Lecture 1 & 2 - Psyc38 PDF

Lecture One → Diagnosis: Conceptual Issues and Controversies “A psychiatric classification system helps to organize the bewildering subforms of abnormality. Such a system, if effective, permits us to parse the variegated universe of psychological disorders into more homogeneous, and ideally more cl...

Lecture One → Diagnosis: Conceptual Issues and Controversies “A psychiatric classification system helps to organize the bewildering subforms of abnormality. Such a system, if effective, permits us to parse the variegated universe of psychological disorders into more homogeneous, and ideally more clinically meaningful, categories (Lilienfeld, Smith & Watts, 2017).” CLASSIFICATION VS. DIAGNOSIS ​ A system of classification → An overarching taxonomy of mental illness ○​ Main classification system – DSM-5 is used in North America ○​ ICD used elsewhere ​ Same approach though ​ Diagnosis → Act of placing an individual, based on BOTH signs and symptoms into a category within that taxonomy ○​ You put more emphasis on symptoms when doing an diagnosis SIGNS VS SYMPTOMS ​ Signs → Observable indicators (e.g., crying in a depressed patient) ○​ Behavioral response that tells you what's going on inside – you can see these ​ Symptoms → Subjective indicators (e.g., feelings of guilt in a depressed patient) ○​ Things that people report to you → I feel guilty, unworthy, hopeless SYNDROME VS DISORDER VS DISEASE ​ Syndrome → Constellations of signs and symptoms that co-occur across individuals (e.g. antisocial personality disorder) ○​ Depression → sadness is typically co-occurring w feelings with appetite disturbance and etc – is there some reason that these signs and syndromes are co-occurring ​ Disorder → Syndromes that cannot be readily explained by other conditions (e.g. OCD) ○​ If you have low mood, sleep disturbance, low energy, no appetite and you have thyroid dysfunction then that's thyroid dysfunction → you can’t have any other explanation for these symptoms maybe it is a mental health condition. ○​ Not the best way to do diagnosis → easy to focus on the numbers and 5/9 criteria of this disorder and ignore the other reasons that these other symptoms might exist (if u never had thyroid tested) or if u had a traumatic experience – easy to start focusing on signs and symptoms and failing to account for other things ​ Disease → Disorders in which pathology and etiology are reasonably well understood (e.g. sickle-cell anemia) ○​ Sickle cell anemia → low energy is a symptom; biological conditions for the most part are thought of as diseases ○​ You know the cause and the symptoms well → degenerative diseases like Alzhiemers ○​ As soon as you understand the underlying biology, it becomes a neurological condition if not then it is a mental health/mental illness “With the possible exception of Alzheimer’s disease and a handful of other organic conditions, the diagnoses in our present system of psychiatric classifications are almost exclusively syndromes or, in rare cases, disorders (Kendell & Jablensky, 2003).” FUNCTIONS OF PSYCHIATRIC DIAGNOSIS ​ 1. Diagnosis as communication ○​ It provides a convenient medium for communicating about a condition, and it summarizes information to aid in other professionals’ understanding of a case. ○​ Easier to communicate a diagnosis ​ 2. Establishing linkages with other diagnoses 1  ○​ Locates a patient’s problems within the context of both more and less related diagnostic categories (e.g. social anxiety disorder and specific phobia are both classified as anxiety disorders in the DSM-5) ○​ Diagnosis also links to other potential diagnoses or other things that might be going on with an individual → anxiety disorders for example are closely related to each other – social anxiety, GAD, phobias – but they all fall under the global umbrella of fear, threat disorders ​ 3. Provision of surplus information ○​ A valid diagnosis generates surplus information regarding a diagnosed patient’s clinical profile, laboratory findings, an individual’s response to treatment, natural history, family history, and potential information regarding endophenotypic indicators. ○​ Gives us extra information about the person → when you see same symptoms across people, you also see that the things that make you at risk for developing thse things are also similar → for example, depression – some sort of negative life event; majority of depressive episodes are started this way ○​ Schizophrenia → previous life traumas are common in 80-100% of