ABNORMAL PSYCHOLOGY PSYC 3443
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ll DISORDER Sleep Disorders Two major types Dyssomnias difficulties getting enough sleep problems with sleeping when you want to complaints about quality of sleep Parasomnias abnormal behavior or physiological events during sleep such as nightmares and sleepwalking Assessment Polysomnograph includes respiration EEG EOG ECG Sleep efficiency percentage of time spent falling asleep vs lying in bed trying to sleep Dyssomnias Primary Insomnia difficulties fallingstaying asleep or with restorative sleep not related to other medical or psychiatric disorders II39Il UU Can be caused by a range of biological eg body andor about sleep factors which likely interact Primary Hypersomnia abnormally excessive sleep Narcolepsy sleep disorder involving sudden and irresistible sleep attacks Cataplexy a sudden loss of muscle tone Sleep paralysis awakening of the mind with muscle paralysis Hypnagogic hallucinations vivid quotdreamsquot characterized by visual and other sensory ie touch hearing physical sensations information Narcolepsy occurs in approximately 03 16 of the population equal sex distribution Other Sleep Disorders Breathingrelated disorders Sleep apnea obstructive CNS mixed Circadian Rhythm disorders Disturbed sleep as a result of difficulty synchronizing with patterns of day and night Medical Treatment of Sleep Disorders Insomnia Benzodiazepines eg flurazepam addictive so don t want longterm use reactive with substances like alcohol because they re both inhibitors HypersomniaNarcolepsy Stimulants eg methylphenidate Breathingrelated disorders Weight loss CPAP Circadian Rhythm Disorder Phototherapy Psychological Treatments CBT effective for Treating Insomnia Education Behavioral PMR Paradoxical intention Stimulus control Sleep hygiene Cognitive beliefs about sleep Other disorders no effective interventions Parasomnias Nightmares frightening dream during REM Sleep terrors occur during NREM sleep not caused by frightening dreams Somnambulism sleep walking occurs during NREM sleep CHAPTER 12 SCIIIIOPIIRENIA AND RELATED DISORDER Nature Ol Schizophrenia and Psychosis An Overview Schizophrenia vs Psychosis Psychosis broad term referring to hallucinations andor delusions May occur in the context of other psychological disorders not just schizophrenia Schizophrenia a type of psychosis with disturbed thought language and behavior Psychosis and Schizophrenia are heterogeneous Schizophrenia The quotPositivequot Symptom Cluster The Positive Symptoms Active manifestations of abnormal behavior distortions of normal behavior Examples include delusions hallucinations and disorganized speech Delusions Disordered Thought Content Gross misrepresentations of reality Examples include delusions of grandeur or persecution Hallucinations Auditory or Visual mostly Experience of sensory events without environmental input Can involve all senses auditory visual tactile olfactory gustatory The nature of auditory and visual hallucinations findings from SPECT studies amp Broca s area Schizophrenia The quotNegativequot Symptom Cluster The Negative Symptoms Absence or insufficiency of normal behavior Examples are emotionalsocial withdrawal apathy and poverty of thoughtspeech Spectrum of Negative Symptoms Avolition or apathy refers to the inability to initiate and persist in activities Alogia refers to the relative absence of speech Anhedonia lack of pleasure or indifference to pleasurable activities Affective flattening show little expressed emotion but may still feel emotion Schizophrenia The quotDisorganizedquot Symptom Cluster The Disorganized Symptoms Include sever and excessive disruptions in speech behavior and emotion Examples include rambling speech erratic behavior and inappropriate affect Nature of Disorganized Speech Cognitive speech refers to illogical and incoherent speech Tangentiality llgoing off on a tangent and not answering a question directly Loose associates or derailment taking conversation in unrelated directions Nature of Disorganized Affect Inappropriate emotion behavior crying when one should be laughing Nature of Disorganized Behavior Includes a variety of unusual behaviors Catatonia spectrum from wild agitation waxy flexibility to complete immobility Diagnosis of Schizophrenia Two or more positive symptoms negative symptoms andor disorganized portion Last for most days for at least 1 month Lots of variability with little overlap in symptoms Individuals with schizophrenia vary widely from each other Subtypes of Schizophrenia Paranoid Type Intact cognitive skills and affect and do not show disorganized behavior Hallucinations and delusions center around a theme grandeur or persecution The best prognosis of all types of schizophrenia Disorganized Type Marked disruptions in speech and behavior flat or inappropriate affect Hallucinations and delusions have a theme but tend to be fragmented This type develops