Abnormal Psych Exam 2
Abnormal Psych Exam 2 Psyc 3330 - 01
University of Louisiana at Lafayette
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This 38 page Study Guide was uploaded by Lauren Notetaker on Friday March 11, 2016. The Study Guide belongs to Psyc 3330 - 01 at Tulane University taught by Constance Patterson in Winter 2016. Since its upload, it has received 175 views. For similar materials see Abnormal Psychology in Psychlogy at Tulane University.
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Date Created: 03/11/16
Abnormal Psych Exam 2 Study Guide Notes: There will be NO questions about neurotransmitters or medications on the exam Goodluck on Tuesday! Chapter 6, Somatic Symptom and Related Disorders and Dissociative Disorders • Relationship between these disorders and stress - the stress causes more symptoms • What was Dr. Francis’concerns about DSM-5 changes in this area? - "real psychiatric problems" are already not given enough attention - newly added diagnoses in the DSM-5 will end up taking away much-needed resources - Somatic Symptoms Disorder "lacks specificity" and could cause the mislabelling of a sizeable proportion of the public as mentally ill - new diagnosis is "overinclusive" —underscored that in the results from …field trials: • Somatic symptom disorder erroneously captured genuine medical disorders in the form of: - 15% of patients with cancer or heart disease - 26% with irritable bowel syndrome or fibromyalgia, and a false positive rate of 7% among healthy people in the general population • What are key features of: Somatic Symptom disorder? - Somatic Symptom Disorders initially appear to be physical or medical (client believes it is medical) - In some cases, an actual medical condition is present but NOT accurately diagnosed (e.g., hyperparathyroidism, lupus, multiple scleroses, chronic fatigue syndrome) - BUT Generally after exhaustive testing underlying psychosocial factors are found to be the cause: • Somatic Symptom Disorders are psychological disorders that masquerade as physical problems - Presence of one or more somatic symptoms that are distressing and/or significantly disrupting to daily life - Excessive thoughts, feelings, and behaviors regarding the somatic symptoms(s) or related health concerns, including one of the following: - Disproportionate and persistent thoughts abut the seriousness of the illness - Persistent and high anxiety about health or the symptoms - Excessive time and energy devoted to the symptoms or to health concerns - Symptoms are persistent, although not necessarily continuous, typically lasting more than 6 months - Most commonly develops in adolescence, more women than men (2:1), often unmarried, lower SES backgrounds - Course is chronic and very hard to treat - Observed in multiple family members (women with a female relative who has this has an estimated 20X greater chance of developing this disorder) - Occurs across cultures and with similar sex ratios - Overuse the health care systems (medical bills estimated up to 9 X more than the average patient) • *It is crucial to rule out genuine health problems • What are key features of: Conversion Disorder? - Presence of one or more symptoms/deficits that affect voluntary motor control or sensory functioning - Symptoms are found to be inconsistent or incompatible with known neurological or medical disease - Causes significant distress - May initially look like a neurological problem, but symptoms may be “at odds” with the way the nervous system is known to work; with less education, the less symptoms are consistent with known medical causes - Examples: • “hysterical blindness”; numbness; “hysterical” aphonia; fainting, loss of pain sensation; loss of hearing; weakness; loss of use of a limb; “psychogenic seizures” - Psychosocial conflict (with traumatic event) is “converted” physical symptoms that affect voluntary or sensory functioning (may be dramatic) - Symptoms seem to have neurological basis (e.g., paralysis, blindness, loss of feeling) - Usual onset late childhood/young adulthood - 2:1 ratio of diagnosed women to men (more likely among men who experience extreme stress) - More common with less educated, low SES, low knowledge of illness, often adopt familiar symptoms - Appears suddenly; relatively rare - Comorbid with depression and anxiety disorders - Outcome is poor even with treatment • What are key features of: Illness anxiety disorder? - (FORMERLY, HYPOCHONDRIASIS) - Preoccupation with having or acquiring a serious illness - Somatic symptoms are absent or only mild in intensity - Anxiety and easily triggered alarm about one’s health - Performance of excessive health related behaviors (e.g., checking one’s body for signs of illness) - Preoccupation with health is chronic, although not necessarily continuous, lasting at least 6 months - NOTE: Based on misinterpreting bodily symptoms; Persists despite medical evaluation / reassurance of health • What is the relevance of a Predominant pain pattern - SOMATIC SYMPTOM DISORDER PREDOMINANT PAIN PATTERN - May begin with illness or injury that has legitimate pain associated with it (but persists after recovery) - Pain is a major issue, long after recovery takes place - May not seek treatment but always feel weak and ill - Condition takes on a “life of its own,” and usually causes the person to seek treatment - If Pain is the primary feature of Somatic Symptom Disorder, there is a predominant pain pattern - Source of pain may be known or unknown - Genuinely in pain - Causes clinically significant distress in social, occupational or other functioning - Psychological factors have important role in onset, severity, exacerbation or maintenance of pain • What are key features of: Body dysmorphic disorder? - somatic symptoms - symptomsARE linked to psychosocial factors - NO voluntary control of symptoms - does NOT have an apparent goal • What are key features of: Factitious disorders? - Imposed on Self (also called Munchausen Syndrome): • Deceptive falsification of physical or psychological symptoms or deceptive production of injury or disease, even in the absence of external rewards • Presentation of oneself as ill, impaired or injured - Imposed on Others (Munchausen by proxy) : • Deceptive falsification of physical or psychological symptoms or deceptive production of injury or disease in another person, even in the absence of external rewards • Presentation of another person (victim) as ill, impaired or injured - The motivation is to be a patient (“sick role”) - People with a factitious disorder can go