ABNORMAL PSYCHOLOGY PSYC 3230
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This 52 page Class Notes was uploaded by Spencer Smitham on Saturday September 12, 2015. The Class Notes belongs to PSYC 3230 at University of Georgia taught by Blount in Summer 2015. Since its upload, it has received 56 views. For similar materials see Introduction to Abnormal Psychology in Psychlogy at University of Georgia.
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Date Created: 09/12/15
Notes First Test Medical health professionals Different ones Scientist practitioner Study by Langer and Abelson Paradigms we39ll cover Psychoanalysis wwwpsywwwcomcareersspecialhtm wwwuncedumip1970PhDApplicantlnfohtm Mental Health Professionals 0 Psychiatrist MD completes a residency in psychiatry after obtaining their medical degree Normally don39t have time for therapy but sometimes do 0 Clinical Psychologist PhD 4 or more years of graduate school at university 1 year of pre doctoral internship most often at a 12 year postdoc residency 0 Clinical Psychologist PsyD Similar training to PhD but generally less emphasis on research Professional schools 0 Counseling Psychologist PhD or EdD similar to Clinical but generally more emphasis on behavioral adjustment At UGA housed in the College of Ed 0 School Psychologist PhD or EdD jobs for Masters level in school systems testing training and therapy counseling 0 Social Workers MSW or PhD multiple job functions and settings Versatile Counselors Therapists Psychotherapists degree Training Specialty Very generic terms could apply to any of the above positions or titles Scientistpracticioner usually referred to for clinical psychology some lean more heavily towards one side or the other Consumer of science enhancing the practice Evaluator of science determining the effectiveness of the practice Creator of science conducting research that leads to new procedures useful in practice Clinical scientist program science first new terms in response to PsyD programs There are many specializations within each of the areas listed adult child adolescent health pediatric forensic severe psychopathology according to age group or type of disorder etc Many settings in which to work academia private practice hospitals mental health agencies schools government settings research institutes What determines how these specialists approach conceptualize and treat mental health problems Degree Title Conceptual ParadigmTheory quotIt is theory which decides what we can observequot Einstein Study by Langer and Abelson Subjects 2 groups behavioral therapists and psychoanalytic therapists 0 What does each group focus on Intervention Both groups watched a 15 min video of a man being interviewed Kind of ambiguous content 12 of each type of therapists were told he was a job applicant and the other half were told he was a mental health patient Outcome measure Each therapist rated his mental health Results 0 There was little change in the behavioral therapists perception in his mental health but a great change in the psychoanalytic therapists perception What do these results mean Paradigms matter They determine what you see and how you interpret it In this case PA was not as useful as the Behavioral paradigm This investigation doesn39t speak to the validity of the two paradigms in general Psychoanalysis Sigmund Freud The first He had a formidable task Are you psychoanalytic in your orientation Unconscious motivation importance of early learning defense mechanisms symbolic meaning of things Probably we all are to some extent PA is both a theory of development and a therapy Stages of development 0 Successful progression or if conflicts at those stages can become fixated and not progress or can regress to ways we were then when under stress quotPsychosexualquot stages Biologically driven via maturation influenced by those around us 0 Oral First 18 months of life nursing getting nourishment being cared for I Oral dependent oral aggressive 0 Anal 18 months to 3 years Toilet training I Anal retentive anal expulsive O Phallic 35 years discover genitals Oedipal and Electra complex Successful resolution identify with same sex parent 0 Latency 5 years to adolescence not much happening 0 Genital Adolescence through adulthood Final stage Being successful in life39s activities Criticized because of too little focus on postadolescent development controversial hard to verify scientifically Psychoanalysis Structure of Mind 2 ways to view 0 1st way Unconscious Conscious Preconscious O lceberg example Unconscious is below the water line 90 of the ice unconscious is the main motivator of our behavior 0 Conscious that which we are aware of about 10 O Preconscious that which can be made conscious At the water line Goal of PA Therapy To make the unconscious conscious We will talk about techniques in a bit 0 2nd way to view ld Ego Superego 0 Id Most primitive part Present at birth Interested only in gratification Libido is the energy force exchangeable term for sex drive Operates on pleasure principle 0 Ego Develops during first year of life Conscious executive functions of thinking forming strategies to get what the person needs Operates on the reality principle 0 Superego Develops through childhood Person incorporates notions of right and wrong from family and society Conscience From latin meaning quotto know togetherquot orjoint knowledge with others Notes starting 825 Continuing psychoanalysis Su perego and Id are conflicting sometimes ego is the mediator Defense Mechanisms Good or bad Their function To protect the ego from anxiety Examples 0 Denial Refuses to acknowledge some objective reality that is apparent to others not just lying O Repression Blocks disturbing thoughts images memories impulses from awareness 0 Displacement Redirects an emotional impulse from a more to a less threatening object Rationalization Conceals true motivation by giving elaborate or socially acceptable reasons for behavior 0 Projection Falsely attributes to someone else your own acceptable urge or impulse I The paranoid person everyone is out to get them but in reality if this projection is really what is going on here this person is actually out to get everyone else 0 Reaction Formation Substitutes thoughts feelings and behaviors that are the opposite of their actual but unacceptable ones 0 Sublimation Generally healthy Directs potentially maladaptive thoughts feelings or behavior into socially acceptable behaviors 0 There are others Psychoanalysis Therapy PA is an insight oriented therapy Goal is to make the unconscious conscious If insight is gained for the reasons for behavior the person should be able to change it Therapy takes years Focus on early experiences and unconscious motivations that play themselves out in current behavior Current behavior is not the main focus Techniques of PA 0 Try to form hypotheses I Free association Person talks about whatever comes up without the usual censoring that occurs in conversations Therapist tries to make connections about the themes the person talks about I Resistance Therapist watches for instances of resistance where the person tries to avoid important but unpleasant topics events I Examples of resistance looking at watch when on topic being late for appt or canceling after discussion of a particular topic changing the topic when talking becoming angry or accusatory to divert attention from topic etc Transference When the client acts toward the therapist as if the therapist was some important person in the client39s past ex mom dad if the therapist is similar to the person from past client may not only react to the therapist as the therapist but the mom or dad for example not necessarily good or bad but something to watch in a sense good because it provides more info but could be a problem in trust I Countertransference not good nota technique therapists must guard against it Therapist acts toward the client as if the client was some important person in therapist39s past Therapists themselves undergo long therapy to uncover their issues I Dream analysis examine symbolic content 0 Interpretation Having gathered information and formed hypotheses the therapist shares hisher insights with the client I Timing is important here The client must be prepared to hear and accept it I If presented too early the therapist might be right but it may be rejected due to resistance 0 Interpretation can lead to client insight that39s a good thing With any therapy care should be exercised 0 What kind of therapy would this be helpful for I Someone high functioning fairly high functioning quotneuroticquot patients Anxious Woody Allen I Not suited for Schizophrenic patients those with less grounding in reality 0 Iatrogenic the treatment makes the situation worse Term applied in medicine and in general in healthcare We must consider this with any treatments 0 Hippocratic Oath quotAbove all do no harmquot Humanistic Client Centered Therapy Rogerian Therapy Carl Rogers Not much theory The working assumption is that if people are given unconditional love they will develop into healthy people Problem is that people are given conditional love loved when they do X not loved when they do Y Conditional love leads to O Distorting the reality about yourself so that you seem lovableacceptable O Walling off the not so acceptable areas of yourself so that you deny parts of yourself Little growth this way Therapy is more of a set of characteristics rather than techniques quotRogerian triadquot or quotTherapeutic Triadquot Warmth empathy and genuineness O Genuineness open spontaneous authentic This provides a model to client and creates a safe atmosphere Unconditional positive regard toward client warmth Empathic understanding Reflecting back to the client their own thoughts and reasons for their behavior This is like a psychological mirror to help show the client him or her self Evaluation Many therapists incorporate some Rogerian approaches but it is not very much practiced today Erik Erikson Stages of Development 1902 1994 Psychosocial stages of development aready placing more emphasis on social aspects Continue throughout adulthood as well as during childhood and adolescence Eight stages Not a therapy but has implications for healthy adjustment Stages have 39prepotency39 in that successful resolution of conflicts orcri at earlier stages presupposes successful resolution of conflictscrises at later stages Crisis Includes both promise and peril You can come out of them better or worse off than before you entered them If it is indeed a crisis you will invariably be changed Often change doesn39t occur without a crisis Why why fix it if it isn39t broken Stages 0 Trust vs Mistrust 1st year parents should provide predictable secure nurturing O Autonomy vs Shame and Doubt 13 years Autonomy is making and implementing decisions Give child choices within safe parameters Don39t be overly critical or restrictive want to wear the red or blue shirt Wearing a shirt or not wearing one was not part of the options 0 Initiative vs Guilt 3 or4 to early school age Child is trying new things Praise their accomplishments Encourage after failures 0 Industry vs lnferiority School age I Developing a sense of competence and accomplishing things Academically socially athletically etc 0 O O Ego identity vs Role diffusion or a Negative Identity Teen years Developing a good sense of who you are vs not knowing or not liking yourself socially spiritually values sexually etc 0 Intimacy vs Isolation Young adulthood Entering into relationships that are of necessity going to demand of you I One night stand not an intimate relationship I Must have some degree of independence to be successful at interdependence Otherwise too needy O Generativity vs Stagnation Middle adulthood I Being productive in one39s life39s work and concerned about and promoting the wellbeing of others Stagnation is being concerned only with yourself stuck Midlife crisis When people attempt to come to grips with the fact that they won39t accomplish everything they wanted in life I Examples career change all depends I Crisis good or bad promise or peril I Empty nest syndrome Feelings of loneliness and depression that can occur in parents when last child leaves home I Examples I Crisis Good or bad promise or peril Integrity vs Despair Older age Looking back over your life and how you39ve lived it looking at where you are now and looking at the end of your life and being okay with it Successful resolution of prior crises helps I What else helps keeping some independence keeping up with similar hobbies I Begin with the end in sight Summary Described as a healthy person39s developmental theory Health is an alternative and an incompatible one to nonhealth or maladjustment The stages are a general pattern In fact there is moving into and out of stages at different points in time for different people 0 Examples Divorce or death of a spouse career change life changing experience Crises O From our lab Posttraumatic growth notion that after a trauma may come out of it better than they were before Maslow Basic needs have to be satisfied before higher needs Don39t start 39therapy39 at the top if needs below that Habitat for humanity Studied people who he believed had become SelfActualized O O Maslow looked at 48 people he considered to be selfactualized Thomas Jefferson Abe Lincoln 0 What did they have in common 0 Acceptance of self and others as they really are rather than wishing for something different 0 Accurate perception of reality no need to distort the facts 0 Intimacy with others They have a few close friends not a lot and value their privacy 0 Personal autonomy they can stick to their judgment even when others disagree 0 Problem centered they have a sense of mission in life 0 Spontaneous 0 Sense of unity with nature and humankind 0 Feeling of brotherhoodsisterhood with others 0 Clear ideas of right and wrong 0 Ability to resist cultural influences that run counter to personal standards 0 Creativeness O perhaps knowing what this is like will help to emulate those with it Behavioral Psychology Where did the other therapies come from Where did behavioral psychology come from Two main branches Classical Conditioning and Operant Conditioning It is really much much bigger than that Today the most common label for behavioral psychology is Cognitive Behavior Therapy CBT In part Behavioral psychology grew in its opposition to Psychoanalytic psychology It was a paradgm clash and such clashes can be very fruitful 