early tends to be chronic tacks periods of remissions Catatonic Type Show unusual motor responses and odd mannerism echolalia echo words echopraxia echo movements This subtype tends to be sever and quite rare Undifferentiated Type quotWastebucketquot category Major symptoms of schizophrenia but fail to meet criteria for another type Residual Type One past episode of schizophrenia Continue to display less extreme residual symptoms odd beliefs Other Disorders with Psychotic Features Schizophreniform Disorder Schizophrenic symptoms for a few months Associated with good premorbid functioning most resume normal lives Schizoaffective Behavior Symptoms of schizophrenia and a mood disorder are independent of one another Prognosis is similar for people with schizophrenia Such persons do not tend to get better on their own Delusional Disorder Delusions that are contrary to reality without other major schizophrenia symptoms Many show other negative symptoms of schizophrenia Type of delusions include erotomanic grandiose jealous persecutory and somatic Events could be happening unlike schizophrenia but aren t This condition is extremely rare with a better prognosis than schizophrenia Brief Psychotic Disorder Experience one or more positive symptoms of schizophrenia Usually precipitated by extreme stress or trauma Tends to remit on its own Shared Psychotic Disorder Delusions from one person manifest in another person Little is known about this condition Schizotypal Personality Disorder May reflect a less severe form of schizophrenia Schizophrenia Some Facts and Statistics Onset and Prevalence of Schizophrenia worldwide About 02 to 15 or about 1 population Usually develops in early adulthood but can emerge at any time average age is 25 Schizophrenia is generally chronic Most suffer with moderatetosevere impairment throughout their lives Life expectancy in persons with schizophrenia is slightly less than average Premorbid phase before 1st psychotic episode 9 active phase positive symptoms active 9 residual phase often negative symptoms still present repetitive cycle of active then residual phases Schizophrenia affects males and females about equally Females tend to have a better longterm prognosis Onset of schizophrenia differs between males and females Schizophrenia appears to have a strong genetic component Schizophrenia Etiology and Treatment Causes ofSchizophrenia Findings from Genetic Research Family Studies Inherit a tendency for schizophrenia not a specific form of schizophrenia Other family members are at increased risk of schizophrenia Twin Studies Risk of schizophrenia in monozygotic twins is 48 Risk of schizophrenia drops to 17 for fraternal twins Adoption Studies Risk of schizophrenia remains high in adopted children with a biological parent suffering from schizophrenia Summary of Genetic Research Risk of schizophrenia increases as a function of genetic relatedness One need not show symptoms of schizophrenia to pass on relevant genes Schizophrenia has a strong genetic component but genes alone are not enough Causes of SchizophreniaNeurotransmitter In uences Neurobiology and Neurochemistry The Dopamine Hypothesis Drugs that increase dopamine agonists result in schizophreniclike behavior Drugs that decrease dopamine antagonists reduce schizophrenialike behavior Examples include neuroleptics and LDopa for Parkinson s disease The dopamine hypothesis proved problematic and overly simplistic Current theories emphasize several neurotransmitters and their interaction Causes of Schizophrenia Other Neurobiological Influences Structural and functional abnormalities in the brain Enlarged ventricles and reduced tissue volume Hypofrontality less active frontal lobes a major dopamine pathway Viral infections during early prenatal development The relation between early viral exposure and schizophrenia is inconclusive F quot about quot39mand quot r Schizophrenia is associated with diffuse neurobiological dysregulation Structural and functional abnormalities in the brain are not unique to schizophrenia Causes of Schizophrenia Psychological and Social Influences The Role of Stress May activate underlying vulnerability andor increase risk of relapse Family Interactions Families of people with schizophrenia show ineffective communication patterns High expressed emotion hostility criticism intrusiveness in the family is associated with relapse The Role of Psychological Factors Psychological factors likely exert only a minimal effect in producing schizophrenia Medical Treatment of Schizophrenia Historical Precursors Antipsychotic Neuroleptic Medications Medication treatment is often the first line treatment for schizophrenia Began in the 1950s Most reduce or eliminate the positive symptoms of schizophrenia Acute and permanent extrapyramidal and Parkinson slike side effects are common Tardive dyskinesia Compliance with medication is often a problem Psychosocial Treatment ofSchizophrenia Historical