to extreme lengths to create authentic looking symptoms of illness: • Some take medications to produce symptoms • May research the ailment(s) they have chosen and are usually well informed about medicine • Will seek painful testing, treatment, and even surgery - Difficult to determine prevalence /incidence • Patients hide the true nature of their problem and seek medical help not psychological treatment • Will “shop” for doctors who will “truly understand” them - More common in women than men • Onset in early adulthood • Often have extensive medical treatment for a medical condition in childhood; common family problems or physical or emotional abuse in childhood • Grudge against medical profession or professionals • May be nurses, laboratory technicians, or medical assistants • Underlying personality disorder or characteristics, such as extreme need to depend on others • What are key features of: Malingering? - Different from the other problems in this category. - On some level the person understands that they are “faking it”. - Create symptoms that allow the person to obtain some advantage: • Insurance benefits • Monetary damages • Winning lawsuits - there IS a voluntary control of symptoms - symptoms MIGHT BE linked to psychosocial factors - there IS an apparent goal • How much conscious understanding of these disorders do the clients/patients have? - they tend to overeducate themselves and as soon as something that could be a symptom occurs, they say “i told you so” • What are general characteristics common to Dissociative disorders and what treatments are common - Identity – the sense of who we are, including our preferences, strengths, values, ideas, needs, is preserved in memory • Connection to the past informs our reactions to the here & now and functions as guide to future - Major disruptions of memory: • Cannot recall new information • Cannot recall information from the past - When these changes in memory lack a physical cause, called “dissociative” disorders (some part of memory dissociates) - Feel detached from self, as though living in a dream, or moving in slow motion - Mild form of this may be experienced by many in overtired or sleep-deprived states or after an extremely stressful experience - Estimates of 31% to 66% of those who have a traumatic event may have a transient dissociative experience - Dissociative symptoms are often found in cases of acute stress and posttraumatic stress disorders • What are key features of: Depersonalization-De-realization disorder? - Does not include a deficit of memory - Typically triggered by high stress - Onset as early as adolescence, usually chronic - Often related to childhood trauma history, may be comorbid with anxiety disorders - Lose sense of self: • Unusual sensory experiences – perceive their limbs, voices, are not their own • Believe something has changed drastically • Loss of “real me” • May feel as though they are outside their own bodies watching themselves • May complain that surroundings seem unreal, confusion about whether they just did something or thought it, sees the world as “through a fog” - The disorder occurs most frequently in adolescents and young adults, it is hardly ever seen in people older than 40 • The disorder comes on suddenly and tends to be chronic - There are few theories and little research to explain depersonalization • Neuropsychological evidence indicates difficulties with attention (easily distracted), problems processing new information (“sense of mind emptiness”), deficits in short term memory, and spatial reasoning. Symptoms linked Voluntary control to Psychosocial of symptoms? factors? Has an apparent Disorder goal? Malingering Yes Maybe Yes Factitious Disorder Yes Yes Yes (medical attention) Conversion Disorder No Yes Maybe Somatic Symptom No Yes Maybe Disorder Illness Anxiety DisordNo Yes No Body Dysmorphic No Yes No Disorder Physical illness No Maybe No • What are key features of: DissociativeAmnesia? 1. Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is beyond ordinary forgetting 2. Significant distress or impairment 3. Symptoms are not attributable to substance abuse or medical condition - Dissociative amnesia may be: • Localized– most common type; loss memory for all events occurring during a specific time period • Selective –memory loss for some, but not all, events occurring within a period • Generalized – loss of memory, beginning with an event, but extends back in time; may include loss of identity; may be unable to recognize family and friends • Continuous – forgetting of both old and new information and events; this is rare - Note: Below are typical with brain damage • Anterograde amnesia -loss of the ability to create new memories after the onset of amnesia • Retrograde amnesia -unable to recall events that before the onset of amnesia • Amnesia primarily impacts episodic memory (autobiographical memory for personal material) • Semantic memory – memory for abstract or encyclopedic information – remains intact (usually) • Although it appears to be rare, rates of dissociative amnesia increase during times of serious threat to one’s health and safety (e.g., war) • • What are key features of: Dissociative Fugue? - A. Sudden unexpected travel away from home or customary place of work, with inability to recall ones’s past - B. Confusion about personal identity or assumption of new identity (partial or complete) - C. Not exclusively part of another dissociative disorder, substance use, or medical condition - D. Clinically significant distress • ~ 0.2% of the population experience dissociative fugue - It usually follows a severely stressful event, although personal stress may also trigger it - People with dissociative fugue forget their personal identities and details about their past, and also flee to different location - The fugue may be short term: may travel somewhere else but do not take on a new identity - The fugue may be more severe: may travel thousands of miles, take a new identity, build new relationships, display new personality characteristics • Dissociative Identity Disorder – know about alters, and characteristics, potential causes and treatment? - Dissociative Identity Disorder (DID; formerly multiple personality disorder) – the person develops two or more distinct personalities (alters) each with unique memories, behaviors, thoughts, and emotions - Onset in late adolescence/early adulthood • Symptoms generally begin in early childhood after episodes of abuse; typical onset is before age 5 - Women 3 to 9 times more likely to be diagnosed MULTIPLE