupt serotonin functioning; impact areas of the brain dealing with mood, cognition, perception -Effects can last up to 12 hours -Tolerance is built up quickly -Withdrawal symptoms are uncommon -Can produce psychotic delusions and hallucinations Cannabis Most widely used illicit substance (32% have tried it) -Cannabis use disorder (CUD) prevalence (3.4% in 12-17 yrs old; 1.5% in adults) -Disorder tends to develop slowly over time (except maybe in youth where it develops faster) Active chemical is tetrahydrocannabinol (THC); strength has increased substantially over time Symptoms: Euphoria, relaxation, sensation of slowed time, impaired judgment, social withdrawal, anxiety (can be severe) -With perceptual disturbances or hallucination-type disturbances (this is a specifier in the DSM) Amotivational syndrome can be found in CUD – individuals feel apathetic and unmotivated DSM-5 has cannabis intoxication and withdrawal diagnoses Other Drugs of Abuse: Inhalants Nature of Inhalants -Found in volatile solvents (liquids that vaporize at room temperature) -Breathed into the lungs directly -Examples include spray paint, hair spray, paint thinner, gasoline, nitrous oxide -Drugs are rapidly absorbed -Effects similar to alcohol intoxication Increases heart rate to get blood to brain; feels stimulated; distorted perceptual experiences Serious health consequences (lung, liver damage; brain damage) -Produces tolerance/prolonged withdrawal symptoms: seizures, hallucinations, nausea, anxiety -Most common in white, rural males aged 13-15 Other Drugs of Abuse: Anabolic Steroids Nature of Anabolic-Androgenic Steroids -Steroids are derived or synthesized from testosterone -Used medicinally or to increase body mass -User may engage in cycling) schedules use followed by a break) or stacking (combining different types) -Steroids do not produce a high -Long-term mood disturbances like depression, anxiety and irritability/aggression Physical problems: liver problems, cancer, cholesterol problems Men: shrinking testicles, reduced sperm count, infertility, baldness, development of breasts, increased risk for prostate cancer Women: growth of facial hair, male-pattern baldness, changes in or cessation of the menstrual cycle, enlargement of the clitoris, deepened voice Administration routes: time to reach brain Inhaling: 7 seconds Snorting: 4 mins Injection -Intravenous: 20 sec -Intramuscular: 4 min Oral ingestions: passes through esophagus and stomach into small intestines where it is absorbed into blood from there -30 min Causes of Substance-Related Disorders: Family and Genetic Influences Results of Family, Twin and Adoption Studies -Substance abuse has a genetic component (40-60% of variance in alcohol use is genetically explained -Much of focus has been on alcoholism Twin studies: 54% alcohol abuse in MZ 28% alcohol abuse in DZ Adoption studies: Adopted children with biological parents dependent on alcohol have higher rates of alcohol use than those without biological parents dependent on alcohol -Common genetic factors for the use of all drugs: which specific drugs are use may be more environmentally determined Multiple genes involved in substance disorder Causes of Substance-Related Disorder: Neurobiological Influences Results of Neurobiological Research -Drugs affect the pleasure of reward centers in the brain. Common to all drugs: activate this pathway for some period of time -The pleasure center: dopamine key neurotransmitter Beings in midbrain and travels towards the frontal cortex -Some drugs work directly with dopamine (i.e. cocaine and amphetamines) while other work indirectly (i.e. opioids inhibit GABA) -GABA turns off reward-pleasure system -May not only activate pleasure systems but deactivate systems related to anxiety and pain (negative reinforcement) -Repeated use may diminish natural levels of these neurotransmitters Causes of Substance-Related Disorder: Psychological Dimensions Roles of Positive and Negative Reinforcement Pos: A particular behavior is strengthened by the consequences of experiencing a positive condition -most drugs result in some pleasurable effects, which makes it more likely that drug will be used again -Animal research support notion that most drugs are reinforcing Neg: a particular behavior is strengthened by the consequence of stopping or avoiding a negative condition -The self-medication and the tension reduction hypothesis: Substance abuse as a means to cope with negative affects -Feels less depressed and anxious and more confident -May be specifically likely to abused drugs that “treat” these problems Cognitive Factors: Expectancies and Alcohol Expectancies are like “if, then” statements: Positive: global positive effects, physical/social pleasures, enhanced sexuality, increased social assertiveness, relation and tension reduction, arousal/power Negative: negative affective change and loss of control These expectancies develop early in life (usually pre-substance use; impacted by parents and peer attitudes; cultural influences; predicts future substance use Cravings can make it difficult to lessen or end substance use -Physical and psychological triggers I.e.: smoking after a meal, after sex, with alcohol, after work Causes of Substance-Related Disorder: Social and Cultural Dimensions Exposure to Drugs is a Prerequisite for Use of Drugs Media, family, peers Parents and the family appear critical -Children between age of 3 and 6 can often identify different types of alcohol by smell -Substance-abusing parents monitor children less carefully, giving them more opportunities to start their own use Societal Views About Drug Abuse Sign of moral weakness: failure of self-control Sign of a disease: caused by underlying processes -No different than other medical disease: biologically oriented The Role of Cultural Factors Influences the manifestation of substance abuse -Which drugs are used…which drugs are used first -The “meaning” of those substances (i.e. spirituality, mindfulness…) Biological Treatment of Substance Related Disorder Agnostic Substitution -Substitute safer drug with a similar chemical composition -Examples include methadone instead of opiates and nicotine gum/patch instead of cigarettes Antagonistic Treatment -Using drugs that block or counteract pleasurable drug effects -Examples include naltrexone for opiate and alcohol problems -Mixed success Aversive Treatment -Drugs that make use of drugs extremely unpleasant -Examples include Antabuse for alcoholism and silver nitrate for nicotine addiction -Limited success Efficacy of Biological Treatment -Usually ineffective when used alone -Better when paired with social support and/or psychotherapy Psychosocial Treatment of Substance-Related Disorder Inpatient vs. Outpatient Care -Overall efficacy is comparable -Inpatient is much more expensive Community Support Programs -Alcoholics Anonymous and related groups -Seems helpful and are strongly encouraged (but their efficacy is questionable) -Follows disease model and idea of complete abstinence -Invokes need to look to “higher power” Controlled Use vs. Complete Abstinence as Treatment Goals -Controlled use: very controversial -Appears to work as well as complete abstinence (but both don’t work too well…) -Now called “harm reduction” -Debated framed by politics more than empiricism Comprehensive Treatment and Prevention Programs -Individual and group therapy -Aversion therapy (i.e. shock and drug) and covert sensitization (imagine negative events and substances use) -Contingency management (rewards and punishments determined by behavior – being substance free) -Relapse prevention Help people deal with ambivalence about stopping Confront costs of use Identify relapse triggers and coping mechanisms -Preventative efforts via education DARE: 10 year follow-up found no differences in substance use between those who did and did not get DARE training
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