Precursors Psychosocial approaches Overview and goals Behavioral token economies on inpatient units Social and living skills training Behavioral family therapy Vocational rehabilitation Psychosocial approaches are usually a necessary part of medication therapy Dissociative Feelings Depersonalization feeling detached from oneself or one s body Derealization feelings of unreality outside objects change shape or size people seem mechanical Dissociative Identin Disorder Multiple personalities identities or quotaltersquot At least 2 distinct identities with own pattern take Unable to recall important information Onset usually in childhood average 15 personalities Prevalence 5 to 1 Characteristic that are high suggestible Dissociative Disorders Depersonalization Disorder Feeling detached from own body or mind in a dream Dissociative Amnesia Generalized amnesia lose all memory including own identity Localized selective amnesia lose memory of specific events usually traumatic during particular period of time Dissociative Fugue Unexpected travel associated with loss of memory Lose memory of own past may assume new identity Dissociative Trance Disorders Trance or I 39 with 39 39 39 39 state in culture Causes Biological vulnerability Twin studies do not support genetic vulnerability to DID Psychological factors Trauma is precipitating events repeated trauma or extreme trauma for DID Child abusechild sexual abuse high risk Suggestibility or ability to autohypnotize False memories Treatment Amnesia amp Fugue Usually get better on their own May help recall events or present information and help integrate into conscious experience Hypnosis and benzodiazepines to aid in recall of events DID No controlled studies of treatment limited success Exposure treatment using PTSD model extinguish cues triggering anxiety and dissociation May use hypnosis to bring memories into conscious awareness CHAPTER 13 DEVEIOPMEN39I39AI DISORDER Attention Deficit Hyperactivity Disorder ADHD An Overview Nature ofADHD Central features inattention overactivity and impulsivity Associated with behavioral cognitive social and academic problems DSMIV and DSMlVTR Symptom Clusters Cluster 1 symptoms of inattention lnattentive subtype Cluster2 ofI r 39 39 and39 I 39 39 r 39 imlsiu subtype Either cluster 1 or 2 must be present for diagnosis Can be combined subtype inattentive amp hyperactiveimpulsive ADIID Facts and Statistics Prevalence Occurs in 412 of children who are 6 to 12 years of age Symptoms are usually present around age 3 or 4 68 of children with ADHD have problems as adults Gender Differences Boys outnumber girls 4 to 1 ADIID Etiology Genetic heritability is very high 80 Neurological dysfunction Comorbidity with learning disorders conduct problems Overall small brain volume frontal cortex basal ganglia cerebellar vermis No evidence of food colors preservatives as causal Maternal smoking during pregnancy is risk factor More negative interaction patterns with parents and teacher appear to be result of ADHD not cause Probability of ADHD diagnosis is greatest in the United States ADHD Treatment Biological treatment through stimulant medication Ritalin or Concerta methylphemidate Cylert pemoline and Dexedrine Damphetamine Adderall Nonstimulant Straterra Medication effects directly target poor attention amp concentration most effective method but do not target social problems Side effects are a concern but with careful monitoring can be minimized Approximately 2530 do not respond to medication Psychological Treatment Behavior Therapy parent training contingency management at home and in school socials s kills training problemsolving anger control Coordination of treatment at home amp school works best Behavior Therapy has the best effect on reducing inappropriate behaviors improving social functioning improving academic functioning in shortterm Combination Treatments MTA study 5 sites over 5 years compared medication alone BT alone and combination treatment Best outcome on the widest number of areas is with 39 39 39 but quot had best specific effect on increasing attention Learning Disorders An Overview Scope of Learning Disorders Problems related to academic performance in reading mathematics and writing Performance is substantially below what would be expected based on cognitive ability DSMIV and DSMlVTR Reading Disorder Discrepancy between actual and expected reading achievement Reading is at a level significantly below that of a typical person of the same age Problems cannot be caused by sensory deficits poor vision Although may learn to read fluency and comprehension may still not be at expected level DSMIV and DSMlVTR Mathematics Disorder Achievement below expected performance in mathematics DSMIV and DSMlVTR Disorder of Written Expression Achievement below expected performance in writing Learning Disorders Some Facts and Statistics Incidence and Prevalence of Learning Disorders 1 to 3 incidence of learning disorders