PERSONALITY DISORDER • MPD Captures the public’s imagination: ◦ Chris Sizemore is considered the first documented case of Multiple Personality (20 alters) Disorder (1950s) ◦ Dr. Corbett Thigpen, U. of Georgia was treating her ◦ Joanne Woodward DISSOCIATIVE IDENTITY DISORDER • At any given time, one of the alters dominates the person’s functioning ◦ Usually one of these personalities – called the primary, or host, personality – appears more often than the others ◦ The transition from one alters to the next (“switching”) is usually sudden and may be dramatic • Do “alters” know and interact? ◦ Relationships among alters differs ◦ Three kinds of relationships: • Mutually amnesic relationships – none of the alters have awareness of others • Mutually cognizant patterns – all alters aware of all others • One-way amnesic relationships – most common; awareness varies: some alters are aware of others, but the awareness is not mutual ▪ Those who are aware (“co-conscious alters”) are usually “quiet observers” • Previously believed that most cases of the disorder involved 2-3 alters but average number has been demonstrated to be much higher – 15 for women, 8 for men (cases with more than 100) • Alters can show dramatically different characteristics, including: ◦ Demographic characteristics • Alters may differ in age, sex, race, and family history • Abilities and preferences ◦ Encyclopedic knowledge is unaffected by dissociative amnesia or fugue, in DID it is often disturbed ◦ Alters can have different abilities, areas of expertise such as driving a car, speaking foreign languages, or playing a musical instrument • Physiological responses ◦ Researchers have discovered that alters can have significant physiological differences, including autonomic nervous system activity, blood pressure levels, and allergies Chapter 7, Mood Disorders and Suicide • Learned helplessness - Seligman’s Learned helplessness theory which can lead to depression, was his early work; then he asked what can we do do be happy - First response to stress is anxiety with prolonged stress that cannot be resolved (no control), experience hopelessness; when it goes on and person can't make it go away, they accept that's the way it is - Thoughts become increasingly negative toward self - Attitudes become negative in general - The person gives up • Beck’s depressive triad - Beck’s Depressive Cognitive Triad: Self / Own Situation / Future - After a series of negative events in childhood, a person can develop a deep seated negative schema (enduring cognitive belief system) that promotes negative thinking and negative interpretations • Distorted thinking makes the person overly invested in controlling things; negative thoughts become automatic • Feel overly responsible for everything (bad) that happens • Constant feedback to self about failure • Negative self-evaluation – believes can’t do anything right • Thoughts become automatic and pervasive • Become increasingly negative about the world in general • See the future as negative – “nothing good can happen” • Self fulfilling and self-perpetuating • More individualized than we give credit to, same diagnostic often have different patterns of symptoms • Cognitive vulnerability for depression - Underlying biological susceptibility - Depression becomes associated with a pessimistic explanatory style and negative cognitions - Cognitive vulnerabilities predispose some people to have negative expectations (future orientation - careful not to expect much out of tomorrow), then view all events negatively and interpret experiences negatively, thus raising their risk of depression - Children with depressed mothers tend to show depressive symptoms when faced with minor stress (compared to children without depressed mothers) even before age 1; powerful in predicting later problems • How do different styles of attribution tend to lead to depression or prevent depression - InternalAttribution – personal factors are responsible for outcome (“I am smart so I did well on the exam”) - ExternalAttribution – some external factor is responsible for the outcome (“The teacher doesn’t like me so she gave me fewer points”) - StableAttribution – some stable, ongoing factor is responsible (“I am the kind of person who will do well”) - Unstable (Flexible)Attribution – causes will be variable (“My poor grade is probably due to my heavy course load this term”) - GlobalAttribution – an overarching interpretation of causes that can be applied to many situations (“I am a lousy student”) - Specific Attribution – applies to particular situation but not others (“I struggle with advanced math, but I am a good student in all my other courses”) - Pay attention to attributional style • Know sex differences in mood disorders Mood disorders Unipolar: mania alone, depression alone, Bipolar: depression and mania Depressive disorders may not be a combination Patterns differ for individuals ◦ Women are more likely to be depressed (70% of dysthymic or depressed individuals) ◦ Men and women experience bipolar disorders at about the same rate ◦ Socialized sex roles are likely to contribute to different rates: • Women may be socialized to endure whatever happens • Women are socialized to connect and care for others and tend to worry / blame selves when things happen • Women experience disproportionate poverty, sexual harassment and abuse; have less social power, tend to earn less, and are more likely to experience disrespect • Men are socialized to take charge • Can include multiple factors, for example, single mother with low wages, poor social resources, little social power ◦ Marital Problems contribute to depression for both men and women ◦ Men typically withdraw / Women get depressed • Pay attention to the contributions from parts of the integrative model to developing depression Integrative theory • Genetic predisposition, Inadequate coping, Negative cognitive style • Overactive neurological response to stress in the environment (a general, likely to be an inherited tendency) • Psychological vulnerability (tendency to have negative or pessimistic thoughts; feelings of inadequacy) • When vulnerabilities are triggered by events, person may feel overwhelmed and “give up” • Stressful life events trigger stress hormones which affect neurotransmitter systems, changing brain chemistry • Interpersonal relationships serve to buffer the impact (Note: recent research has replicated the findings about the power of social support) • But why are different people vulnerable to different kinds of mood disorders? Current models do not