0 See Thomas Kuhns The Structure ofScentific Revolutions Classical Conditioning Pavov Unconditioned Stimulus US A stimulus which with no prior learning required is capable of eliciting an unconditioned response Unconditioned Response UR The response elicited by an unconditioned stimulus O Salivation knee jerk nausea and vomiting to chemotherapy O No conditioning or learning has occurred thus far Conditioned Stimulus CS An originally neutral stimulus which through association with the unconditioned stimulus US comes to elicit a close approximation of the original unconditioned response UR Conditioned Response CR The response elicited by the CS The definition of CS really defines Classical Conditioning predictive quality is what brings this about Classical Conditioning Extinction 0 So how do you make a classically conditioned response go away floor is slippery because of too much salivation O Presenting the CS without having the US follow it and doing it repeatedly After a period the CR will diminish How would you help the dog not to salivate to the bell I How would you treat Anticipatory nausea amp vomiting How would you treat dental anxiety using only an extinction paradigm 0 What you are doing is lessening the predictive value of the CS Predictive of the US following it 0 Another phenomenon Spontaneous Recovery After a period of extinction this is a reemergence of the CR to the CS following a period of rest and time This is not due to learning I Classical Conditioning Generalization 0 What if the dog is presented with other soundsgraph O Other stimuli to the extent that they resemble the CS will elicit some degree of the CR 0 This is not due to additional training but is considered to be a given in classical conditioning Classical Conditioning Discrimination 0 Graph it How could you get that graph 0 In a perfect discrimination graph you would have lots of salivation to the CS and little to none to adjoining stimuli 0 Two things required I Continued representation of the CS with the US The CS predicts food will be forthcoming Repeatedly presenting adjoining stimuli with no US ever following them Adjoining stimuli predict that food will NOT be forthcoming Operant Conditioning BF Skinner He worked with who or what pigeons Walden ll utopian world with operant conditioning as a foundational teaching approach Check it out Positive Negative l Reinforcement Punishment Positive The behavior results in something being added Restated something is added following the behavior positive does not equal good Negative the behavior results in something being taken away negative does not equal bad Reinforcement an increase in the behavior frequency intensity duration because of the consequences that behavior produces Punishment A decrease in behavior because of the consequences that behavior produces Positive reinforcement Positive punishment Negative punishment Negative reinforcement 0 Two words to cue you that it is NR escape and avoidance from or ofsomething aversive O A lot of maladaptive behaviors are kept up through negative reinforcement Why is it never advisable to use only punishment to try to change behavior Because you39re not increasing the likelihood of anything just decreasing behaviors can39t eliminate all bad behaviors with this best to use a combination 0 quotsit downquot study Stimulus control of behavior Control of behavior by the stimuli which precede it 0 Examples not hungry till see or smell Functional Analysis of Behavior An examination of the ABCs Antecedents behavior and consequences Define each in this contingency O Antecedents come before behavior prompt or cue Increasing behavior 0 Shaping Most basic way to train a new behavior Perform a Task Analysis break a complex task down into its component parts Next teach Success Approximations of the desired behavior You do this by teaching each of the component parts in order I Exs teaching a rat to bar press teaching chelsea to sit teaching a person with MR to put on their pants 0 Modeling this is an efficient way of teaching complex behaviors not usually taught through shaping Modeling requires 2 people The model and the imitator of the model Exs dancing child and parent Decreasing behavior 0 Extinction What happens when you start an extinction program 0 000 0 So what do you need to be sure to do There is an increase in responding at the beginning of an extinction program is called an extinction burst so do not reinforce during an extinction burst must wait it out I Baseline preextinction level of behavior Contingincy DRO Differential Reinforcement of Other behavior I Examples Barbara Hair puller Time out from Reinforcement Interrupting the chain of behavior Reprimandspunishment Response cost Cognitive Behavior Therapy CBT Uses the same basic learning building blocks that we have looked at thus far The underlying principles bricks of BT are the same they are just applied to different types of behaviors We describe things verbally all the time 0 Examples Phone rings late at night Appreciation of the person39s phenomenological world how they see and describe it Some ways lead to better adjustment some to worse adjustment CBT39s goal is to identify and modify those maladjustment inducing cognitions 2 of the key players Aaron Beck and Albert Ellis 0 O 0 Albert Ellis 19132007 first Rational Emotive Therapy or RET He believes people get in trouble because they have lrrational Beliefs I quotl have to be loved and accepted by all people at all times and if I39m not that39s terriblequot If you believe that how would you feel How would you identify such an lrrational Belief that someone might have Would they say that I May hear things like no one likes me I hate it when people don39t like me s From those things said can find the lrrational Belief and induction finding the general rule going from specific to general other way is deduction going from general to specific Induction and deduction are basic tactics in all of science I Editorial comment I believe induction is too often ignored for the sake of theory testing in psychology and medicine This means that there is less attention to theory building starting from the foundation of basic empirical data and observations lnduction is much more creative Aaron Beck MD 1921 and daughter Judith PhD She now heads the Beck Institute for Cognitive Therapy Beck39s Therapy is actually called Cognitive Behavior Therapy I In principle much more in common with than different from RET Cognitive triad Bad me bad world bad future His therapy uses a process called Collaborative Empiricism The therapist and client work together to examine the data of the client39s life I Automatic Thoughts Thoughts the client thinks automatically which cause them to stress CBT Beck Teach client what automatic thoughts are Therapist and client work together to identify automatic thoughts Together therapist and client examine the validity of them and challenge that presumed validity Modify specific automatic thoughts similar to specific examples of an irrational belief for ellis Try to modify their Cognitive schema Their general way of viewing the world similar to changing lrrational Beliefs Maintenance and Generalization of Behavior Change You first have to accomplish changing a behavior The next step is having that behavior continue to stay changed over time maintenance or extend the change to other settings and situations generalization Maintenance is a specific instance of generalization generalization over time Other dimensions of generalization include Across settings across caregivers across behaviors etc Maintenance can be very difficult to accomplish weight smoking exercise study habits paying bills on time Maintenance and Generalization Promoting Strategies Mostly from Trevor Stokes and Don Baer an lmplicit Technology of Generalization Journal of Applied Behavior Analysis Introduction to Natural Communities of Reinforcement Examples good and bad Reinforcement trap having bhvr locked in by reinforcers Use lndiscriminable Contingencies Continuous vs Intermittent Reinforcement Schedule Which promotes better maintenance and why Which would you use if you wanted behavior to extinguish quicker Program Common Stimuli Eliminate Secondary Gain person receives reinforcers for bad behaviors Relapse prevention abstinence Violation effect Attribution to self Does therapy work Two important terms in this discussion Efficacy and Effectiveness Efficacy A demonstration that therapy produces significant effects in research investigations This is what is typically published in journals Effectiveness Refers to how useful the treatment is in naturalistic clinical settings in the real world example in mental health centers hospitals etc Efficacy could be considered to be necessary but not sufficient for Effectiveness For Efficacy studies the answer is generally quotyesquot Treatment gt placebo in 80of studies This is true for child and adult treatment studies 75 of treatment studies used CBT This means that most of the treatment outcome literature reflects CBT rather than other approaches Regarding Effectiveness there are fewer studies and the results are not as impressive Several differences between treatments applied in research studies and those in clinical settings this is an oversimplification for the sake of time Treatment failures are not likely to be published in any field There may be more comorbidity 2 or more diagnoses in applied settings mental health center hospital may be more severe cases in reality expertmentat sludtes Helping Make therapy More z ivz can zppw thetherzpy currec y errmne whmh treatments hasthe must suppun fur parttcmar pattert prugrams det Tram smenttstvraetttmners Adequatetrammg Slaf rgfundmgtu pruvtde guud care TX treatments Nu ezrmng reqmred Lezrmrg reqmred cs Ttmeruul tram remfurcemem wpesomeseanh a t murerepresentatwe ufgruupsrztherthzn nd wduz s peupte chnmat wurktherzpytendstu be dmgrzphm There susquy sumetensmn betweenthesetwu appruzches Research Designs n r Hness and curretated cundmuns are gathered a prevatenceprupumunutpeuptewtthaparttcmarcundttmntunessata gwen pmmmume usquyherme 0 Incidence Number of new cases in a unit of time Usually a year Risk factor A condition variable which if present increases the risk of a disorder Protective factor A condition variable which if present decreases the risk of a disorder Some risk and protective factors are correlated but are not malleable changeable 0 Gender hereditary past experiences Others are correlated and are malleable These are the ones that have the greatest chance of informing treatment These are the ones that have potential to inform the design of treatment interventions 0 Skills knowledge behaviors diet Naturalistic Observation Watching animalspeople in their natural environment and observing what happens 0 Be as unobtrusive as possible 0 Goal is to determine rules for the animal39s behavior 0 Ethologists did this Conrad Lorenz and ducks 0 My work with children undergoing painful and frightening medical procedures Correlational methods Examine the extend to which changes in one variable covary or change with changes in a different variable 0 Positive and negative correlations Signs tell the direction 0 Magnitude goes from O to 10 0 Examples Depression and activity level Education and income I SES and intake of saturated fat I Height and weight 0 Which is the larger correlation I 83 24 07 42 75 83 O Considerations with correlational methods Bidirectionality XgtY Y gt X I Does low activity level can lead to depression or does depression can lead to low activity level I Third variable problem Z gt XampY I Churches cause bars or bars cause churches I Ice cream consumed is correlated with drownings I Expensive jewelry worn correlated with longivity Maxim You can39t infer causation from correlation Can you have causation without correlation No Can you have correlation without causation Yes Bottom line Be wise in your consideration of data Don39t let the best be the enemy of the good cigarette smoking and lung cancer 0 Longitudinal following same people across time 0 Cross sectional people of different ages viewed at same time Case Study Detailed examination of a person39s life and psychological problems You can see examples with Freud Other types of more databased examples follow 0 lnserts from studies 0 Limitations I You can39t make causal statements strictly speaking changes could be due to extraneous factors I Sunspots on Alpha enturi changes in allergens changes in Obama39s health care policies change in family dynamics furloughs at the state39s flagship university maturation etc I Ways they can be useful Positive points I When dealing with rare phenomenon I To disconfirm a universally held belief I Practicing clinicians can contribute to the literature I Generate data that encourages later experiments Experimental Methods manipulation of an independent variable treatment and examining the results on a dependent variable outcome Only this approach can show cause and effect 0 Two general types Group designs and Single Subject Experimental designs Simplest case 2 X 2 design 2 group design CBT vs no treatment control for depression I Look over you material in the book regarding this 0 Single subject research designs Two main types Reversal or withdrawal designs and multiple baseline designs 0 Single subject research designs WithdrawalReversal designs first At least 3 phases are necessary BL TX BL better known as ABA Examples I Where is control demonstrated How is control demonstrated Advantages I It shows cause and effect provided the behavior reverses Disadvantages I Not always ethical to remove treatment I Some behaviors won39t reverse skills 0 Single subject research designs Multiple baseline design 2 phases Baseline and treatment Also it must be across something such as behaviors subjectsparticipants or settings I Same logic as reversal designs Classification 0 Different kinds of classification systems 0 Categorical You have it or you don39t 0 Dimensional It is a question of degree You can have more or less of many characteristics Height weight anxiety depressionsadness O Prototypical approach Some key features of a disorder are essential for a diagnosis Other features may or may not be present thus allowing variability in expression 0 Features of any classification system reliability and validity 0 Reliability means agreement For diagnosis two diagnosticians can agree that a person has the same diagnosis Different kinds interrater temporal internal