in the United States Prevalence is highest in wealthier regions of the United States Prevalence rate is 10 to 15 among school age children Reading difficulties are the most common of the learning disorders About 32 of students with learning disabilities drop out of school School experience for such persons tends to be quite negative Causes of Learning Disorders Genetic Component Concordance rate among identical twins almost 100 Chromosome 6 and 15 Neurological deficits complex varied High comorbidity with ADHD but distinct 3050 of those with ADHD have at least 1 learning disorder 3050 of those with a learning disorder have ADHD Treatment of Learning Disorders Requires Intense Educational Interventions Remediation of basic processing problems teaching visual skills Improvement of cognitive skills instruction in listening Targeting behavioral skills to compensate for problem areas Data support Behavioral Educational Interventions for learning disorders Americans with Disabilities Act and Rehabilitation Act require reasonable accommodations for students with disabilities to ensure equal access to education DEVElOPMEITAl DISORDER Pervasive Developmental Disorders An Overview Nature of Pervasive Developmental disorders Problems occur in language socialization and cognition Pervasive means the problems span the person s entire life Examples of Pervasive Developmental Disorders Autistic disorder Asperger s syndrome Treatment of Autism and other PDD s focuses upon Acquisition of language skills Improving quality of social interactions Acquiring greatest possible functional skills The Nature ofAutistic Disorder An Overview Autism Significant impairment in social interactions and communication Restricted patterns of behavior interest and activities Three Central DSMIV and DSMlVTR Features of Autism Problems in socialization and social function Problems in communication 50 never acquire useful speech Restricted patterns of behavior interests and activities Autistic Disorder Facts and Statistics Prevalence and Features of Autism Rare condition Affecting 2 to 20 persons for every 10000 people but prevalence is increasing incredibly Autism occurs worldwide Symptoms develop before 36 months of age Autism and Intellectual Functioning 50 have le in the severtoprofound range of mental retardation 25 test in the mildtomoderate IQ range IQ of 50 to 70 Remaining people display abilities in the borderlinetoaverage IQ range Better language skills and IQ test performance predict better lifetime prognosis Increasing Prevalence 1966 epidemiological study Lotter 1966 4510000 05 2002 review of recent studies 60 per 10000 autism spectrum disorders 6 8 to 30 per 10000 for autistic disorder 3 Probably reasons for increase Identification of children with higher and lower intelligence Broadening and refining of criteria General awareness of the disorder Diagnosing disorder in children with other difficulties Asperger s Disorder Part of he Autistic Spectrum The Nature of Asperger s Disorder Such persons show significant social impairments Restricted and repetitive stereotyped behaviors May be clumsy and are often quite verbal pedantic or overly formal speech Do notshow severe delays in language and other cognitive skills Prevalence of Asperger s Disorder Often underdiagnosed Affects about 1 to 36 persons per 10000 people Causes of Autism Spectrum Disorders Significant genetic component Families with autistic child have 35 risk of having a second child with autism rate in general population is 0205 Possiblyprobably neurological dysfunction High rate of MR clumsiness abnormal posture or gait Abnormally small cerebellum No evidence for psychosocial causes Poor parenting does not lead to autism or related disorders no llrefrigerator mothersquot Treatment Specialized behavioral techniques using shaping discrimination training reinforcement to teach small steps Communication speech sign language use or picture board Socialization eye contact some limited social behavior does not usually result in quotnormalquot relationships friends Intensive early intervention shows significant and in some cases dramatic treatment 2040 hrswk beginning before age 6 2 years This is the most important and best treatment for the disorder Support for family Mental Retardation MR And Overview Nature of Mental Retardation Belowaverage intellectual and adaptive functioning Range of impairment varies greatly across persons Mental Retardation and the DSMIV and DSMIVTR Significantly subaverage intellectual functioning IQ below 70 Concurrent deficits or impairments in two or more areas of adaptive functioning MR must be evident before the person is 18 years of age DSMIV and DSMltIVltTR Levels ofMental Retardation MR Mild MR 85 Includes persons with an IQ score between 50 or 55 and 70 Moderate MR 10 Includes persons in the IQ range of 3540 to 5055 Severe M R 34 Includes people with IQs ranging from 2025 up to 3540 Profound MR 12 Includes