explain the variations of Mood Disorders very well Two key orders - depressive kind of mood states and manic kind of mood states • What are key features of: depression? - Significant deviation in ongoing or episodic mood state (episodes stretch into weeks, months or years) - Depression – negative mood state that persists for some period of time and includes: - Mood = feeling sad, down, sense of emptiness - Anhedonia = loss of energy and inability to engage in anything that brings pleasure or fun - Cognitive changes = negativity, difficulty concentrating, feeling guilty, feel inadequate - Physical Impact = feeling of being slowed down, unmotivated, difficulty starting / finishing things - Emotional Impact = overwhelming sadness, may cry easily or become irritable - Self-denigration – disparaging or belittling oneself - Rumination – continually thinking about certain topics or reviewing events that have transpired - Anhedonia – loss of the capacity to derive pleasure form normally pleasant experiences - Grandiosity – an overvaluation of one’s significance or importance; powerful indication of mania • What are key features of: mania? - Abnormally elevated mood which persists for some time - Decreased need for sleep - Pressured speech, more talkative than usual - Racing thoughts or flight of ideas - Highly distractible - Increase in activity may be goal directed or agitation - Excessive involvement in pleasurable activities that have high potential for painful outcomes (sexual, investment, gambling, buying) - Causes marked impairment in social, occupational or other activities - Poses threat of harm to self or others - Not due to substance abuse or medical condition • What are key features of: Major Depressive Episode? • Science is getting better so diagnosis is becoming better but some people just don't fit • Five or more symptoms are present for at least the same two week period and represent a change from previous functioning: ◦ Depressed mood most of the day, every day ◦ Markedly diminished interest in almost all or all activities all day, every day ◦ Significant weight loss (not dieting) or gain (e.g., more than 5% of body weight) or increase of loss of appetite which can cause more issues in and of itself ◦ Insomnia or hypersomnia nearly every day ◦ Psychomotor agitation or retardation nearly everyday that can be observed by others ◦ Fatigue or loss of energy nearly every day; hyper/o sonic - sleep all the time ◦ Feelings of worthlessness or excessive or inappropriate guilt ◦ Diminished ability to concentrate or think, indecisiveness nearly every day ◦ Recurrent thoughts of death or suicide, or an attempt ◦ Cause significant distress ◦ Symptoms are not better accounted for by another depressive disorder Major depressive disorder, recurrent • Presence of a major depressive episode (previously 2) • Not better accounted for by another mental disorder • There have never been manic or hypomanic episodes (unless substance induced) • Current clinical status: Mild / Moderate / Severe • Specifiers: • With or without psychotic features (distorted perception) • With catatonic features (“statue like”) • With anxious distress (do not meet criteria forAnxiety disorder) • With melancholic features (severe physical features) • With atypical features (e.g., overeat, oversleep) • With postpartum onset (more than “baby blues”) • *See your text for additional specifiers • What are key features of: Dysthymic Disorder? Persistent Depressive Disorder (Dysthymia) - Apattern of mild depression (may be irritable mood in children) - Occurs for an extended period of time (2 yrs. for adults/1 yr. for children) - May include: • loss of appetite OR overeating • Insomnia or hypersomnia • low energy or persistent fatigue • low self-esteem or self-confidence • poor concentration, difficulty making decisions • feeling hopeless - During the 2 yrs. Symptoms not absent more than 2 mo. at a time - Never have a manic episode - Earlier onset, more concerned about persistent through life span - There may have been a previous depressive episode if full remission (for at least 2 months) - There has never been a manic episode - Does not occur exclusively during a psychotic episode - Not due to substance abuse or medical condition - Symptoms cause significant distress or impairment (social/occupational/other) - Early onset: before 21; Late onset: 21 or older; Specify for most recent 2 years of disorder - With atypical features • Why are we concerned about potential over-diagnosis among those experiencing bereavement? - Normal response to death or loss; generally loved one - Usually lasts several weeks to several months - Mood state is often sad, overwhelming - May include difficulty concentrating, loss of motivation, physical slowing down, withdrawal from others - DSM 5 includes grief for more than 2 weeks , even after the death of a loved one, as a symptom of Major Depressive Disorder! What are potential concerns here? • Given pills and screws up their neurotransmitters • Allows for all kinds of treatment for ppl who may not need or benefit from it - We grieve as deeply as we love. It is natural to mourn the loss of someone we love. These feelings are not symptoms of mental illness but essential to what it means to be human.” • What is Postpartum onset? How common is it? - Eating and sleeping disturbances – either too much or too little - Anxiety - mind races with fears and worries and can’t shut it off. Dimensions Features Biological Genetic predisposition, neurotransmitter dysfunction, brain structure abnormalities, abnormal cortisol levels, REM sleep disturbances Psychological errors in thinking, learned helplessness, stable internal and negative attributions Sociocultural Lower socioeconomic status, cultural differences, female socialized gender roles Social Stress, lack of social support; inequities and lack of opportunities for some cultural groups - Feelings of guilt and shame – a sense that they are “not doing this right,” convinced they are a bad mother - Anger and irritability. - Uncontrollable thoughts of harming or harm coming to the baby. - Just not feeling “like yourself.” - Symptoms usually appear within the first three months after a baby is born, and peak around the four-month mark. Can go on for years if undiagnosed and untreated. - About 10-20% of new moms have some level of depression beyond “baby blues” • What is Seasonal affective disorder? Be able to recognize its course and prognosis. - With long dreary season of winter (or in some geographical areas) there is a tendency to experience