consistency O Validity Another term is quotusefulnessquot I Different kinds of validity I Can you have a valid classification system without a reliability No 0 Etiological validity past Where did this disorder or condition come from What caused it 0 Concurrent validity present Knowing this diagnosisclassification what other new information can we learn 0 Predictive validity future What is the prognosis What is the course of this disorder 0 Book construct and content validity Benefits of a Classification system 0 In addition to possible etiological concurrent and predictive validity classification may also lead to Discovery of the best treatment options I lncrease communication among scientist I Help in administrative decisions allocation of personnel and other resources and in obtaining reimbursement Drawbacks of a Classification system 0 Labeling Others may react negatively toward the person because of the label The person may misbehave consistent with the label 0 In either case the label becomes somewhat of a selffulfilling prophesy The DSM Diagnostic and Statistical Manual of the American Psychiatric Association Current version is the DSMIV TR there have been 4 prior versions DSMV is being prepared now Revisions are done largely through consensus of experts Traditionally DSM has been considered to be a Categorical system You either are diagnosable with X or you are not 0 Even the Prototypic approach to classification noted in your book still fits into a categorical system Each of the mental disorders is classified as a clinically significant behavioral or psychological syndrome or pattern that occurs in the individual that is associated with O Painful distress 0 Disability andor 0 A significantly increased risk for suffering death pain disability or some important loss of freedom Where does the disorder reside 0 quotWhatever its original cause it must currently be considered a manifestation of a behavioral psychological or biological dysfunction in the individual Neither deviant behavior eg political religious or sexual nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual as described abovequot pp 910 of DSM IV Criticisms of the DSM O The diagnostic categories may be viewed as static of fixed This doesn39t account for people moving into and out of the diagnostic range or from one category to the next There are also high rates of comorbidity 2 or more diagnosis 0 People who are subclinical not diagnosable may not receive treatment 0 There is a lack of emphasis on environmental and contextual factors parenting 0 There is considerable heterogeneity within diagnostic categories 2 people who have the same disorder who look and act very different 0 Boundary cases those who are at orjust below the cutoff for a number of symptoms are hard to diagnose in anything but a probabilistic fashion DSM 0 It is a 5 axis diagnostic system 0 Axis I Clinical disorders and other conditions that may be a focus of treatment 0 Axis II Personality Disorders and Mental Retardation long standing conditions 0 Axis III General Medical Conditions important think about stress relating to ulcers things like that 0 Axis lV Psychosocial and Environmental Problems family or interpersonal stress low social support negative life event Usually note them within the last year 0 Axis V Global assessment of functioning how well adjusted during last period of time Digression a few questions 0 What is the prognosis for someone with high versus low levels of stress Axis lV before becoming diagnosable person who had lost everything vs person who had not with same level of depression person who had lost everything has better prognosis because they deal with regular stressors better and also the level of depression would be more normal after large levels of stress 0 What is the prognosis for someone with a high versus a low GAFglobal assessment of functioning a year prior to diagnosis Best predictor of future is past Sroufe39s Pathways Framework 0 quotpathology may be thought of as a succession of branchings which take the child away from pathways leading to competent developmentquot p 253 of article 0 Show his model The tree My running the river 0 These come from pp 253254 of your article Write briefly 5 points Disorder is deviation over time A failure at any point in time is best viewed as placing an individual along a pathway potentially leading to disorder or moving the individual toward such a disorder Multiple pathways to similar outcomes Individuals beginning on different pathways may nevertheless converge toward similar patterns of adaptation EQUIFINALITY equal finally Different outcomes from the same pathway The concept of successive branching39s suggests that individuals beginning on a similar pathway may diverge ultimately showing different patterns of pathology or no pathology MU LTlFlNALlTY multiple finallys Change is possible at many points Despite early deviation changes may lead the individual back toward a more adaptive pathway Even when a maladaptive pathway is enjoined Return to positive functioning often remains possible this is hopeful The researchers questions are what factors lead to positive and negative changes try to identify malleable causal risk and protective factors Change is constrained by prior adaptation The longer a maladaptive pathway is enjoined the less likely it is that the person will reclaim positive adaptation This is a cautionary note tempering the optimism of the prior point Protective or Resilience factors Taken from Masten and Coatsworth 1998 Portrayed in book by Marsh Model of Abnormal Psychology we will use is DiathesisStress Slightly changed definition from your book Diathesis is your predisposition toward a disorder This includes your heredity plus your earlierearning experiences note comments about the part in italics Stress Current factors stressful events that combine with our diathesis to lead to us developing or not developing a disorder Be familiar with the Reciprocal GeneEnvironment model too Hypothesis that people with a genetic or in my opinion also their earlierearning history predisposition for developing a disorder may also have a genetic tendency to create environmental risk factors to create a disorder pp 3839 Kelleher et al 2000 Increasing identification of psychosocial problems 19791996 Two sets of data collection Monroe County Study in 1979 Rochester NY Child Behavior study in 1996 Nationwide and in Rochester Goal was to identify children39s behavioral emotional or school problems treated or untreated regardless of the purpose of the visit There was a substantial increase in pediatrician identified problems 68 vs 187 They examined their data and study procedures for several possible confounds These were eliminated trying to find why the increase Did find changes in risk factors They did find that the change in the proportion of children not living with both parents increased from 15 to 25 a 67 relative increase In both years children in single parent homes were more likely to be identified Medicaid the percent of children enrolled in Medicaid almost tripled over the years another risk factor SES Botom line the increases were tied to an increase in Risk Factors Not pages 814 4151 5764 7984 104105 DSM Where does quotdisorderquot reside Criticisms of the DSM The 5 axis digression Who has the better prognosis Sroufe Pathways framework The tree canoeing 5 points some new terms Protective or resistance factors Modal ofabnormal psych we39ll use Kelleher et al Why the changing rates Notes Second Test Tuesday September 22 2009 503 PM Anxiety Key Aspects of Anxiety 0 Anxiety disorders are comorbid with many other things is featured along with many other disorders 0 It is aversive Most important point it is the aversiveness that motivates behavior 0 It is disruptive People find it hard to think when they are superanxious perform well etc 0 It has psychological and biological aspects 0 Shuttle Box Example understand this Electric grid wall between two sides of the grid not impossible to get over light on either side of the grid Run conditioning experiment turn the light on on one side electrify grid on that side person will try to get to the other side ESCAPE will have same arousal reaction to the light and instead of escaping will AVOID so initial escape then avoidance Deactivate grid but keep light will still jump to the other side will continue to follow this pattern forever or almost forever Light paired with grid is classical conditioning the avoidance and escape is negative reinforcement I This is anxiety disorders Some Definitions Fear Emotion of an immediate alarm reaction to present danger Rational apprehension Strong sympathetic nervous system arousal Anxiety A negative mood state characterized by bodily sensations of physical tension and by apprehension about the future danger or misfortune Panic Attack lntense fear panic occurring at an inappropriate time in the absence of an objective threat It is accompanied by intense physical symptoms Graphic from book Specific Phobia O Phobia from p 137 Persistent excessive or unreasonable fear of a specific object or situation Thefearis irrational in that it does not match the objective dangers of the situation I Must last 6 months I The phobic object is avoided or tolerated only with excessive anxiety or distress lnterferes with daily life functioning Subtypes of Specific Phobia O Bloodln39uryln39ection People with this type almost always differ in physicological responses compared to other types of phobias 0 Instead of the usual surge in sympathetic nervous system activity and increased HR and BP there is a marked decrease in HR and BP 75 faint O Bll Phobia can lead to avoidance of medical and dental care 0 Strong familial component 65 of people withthis phobia have a 1st degree relative with it 0 Peak age of onset is usually about 9 years old 0 Animal Type animals and insects Peak onset is around 7 years old 0 Natural Environment Type storms heights water These tend to cluster lfyou have one storms you are likely to have another water 0 Situational public transportation enclosed places flying bridges driving tunnels etc Tend to emerge in the early to mid 20s Run in families 0 Other types loud sounds clowns choking General Info on Phobias 0 Common about 125 lifetime prevalence rate About 9 diagnosable at any 1 year period 0 41 Female to Male ratio overall varies by specific type 0 If you have a phobia there is a 31 someone else in your family will have one 125 base rate in population Often family member will have same type phobia Theories How do you become phobic 0 Direct experience about 50 could remember some traumatic experience Example actually choking being bitten by an animal Classicalconditioning OH Mower39s 2 Factor theory Those 2 factors are I Classicalconditioning I Negative reinforcement 0 Indirect or Vicarious Experience Modeling if parent is afraid of dog this shows child that dogs are to be feared Works with adults too I Information transmission simply being told or warned that something is to be feared O Seligman39s Preparedness Theory of Phobias This states that we are prepared or biologically hard wired to become afraid of particular stimuli snakes spiders closed places heights etc This part of his theory seems true We are more afraid of these things Seligman continued Data on prevalence is true I Seligman speculates as to why this is He speculates that our fears are due to evolution Our ancestors were afraid of those things avoided them and survived and reproduced The ones that weren39t afraid of them died out I As an alternative it could be that we39re just designed that way 0 Barlow39s Triple Vulnerability theory for all anxiety disorders Biological vulnerability inherited contribution to negative affect or anxious responding Generalized psychological vulnerability the sense that things are uncontrollable unpredictable and dangerous Childhood experiences of unresponsive overproductive and overrestrictive parenting as possible risk factors Specific Psychological vulnerability something more immediate and focused Ex being bitten or told that dogs are dangerous This specific vulnerabilityfocuses on the other two risk factors Treatment 0 The treatment of choice for all of the anxiety disorders is in its most general form Exposure and Response Prevention 0 What do you expose them to 0 What response do you prevent 0 Every more specific treatment is really geared toward accomplishing Exposure and Response prevention 0 Two types of approach Gradual and Dramatic Gradual includes In Vivo Exposure and Systematic Desensitization I In Vivo Exposure Exposing someone to the feared object in the real world I Construct a fear hierarchy I Gradually progress up the fear hierarchy moving from least to most feared stimuli I sounds like shaping Systematic desensitization gradual exposure using imagination while the person remains deeply relaxed Works well when exposure in the real world is not possible or desirable I Construct a fear hierarchy I Teach relaxation skills you can39t be relaxed and anxious I Expose the person via imagination while they remain relaxed It is still best to include real world exposure if possible and advisable fear of flying eventually you want them to get on a plane I Flooding expose them to the most feared object and not letting them leave Not used much anymore not necessary Another technique that can be used is modeling This is vicarious exposure It can be used alone with some success or in conjunction with In Vivo Exposure Separation Anxiety Disorder 0 O O O O O 0 Panic O O 0000 Panic O O O O O O O O 0 Children39s excessive unrealistic and persistent fear that something will happen to Their parents or other important people in their lives Or happen to them that will lead to separation from their parents 612 of children havehad this School refusal is common in these children because What techniques might they use to avoid going to school Could be conscious or not Not the same as school phobia SAD generally progresses from mild to severe Physical complaints occasional absence gt frequent tantrums clear refusal cutting class makes it harder to go back Precipitating events moving a new school death or illness of parent or relative missing school due to illness fear of criticism etc Most children recover from mdisorder though they may go on to develop a different anxiety disorder The underlying tendency toward anxiety disorders may continue Attacks Panic Disorder and Agoraphobia Panic attacks are