people with IQ score below 2025 Other Classification Systems for Mental Retardation MR American Association of Mental Retardation AAMR Defines MR based on levels of assistance required Examples of levels include intermittent limited extensive or pervasive assistance Classification of MR in Education Systems Educable mental retardation IQ of 50 to approximately 7075 Trainable mental retardation IQ of 30 to 50 Severe mental retardation IQ below 30 Implications of Different MR Classification Systems Mental Retardation MR Some Facts and Statistics Prevalence About 1 to 3 of the general population 90 of MR persons are labeled with mild mental retardation Gender Differences MR occurs more often in males maletofemale ratio of about 61 Course of MR Tends to be chronic but prognosis varies greatly from person to person Biological Causes Genetic only about 30 cases of MR Tuberous sclerosis rare but 60 have MR PKU restricted diet til age 7 since unable to break down phenylalanine LeschNyhan syndrome Chromosomal abnormalities Down syndrome trisomy 21 extra 21st chromosome Fragile X syndrome Psychological amp Social Causes Culturalfamilial retardation 70 cases of MR mild to moderate MR Combination of biological and psychological factors Abuse neglect social deprivation Treatment of MR Goal of maximizing functioning Select reasonable goals for areas of functioning Selfcare dressing feeding self Communication Social skills Tasks of daily living transportation buying groceries Cognitive skills developed as appropriate read write make change Use behavioral techniques to teach skills shaping repeated trials reinforcement Individuals with MR have higher rate of other psychological disorders depression psychosis COGNITIVE DISORDER Nature ofCognitive Disorders Perspectives on Cognitive Disorders Cognitive processes such as learning memory and consciousness are impaired Most develop later in life Three Classes of Cognitive Disorders Delirium Often temporary confusion and disorientation Dementia Degenerative condition marked by broad cognitive deterioration Amnestic disorders Memory dysfunctions caused by disease drugs or toxins Delirium An Overview Nature of Delirium Central features impaired consciousness and cognition Impairments develop rapidly over several hours or days Examples include confusion disorientation attention memory and language deficits Facts and Statistics Affects 10 to 30 of persons in acute care facilities Most prevalent in older adults AIDS patients and medical patients Full recovery often occurs within several weeks Medical Conditions related to Delirium Medical Conditions Drug intoxication poisons withdrawal from drugs Infections head injury and several forms of brain trauma Sleep deprivation immobility isolation and excessive stress DSMIV subtypes of Delirium Delirium due to a general medical condition Substanceinduced delirium Delirium due to multiple etiologies Delirium not otherwise specified Dementia An Overview Nature of Dementia Gradual deterioration of brain functioning Affects judgement memory language and advanced cognitive processes Dementia has many causes and may be reversible or irreversible Progression of Dementia Initial stages Memory impairment visuospatial skills deficits Agnosia inability to recognize and name objects most common symptoms Facial agnosia inability to recognize familiar faces Other symptoms delusions depression agitation aggression and apathy Progression of Dementia Later stages Cognitive functioning continues to deteriorate Person requires almost total support to carry out daytoday activities Death results from inactivity combined with onset of other illnesses Dementia Facts and Statistics Onset and Prevalence Can occur at any age but most common in the elderly Affects 1 of those between 6574 yea rs of age Affects over 10 of persons 85 years and older 47 of adults over the age of 85 have dementia of the Alzheimer s type Incidence of Dementia Affects 23 of those 7579 years of age and 85 of persons 85 and older Rates of new cases appear to double with every 5 years of age Gender and Sociocultural factors Dementia occurs equally in men and women Dementia occurs equally across education level and social class DSMlV and DSMlVTR Classes of Dementia Dementia of the Alzheimer s type Vascular Dementia Dementia due to other General Medical Conditions SubstanceInduced Persisting Dementia Dementia due to Multiple Etiologies Dementia Not Otherwise Specified Dementia of the Alzheimer s Type DSMlVTR Criteria and Clinical Features Multiple cognitive deficits that develop gradually and steadily Predominant impairment in memory orientation judgment and reasoning Can include agitation confusion depression anxiety or combativeness Symptoms are usually more pronounced at the end of the day Range of Cognitive Deficits Aphasia Difficulty with language Apraxia impaired motor functioning Agnosia Failure to recognize objects Difficulties with planning organizing