depressive symptoms - Fatigue, excessive sleep, weight gain, overeating, pervasive sense of sadness - Most common among young people and more common among women - Hypothesis: different cycles of light with seasons affect biological cycles, and affect production of serotonin (neurotransmitter) - Generally remits with longer periods of daylight in Spring; Can be treated with full spectrum lighting - Usually in winter • Bipolar I and II – what is the difference? Bipolar II disorder • Unipolar mania doesn't stay, just mania • Presence or history of one or more major depressive episodes • Presence or history of at least one hypomanic episode* • But there has never been a full manic or mixed episode • Not better accounted for by another mental disorder • Symptoms cause significant clinical distress, or impairment in social, occupational or other important areas of functioning • Specify for current episode: ◦ Hypomanic (less severe pattern of behaviors) or Depressed ◦ Severity (Mild; Moderate; Severe)/ Remission / Psychotic ◦ Chronic (catatonic, melancholic, atypical features) ◦ Postpartum onset ◦ Longitudinal course ◦ Seasonal pattern (applied to depression) ◦ With rapid cycling Bipolar I disorder • More extreme bc they have to have full blown manic episode • Criteria is the same for Bipolar II except diagnosis requires • One or more Manic Episodes or Mixed Episodes • What is Cyclothymic disorder? - Chronic mood disorder (at least two years) - Low levels of depressive and manic symptoms - Don't meet criteria for mania or depression - Have to rule out substance abuse - Numerous episodes of hypomania (manic features but lower degree of severity) - Numerous periods of depressed mood or loss of interest in activities which were previously enjoyable/pleasurable but do not occur with the severity to meet criteria for Major Depressive Episode - No Major Depressive Episodes, Manic episodes or mixed during the first two years of the disorder - The symptoms are not better accounted for or superimposed on another disorder - Not due to substance abuse or any medical condition - Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • What are the issues around accurate diagnosis of mood disorders? • Research has indicated that: ◦ Family physicians, internists, and pediatricians fail to recognize depression in over 50% of those who have it; ◦ National Mental HealthAssociation estimates that as many as 80% of those with bipolar disorder may be misdiagnosed or undiagnosed; ◦ Around 123 million new cases of mood disorders occur each year, worldwide; ◦ Immigrants to the U.S. from all other cultures are less likely to be depressed than U.S. natives (unless they come before age 12, then the rate is roughly equal); ◦ Those with bipolar disorder are more likely than those with other mental illnesses to engage in criminal behavior, especially during manic episodes/phases; ◦ Professional football players who had three or more concussions during their careers are 3X more likely to develop a mood disorder; 26% of former professional football players have had three or more concussions. ◦ They may commit crimes; most likely to have criminal backgrounds bc of impulsivity with manic phase • Depression in childhood and adolescence – how is it different from/same as adult? Development in childhood - Psychodynamic theories in 1960s-70s - postulated that children did not get depressed - Children DO get depressed: * ◦ Behavior: may be more agitated, restlessness or have reduced activity, less social contact, sarcasm, screaming * ◦ Changes in attitude: feel worthless, pessimistic, hopeless, attitudes toward school change, less motivated, dread the future and feel hopeless, may feel doomed to failure * ◦ Physical Changes: changes in appetite, sleep patterns, feeling tired; physical complaints such as headache, stomachache, nausea, nonspecific, persistent aches and pains ◦ Thinking: preoccupied, self-critical, self-conscious, slowed thoughts, difficulty concentrating or remembering ◦ _ Mood: irritability, exaggerated and persistent sadness, guilt, or shame, intermittent periods of sadness with other emotions in between periods Typical childhood patterns Domain Depression Mania Affective Feelings of sadness, dejection and Elation, grandiosity, irritability worthlessness, apathy, anxiety, brooding Cognitive Pessimism, guilt, inability to concentrate, Flighty and pressured thoughts, lack negative thinking, loss of interest and of focus and attention, poor motivation, suicidal thoughts judgment Behavioral Social withdrawal, lowered productivity, Overactivity, extreme talkativeness, low energy, anhedonia, neglect of personal speech difficult to understand appearance, agitation Physiological Appetite and weight changes, sleep High levels of arousal, decreased disturbance, loss of sex drive need for sleep, increased sex drive • Infants – quiet, unresponsive, passive • Preschooler – withdrawn, inhibited, appears shy • Elementary ages – argumentative, combative • Teen – express feelings of guilt or hopelessness • no one pattern adequately describes childhood patterns at any given age or developmental staqe until adulthood (when there may still be some individual features) • We don’t know as much about depression in childhood as we need to know: • Estimates for prevalence and incidence are varied • Ages 2-5 estimates are about 1.5% of U.S. pop. • About 20-50% of children experience symptoms or syndrome • Adolescents experience depression at the same rate as adults • About 50% males/50% females in childhood at adolescence, girls have higher rates • High levels of comorbidity: anxiety, conduct disorders,AD/HD Adolescence • Symptoms are more like adults: ◦ Heightened risks with adolescents, especially with manic episodes: dangerous and risky behaviors, suicide attempts ◦ Complicated by expectations of culture (e.g., independence vs. dependence; acculturation demands, etc.) • We know from the research that stronger symptoms in childhood and adolescence predict more significant problems with mood disorders in adulthood and less positive adult outcomes. • Many children and adolescents who have significant mood problems are not identified or treated • Treatment of mood disorders Mood disorders • Major depression • Biploar • Dysthymia • Cyclothymia Medication • Depends on the kind of mood disorder • Most medications work in one way or another with the serotonin neurotransmitter system • Prescribing medication is not an exact science, but research does inform what kinds of medication tend to work better for the varied kinds of mood