people with schizophrenia; what is the abuse history? ○​ What is the problem with this? It is very stereotypical, you start to assume but for example in schizophrenia case - for 20% of patients, the assumption is incorrect ○​ Have to use diagnosis very carefully – can use it to guide but not to stereotype DEFINING MENTAL DISORDER ​ Statistical Model ○​ Disorder has to be statistically rare, disorders are infrequent in the general population – challenge is where do you make that cut off? Is it 10%, 1% → more challenging when you think about mental health illness and its prevalence. ○​ Disadvantages: ​ No guidelines for cutoff between abnormality and normality ​ Silent on the crucial question of which dimensions are relevant to abnormality ​ Assumes all common conditions are normal (Wakefield, 1992) ​ Subjective Distress Model ○​ Core feature of mental disorders is psychological pain experienced by a person – doesn't matter if it's rare – is this upsetting to the person? Yes – then mental health disorder ○​ Disadvantage: ​ Fails to distinguish ego-dystonic conditions (those that conflict with one’s self-concept) → (these produce distress, example is depression) from ego-syntonic conditions (those that are consistent with one’s self-concept) → (example is anorexia) ​ In some ego-syntonic conditions, individuals do not see their behavior as problematic (e.g., antisocial personality disorder). ​ Fails to distinguish how long and how intense the distress is ​ Biological Model ○​ Disorder defined in terms of biological (or evolutionary) disadvantage to an individual (e.g., increased risk for suicide in depressed patients, Joiner (2006)). ○​ Mental health disorder that confers a disadvantage to passing on your genes ○​ Disadvantage: ​ Some behaviors incur such disadvantages but are not disorders (e.g., military combat). ​ Some disorders do not incur long-term decrease in evolutionary fitness but are disorders (e.g., specific phobia) ​ Need for Treatment ○​ Disorder is any condition that is characterized by a need for medical intervention by a health professional (Kraupl Taylor, 1971) ○​ Disadvantage: 2  ​ Many mental disorders, such as schizophrenia are indeed viewed as necessitating treatment. ​ However, some conditions require medical intervention but are not necessarily disorders (e.g., pregnancy) ​ Harmful Dysfunction → MOST COMMON DEFINITION ○​ Disorders are harmful dysfunctions: socially devalued (harmful) breakdowns of evolutionarily selected systems (dysfunctions) (Wakefield, 1992) ○​ Has to be within your social realm – has to be a break down of an evolutionary effective system (something that is beneficial to you) ○​ This fits more because relies less on subjective distress if it’s socially devalued (ex; someone with schizophrenia) – they can't work anywhere, makes them unable to function in society ○​ Disadvantage: ​ Such operationalization of disorder acknowledges that most disorders are negatively perceived by others. However, rudeness and racism are also negatively perceived, but do not constitute a disorder. ​ Many medical disorders are adaptive defenses against threat or insult (e.g., vomiting in the flu). Similarly, many psychological conditions are adaptive reactions to threat ​ Combination of statistically frequent and subjective models ​ Roschian Analysis – dont need to know in lots of detail ○​ Concept of mental disorder lacks defining features and possesses intrinsically fuzzy boundaries ○​ At the fuzzy boundaries of disorder is where controversies concerning whether a psychological condition is really a disorder more frequently arise ○​ Disadvantage: ​ Even if the Roschian analysis is correct, the absence of an explicit definition of mental disorder, doesn’t imply that specific mental disorders themselves are not amenable to scientific inquiry PSYCHIATRIC CLASSIFICATION FROM DSM-I TO THE PRESENT ​ DSM-I (APA, 1952): First clear attempt at describing major psychiatric diagnoses in one manual, facilitating interrater reliability among clinicians and researchers. ​ DSM-II (APA, 1968): Similar in scope to DSM-I; greater detail concerning signs and symptoms of disorders ​ Major criticisms: ○​ Low interrater reliability for many of the diagnoses ○​ Not theoretically agnostic; influenced heavily by psychoanalytic concepts of disorders, and Adolph Meyer (1966-1950) ○​ Neglected consideration of contextual factors that can influence etiology and maintenance of psychopathology (e.g., co-occurring medical disorders and life stressors) ​ DSM-III (APA, 1980) and Beyond ○​ Dramatically increased coverage of disorders and detailed guidelines for making diagnoses. ○​ Standardized Diagnostic Criteria ​ Signs and symptoms of each disorder explicitly delineated ○​ Algorithms and Decision Rules for Diagnoses ​ Highly structured guidelines for number of symptoms and combinations of symptoms that must be met for a diagnosis ○​ Hierarchical Exclusions Rules ​ “Think organic” – reminding diagnosticians to rule out potential physical causes of mental disorders before diagnosing them ○​ Improved interrater reliability ​ Though development of structured and semistructured diagnostic interviews – Structured Clinical Interview for DSM ○​ Multiaxial Approach 3  ​ Evaluations along series of axes (e.g., Axis I – major mental disorders, Axis II – personality disorders) ​ Forced a holistic approach to diagnoses Dropped in DSM-5 due to lack of high-quality scientific evidence (APA, 2013) ○​ Theoretical Agnosticism ​ Agnostic with respect to etiology of disorders (with exception of posttraumatic stress disorder) ​ Permits use of the manual by practitioners of many different theoretical backgrounds ​ Facilitated scientific progress, by allowing researchers to compare which theoretical orientations most scientifically supported explanations for specific disorders (Wakefield, 1998). ​ DSM-III-R and DSM-IV ○​ Retained major features/innovations of DSM-III ○​ Gradual move to a polythetic approach to diagnosis ○​ Potential disadvantage of polythetic approach is extensive heterogeneity at the symptom and etiological levels ○​ Many argue that this disadvantage is outweighed by higher interrater reliability of the polythetic approach (Widger, Frances, Spitzer, & Williams, 1991) ○​ Relaxation of many DSM-III’s hierarchical exclusion rules (Pincus, Tew, & First, 2004) ○​ DSM-IV added appendix for culture-bound syndromes (e.g., koro and taijin kyofusho) ​ DSM-5 ○​ Published in May 2013 (APA, 2013) / DSM-5-TR (APA, 2022) ○​ Retained most of major categories of DSM-IV ○​ Dropped multiaxial system introduced in DSM-III ○​ Attempted to decrease proliferation of new diagnoses by necessitating rigorous validity data for new diagnoses ○​ Already widely criticized, such as for lowering diagnostic threshold for several diagnostic categories (Batstra & Frances, 2012a) ○​ Further criticized for inadequate field trials focusing on clinical feasibility and interrater reliability, rather than validity of new diagnostic categories or effects of altering extant categories on prevalence of disorders (Frances & Widiger, 2012) CRITICISMS OF CURRENT CLASSIFICATION SYSTEM ​ Comorbidity ○​ High levels of co-occurrence and covariation among many diagnostic categories ○​ One disorder may lead to others; two disorders may mutually influence each other, or both may be different expressions of the same underlying liability ○​ May result from overlapping diagnostic criteria or clinical selection bias (du Fort, Newman, & Bland, 1993) ○​ Although comorbidity is frequent among all mental disorders, it is especially common in personality disorders (Widiger & Rogers, 1989) ○​ Often underestimated in clinical practice (Zimmerman & Mattia, 2000) ○​ May be attaching multiple labels to different manifestations of the same underlying condition ​ Medicalization of Normality ○​ Increased number of diagnoses in DSMs, especially DSM-5 Lowered threshold for extant diagnoses in DSM-V (e.g., increasing age of onset and decreasing proportion of symptoms) ○​ May reflect splitting of broad diagnoses into narrower subtypes (Wakefield, 2001) rather than increased coverage ○​ DSM-V also practiced lumping of narrower diagnostic categories into broader ones (e.g., lumping autistic disorder, Asperger’s disorder, and childhood disintegrative disorder, into autism spectrum disorder) ​ Low Reliability of Diagnoses 4  ○​ You would hope that your diagnosis should be the same if ur using the same manual – but in actuality it is very bad ○​ Increased number of diagnoses in DSMs, especially DSM-5 ○​ Lowered threshold for extant diagnoses in DSM-V (e.g., increasing age of onset and decreasing proportion of symptoms) ○​ May reflect splitting of broad diagnoses into narrower subtypes (Wakefield, 2001) rather than increased coverage ○​ DSM-V also practiced lumping of narrower diagnostic categories into broader ones (e.g., lumping autistic disorder, Asperger’s disorder, and childhood disintegrative disorder, into autism spectrum disorder) INTER-RATER RELIABILITY OF DSM-5 DIAGNOSES ​ The graph is a correlation chart ​ Which has the highest reliability vs the lowest? ○​ Highest – major neurocognitive disorder, ptsd, complex somatic symptoms disorder revised ​ Why? Major neurocognitive disorder – is not quite a biological test we can do but you can do neuropsychological tests – not fully neurology but as close to neuro as it can get → not fully objective and subjective ​ Ptsd → for PTSD u need a big traumatic event ○​ Lowest – mild TBI, OCPD, MDD, APD, GAD, mild ADD CRITICISMS OF CURRENT CLASSIFICATION SYSTEM ​ Unsupported Retention of a Categorical Model ○​ DSM is exclusively categorical at measurement level- individuals either meet a diagnostic criteria for a disorder or not ○​ Problematic due to growing evidence that many DSM diagnoses are underpinned by dimensions rather than taxa ○​ Measuring most disorders dimensionally almost always results in higher correlations with external validating variables, compared to measuring categorically (Craighead, Sheets, Craighead, & Madsen, 2011) DIMENSIONAL APPROACHES ​ Very useful – maybe more than lumping people together ​ Growing evidence for dimensionality of many psychiatric conditions ​ Many suggest using sets of dimensions from personality science to aid in psychiatric diagnosis (Krueger et al., 2011; Widiger & Clark, 2000) ○​ Five-Factor Model (FFM; Goldberg, 1993) ​ However, there is disagreement due to lack of demonstrable clinical feasibility, and about nature and number of personality dimensions to be used ​ Distinction between basic tendencies and characteristic adaptations is often neglected (Harkness & Lilienfeld, 1997) ​ Personality dimensions may not be sufficient by themselves to capture full variance in psychopathology DIMENSIONAL APPROACHES ​ HiTop → THE HIERARCHICAL TAXONOMY OF PSYCHOPATHOLOGY ○​ Most current ○​ Know how HiTop works ○​ What diseases share common characterizations? ○​ HiTop doesn't take a theoretical approach, takes a data approach – people with MDD score like those with GAD and PTSD in terms of scores → what is being said is look at the data and then from there you create groups → this makes sense ○​ Can this be applied in a clinic? Doesn’t seem to much different than our current classification system – because you still end up back at diagnostic categories ​ RDoC ○​ Developed by the National Institute of Mental Health (NIMH) in the United States. 5  ○​ Project to create a framework for research on pathophysiology, especially for genomics and neuroscience, which ultimately will inform future classification schemes. ○​ RDoC Units of Analysis ⇒ Genes, Molecules, Cells, Circuits, Physiology, Behavior ○​ Rdoc works well for guiding research but does nothing for a person at an everyday clinical level → Purely research RDOC DOMAINS ​ Domains reflect contemporary knowledge about major systems of emotion, cognition, motivation, and social behavior. ○​ Negative Valence Systems are primarily responsible for responses to aversive situations or context, such as fear, anxiety, and loss. ○​ Positive Valence Systems are primarily responsible for responses to positive motivational situations or contexts, such as reward seeking, consummatory behaviour, and reward/habit learning. ○​ Cognitive Systems are responsible for various cognitive processes. ○​ Systems for Social Processes mediate responses in interpersonal settings of various types, including perception and interpretation of others’ actions. ○​ Arousal/Regulatory Systems are responsible for generating activation of neural systems as appropriate for various contexts and providing appropriate homeostatic regulation of such systems as energy balance and sleep. ○​ Sensorimotor Systems are primarily responsible for the control and execution of motor behaviours, and their refinement during learning and development CATEGORICAL DIAGNOSIS ​ DSM 5 is the least bad option that we currently have CONTINUUM OF EXPERIENCE ​ Where the line is and where the box is, separate from each other, is not clear and is blurry – changes with more information we receive → mood exists on a continuum – has the most positive mood ever on one side and most negative on the other side, same for anxiety ​ Psychosis – hearing voices, UNDERSTANDING MENTAL HEALTH ​ Biological ⇒ Genetics Neurotransmitters Neural Function Physiology ​ Psychological ⇒ Cognitive Emotional Behavioural ​ Social Interpersonal relationships ⇒ Sociocultural context Environment Lecture Two → GAD & PTSD GENERALIZED ANXIETY DISORDER ​ SYMPTOMS AND DIAGNOSTIC CRITERIA ○​ Excessive worry occurring on more days than not about a number of events, activities, or topics – fear and worry across multiple domains of a person's life ○​ Must persist for at least 6 months ○​ Increased frequency, intensity, and the individual’s perceived inability to control the worry distinguish the worries in GAD from normal worries – is this worry occurring outside of another disorder? Do you have periods of time where the mood disorder remits but the anxiety is still there? If the anxiety is till there within the context of another disorder, it's not GAD – probs a feature of that other disorder. ○​ Per DSM-5 cannot make diagnosis if worry is better explained by another mental disorder, and if excessive worry occurs only during the course of a disorder from the following categories: ​ 1. Depressive disorders ​ 2. Bipolar and related disorders ​ 3. Psychotic disorders ​ DIAGNOSIS: COMORBIDITY 6  ○​ 80% of respondents with a principal GAD diagnosis also had a comorbid mood disorder (Judd et al., 1998) ○​ Current principal diagnosis of GAD is highly comorbid with other disorders: ​ Panic disorder with or without agoraphobia (42%) ​ Social phobia (42%) ​ Major depressive disorder (MDD) (29%) (Brown et al., 2001) ○​ Rates of personality disorders are also elevated in GAD including: ​ Avoidant (26%) – not to approach things, goes hand in hand with GAD ​ Paranoid (10%) ​ Schizotypal (10%) (Brawman-Mintzer et al., 1993) ​ NEUROBIOLOGY ○​ Individuals with GAD and other anxiety disorders may have diminished GABA activity (Friedman, 2007) ○​ Norepinephrine also implicated in GAD, but data regarding its role in GAD are mixed ○​ Serotonin (5-HT) also broadly implicated, with studies suggesting that low levels of serotonin/serotonin receptor dysfunction, particularly in the midbrain region, are linked with increased anxiety (Nikolaus, Antke, Beu, & Müller, 2010). However overall findings have also been inconclusive ○​ Some evidence of overproduction of cortisol in GAD exists, though research findings are again inconclusive (Tiller, Biddle, Maguire, & Davies, 1988) ​ PSYCHOPHYSIOLOGY ○​ Individuals with GAD have demonstrated lower heart rate variability during period of worry and rest, decreased parasympathetic activity during period of worry and reset (Thayer, Friedman, & Borkovec, 1996), and impaired habituation of heart rate activity to neutral words (Thayer, Friedman, Borkovec, Molina, & Johnsen, 2000) – don't get as much of a change between the ups and down. When GAD ppl r at rest, there is higher baseline increase but that also means there isn't much of a dramatic increase in the anxious situation ○​ Suppressed and rigid autonomic activity that is associated with worry may have implications for the maintenance of worry, providing individuals with short-term avoidance of physiological responses to stress, but impairing long-term adaptation to stressors ○​ Many inconsistencies across research, and further investigation needed ​ INFORMATION PROCESSING BIASES IN WORRY ○​ Individuals with GAD interpret ambiguous stimuli as threatening, and have biases in memory for threatening events ○​ Individuals with GAD take longer to name the colors of threatening words than non threatening words on an emotional Stroop paradigm (Mathews & MacLeon, 1985) ​ EMOTIONAL STROOP ○​ Couch, fight, lamp, argue ○​ Read the colour of the word ○​ See an enhancement of the Stroop task for the threatening words for people with GAD ​ INFORMATION PROCESSING BIASES IN WORRY ○​ Also demonstrate attentional bias on the visual dot-probe task in response to threat words (MacLeon, Mathews, & Tata, 1986), negative words (Mogg, Bradley, & Williams, 1995), emotional faces (Bradley et al., 1999) and aversive pictures (MacNamara & Hajcak, 2010) ○​ What side of the screen did the dot show up at? What you tend to see → if your attention is on the left side and the dot is there, then you are faster at saying it is on the left but if its on left and it shows up on right, you are slower at responding cus you have to shift your eyes to the right side → put up chair and war on the screen – GAD ppl more drawn to the threat based word; when the words disappear and the dot comes up, they respond faster if it is on the side with the threat word and slower if it the dot shows up where the neutral word is. ​ AVOIDANCE THEORIES OF WORRY 7  ○​ College students who meet diagnostic criteria for GAD report more use of worry to distract themselves from emotional topics (Borkovec & Roemer, 1995) ○​ Self-report