not a disorder What happens to a person when they experience a panic attack physically Thoughts they have short shallow breathing chest pains etc think they39re going to die feeling out of control helplessness some depression Panic attack properly speaking involves 4 or more of the 13 symptoms on page 120 The attack is suden and builds rapidlyto a peak It is often accompanied by a sense of imminent danger doom and an urge to escapeflee Panic can be Situationally bound It only occurs in specific situations This could be true in specific phobias or social phobia Situationally predisposed More likely in some situations but not inevitable in that situation Unexpected The person doesn39t know where or when the next one will occur Panic can occur with a number of anxiety disorders Disorder Recurrent unexpected panic attacks followed by at least one month of persistent concern about having another Frequency can vary widely Many people with PD report frequent anxiety not directed toward anything The picture that emerges is a High background level of anxiety with precipitating events that push the anxiety to panic levels In some cases precipitated by loss of an important interpersonal relationship leaving home divorce breakup Major depression is a common comorbid condition 5065 of cases This is true of most of the anxiety disorders panic would come first then become depressed as a result likely scenario Mitral Valve Prolapse A heart problem that can include paniclike symptoms Usually not serious Treatable PD is 25 times more common in women than men Course Usually begins in adolescence to mid30s O A person can have PD without Agoraphobia Agoraphobia with Panic Disorder 0 Agoraphobia usually begins within the first year of experiencing panic attacks 0 Essential Feature Anxiety about being in places or situations in which escape might be difficult or embarrassing or in which help may not be available in the event of having a panic attack I Physical and social restraints involved 0 This anxiety typically leads to pervasive avoidance of situations like being outside the home in a crowd home alone etc 0 Often the person can be in a feared situation if with a trusted companion O The person39s ability to accept normal life responsibilities is severely impaired O 95 of people with Agoraphobia have a past or current diagnosis of PD The other 5 have panic like symptoms 0 Panic attacks or panic like symptoms are central to the development of agoraphobia O Aversive fleeing panic in a maladaptive way 0 How does Agoraphobia become more pervasive in terms of the number and types of places someone avoids Even to the extent of being homebound how does it generalize to new places 0 Remember Program Common Stimuli What are some of the Common Stimuli I External Internal lnteroceptive avoidance 0 quotFear of fearquot Treatment 0 Exposure and response prevention 0 Graduated exposure that is geared to reducing agoraphobic avoidance Person is exposed to the feared situations I Works for 70 of cases Some symptoms often remain 0 Panic control therapy for panic attacks Technique that uses graduated exposure to feared somatic sensations and modifications about the person39s attitude towards them 0 Drugs 0 Relaxation breathing cognitive coping statements can make it easier for the person to be in the feared situation ObsessiveCompulsive Disorder 0CD O OCD is recurrent obsessions and compulsions that are severe enough to be time consuming and that cause marked distress or significant impairment 0 Obsessions Recurrent thoughts images or impulses that are experienced as intrusive and that cause marked anxiety and distress More than just excessive worries about real life problems 0 The person attempts to suppress or neutralize them 0 What are some of the more common examples 0 Common examples contamination repeated doubts did I hit that person in traffic Left iron on Door locked having to have or do things in order 0 Compulsions They are repetitive behaviors hand washing ordering checking or mental acts counting repeating words silently the goal of which is to decreaseanxiety O The relationship between anxiety and obsessions and compulsions is different 0 Compulsions anxiety 0 Obsessions anxiety O The result though is that the whole behavioral chain seems to be reinforced 0 Checking and washing are the most common compulsions 0 Frequently in addition to escape washing or checking there is also avoidance not shaking someone39s hand or not touching the door handle 0 3550 of people with Tourette39s disorder have OCD Not many with OCD have Tourette39s 0 About equally common in males and females Usually begins in adolescence or early adulthood Made worse by stress Treatment 0 Exposure and response prevention 86 respond with improvements Acute and PostTraumatic Stress Disorder ASD and PTSD O O O O O O O 0000 ASD Essential feature is development of characteristic anxiety dissociative and other symptoms that occur within 1 month posttrauma This is really PTSD occurring within the first month posttrauma Many people with ASD go on to develop PTSD Some are not diagnosable with ASD but later develop PTSD What are traumas that can produce ASD and PTSD How can you acquire this Direct experience with event that involves actual or threatened death serious injury or threat to one39s personal integrity I Witnessing such an event Learning about such an event to someone especially if close to you Being diagnosed with a life threatening illness I Etc While experiencing the trauma or later the person has at least 3 of the following dissociative symptoms I Sense of numbing I Detachment Absence of emotional responsiveness Reduced awareness of surroundings I Depersonalization or derealization Dissociative amnesia Following the trauma the traumatic event is persistently reexperienced and the person repeatedly tries to avoid anything that reminds them of the trauma Avoidance and reexperiencing are key features They also tend to be chronically overaroused anxious and depressed lf ASD moves beyond 4 weeks it becomes PTSD Some predictors Severity persistence and degree of exposure to the trauma biggest predictor Family history of anxiety disorders Your having a preexisting disorder I Family instability support unpredictability Childhood history of trauma Lack of meaning in your suffering vs suffering for a cause I Lack of social support friends others PTSD Acute 13 months I Chronic 3 months or longer I With delayed onset Develops at least 6 months after trauma Course recovery occurs within 3 months following trauma for 12 of people with PTSD 000 O O 0 00000000000 0 000 O 0 Therapy can be delicate Trick is to reexpose so that it is therapeutic rather than traumatic lmaginal exposure Develop a trauma narrative that is reviewed extensively in therapy in a safe place I Along with it correct misassumptions such as blaming self Emotions may flood in frightening but good Structured interventions soon after a trauma delivered to those who require help may be useful in preventing the development of PTSD 12 sessions of cognitive behavioral therapy gt 11 PTSD vs self help book gt about 60 Forcing trauma victims to single session in which they are required to express feelings whether they were distressed or not can be harmful Essential feature Excessive worry and anxiety occurring more days than not for at least 6 months about a number of activities and events Once stops worrying about one thing moves to another Physical symptoms chronic muscle tension is the main one Also high arousal Mental agitation fatigue irritability difficulty sleeping People with GAD worry about little things About 100 of people with GAD would agree with that 50 of other axiety disorders Adults kids health money chores money time job Children athletic academic social performance injury Prevalence about 3 at any one time 6 lifetime Onset is general course chronic Many people say they have always been that way a worrier Contributing factors Autonomic restrictors Do not respond physiologically HR BP as much as other anxiety sufferers High sensitivity to threat in general Hypervigilant to sources of threat Although arousal is low they have very active brain activity suggestive of worrying but not of staying with a topic long enough to process experiencebe exposed to the negative affect associated with the topic Instead they move to some other worry topic So people with GAD may avoid unpleasant negative affect and imagery but also do not work through the problems to arrive at a solution Worry seems to be avoidance of greater negative affect If this is correct worry may be the negatively reinforced escape and avoidance behavior Treatment I Help them evoke worry during therapy and confront anxiety provoking images and thoughts headon rather than avoiding Newer therapies include focusing on and acceptance of distressing thoughts and feelings Acceptance based therapies help patients stay in contact with unpleasant experiences CBT with children works very well for GAD and Social Phobia Identifying anxiety cognitive coping statements relaxation other components Experimental Avoidance the phenomenon that occurs when a person is unwilling to remain in contact with particular private experiences and takes steps to alter the form or frequency of these events and the contexts that occasion them I They argue that many forms of psychopathology are viewed as unhealthy forms of EA DSM categories mentioned specifically include Substance Abuse Pznchwsurderwwth Aguraphumz The behzvmruf sumdequot sz me edve zvmdznce AH uftheznxwmy msurders Treatment mdudes Expusure and respunse prevemun techmques Acceptance basedtechmquesmcmdwg Marbtt surge suffenrg m he p wwthtreztment uf substance abuse Jacubsun sacceptancetherapyfurmzntz therapy Meduzuunandacceptancemmeztmemufchmmcpzm y H m n A m u a A m r f bemg zmne GO ThuLghts emutmns QC Behzvmr physm ugy Wernzhzmg dwsurders Anxwet surder D Sumzuzztmnr z mems p zyed um physmzHy Externzhzmg msurders ADHD APD Mood Disorders Diagnostic Categories 0 Major depressive disorder MDD also called unipolar depression 0 Bipolar disorder aka manic depressive O Dysthymic Disorder DD 0 Cyclothymic Major depressive episode diagnostic criteria 0 5 or more of the following symptoms present for the same 2 week period At least 1 symptom is either a depressed mood or b loss of interest or pleasure Depressed mood most of day nearly every day Loss of interest or pleasure in allmost normal activities Weight fluctuations 5 up or down Sleep changes Changes in motor activities Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt how they view themselves Diminished ability to concentrate or indecisive nearly every day Recurrent thoughts of death or suicidal ideation D Diagnostic criteria Presence of one or more Major depressive episodes Not better accounted for by something else There has never been a manic episode or hypomanic episode E E OUOOOUOOOOOOOOO U Twice as common in adolescent and adult females as malesabout the same rates in prepubertal childeren Lifetime prevalence rates 1025 for females 512 for males Usual age of onset book indicates onset age is 30 but 1020 of teens exhibit significant depression that may not get better on its own The incidence of depression and suicide seem to be steadily increasing and onset seems to be at younger ages Two subtypes single episode rare or recurrent 2 or more episodes separated by at least 2 months of not being depressed Duration of first episode is typically 49 months Here is some evidence to suggest that periods of remission grow shorter with subsequent episodes The numbers of prior episodes is related to the probability of subsequence episodes 5060 of people who have 1 have a 2nd 70 of ppl who have 2 have a 3rd 90 of ppl who have 3 have a 4th Possible reasons Higher diathesis Kindling effect Either you are basically changing brain structure by brain functioning or there is something like a psychological scar that predisposes further depression maybe both 0 1 year after a MDD episode people tend to still have some symptoms but are not diagnosable O MDD is higher in relatives of person with MDD than in the general population Dysthymic Disorder DD 0 In general longer duration and less intensity than MDD O O O O O O DX Criteria includes Depressed mood for most of the day more days than not for at least 2 years 0 Presence while depressed of at least 2 I Poor appetite or overeating sleep problems low energy or fatique low selfesteem poor concentration or difficulty making choices feelings of hopelessness Not having manic or Manic Episode 0 Distinct period of abnormally and persistently elevated expansive or irritable mood lasting at least one week More talkative than usual or pressure to keep talking Flight of ideas feeling like your thoughts are racing Distractability Increase in goal directed activity socially work school sexually or motor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences sex spending drugs bad investments alcohol etc 0 There are hypomanic episodes Shorter duration requirement less intense symptom presentation Not severe enough to cause marked impairment or require hospitalization olar Disorder 0 Bipolar 1 in particular one or more Manic Episodes or Mixed episodes Often the person also has one or more major depressive episodes not necessarily though People with Manic episodes often do not recognize they are ill and they resist treatment Lifetime prevalence around 1 Mean age of onset mid 20s could run from adolescence through 50s A recurrent disorder 90 who have one manic episode have another but duration is shorter Greater number of lifetime episodes Duration is often a few weeks to several months Rapid cycling from mania to depression or in and out of mania is associated with worse prognosis O lnterval between episodes decreases as the person ages more episodes Cyclothymic Disorder 0 2 yrs of numerous periods of hypomanic episodes and numerous depressive episodes 0 Hasn39t been without these symptoms for more than 2 months 0 No MDD or Manic Episodes present in the last 2 years 0 Basically like longer lasting and less intense than Bipolar Disorder Depression Theorists and Associated Therapies 0 Ferster39s Disrupted Systemsfor Obtaining Reinforcement Explain Examples Not just bad stuff but also good stuff I Therapy is find something else to occupy your time Add other purposeful activities to your repitoire O Seligman39s Learned Helplessness also did phobias Background diagram 0 Later AttributionalReformulation of the Learned Helplessness