disorders • Proper treatment may require persistence and patience, and a trial and error approach, as sometimes things that “should” work do not. • Tryptophan has a powerful impact on depression Talk Therapies • Cognitive Behavior Therapy works well – Uses an approach to understand negative, often automatic thought patterns and change these and learn to interrupt and then change thoughts to promote better coping; recognize, develop, and stop neg and introduce pos • Psycho-educational interventions – Teaching about the disorder and how to recognize symptoms, seek help, cope with the disease, and live in a positive way • Group therapy – helps with social isolation and increases understanding and coping strategies; members learn, model, and support each other ECT • Aform of therapy for very severe or intractable depression • Highly controversial • Uses small amounts of electricity to induce seizures • Patients are anesthetized, and are given muscle relaxers • Usually effective after a few treatments (6-10) • Side effects are temporary loss of short term memory, confusion; usually restored within a few hours Prevention • General prevention strategy: • Employ a public health model with universal screening and programming to increase resilience among a large population or group • Target high risk groups and intervenes with specific training to build stronger skills and promote better coping • Identify those who are already having symptoms and intervene individually to treat early stages Prevention of Relapse • Train the client to understand the disorder • Use medication for longer periods of time to treat latest episode • Use CBT to help alleviate thought patterns that promote depression • Cognitive Behavior Therapy and Empirically Supported Treatment - this therapy gets the individual to focus on their thoughts and feelings of depression; the therapist can inquire the automatic thoughts of the patient and further understand her perspective • *Suicide – although we were not able to cover all the material in class, pay attention to the PPT • Shocking numbers of people kill themselves each year: ◦ Documented as about 40,000 each year, but researchers believe this may half (80,000?) or a third (120,000?) the actual number ◦ Worldwide, suicide kills more people than homicide or HIV/AIDS ◦ Minority groups do choose suicide in large numbers as a rule, but Native American tribes are an exception to this ◦ Most suicide completers are white ◦ Among teens, the rates have skyrocketed over the past several decades to become 3 leading cause of death ◦ Prevalence among ethic group teens varies ◦ Suicides have also increased among senior citizens • Young children can attempt suicide (despite theory that says no) ◦ Fifth leading cause of death for ages 5 to 14 in the U.S. ◦ Among adolescents there is an attempt for about every 3-6 thoughts about suicide • Males are more likely to COMPLETE suicide due to more violent means chosen (e.g., guns, hanging) • Females attempt suicide about three times more frequently than men • Females generally use less painful means (e.g., overdose) • More elderly men commit suicide, more middle aged women • Among college students, suicide is the second highest cause of death • Idle thoughts about suicide may be common but recurrent and significant thoughts should be taken very seriously • Why do we believe suicide is under-reported? • it depends on how many are actually documented • many are the people who deliberately drive off cliffs or into a bridge and often people will affiliate a person’s suicide to medical causes • Why have we likely seen increased suicide rates?Among which groups is suicide rising? • the rise for the elderly is because of growing incidence of illness with loss of social support which leads to depression ◦ Minority groups do choose suicide in large numbers as a rule, but NativeAmerican tribes are an exception to this ◦ Most suicide completers are white ◦ Among teens, the rates have skyrocketed over the past several decades to become 3 leading cause of death ◦ Prevalence among ethnic group teens varies ◦ Suicides have also increased among senior citizens • Females attempt suicide about three times more frequently than men but men are more likely to COMPLETE a suicide • What are common characteristics of suicidal people? - suicidal ideation : thinking seriously about suicide - suicidal plans : the formulation of a specific method for killing oneself - suicidal attempts : the person survives - some do it for honor, relief, believing the world will be better, punishment to self or others • What is “suicide contagion”? - Some people who are “at risk” will attempt suicide after learning about a completed suicide - Widespread information about a suicide raises the risk that others will attempt - As many as 5% of adolescent suicides are the result of a “contagion effect” - Media treatments often “romanticize” suicide - Method is described so a means to suicide is apparent - The more the person represents a model (“like me” “similar problems”) or represents hopelessness (“if someone like that can’t find a way to live, how could I?”) the more risk they confer to those at risk • What are identifiable risk factors for suicide? - Family history of suicide: genetic or learned behavior? (risk is increased times 6 – more for sibling) - Neurobiology: low levels of serotonin - Existing psychological disorder: About 80% of completed suicides have a diagnosable disorder (mood/substance/impulse control) - Majority of those with mood disorders DO NOT attempt suicide however a large majority of those who complete suicide do have a mood disorder - Alcohol use is associated with many suicides - Substance abuse coupled with other factors including disorders, impulsivity or risk seeking increase risks for adolescents - Stressful life events are often a trigger Chapter 8, Eating and Sleep-Wake Disorders • Why discuss obesity in a DSM-oriented course when it is not in DSM-5? - Epidemic in the US: ◦ 70% of US adults are overweight, and more than one-third of U.S. adults (35.7%) are obese (2011) ◦ Problem bc health becomes compromised ◦ Percentage is increasing ◦ Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death. ◦ In 2008, medical costs associated with obesity were estimated at $147 billion (91% of U.S. healthcare costs); the medical costs for people who are obese were $1,429/yr. higher than those of normal weight • What contributes to rapidly rising rates of obesity in our culture? - Spread of ”modernization” ◦ Inactive, sedentary lifestyle + high fat foods - Genetics ◦ Accounts for only about 30% of the cause - Biological factors ◦ Initiation and maintenance of eating - Psychosocial factors ◦ Impulse control, affect regulation, attitudes • What are negative impacts of obesity? - Lower life expectancy, Fewer employment opportunities, Bone probz, Deep vein thrombosis - blood clots that form then detach and cause major strokes; can be fatal, Cancer, Hernia, Join problems, Heart attacks, Breathing probz, High blood pressure, Type 2 diabetes, Increased sweating, High cholesterol,Arthritis, Lower self esteem, Depression, Limited mobility, Social discrimination • What are treatment approaches and what works? - Progression from least to most intrusive ◦ Self-directed weight loss programs ◦ Commercial self-help programs ◦ Behavior modification programs ◦ Bariatric surgery • 15% of patients who have bariatric surgery fail to lose significant weight - Efficacy ◦ Moderate for adults ◦ Higher for children and adolescents • Family involvement Bulimia Nervosa – know diagnostic criteria and subtypes; medical consequences and • comorbid disorders; male/female differences; treatment - Binge eating: ◦ Excess amounts of food ◦ Perceives self as ‘out of control’ ◦ They usually plan it, go buy a shit ton and eat them all then they do something to compensate - Compensatory behaviors: ◦ Purging (self-induced vomiting, diuretics - dangerous bc mess up electrolyte balance, laxatives - ineffective, not really damaging) ◦ Excessive exercise (prolonged daily, or multiple daily sessions) ◦ Fasting then go back to binging, not significant weight less like anorexia - Beliefs: others’impressions, their popularity and self-esteem are determined by weight and body shape Bulimia Nervosa – Clinical Description • Two Subtypes ◦ Purging (most common) • Vomiting, laxatives, or diuretics ◦ Nonpurging • Exercise and/or fasting • 6-8% of those with Bulimia • The majority of those who have this disorder are within 10% of ‘normal weight’for their height and age Bulimia nervosa • Medical consequences: ◦ Salivary gland enlargement (face looks chubby) ◦ Erosion of dental enamel (inner surface of front teeth) ◦ Electrolyte imbalance – very dangerous condition • Kidney failure - usually have dialysis • Cardiac arrhythmia - not funcitoning normal; can damage heart • Seizures - basically brain function ◦ Intestinal problems (especially with laxative abuse) ◦ Permanent colon damage ◦ Hand calluses (from stimulating gag reflex) • Comorbid psychological disorders ◦ Anxiety (80.6%) ◦ Mood disorders (50-70%) ◦ Substance abuse (36.8%) - pushes ppl to do things that they may not want to do in addition to that, potential for suicide goes up • Bulimia ◦ 90-95% female • Caucasian, middle to upper class ◦ Onset = age 10 to 21; but people can develop later ◦ Chronic, if untreated • Bulimia in men ◦ 5-10% male • Caucasian, middle to upper class • More likely to be gay or bisexual • Athletes with weight regulations, models, actors ◦ Onset = older than for females • Anorexia – diagnostic criteria and subtypes; medical consequences and comorbid disorders; male/female differences; treatment - “Out of control and overly-successful” weight loss ◦ 15% below expected weight (by time of treatment the average person diagnosed with this disorder is 25-30% below expected weight for body type) ◦ Intense fears • Gaining weight • Losing control of eating - Relentless pursuit of thinness - Often begins with dieting - Two Subtypes ◦ Restricting – limit caloric intake through diet and fasting ◦ Binge-eating-purging – around half of anorexics; unlike bulimic who is close to normal weight, these ppl maintain very low weight; huge body image distortion - Associated features ◦ Body image disturbance – believe they are fat ◦ Pride in diet and control – thinner = success ◦ Rarely seek treatment – do not recognize problem - NOTE: pro-ana (and pro-mia) promoting this disorder ◦ Expecations are young teens and young women are most likely to develop this, but recent research has indicated that older women are also at risk - Medical consequences: ◦ Amenorrhea – although relatively common, dropped from DSM-V (prevented male diagnosis) ◦ Dry skin ◦ Brittle hair and nails ◦ Sensitivity to cold temps ◦ Lanugo – downy hair on limbs or face ◦ Cardiovascular problems ◦ Electrolyte imbalance – can be fatal - Comorbid psychological disorders are common: ◦ Anxiety • OCD – may use rituals to avoid eating ◦ Mood disorders (71%) ◦ Substance abuse • Suicide is a risk and increased with use of alcohol and other substances ◦ More female than males • Caucasian, usually middle to upper class ◦ Onset = age 13 to 18 ◦ Chronic and often lifethreatening ◦ Resistant to treatment - Childhood onset issues? ◦ Adolescent onset • Parent, peer and cultural pressures - Upset with weight gain associated with normal hormonal changes and changes in body associated with puberty and maturation - Interaction with social ideals – media impact • What are key features of: Binge eating disorder? - Marked distress because of binge eating but do not engage in extreme compensatory behaviors and therefore cannot be diagnosed with bulimia ◦ Often seek weight-control programs (estimated 20%) ◦ 50% among candidates for bariatric surgery ◦ Better response to treatment than other eating disorders - Associated Features ◦ Many are obese ◦ Tend to be older at onset ◦ Tend to have more psychopathology ◦ compared to non-binging obese ◦ Very concerned about shape and weight • What do we know about cross cultural differences in eating disorders? - NorthAmerican minority populations • Immigrants to western cultures - significant changes in eating and in foods available • Increase in eating disorders • Increase in obesity - Cultural values - Standards for body image • Know developmental considerations and impact of features of the integrative model - Developmental considerations ◦ Adolescent onset • Parent, peer and cultural pressures - Upset with weight gain associated with normal hormonal changes and changes in body associated with puberty and maturation - Interaction with social ideals – media impact • Treatment and prevention - at least one psychological treatment is effective especially for bulimia nervosa • targeted at low self esteem and developing an individual identity • targeted at disordered patterns of family interaction • now aware that eating disorders can overlap so treatment is “transdiagnostic” - certain drugs may help but no strong evidence - CBT - Prevention : eliminate an exaggerated focus on body image and encourage embracing one’s body • Sleep disorders: what are common comorbid conditions? - Can be comorbid with other psychological disorders - “Disturbed sleep” is common with Schizophrenia,Autism Spectrum Disorders, Major Depression, andAnxiety Related Disorders - “Disturbed sleep” can also contribute to the development of psychological disorders - Substance use disorders have significant impact on sleep cycle and are associated with sleep disorders • Know generally the stages of sleep - NonREM sleep is made up of 4 stages. - Acompleted sleep cycle is a progression from stages 1-4 before REM sleep is attained, - After a period of REM sleep the cycle starts over again. - Stage 1: Polysomnography (sleep readings) show: • Between wakefulness and Stage 1 sleep eyes are closed, body movement and all body activity slows down, the person is relaxed • One can be awakened without difficulty • If aroused, a person may feel as if he or she has not slept • May last for 5 to 10 minutes • May notice the feeling of falling during this stage, which may cause a sudden muscle contraction (hypnic myoclonia). - Stage 2: Polysomnographic readings show: Light sleep • • Spontaneous periods of muscle tension mixed with periods of muscle relaxation. • Heart rate slows Body temperature decreases • • The body prepares to enter deep sleep. - Stages 3 and 4: Deep sleep stages, with stage 4 more intense than Stage 3. • known as slow-wave, or delta, sleep • If aroused from deep sleep, a person may feel disoriented for a few minutes. • During this kind of sleep, the body repairs and regenerates tissues, builds bone and muscle, and appears to strengthen the immune system • As you age, you sleep more lightly and get less deep sleep.Aging is also associated with shorter time spans of sleep stages, although studies show the amount of sleep needed DOES NOT appear to diminish with age • What is REM sleep and what is its function? - REM sleep occurs about 90 minutes after sleep onset. - The first period typically lasts 10 minutes - Each recurring stage lengthens; final one may last an hour. - Polysomnograms: brainwave patterns similar to wakefulness - Heart rate and respiration speed up and become erratic - Eyes move rapidly in different directions - Intense dreaming occurs as a result of heightened brain activity - Paralysis occurs simultaneously in the major voluntary muscle groups. REM is a mixture of encephalic (brain) states of excitement and muscular immobility. ( ‘paradoxical sleep’) - Percentage of REM sleep highest during infancy and early childhood. Infants can spend up to 50% of their sleep in the REM stage of sleep - In adolescence and young adulthood, percentage of REM sleep declines.Adults spend only about 20% in REM • What are general commonalities of Dyssomnias? - Dyssomnias = difficulties getting enough sleep, problems getting to sleep or having sleep that is of poor quality (amount; quality; or timing of sleep) • Characteristics of insomnia and treatment - Insomnia = trouble falling asleep (initiating); staying asleep (maintaining; wake during the night and cannot go back to sleep); wake up too early and cannot return to sleep; seem to sleep well but are not rested when they wake up (nonrestorative) • Episodic = less than 3 months but at least one month • Persistent = lasts more than 3 months • Recurrent = two or more episodes within 1 year - NOTE: Many people experience insomnia during times of stress (est. 1/3 of US in a given year) - Women report at a higher rate than men - Generally, rates of Insomnia increase with age - 20-40% of children experience insomnia - Higher rates among teens - More than a quarter of older adults 55-64; - About 21% of those over 65 - Question: How much of insomnia is due to learned behavior or poor sleep habits? Many indicators that patterns are learned, but we lack clear research base treatment - Prevention – establishing good sleep habits - Short acting drugs that induce sleep (unless these also induce anxiety) - Long-acting drugs – more side effects and dependence is a risk; rebound insomnia; drowsiness; may be related to risk of injury or death through sleepwalking related problems - Phase delays – going to bed later, training to gradually increase periods of time asleep - Use of lights to reorient to sleep cycle - Psychological – stimulus control (use the bed for sleep) and cognitive behavioral interventions • Characteristics of narcolepsy - Rare Disorder includes both daytime irrepressible sleepiness, and cataplexy = the person is awake, experiences strong emotion (anger or happiness), loses muscle tone (may be partial or whole body), and immediately falls asleep (goes directly into REM sleep) - Criteria: 3 X a week, over at least 3 months - DSM-5 criteria reference cerebrospinal fluid (CSF) testing* and criteria from polysomnography data (nocturnal) - Often also report sleep paralysis – a brief period when awake but cannot move or speak - Hypnagogic hallucinations – vivid and terrifying experiences at the beginning of sleep • Know features of Circadian Rhythm sleep wake disorder and subtypes - and night (a function of the hypothalamus)difficulty adjusting to current patterns of day - Amount of light is related to awakening increased alertness in the morning and slowing down and getting sleepy at night - Several types: Jet lag type, shift work type, delayed sleep phase type - Could there be an additional one associated with electronics? - Impact on health can be extreme: increased rates of cardiovascular disease, ulcers, breast cancer, and greater risk of personality disorders • How can we prevent Dyssomnias? - Maintaining a regular bedtime - Having a regular routine at bedtime - Avoiding caffeine, alcohol, and nicotine - Using the bedroom only for sleep - Avoiding stressful activities in the bedroom - Getting up at the same time each day - Exercise during day, not within 2 hrs of bedtime - Reduce noise and light in bedroom - Increase exposure to natural light in the daytime - Avoid extreme heat in the bedroom - Drink milk before going to bed • Parasomnias- know characteristics of each Non-REM sleep arousal disorders: sleepwalking disorder - “Somnambulism” occurs during nonREM sleep so person is not acting out a dream - Typically occurs during the early hours of sleep - Can be sitting up in bed, but generally is diagnosed with walking around during sleep - Blank, staring face, relatively unresponsive to efforts to communicate with them, hard to awaken - May be disoriented or confused if awakened but will become alert within a few minutes. - Approx
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