sequencing or abstracting information An Autopsy is required for a Definitive Diagnosis Alzheimer s Disease Facts and Statistics Nature and Progression of the Disease Deterioration is slow during the early and later stages but rapid during middle stages Average survival time is about 8 years Onset usually occurs in the 60s or 70s but may occur earlier Prevalence of Alzheimer s Disease Affects about 4 million Americans and many more worldwide Prevalence is greater in poorly educated persons and women Prevalence rates are low in ethnic groups Japanese Nigerian Amish Vascular Dementia An Overview Nature of Vascular Dementia Progressive brain disorder caused by blockage or damage to blood vessels Second leading causes of dementia next to Alzheimer s Onset s often sudden stroke Patterns of impairment are variable and most require formal care in later stages DSMIV Criteria and Incidence Cognitive disturbances that are identical to dementia Unlike Alzheimer s obvious neurological signs of brain tissue damage occur Incidence is believed to be about 47 of men and 38 of women Causes of Dementia The Example ofAlzheimer s Disease Current Neurobiological Findings Neurofibrillary tangles occur in all brains of Alzheimer s patients Amyloid plaques accumulate excessively in brains of Alzheimer s patients The role of amyloid proteins Brains of Alzheimer s patients tend to atrophy Multiple genetic abnormalities implicated in Alzheimer s Summary of Cognitive Disorders Cognitive Disorders span a range of deficits Attention memory language and motor behavior Causes include medical conditions drug use or environmental factors Most Cognitive disorders result in progressive deterioration of functioning Few Treatments exist to reverse pattern of damage and resulting deficits Depression common Family support may be crucial PERSOIAII39I39Y DISORDER Personality Disorders An Overview The nature of personality and personality disorders Enduring and relatively stable predispositions ways of relating and thinking Predispositions are inflexible and maladaptive causing distress andor impairment Coded on Axis II of the DSMIV and DSMlVTR Not diagnosed until over 18 years old Categorical vs Dimensional Views of personality disorders DSMIV and DSMlVTR Personality Disorder Clusters Cluster A Odd or eccentric cluster paranoid schizoid Cluster B Dramatic emotional erratic cluster antisocial borderline Cluster C Fearful or anxious avoidant obsessivecompulsive Personality Disorders Facts and Statistics Prevalence of Personality Disorders About 05 to 25 of the general population Rates are higher in inpatient and outpatient settings Origins and Course of Personality Disorders Thought to begin in childhood Tend to run a chronic course if untreated CoMorbidity rates are high Gender Distribution and Gender bias in Diagnosis Gender bias exists in the diagnosis of personality disorders Cluster A Paranoid Personality Disorder Overview and Clinical Features Pervasive and unjustified mistrust and suspicion The Causes Biological and psychological contributions are unclear May result from early learning that people and the world is a dangerous place Treatment options Few seek professional help on their own Treatment focuses on development of trust Cognitive therapy to counter negativistic thinking Lack good outcome studies showing that treatment is efficacious Cluster A Schizoid Personality Disorder Overview and Clinical Features Pervasive pattern of detachment from social relationships Very limited range of emotion in interpersonal situations The Causes Etiology is unclear Preference for social isolation in schizoid personality resembles autism Treatment Options Few seek professional help on their own Focus on the value of interpersonal relationships empathy and social skills Treatment prognosis is generally poor Cluster A Schizotypal Personality Disorder Overview and Clinical Features Behavior and dress is odd and unusual Most are socially isolated and may be highly suspicious of others Magical thinking ideas of reference and illusions are common Risk for developing schizophrenia is high in this group Many also meet criteria for major depression The Causes Schizoid quot A 39 ofa quot 39 39 genotype 1 I n r Left hemisphere and more generalized brain deficits Treatment Options Main focus is on developing social skills Treatment also addresses comorbid depression Medical treatment is similar to that used for schizophrenia Treatment prognosis is generally poor Cluster B Antisocial Personality Disorder Overview and Clinical Features Failure to comply with social norms and violation of the rights of others Irresponsible impulsive and deceitful Lack of conscience empathy and remorse Relation between Psychopathy and Antisocial Personality Disorder Relation between ASPD Conduct Disorder and Early Behavior Problems Many have early histories of behavioral problems including conduct disorder Many come from families with inconsistent parental