theory lnternal external Stable unstable I Global specific I Cause or result of depression lnternal stable global associated with depression 0 More on the Attributional Reformulation I Depressogenic attributions include internal stable and global attributions for bad thing further explanations different pairings of goodbad things 93 390 00000 0000000 O LewinshonP r n E ha y r 39 quot 39 extension of Ferster Person experiences too much punishmentaversive events and too few reinforcers I Reasons person may be in a punishing environment person may exhibit behavior that leads to no reinforcement andor to punishment Skills training could be used for the second point possibly changing environment or attributions for the first I Therapy consists of I Daily monitoring of moods and activities Positive Tracking I Relaxation trainingskills training I Time management to prepare for daily activities I lncrease pleasurable activities aka BehavioraActivation O Rehm39s Self Control Theory of Depression I Selfmonitoring They focus on bad events and short term aversive or minimally reinforcing consequences of behavior So teach them to learn more about themselves Selfevaluation I Selfreinforcementpunishment administer too much self punishment and too little self reinforcement If they change self evaluation criteria this could be changed I Cognitive triad Beck39s Cognitive Therapy Automatic thoughts Cognitive schema I Lots of data supporting effectiveness 0 Another therapy Interpersonal Therapy has good data supporting effectiveness 0 The prior therapies as well though not all are widely applied with adult populations ECT Electro Convulsive Therapy 0 Unknown mechanism of action 0 Useful for Depression not treatable by other means 0 Anesthesia muscle relaxants electric shock seizure of a couple minutes duration 0 Some loss of shortterm memory Possibly permanent loss for recent events Other neurochemical changes 0 High relapse rates if not maintained on meds or treatment Effectiveness O Medications CBT and Interpersonal therapy have evaluated most Similar effectiveness during treatment 0 Relapse is much greater following removal of medication than following termination of therapy 0 There may be some added benefit of combining the med and psychological treatments 0 For Bipolar use medication and psychotherapy Lithium Carbonate is the standard Use to treat and maintain Attend to other topics in this chapter 0 SAD o Grief 0 Marital relationship and depression I Gender differences in depression following divorce 21 of women 17 of men 0 First episode of depression following divorce I 14 of men 5 of women 0 Depression can also lead to deterioration in marital relationship poor parenting isolation etc 0 Just for fun D x 2 D x 1 Never married single shacking Rank order rates of depression most to least 0 Divorced twice cohabitation divorced once never married married gtgt rankings of incidence of depression 0 Social support is great buffer against depression Anxiety and Depression 0 Almost all depressed people are anxious but not all anxious people are depressed 0 Pure depressive symptoms Inability to experience pleasure anhedonia I Depressive slowing motor and thought n More negative usually more negative Table 64 of text Suicide 0 A top 10 cause of death in our society 1213100000 0 3rd leading cause for 1524 year olds 0 Highest rate is in 65 years old and over Why 0 Men more likely to kill self 34 times so Use more lethal means Guns in 23 cases for men Women attempt more often men are more successful bc they use more lethal means 0 Women more likely to attempt 3 times so more likely to use 0 Racial differences Caucasian more than most races except for native americans alcoholism loss of culture have a higher rate in race Married less than single widowed divorced Religioust devout less than others Some professional groups physicians dentists psychiatrists unskilled laborers College students more than comparable age groups 0 Highest suicide rates for marital status divorced widowed single married Suicide predictors O O O O 0 Recent major stressful events 0 Poor health especially a terminal illness 0 History of suicide attempts 0 Talking about suicide especially with a well worked out plan 0 Poor social support 0 History of drugalcohol abuse 14 are intoxicated 60 have some alcohol prior to suicide 0 A recent suicide modeling 0 Sudden loss of interest in normal activities 0 Appearance of coming out of depression 0 Giving away lots of things making out wills putting affairs in order What to do 0 If someone is talking about it or you think they may be thinking about it you should Talk to them about it get them help Suicide contracts Remove means Therapy to relieve depression Therapy after an attempt OOOO Malingering Factitious Disorder and Somatoform Disorders Ch 5 Malingering O This is intentionally feigning illness to achieve some external gains or avoid some undesired activities 0 External gain examples 0 Avoided activities include 0 The person is aware they are producing the symptoms Factitious disorder 0 Intentional production of physical or psychological symptoms 0 These include complaints selfinduced conditions exaggeration or exacerbation of preexisting medpsych conditions No apparent external motivation except attention The sick role the person is reinforced for sick role behavior Examples Codie Extensive medical knowledge possibly background Chronic course early adult onset Often begins after hospitalization for a general medical condition or psych disorder 0 Variant Munchausen Syndrome by Proxy I Deliberant production or feigning of physical or psychological symptoms in another person under their care Typical pattern child victim maternal perpetrator dad may collaborate I Possible victims infant preschool child adolescent or spouse possible collaborator or elderly under their care Motivation For perpetrator to assume the quotcaring for the sick personquot role 0 Associated features life stressors pathological lying may be insufficiently concerned about victim39s condition 0 More common in people who I Received extensive medical treatment as a child I Carry grudge against medical professionals Have worked in the medical field Had a 39relationship39 with a physician I Underlying dependent exploitive selfdefeating personality 0 Believed 1030 of victims die 0 Examples Scottish Rite article in text MCG example Somatoform Disorders 0 Presence of physical symptoms which suggest a general medical condition but are not attributable to or fully explained by a medical condition 0 They differ from malingering or FD in that the symptoms are not intentionally produced 0 Five types Hympchondriasis Somatization disorder I Conversion disorder Pain disorder Body dysmorphic disorder Hypochondriasis O Preoccupation with fears of having or the idea that one has a serious disease based on misinterpretation of one or more than one bodily symptom or sign Persist despite reassurance 0 Prevalence 49 early onset chronic waxes and wanes 7 in medical clinics O Cooccurring mood and anxiety disorders 0 Which health practitioners do they go to 0000 O O O O N 5 Psychologist psychiatrists social workers or They go to a physician Reassurance provides only short term relief if any Attention focuses on misinterpretation of physical symptoms gt more anxiety gt more physical symptoms Anxiety sensitivity catastrophic interpretation of physical or cognitive signs of anxiety arousal Correlated with many somatoform disorders Develops in context of having had a physical disease or living in an environment with others who had physical disease or other illness models Toward a Unified Treatment of Disorders The Negative Affect Syndrome Point 1 Overlap among disorders 0 Hi comorbidity among the anxiety disorders and between anxiety disorders and mood disorders Lifetime rate of 76 High overlapping symptoms Table 64 of your text Rather than being different disorders there may be a general syndrome with heterogenetity of expression of symptoms Point 2 Nonspecific Psychological Treatment Response 0 Psych treatment of any one emotional disorder produces significant improvement in additional comorbid anxiety and mood disorders Point 3 Latent Structure of the Emotional Disorders 0 DSM is reliable but of questionable validity O Seems to distinguish minor variations on broader underlying syndromes 0 Negative affect is part of the structure of both anxiety and mood disorders Therefore the different mood and anxiety disorders may be quotblips on the background of Negative affect syndromequot Implications for treatment programs Look for the essential and common ingredients of effective treatments for these disorders Essential Treatment Components for Negative Affect Syndrome Alter antecedent cognitive appraisals O CBT focuses on evaluating the rationality of negative appraisals of threat and substituting more realistic adaptive appraisals in their place 0 Reappraisals can focus on i The probability of a negative event happening probability overestimation ii The consequences of a negative event if it did happen castrophizing Prevent EmotionExperiential Avoidance 0 To be comprehensive assess for and if indicated target cognitive behavioral and somatic experiential avoidance Facilitate action tendencies not associated with emotion that is distressed O This is really talking about incompatible behaviors cognitive motoric or somatic 0 These new behaviors are nonanxious and nondepressed ex Behavioral Activation for treatment of depression confronting vs fleeing laughing vs being sad or afraid O O Dissociative Disorders Broad classification For these disorders there is a disruption in the normal integrative processes of memory identity and perception of the environment 3 types we will focus on dissociative amnesia fugue identity disorder Criteria is in the book Dissociative Amnesia Major feature one or more episodes of inability to recall important personal information usually of a traumatic or stressful nature which is too extensive to be explained by normal forgetting This is a reversible memory disorder The gaps are usually related to traumatic or extremely stressful events Types of amnesia Localized most common Fails to recall events in a circumscribed period of time Ex the trauma and first few hours after the event Selective Recalls some but not all events during a circumscribed period of time Generalized encompasses the person39s whole life Continuous from trauma to the present the memory tape is on erase Movie Memento 50 first dates Systematized loss of information for categories of information People with the latter three types may later be dx with DID 5 of soldiers during war mostly those who were under fire similar to Can occur in any age group More common in adolescence or later What is the function of amnesia or of dissociation in general avoidance of event Many recover on their own Why Dissociative Fugue Diagnostic criteria in book Sudden unexpected travel away from one39s home or usual place of daily activities along with inability to recall some or all of one39s past This may be accompanied by identity confusion or assumption of a new identity So forgetting and leaving Travel could be far or near the person generally appears without psychopathology during this experience Prevalence rare about 2 Fugue states usually end abruptly with the person recalling most of what happened while quotawayquot Dissociative Identity Disorder Old term was multiple personality disorder Personality is a relative enduring pattern of perceiving relating to and thinking about the environment and one39s self that is exhibited in a wide range of important personal and social contexts DID involves 2 or more distinct identities or personality states each with its own relatively enduring pattern They recurrently take control Some forgetting is involved too when the other personality controls Usually there is a primary identity often dependent guilty depressed Others have distinct history selfimage name and may contrast with the primary identity strong outgoing varies from 2100 Usual is about 15 identities Chronic course Diagnosed more in women Only one interacts with environment at any one time but others may listen in Names may reflect personality melody for someone with musical ability Ex 3 faces of Eve from Bruce at MUSC Backgrounds Many with DID experience extreme abuse as children 97 report this They are highly suggestible high in hypnotizability This is thought to generate from self hypnosis to escape the trauma of abuse Barlow believes that this develops due to trauma in a developmental stage that goes to about 9 years of age The of personalities for a person with DlD has gone up over the years Some believe this is due to therapists subtle encouragement of a different identity in suggestible people Others believe it is a real disorder Supporting data handedness eye function acuity refraction eye muscle balance pain tolerance response to allergens blood pressure Some things that are hard to explain Therapy Dx diagnostic For amnesia and fugue techniques to restore memory Have others tell them the forgotten material Free association Whatever comes to mind Tell their story like your retracing your steps to finding your keys Hypnosis For DlD No evidence based treatment guided by clinical wisdom Using a PTSD type approach gently reexperience the trauma Thus lessening the need to dissociate or switch from one personality to another Attempt to integrate the different aspects into one Notes Third Test Tuesday November 03 2009 558 PM Chapter 7 Psychological and Social Factors that Influence Physical Health 0 Several overlapping areas here Physical health is influenced by and influences our psychological and social functioning eg lifestyle leading to disease and disease influencing our adjustment I Behavioral medicine interdisciplinary approach to applying behavioral science to the prevention diagnosis and treatment of medical problems and adjustment to medical problems I Health psychology adult or childadolescent and Pediatric psychology childadolescentfamily are similar terms 0 Psychological Factors Influencing Medical Condition axis in DSM O O A general medical condition is present axis lll note that this differs from malingering factitious one could be induced here and somatoform disorders Psychological factors adversely affect the general medical condition in one of the following ways Psychological factors influenced the course of the medical condition development exacerbation delayed recovery from Interfere with the treatment of a medical condition Constitute additional health risks for the individual Stress related psychological responses precipitate or exacerbate the medical condition Specifiers Medical condition affected by Mental disorder dep more HA I Psychological symptoms anxiety gtmore asthma I Personality traits or coping style denial of need for surgery type a behavior gt CVD I Maladaptive behaviors overeat no exercise unsafe sex I Stress related psychological responses stress gtucer headaches A widely used term in this area is stress Hans Stress is thought of in 2 ways I Something external that influences us Our reactions to events in our lives There is utility to both views Selye 19071982 General Adaptation Syndrome AlarmReaction fight or flight syndrome person recognizes the stressor and the person39s More body reacts to it Bear in the woods or an attacker Fight or flee What are our more typical stressors today Resistance during this stage the person adapts and appears to be coping but it takes its toll prolonged exposure Exhaustion system breakdown disease death on the GAS In response to stress our adrenal glands secrete cortisol widely accepted as a stress hormone Prolonged excessive cortisol may kill cells in the hippocampus which over time further decreases our ability to regulate stress This brain damage may be associated with other cognitive deficits Other factors can simulate this including prolonged depression and anxiety pp 262 265 and other parts of this chapter Some Social Factors and Stress Sapolsky studied baboons Those low in social dominance were badly bullied and had few privileges Dominant males had low resting cortisol but when emergencies occurred their levels rise quickly to meet challenge Subordinant males have high resting cortisol chronic stress and levels do not rise as quickly in face of challenge They continually secrete cortisol Subordinant males have less immune response less HDL protects against CV disease Predictability and controllability seem to be functional factors contributing to their stress 0 Human equivalents Lazarous believes stress is the result of an appraisaprocess if the person appraises I Demands stressor appraisal gt Resources ability appraisal stress I Resources gtDemands healthy challenge not stressed Note more predictable more controllable I A person may actually have good abilities but if they don39t think they do they will be more stressed in demanding situations Holmes and Rahe39s Social Readjustment Rating Scale I A group of people rated a number of life events in terms of Life Change Units LCUs Marriage was assigned a weight of 50 I Had another group use scale as a checklist did you experience these events in the last year 2 years I Found that as our LCUs go up so does our likelihood of developing physical disease I LCUs of sick people who develop illness is generally higher in the last year than those who stay healthy I If LCUs over 300 particularly detrimental I From colds and fevers to increased likelihood of death of surviving spouse following death of mate Scale even positive events can demand change Type A behavior Has been associated with the development of cardiovascular disease Type A Personality is I High strung easily stressed uptight multitasking Type B is much the opposite of that Turns out that Type A a multicomponent construct is not so much related to CV disease Hostilityanger seems to be the really bad player Review areas and special applications in your text I Pyschoneuroimmunology I Acute and chronic pain I Cancer I Cardiovasculardisease I Injury prevention I Adopting healthy lifestyle behaviors I Medical adherence I Obesity I Etc High quality social relationships help Biofeedback meditation andor relaxation training to lower physiological stress CBT to change cognitions from stress inducing to stress reducing Reduce denialavoidance coping behaviorsstyles Skills training social skills assertion training time management job skills etc Disorders Common to Childhood Most disorders are first seen in children and adolescents though they may not be diagnosed until adulthood Some diagnoses O Bronfenbrenner39s Ecological model as a child so many systems that are influencing that all contribute to any child dysfunction that is present and also all can help For the lnternalizing Disorders 0 We have covered that alreadyAnxiety Depression and Somatoform Disorders 0 Separation anxiety was a childhood disorder 0 Most others start in childhood and some are more common in childhood 0 Heterotypic continuity the specific behavioral symptoms change over time but the type or general pattern stays the same I So for example some may no loner be diagnosable with Separation Anxiety Disorder but may instead quotdevelopquot another anxiety disorder Heterotypic continuity says that the symptoms changed but the pattern stayed the same Attention DeficitHyperactivity Disorder 0 In general ADHD describes someone with developmentally inappropriate behaviors in two categories 1 attention andor 2 hyperactivityimpulsivity O lnattention child finds it difficult to keep their mind on work or play activities or to follow through with requests or instructions They may attend easily to things they enjoy but have greater difficulty than others attending to less enjoyable tasks Their main deficit is Sustained attention I Parents complain that they can39t concentrate don39t follow instructions are disorganized distractible forgetful daydream don39t finish activities They are best working on selfpaced tasks and ones they find interesting 0 Hyperactivitylmpulsivity is best viewed as one dimension because they cooccur Cognitive impulsivity disorganization hurried thinking neeed for supervision Behavioral impulsivity calling out in class saying something without thinking acting without considering consequences I More associated with ODD and CD Hyperactivity children with hyperactivity are constantly in motion I Move more than other children even when sleeping I Greatest differences with other children is when they are required to inhibit motor activity such as School church Hyperactivity is a specific marker for ADHD as opposed to other disorders or normal children Attention deficit is not a specific marker Other disorders with inattention Mania sleep disorder anxiety depression 0 3 types I Primarily lnattentive type I Primarily HyperactiveImpulsive type Combined type 0 Associated Features I some are I Direct results of the disorder school failure I lndirect results depression following peer rejection I Due to a comorbid disorder ODD or CD Intellectual deficits usually lower on IQ tests Academic functioning lower grades more failed classes expulsions and dropouts I Health problems more respiratory problems and allergies enuresis and encophresis and sleep problems High accident proneness I 15 have 4 or more serious accidents I More head injuries accidental poisonings pedestrian bike or auto accidents More sexual partners more children born without marriage n More cigarette smoking Seems to be associated with shorter lifespan I More family problems I More negativity in family I Parenting stress I Low sense of parental confidence I Greater maternal depression the omnipresent correlate of child problems feel like they have no control of child child may act out to get attention in response to maternal depression I More marital conflict separation divorce Greater peer problems Less sharing more rejection CoMorbidity I 5080 comorbid with another disorder I Nearly 50 with ODD or CD I Anxiety andor Depression in about 1525 I Small proportion have Tourett39s Disorder However 50 of those with Tourette39s Disorder have ADHD ADHD Symptoms more likely when Child is tired I Task is complex More restraint required to complete task Low immediate feedback I Not supervised eg mom is doing something else I In public place church or synagogue mall ADHD symptoms less likely when I Unstructured free play I Novel situation Activities that do not require task persistance recess Prevalence and course one of the most common child referral problems 35 prevalence rate 23 for girls 69 for boys Course 2550 of kids outgrow or learn to cope with their ADHD I 3050 continue to have problems in adulthood Predictors of negative outcome Low IQ more symptoms CDODDDepression present parental psychopathology poor discipline practices Where does it come from Genetic factors tends to run in family 1 parent ADHD 13 chance for child to be too Family factors help shape the child39s biological vulnerability Family conflict may be related to the emergence of ODD and CD Family conflict can also result from ADHD ln blinded placebo drug study family conflict went down when ADHD symptoms decreased Bidirectionality Treatment I There is no cure Treatments aim to reduce symptom severity and associated difficulties 3 evidence based treatments I Behavior therapy CND stimulant medication both I Meds This is probably the main and most common approach Stimulant meds increase arousal or alertness in the CNS Ritalin is the most common one used I 80 of kids improve attention impulse control persistence offtask behavior disruptive behavior noncompliance I 20 don39t improve large differences in response to meds in those who do improve some kids report feeling a little sad on meds but most report feeling better about self I Lower appetiteless sleep for some Some growth retardation but long term growth doesn39t seem to be affected High doses can be damaging compulsive behaviors movement disorders hypertension I Relapse virtually guaranteed when meds removed I Behavioral parent training and behavioral interventions in the classroom Parent training is almost identical to that used for noncompliance I Parent training special time praisereinforcement giving commands ignoringextinction time out and other forms of punishment Special time something intended to break up negative dance 510 minutes where you don t command or anything but just give attention and praise just nothing negative ln schools small doable tasks high supervision and prompts high feedback low distraction environment praisereinforcement timeoutpunishment Oppositional Defiant Disorder ODD and Conduct Disorder CD 0 ODD is the least severe form of disruptive behavior disorder 0 A pattern of negativistic hostile and defiant behavior lasting at least 6 months with 4 or more of the following Often I Loses temper Argues with adults I Defies or refuses to comply with rules or request I Deliberately annoys people Blames others for their mistakes or behavior ls touchy or easy annoyed I Angry and resentful Spiteful and vindictive CD 0 CD is diagnosis for children with more severe forms of aggressive and antisocial behavior inflicting pain on others interfering with others39 basic rights through physical and verbal aggression stealing or committing acts of vandalism Many are apprehended for delinquent illegal behavior With CD specify childhood or adolescent onset also mild moderate severe Aggression is a very stable behavior It generally decreases as people age but 2040 year follow up studies show correlations of 70 for aggression O Terminology Childhood onset vs Adolescent onset Undersocialized or solitary aggressive type vs Socialized or group delinquent type I Group type has best prognosis because social influences are changeable I Lifecourse persistant vs Adolescentlimited path Are ODDCD and APD the same or different disorders 0 For ODD and CD ODD symptoms usually emerge by age 6 CD by age 9 0 Many of the same types of symptoms differ in severity O O 0 Risk factors are the same impoverishment family discord history of APD stronger correlation with CD Looking forward in time Time 1 Time 2 3 yrs later Time 3 x yrs later A ODD 25gtCD l B CD2540gt APD C ODD 10 APD ODD50gtCD ODD25gtnot diagnosed Looking Backward in time ODDlt90CDlt100APD Heterotypic continutity propensity stays the same diagnosis changes often shows up in these disorders BoyGirl Conduct problems 0 CD typically develops later in girls than boys Through childhood 41 gender ratio Rates are more similar in adolescence 0 Girl CD is more covert aggression such as as opposed to overt male aggression 0 Girls also get involved with CD boys Sexual acting out other things too 0 Some progression for both from school underachievement and discipline problems to stealing aggression and to possible arrests etc Associated Symptoms and CoMorbidity O IQ deficits 0 School problems lower grades failure expulsion dropout O ADHD 3550 0 Health problems death rates for CD vs nonCD boys are 34 times higher by age 30 drug abuse homicide suicide accidents 0 More substance abuse earlier intercourse and more sexual partners STDs teen pregnancies 0 Higher anxiety and depression too However those who are callous and unemotional show less anxiety and depression Etiological Factors 0 Difficult temperament 0 Genetic factors 0 Neurological factors 2 hypothetical symptoms I Behavioral inhibition system BlS produces anxiety and inhibits in presence of novel or threatening situations Signals punishment Don39t do it Behavioral Activation System BAS activates behavior in response to reward or non punishment go for it Hypothesized to be an imbalance between the reward and inhibition systems with a relatively overactive BAS and inactive BlS See page 449 of book 0 Support for BASBIS I CD children and adolescents have low psychophysiological arousal Lower resting adrenalinecortisol than nonCD boys Lower BlS I This gives some possible reason why they may not be as likely to learn from punishment it isn39t as aversive or punishing They seem overly motivated by rewards even when the payoff is low and the likelihood of loss is high 0 Family factors I Parental APD is a strong predictor of CD in children Also parental aggression and maternal depression are positively correlated I Parentchild interaction I More marital problemsdivorce in parents I Low supervision I Harsh amp inconsistent discipline I Often lack positive parent role model Patterson39s Coercion Hypothesis Both parent and child are reinforced for their use of coercion to get what they want So coercive interactions increase in the home I Coercive behaviors include yelling screaming threatening harsh and abusive discipline etc I Both parent and child use them Modeling plus they work shortterm I They create shortterm gain and longterm pain placing child on maladaptive pathway 0 Treatment For children with ODD Behavioral parent training is an Evidence Based Treatment I The same