discipline and support Families often have histories of criminal and violent behavior Neurobiological Contributions and Treatment of Antisocial Personality Prevailing Neurobiological Theories Brain damage Little support for this view Underarousal hypothesis Cortical arousal is too low Cortical immaturity hypothesis Cerebral cortex is not fully developed Fearlessness hypothesis Psychopaths fail to respond with fear to danger cues Gray s model of behavioral inhibition and activation neurobiological dysfunction Reward system overrides the behavioral inhibition system Treatment Few seek treatment on their own Antisocial behavior is predictive of poor prognosis even in children Emphasis is placed on prevention and rehabilitation Often incarceration is the only viable alternative Cluster B Borderline Personality Disorder Overview and Clinical Features Patterns of unstable mood and relationships Impulsivity fear of abandonment coupled with a very poor selfimage Selfmutilation and suicidal gestures are not uncommon Most common personality disorder in psychiatric settings Comorbidity rate are high More often diagnosed in females than males sexist effect Men more likely to be diagnosed with bipolar disorder The Causes Borderline personality disorder runs in families Early trauma and abuse seem to play etiologic role Treatment Options Few good treatment outcome studies Antidepressant medications provide some shortterm relief Dialectical behavior therapy is the most promising psychosocial approach Uses mindfulness awareness of emotions nonjudgmentally Cluster B Histrionic Personality Disorder Overview and clinical Features Patterns of behavior that are overly dramatic sensational and sexually provocative Often impulsive and need to be the center of attention Thinking and emotions are perceived as shallow Common diagnosis in females The Causes Etiology is largely unknown ls histrionic personality a sextyped variant of antisocial personality Treatment Options Few good treatment outcome studies Treatment focuses on attention seeking and longterm negative consequences Targets may also include problematic interpersonal behaviors Little evidence that treatment is effective Cluster B Narcissistic Personality Disorder Overview and Clinical Features Exaggerated and unreasonable sense of self importance Preoccupation with receiving attention Lack sensitivity and compassion for other people Highly sensitive to criticism Tend to be envious and arrogant The Causes Link with early failure to learn empathy as a child Sociological view Narcissism as a product of the llmequot generation Treatment Options Extremely limited research Treatment focuses on grandiosity lack of empathy unrealistic thinking Treatment may also address cooccurring depression Little evidence that treatment is effective Cluster C Avoidant Personality Disorder Overview and Clinical Features Extreme sensitivity to the opinions of others Highly avoidant of most interpersonal relationships Are interpersonally anxious and fearful of rejection The Causes Numerous factors have been proposed Early Development A difficult temperament produces early rejection Treatment Options Several wellcontrolled treatment outcome studies exist Treatment is similar to that used for social phobia Treatment targets include social skills and anxiety Cluster C Dependent Personality Disorder Overview and Clinical Features Excessive reliance on others to make major and minor life decisions Unreasonable fear of abandonment Tendency to be clingy and submissive in interpersonal relationships The Causes Still largely unclear Linked to early disruptions in learning independence Treatment Options Research on treatment efficacy is lacking Therapy typically progresses gradually Treatment targets include skills that foster independence Cluster C ObsessiveCompulsive Personality Disorder Overview and Clinical Features Excessive and rigid fixation on doing things the right way Tend to be highly perfectionistic orderly and emotionally shallow Obsessions and compulsions are E The Causes Are largely unknown Treatment Options Data supporting treatment are limited Treatment may address fears related to the need for orderliness Other targets include rumination procrastination and feelings of inadequacy lEGAl AID l39l39lIICAl IS Mental Health and the Legal System An Overview A variety of legal and ethical issues exist in regard to mental health and abnormal psychology The nature of civil vs criminal commitment Balancing ethical considerations vs legal considerations The role of psychologists in legal matters Expert witnesses forensic psychology Rights of patients and research subjects Practice standards and the changing face of mental health care Civil Commitment Overview Criteria and Oversight Authority Civil Commitment Laws Address legal declaration of mental illness Address when a person can be placed in a hospital or institution for treatment Such laws and what constitutes