sort of behavioral training program is used with adolescents with CD but prognosis is less optimistic Therefore catch them early Mental Retardation 0 Significantly subaverage intellectual functioning IQ of approximately 70 or below 0 Concurrent deficits or impairments in present adaptive functioning I At least 2 of the following communication selfcare home living selfdirection functional academic skills work leisure health safety use of community resources socialcommunication skills 0 Onset before age 18 O 4 levels Mild IQ of 50 or 55 to 70 Moderate 3540 to 5055 Severe 2025 to 3540 Profound lt20 or 25 0 These levels are based on standard deviations from the mean of 100 on an IQ test 0 Mostly normal IQ Curve In fact not exactly normal There is a bump on the lower end Still the greatest of people with MR fall into the mild classification Personality Disorders 0 Personality is a relatively enduring pattern of thinking about perceiving and relating to the environment and oneself that is exhibited in a wide range of important personal and social contexts same definition given for DID 0 Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of culture is inflexible and maladaptive has an onset in adolescents or early adulthood is stable and leads to distress or functional impairment 0 PDs tend to be lifelong O AXIS II in DSM 5 axis system Some of the most difficult problems to treat 415 of adults have them Person with a PD can be comorbid with another PD and with an Axis I diagnosis 0 10 Personality Disorders3 clusters Odd or Eccentric PDs some features resemble schizophrenia O Paranoid O Schizoid O Schizotypal Dramatic PDs O Antisocial O Borderline O Histrionic O Narcissistic Anxious PDs O Avoidant O Dependent O ObsessiveCompulsive 000 l Odd cluster PDs I Odd cluster PDs seem to be more common in males Paranoid PD Pervasive pattern of suspiciousness of others such that their motives are interpreted as malevolent I Diagnostic criteria Suspect others are exploiting harming or deceiving them Preoccupied with doubts about loyalty of friends or associates Reluctant to confide fear info will be used against them Reads threatening or demeaning meanings into benign comments Bears grudges and unforgiving Perceives attacks quick to react angrily Unjustified recurrent suspicions about fidelity of spouse or sexual partner They also tend to be critical of others What defense mechanism is used So what is really going on they39re projecting I Therapy is unlikely to be successful No trusting relationship I Solitary behavior in childhood Schizoid PD I Pattern of detachment from social relationships and a restricted range of expression of emotions I Diagnostic criteria Doesn39t desire or enjoy close relationships including within family Almost always chooses solitary activities Little interest in sexual experiences with another person Takes pleasure in few if any activities Lack of close friends or confidants other than family Appears indifferent to praise or criticism Shows emotional coldness and detachment lsolates because don39t seem to like or need social contact They stay to themselves Occupations I Not usually seen in clinical settings Little data on treatment effectiveness Schizotypal PD Pattern of interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive and perceptual distortions and eccentricities of behavior I Diagnostic criteria 5 of 9 Ideas ofreference belief that coincidental and meaningless events have special meaning for them Odd beliefs and magical thinking eg ESP Unusual perceptual experiences Odd thinking and speech eg vague circumstantial overelaborated Suspiciousness and paranoid ideation Inappropriate and constricted affect Behavior or appearance that is odd eccentric or peculiar Lack of close friends or confidants other than family Excessive social anxiety related to suspiciousness or selfdoubt Could be apparent in childhood as solitariness poor peer relationships under achievement I More prevalent in families with schizophrenia Some but not a lot go on to develop schizophrenia Often comorbid with MDD Treatment One study used antipsychotic medications community support and social skills training to reduce symptoms or delay development of schizophrenia Positive symptoms are much more associated with Schizotypal than paranoid PD Schizotypal positive for all 3 examples of positive symptoms Paranoid only for thinking others out to get them could be thought of as Ideas of Reference Cluster B Dramatic Personality Disorders Antisocial Personality Disorder APD I Pervasive pattern of disregard for and violation of the basic rights of others Other words associated with this disorder are Psychopath and Sociopath Diagnostic criteria need 3 of 7 by age 15 Failure to conform to societal norms for lawful behavior and repeatedly doing things that could lead to arrest lmpulsivity or failure to plan ahead Deceitfulness as indicated by lying use of aliases or conning others for personal profit orfor pleasure I Con men for the fun of it may be smooth better liars lrritability and aggressiveness fightsassaults Reckless disregard for safety of others Consistent irresponsibility work financial obligations family responsibilities relationships Lack of guilt or remorse Indifferent to or rationalizes hurting or stealing from another Must be 18 years of age to be diagnosed with APD Must have been diagnosable with CD prior to age 15 So these are kids with CD who grew up and did not change I Strong familial pattern Many with APD are arrested for crimes More common in men than women I Some decrease in severity in decade of 40s and beyond I Studies with APD Lykken et al People with psychopathy learn to obtain rewards as quickly as others but learn to avoid shock punishment and anxiety situations much more slowly I Do about as well as others when trying to achieve rewards but when trying to avoid punishment perform much worse than others without APD Schacter and Latane Psychopath and Nonpsychopath prisoners Focused on learning avoidance of shock under conditions of placebo baseline and adrenaline hi arousal injections I When give adrenaline psychopaths perform better than nonpsychopaths I Work better on adrenaline so assuming APD have normally low levels of arousal YerkesDodson Law I There is a curvilinear relationship inverse U shaped between arousal and performance This data support underarousal hypothesis of APD it helps explain their thrill seeking behaviors and failure to learn from punishment Suggests they are underaroused and seeking optimum arousal Same neurobiological explanation as with Conduct Disorders Overactive BAS and underactive BIS Behavior activation and Inhibition system Most therapists agree that APD is almost impossible to treat Incarceration Page 451 shows some iatrogenic effects of a treatment program They became better manipulators Implications Treat ODDpreferably or CD very early is best approach Borderline PD I Pervasive pattern of instability of interpersonal relationships selfimage and marked impulsivity I Diagnostic criteria 5 of 9 Ex Glenn Close in PamAttraction Frantic efforts to avoid real or imagined abandonment fear it but not comfortable in relationships Pattern of unstable relationships alternating between extremes of idealization and devaluation splitting Identity disturbance Unstable selfimage Will frequently seek to identify with others or others identity I Example ofa person who would become a forester medical professor MHP cook depending on the guy or friend of the month I Shifting unstable identities Impulsivity in 2 areas that could be damaging spending provocative and unsafe sex substance abuse binge eating Recurrent suicidal behavior gestures threats or selfmutilation B39s girlfriend person on psych ward cutters why cutting I Suicide rate of 685 Affective instability and reactivity emotional Chronic feelings of emptiness Inappropriate intense anger Difficult to control displays of anger fights Woman on ward TB Occasionally stress related paranoid ideation or dissociation Additional info Factors in childhood include physical and sexual abuse not to quite same extent as DID Early parental loss or separation whether through death or abandonment Thinking is that these lead to low selfesteem increased dependence and low ability to cope with separation Associated features Tend to undermine self when goal is about to be achieved More secure in relationships with pets or inanimate possessions Mood disorders and substance abuse commonly cooccur Other comorbidities too Recurrent job losses interrupted education broken marriages plural The strange saga of 5 Some mellowing in 40s and beyond but still problematic Familial pattern Quotation from Kellerman39s Silent Partner 1989 I Lanihan Dialectal Behavior Therapy is the best thing going for them Moderate successes good given severity Better than alternatives Sets limits on behavior therapists don39t get sucked into pathology and taught to tolerate emotion Acceptance based therapy Histrionic PD Pattern of excessive emotionality and attention seeking I Diagnostic criteria in text 5 or more symptoms They are uncomfortable in situations where they are not the center of attention Often inappropriately sexually seductive and provocative in behavior Rapidly shifting shallow emotions Consistently use physical appearance to draw attention to self Style of speech is excessively impressionistic and lacking in depth superficial Very dramatic theatrical and use exaggerated expressions of emotion ls suggestible easily influenced Considers relationships more intimate than they are Differ from Narcissistic in that NPDs crave attention because of their imagined superiority Histrionic PDs are willing to be viewed as fragile and dependent to get attention I More common in females we think Narcissistic PD Pervasive pattern of grandiosity in fantasy or behavior need for admiration and lack of empathy Diagnostic criteria Grandiose sense of selfimportance exaggerates achievements expects to be recognized as a leader Preoccupied with fantasies of unlimited success power brilliance beauty etc Believes heshe is unique or special Has sense of entitlement unreasonable expectations of especially favorable treatment or compliance with expectations lnterpersonally exploitive Takes advantage of others for personal advantage Lacks empathy Often envious of others Haughty and arrogant Other info Gender ratio is more males than females Cluster C Anxious or fearful personality disorders I Names largely imply what they are Avoidant PD Pattern of social inhibition feelings of inadequacy and hypersensitivity to criticism I Dependent PD Excessive need to be taken care of Submissive and clinging fears separation I ObsessiveCompulsive PD OC PD preoccupied with orderliness perfectionism and mental and personal control at the expense of flexibility openness and efficiency Gets into rules details organization and schedule so much that the main point is missed Perfectionism interferes with task completion 2 students at AL and GA Workaholic vs rounded family and friend life Overly conscientious or moralistic Can39t discard worthless or worn out objects even when they behave badly Reluctant to delegate micromanager if they do delegate Miserly in spending for self or others largely out of fear of future catastrophe Rigid and stubborn All of this is similar to OCD but different Schizophrenia Focuses on only those who exhibit most extreme signs DSM criteria At least 2 of the following one if delusions are bizarre Delusions I Significant distress or impairment Not due to the effects of a drug medication or general medical condition Prominent symptoms 3 types of symptom clusters Positive symptoms pathological excesses Negative symptoms pathological deficits I Disorganized symptoms disorganized patterns of speech or behavior Positive symptom cluster Delusions beliefs people hold that aren39t founded in reality Persecution people are against you most common someone is out to get me Grandeur you are someone famous an historical figure I am the president of the united states Reference assigning personal meaning to meaningless events the headlines in the newspaper are conveying secret messages to me Hallucinations experiences of sensory events in the absence of sensory stimuli Can be in all 5 senses Extreme hallucinations meeting primary criteria alone I Running commentary I Two voices conversing Most frequent type is auditory Negative Symptom cluster Pathological deficits Avoition lack of motivation I Alogia poverty of speech Anhedonia lack of experiencing pleasure Affective flattening a lack of emotion I Depression VS schizophrenia negative symptoms Depression affect is intensely painfuldistressing Schizophrenia affect is diminished or empty Disorganized Symptoms I Severe and excessive speech or behavior patterns Disorganized speech patterns Loose associations ideas that are not attached to any one topic quotTrain of thoughtquot is derailed Neologisms made up words that only make sense to that person Preservation repeating the same word or theme Blocking start to say something but you lose track of the thought Schizophrenic individuals may misinterpret this how someone else is interfering Thought broadcasting thinking others can hear your thoughts Thought insertion thinking others are inserting thoughts into your head Grosst disorganized or catatonic behavior Inappropriate affect ex laughing at a very sad story Disorganized appearance I Disheveled hair and clothing inappropriately dressed for the weather summer with winter coat Phases Prodromal phase clear deterioration from previous level of functioning Impairment in rolesocial functioning Peculiar behavior Neglected personal hygiene Disturbances in communication Unusual ideas quotnot being themselvesquot Negative symptoms predominate Kindling effect I Predisposition and prevention Two ways of entering prodromal phase I Process schizophrenia I Slow deterioration More diathesis Poorer prognosis I Reactive acute schizophrenia Rapid decline Stress I Better prognosis I Active Phase and Residual Phase Active phase I Florid symptoms I Positive symptoms I Stress Residual phase I Negative symptoms I Behavior similar to prodromal phase Over time span of time between active and residual phases decreases with symptomology worsening Subtypes of Schizophrenia Paranoid Preoccupation with one or more delusions or frequent auditory hallucinations lntact cognitive functioning and affect Without the following as prominent symptoms I Disorganized speech I Disorganizedcatatonic behavior I Flatinappropriate affect Best prognosis of all types of schizophrenia Aloof anxious angry argumentative Danger lies in acting on hallucinations and delusions I Disorganized Marked disruptions in speech and behavior Flat or inappropriate affect prominent Hallucinations and delusions tend to be fragmented Develops early tends to be chronic lacks remissions Worst prognosis I Catatonic Motor involvement unusual and odd Echolalia or echopraxia mirroring speech or movement Waxy flexibility drawing class the wooden people stay in certain positions but can still be moved Excitability lmmobility statuesque Cannot be moved Negativism if someone moves you you move back to where you were Tends to be severe and quite rare Undifferentiated Wastebasket category I Residual type Given when in the residual phase after one episode of schizophrenia Continue to have less extreme residual symptoms I Odd beliefs unusual perceptual experiences that are not as extreme Onset and prevalence Onset late adolescence to early 20s I Prevalence 1 of the population Earlier onset seen in males but likelihood of onset decreases with age Opposite in females Course of schizophrenia I Chronic in nature Usually moderate to severe lifetime impairment Active and residual phases time between decreases in longterm with chronic course Life expectancy is slightly less than average I Suicide 2040 make one attempt 15 commit suicide I Accidents acting on hallucinations amp delusions I Inadequate medical care paranoia added to difficulty communicating in general I Smoking 8090 smoke I Homelessness Prognostic features I Better prognosis Relatively normal childhood Being a female Brief duration of active phase No family history O derzge at unset Acute unset reacmevs prucess Guud premurddmnctmmrg Parana d smdumsprurmnem Guud mmz respunsetu medmztmn prugnussuverme Me ufthwrdsmthe wdeu New research suggests a mare spem c cuurse that charges war we 1nyrs after rsl e sude 25 cump ete y recuvered 14 much mpruved but re ztwe y mdependent 141mpruvedbut requmng extenswesumz suppurt 15 huspuahzed ummpruved 117 deceased rmsz duetu smde 14 cump ete y recuvered 35 much mpruved re ztwe y mdependem 15 mpruved m requmng Extenave sumz suppurt 117 huspuahzed ummpruved 15 deceased rmsz due m sumde Theunesun eumugy and mamenance Genetm a n runmemz andaumzhr uences Fzm yfzdurs Genech WWW manna Mm newer an 25 FameDye r we Twm smdres Mu gmctwmsztznmcrezsedniuverfrzt Aduptmn Slumssrwifurschwzuphremz remzm Caseswherez bm ugmz parent hassch mph cenesdu nut seemtu may a part m whmhtype urscmzuphrenra Genera genetmdwztheswsfurthezspectrumufpschutmsymmcl emz twms drzyguuc Shng rerua deve ups ms m pm ma M cur AHAH n drsease armchemrcawheurres Th dupzmmeDAHputheas Drugsthzt rncrease duparmne sdupz mcrease schrmphrema hke behzvmrs hat rncrease duparmne nedrmepucs decrease schrzuphrema hke behzvmrs re ztwe excess ur D am y hypmhesrs Onetype ufDA receptur rsmure presem m drarnsursumewrm scmzuphrema Parkmsun sdwsezsesz zck ur DA Drugst scmzuphrema n fur thws DA zmwty km a Surnamespruducesschwzuphremzshke smpmms muvements due m the decrease m DA Duparmne mpumesrsrsuverwsrm Current themes 7 emphzaze many nedrutransmruers and thaw rmeracuuns but nuthmg rsdermmvevn Neurabm ugmz themes En zrged ve ndes Decreased grey matter cuncemrauun prenatawadurs Vra mfedmns Verfmc es Pmk bzd b ueguud premm themes 20quotiz ra mfemunsdunng pregnancy ngherrateufschw uphremzm bzbwesw dunngthewmtermu seam Pregnancy and dehvery prub ems En runmemz sue cumphcztmnsm b2 Neurubmmgmz cum Nut d Thompson el al 2001 Se muther swere nthe Secundmmesler mm m Sums slud es m nut w my ssmthese uuzuunsurgenamcunmmmmu mm bweswhu zter deve up scmzuphremz usmns usuc mtenz r curre nurmzhues present m A su nut pram Oman Wm H Summa themes Hugh 2mm any 5 em sum m 2H mdM h 5 er SEsJuwer number uf ndwwduz swwth scmzuphremz n me ndwwduz swwth Ether msurders uzxswn bm ugmz dygeguxztm cmzuphremz thruughuutthe mam I Why Sociogenetic hypothesis increased stress in lower SES leads to higher expression of schizophrenia Social drift hypothesis with increased impairment caused by schizophrenia individuals drift in social status and class Stress and Familial factors I The role of stress May activate underlying vulnerability May also increase risk of relapse I Family interactions Families show ineffective communication patterns Expressed emotion EE not a good thing measurement of hostility criticism and overinvolvement within the familyhousehold High EE associated with higher rates of relapse Treatment options I Iatrogenic psychoanalysis Too much introspection for cognitively impaired individuals Can actually do harm Humanistic not useful I Behavioral social skills training coping with stress Cognitive behavioral Examine alternate explanations for delusions and hallucinations control lnsight necessary may be useful in less impaired individuals Effectiveness unclear Family therapy Psychoeducation Reduce expressed emotion less overinvolved Supportive skills Problemsolving skills I Medication Antipsychotic medications neuroleptics I First line of treatment essential I Introduced in 1950s I Decrease positive symptoms I Not as effective on negative symptoms Side effects I Extrapyramidal and Parkinson39slike side effects Tremors slurred speech sustained muscle contractions Tardive dyskinesia I Uncontrollable repetitive grimacing tongue movements or other parts of the body Sometimes permanent sometimes reversible Neurotransmitter systems exact mechanisms unknown in many cases I Concentional antipsychotics develop higher degrees of extrapyramidal side effects Atypical antipsychotics have lower degrees of these I Compliance with medication is often a problem Noncompliance rates of up to 74 Side effects a big issue Increase in doctorpatient communication over medications39 purpose and side effects to decrease Combined Treatment options I Medication drastically decreases rate of relapse Medication social skils family therapy proven to be most effective in preventing relapse I Tends to delay rather than to prevent relapse but this is good because it decreases the amount of active episodes over lifetime Prevention Identify and treat atrisk children I Some risk factors identified but nothing definitive Longitudinal studies in progress with results to come Family therapy for atrisk families Vaccinations for viruses before pregnancy Preventative medication lmproved prenatal care Final notes I From the book do not worry about other psychotic disorders covered in chapter 12 on pages 480481 in latest edition Dr Jennifer McDowell schizophrenia research at UGA I Also a 3900H course offered sometimes on schizophrenia and bipolar disorder Torrey EF 2006 surviving schizophrenia a manuaforfamiies patients and providers Eating and Sleep Disorders Chapter 8 0 Two major types of DSMIV eating disorders Anorexia nervosa and bulimia nervosa I Severe disruptions in eating behavior I Extreme fear and apprehension about gaining weight Stron sociocultural origins westernized views 0 Other subtypes of DSMlVTR eating disorders I BED binge eating disorder 0 Obesity a growing epidemic Dsm V 0 How people with bulimia see themselves it s a perceptual Bulimia Nervosa Overview and defining features Binge eating hallmark of bulimia O Binge I Subjective feels like binging but it is a normal amount of food Objective is a very large amount of food In either case eating is perceived as uncontrollable O Compensatory behaviors Purging I Selfinduced vomiting diuretics laxatives I Some exercise excessively whereas others fast 0 DSMlVTR subtypes of bulimia Purging suptype most common subtype I Nonpurging subtype about one third of bulimics 0 Associated medical features I Most are within 10 of target body weight Purging methods can result in severe medical problems I Vomiting chubby face erosion of dental enamel dysregulation of electrolytes I Laxative abuse severe constipation permanent colon damage 0 Associated psychological features Most are overly concerned with body shape I Fear of gaining weight I Most have comorbid psychological disorders I Strong relationship to anxiety disorders not as strong with mood and substance use disorders Case example History 0 J reported that she began dieting in the 7 h grade She recalled that the first time that she denied food was at a breakfast meal in eighth grade After that point she began to restrict her eating to the point that she described herself as having anorexia nervosa in the eighth grade She lost a significant amount of weight She reported that she began binge eating during her freshman year of high school and self induced vomiting around that same time J stated that her weight fluctuated between 130 lbs and 97 lbs during her middle and high school years Pattern of eating 0 J reported that she did not eat any meals at all She stated that every time she eats she vomits She stated that therefore at this point she only eats when she binges She reported going without any food for eight hours or more on half the days of the month and has tried at various times to restrain her eating For example she reported that she threw out all the food in her home and tried to restrict her eating to salad and egg beaters in order to avoid triggering a binge Binge Eating and Purging Symptoms O J reported that she engages in binge eating and purging every day and has done so consistently for the past three months She stated that on a typical day she buys food to binge on before class starts binge eating when she gets home from class and then stops between 9 and 10 in the evening and starts drinking She described the day before the assessment as a typical day She reported that she ate nothing until 200 She bought food at 100 went home and started eating She stated that between 200 and 1000 PM she ate 1 lb of turkey 1 lb of tater tots 1 large can of Pringles potato chips 1 bag of salad a box of 52 fish sticks 3 packages of Ramen noodles 2 full microwave bags of popcorn and 16 slices of cheese She estimated that she self induced vomiting 15 times between 200 and 1000 PM After 1000 PM she consumed 1 large box of Triscuit crackers and had two mixed drinks Stats and Causes Stats I Majority are female Onset around 16 to 19 years of age Peak age of onset at age 18 but can occur much earlier ie middle school I Lifetime prevalence is about 11 for females 01 for males I 68 of college women suffer from bulimia Tends to be chronic if left untreated Causes of BN I Evidence that BN does primarily affect women in Western cultures One of the main causes of BN is dieting Cultural influences on BN and Eating disorders 0 Society 0 Western standards of female attractiveness push women to be very thin refer to chart on next slide 0 Most women do not like their body type quotnormative discontentquot Society and Appearance 0 80 of american women are unhappy with their appearance 0 42 of 1st3rd grade girls want to be thinner O 50 of 9 yearold girls and 80 of 10 yearold girls have dieted Medical and Psychological Treatment of Bulimia Nervosa 0 Medical and drug treatments I Antidepresants O Psychosocial treatments Cognitivebehavioral therapy CBT evidence based treatment I Dialetical behavioral therapy DBT also shown to be effective I Interpersonal psychotherapy Family therapy AN Overview and Defining features 0 Successful weight loss hallmark of anorexia I Defined as 15 below expected weight lntense fear of obesity and losing control over eating I Anorexics show a relentless pursuit of thinness Often begins with dieting O DSMlVTR subtypes of anorexia I Restricting subtype limit caloric intake via diet and fasting I Bingeeatingpurging subtype about 50 of anorexics Majority are female 9095 and white From middle to upper middle class families Usually develops around age 13 or early adolescence peak age between 1418 High levels of perfectionism More chronic and resistant to treatment than bulimia Cooccurrence with anxiety disorders OCD few comorbid substance abuse patterns in restricting subtype Genetic heritability 0 Over 50 of the vairance in AN symptoms is due to genetic causes 0 AN found in several different cultures throughout the world and throughout time 0 Heritability index is high after puberty nonshared environmental causes account for the most variance before puberty Keys Study Men volunteered for study at University of Minnesota Placed on semistarvation diet for six months Effects of Starvation Some developed binge eating Some developed symptoms of AN fear of food I Some developed rigid thinking patterns similar to OCD Goals of psychological treatment of anorexia nervosa General goals and strategies I Weight restoration first and easiest goal to achieve I Psychoeducation Behavioral and cognitive interventions I Target food weight body image thought and emotion I Treatment often involves the family I Longterm prognosis for anorexia is poorer than for bulimia Binge Eating disorder overview and defining features I Binge eating disorder appendix of DSMlVTR I Experiment diagnostic category I Engage in food binges without compensatory behaviors I Associated features I Many persons with bingeeating disorder are obese I Concerns about shape and weight I Often older than bulimics and anorexics I More psychopathology vs nonbinging obese people Medical and Psychological Treatment of Binge Eating Disorder I Medical treatment I Sibutramine Meridia I Psychologicaltreatment I CBT 0 similar to that used for bulimia 0 appears efficacious I Interpersonal psychotherapy O Equally as effective as CBT I Selfhelp techniques 0 Also appear effective Obesity Background and Overview I Not a formal DSM disorder I Proposed to be in DSMV I Statistics I In 2000 30 of adults in the United States were obese 32 in 2004 I Mortality rates 0 are close to those associated with smoking I Increasing more rapidly O for teens and young children I Obesity 0 Is growing rapidly in developing nations Obesity and Disordered Eating Patterns I Obesity and and night eating syndrome I Occurs in 715 of treatment seekers I Occurs in 27 of individuals seeking bariatic surgery I Patients are wide awake and do not binge eat I Causes I Obesity is related to technological I Genetics account for about 30 obesity cases I Biological and psychosocial factors contribute as well I Treatment I Moderate success with adults I greater success with children and adolescents I Treatment progression from least to most intrusive options Summary of Eating Disorders
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