mental illness vary by state quotMental illness means a substantial disorder of thought mood perception psychological orientation or memory that significantly impairs judgment behavior capacity to recognize reality or ability to meet the ordinary demands of life Dangerous to Self or Others Central to Commitment Proceedings Assessing dangerous The role of mental health professionals Knowns and unknowns about violence and mental illness Civil Commitment General Criteria for Civil Commitment Demonstrate that a person has a mental illness and need treatment often exclude substance useabuse Show that the person is dangerous to self or others Bias based on gender raceethnicity Predicting groups with higher likelihood of dangerous behavior vs predicting individual s likelihood of dangerous behavior Establish a grave disability inability to care for self Governmental Authority Over Civil Commitment Police power protection of the health welfare and safety of society Parens patriae state acts a surrogate parent Civil Commitment Changes Supreme Court cases prohibit confinement of nondangerous person who is capable of surviving by self or with help of willing amp responsibly family or friends More restrictive commitment laws may result in mentally ill beingjailed for criminal offenses Deinstitutionalization movement led to increase in homelessness rate Of the 2535 million homeless 2530 are mentally ill Lack of community mental health facilities to replace large inpatient hospitals The Civil Commitment Process Initials Stages OK Protective custody Emergency Evaluation lt12 hours Emergency Detention lt72 hours Subsequent Stages Involve normal legal proceedings in most cases Determination is made by a judge regarding whether to commit the person Criminal Commitment Insanity Defense M Naghten Rule do not know nature amp quality of act performing or did not know act was wrong Irresistible impulse even if aware that act was wrong no longer had power to choose between right and wrong lacked free agency Durham Rule was criminal act the result of mental disorder American law Institute Standard because of mental illnessdefect must lack capacity to understand criminality of behavior or to avoid it M Naghten amp Irresistible impulse but cannot be result of antisocial or repeated criminal behavior Insanity Defense Reform Act 1984 ifdue to mental illness or mental retardation unable to appreciate wrongfulness of conduct at the time of the offense Diminshed capacity mental illness can diminish ability to understand nature and impact of one s behavior issue of intent Public perception of frequency of insanity defense and the time of hospitalization is highly inaccurate Fewer than 1 cases use insanity defense Length of hospitalization often longer than prison term if had been convicted of the crime Guilty but mentally ill convicted but either go to prison or mental hospital or combination of 2 sentence given Competency to Stand Trial Must be able to participate in own defense understand the legal proceedings Typically sent to mental facility for treatment if regain competency may then be brought to trial or may never be brought to trial Patient s Rights An Overview The Right to Treatment Mentally ill persons cannot be involuntarily committed without treatment Treatment includes active efforts to reduce symptoms and provide humane care The Right to the Least Restrictive Alternative Treatment within the least confining and limiting environment The Right to Refuse Treatment Often in cases involving medical or drug treatment Persons cannot be force to become competent via taking antipsychotic medication The Right to Confidentiality vs Duty to Warn Confidentiality Protection of disclosure of personal information Limits to confidentiality Duty to Warn Tarasoff Suspicion of neglect or abuse of children or llvulnerable adults Court order Releases of Information The Right to Informed Consent Nature of treatment proposed Condition of treatment including confidentiality Alternative to treatment Research Participant Rights An Overview The Right to be Informed about the Research Involved informed consent not simply consent alone The Right to Privacy The Right to be Treated with Respect and Dignity Right to be Protected from Physical and Mental Harm Right to Choose or to Refuse to Participate in Research without Negative Consequences Right to anonymity with regard to reporting of study finding Right to safeguarding of records Clinical Practice Guidelines and Standards Agency for Health Care Policy and Research Focus on delivery of efficient and costeffective mental health services Dissemination of relevant stateoftheart information to practitioners Establish clinical practice guidelines for assessment and treatment II39IA g sPractIce American quot quot quot Standards for clinical efficacy research Standards for clinical effectiveness research Examples include APA Division 12 list of empiricallysupported treatments