worriers avoid anxiety-provoking images even when instructed to attend to them (Laguna, Ham, Hope, & Bell, 2004) ​ INTOLERANCE OF UNCERTAINTY ○​ Intolerance of uncertainty is a cognitive filter through which a person with GAD views her/her world (Dugas, Buhr, & Ladouceur, 2004) ○​ Experimental manipulation has shown that increasing participants’ level of intolerance of uncertainty leads to increased catastrophic worrying and low mood (Meeten, Dash, Scarlet, & Davey, 2012) ​ METACOGNITION AND GAD ○​ Act of thinking about one’s thought processes ○​ Positive beliefs that a person holds about worry cause him/her to actively select worry as a coping strategy when faced with a stressor. ○​ Type 1 worry is activated (typical worry-everyday events) ○​ If process of worry is not terminated because a felt sense that the person will be able to cope with stressor is not present, then Type 2 worry is activated (worry about worry) ○​ Modern version of CBT for GAD → model that has the best efficacy for helping ppl w this disorder ○​ Focus on 2 types of cognition → metacognition (thinking about our thinking rather than the content) ○​ Positive meta beliefs → why is this worry helpful? Keep me safe? I don’t have control over it ○​ Negative meta beliefs → why is this worry negative? ○​ Behavior → doing something to stop the worrying – substances ○​ Thought control → thought stopping; white elephant – can use distraction to stop thinking about it but this isn't long term – diffusion mindfulness works better for the long and short term worry – let the worry exist but don't engage ○​ Emotions → emotion tied with the trigger; anxiety, fear – more ur worried more it impacts you ​ ENVIRONMENTAL AND FAMILY FACTORS ○​ Relationship between perceived parental alienation and rejection on the one hand and GAD symptoms in a sample of community adolescents on the other (Hale, Engels, & Meeus, 2006) ○​ College students who endorsed criteria for GAD on a questionnaire, also endorsed less secure attachment to their parents than controls (Eng & Heimberg, 2006) ​ PSYCHOLOGICAL INTERVENTIONS ○​ CBT for GAD is the best-studied psychological intervention with good outcomes ○​ Most commonly used components of CBT for GAD treatment are: ​ 1. Psychoeducation ​ 2. Relaxation training ​ 3. Monitoring of cues and triggers for worry ​ 4. Imaginal exposure ​ 5. In vivo exposure (if necessary) ​ 6. Cognitive restructuring ​ RECENT ADVANCES IN CBT FOR GAD ○​ Specific CBT adaptations have targeted: ​ Intolerance of uncertainty ​ Metacognition ​ BIOLOGICAL INTERVENTIONS ○​ Research generally supports the effectiveness of benzodiazepines for GAD treatment (Anderson & Palm, 2006) ​ Benzodiazepines appear to reduce symptoms of worry, tension, and concentration in addition to the somatic features of GAD 8  ​ Can stop working though, they work intermittently but not constantly ​ Concerns for potential development of tolerance, dependence, and withdrawal symptoms ○​ SSRIs are identified as a first-line therapy for GAD (Baldwin et al., 2011) ○​ These are taken away after some time and you see what happens – do people stay well if they have achieved GAD. People with CBT and no meds are less likely to relapse – but ppl with the meds and therapy have a higher relapse rate though and the same rate as with meds. POST-TRAUMATIC STRESS DISORDER ​ PTSD contrasts to most other disorders in that it is a disorder of non-recovery – large number of ppl with very traumatic events, dont acc develop ptsd (majority don’t) the natural course is recovery – if that natural course doesn’t happen then it's PTSD ​ One of the few disorders in which researchers and clinicians can pinpoint the genesis of the disorder and can study risk and resilience factors as people grapple with some of life’s worst events ​ Strongest emotions, biological reactions, thoughts, and escape-and- avoidance behaviors occur during and soon after the traumatic event ​ Those who are eventually diagnosed with PTSD do not typically develop greater symptoms over time; rather, they stall out in their recovery DSM-5 DIAGNOSTIC CRITERIA OF PTSD ​ Criterion A ⇒ An individual must have experienced, witnessed, or learned about the traumatic event of a loved one, or have experienced repeated exposure to the aftermath of traumas, such as the experiences of first responders ​ Criterion B ⇒ An individual must exhibit at least one of the intrusion symptoms, which include persistent and distressing memories of the trauma, recurrent distressing nightmares about the traumatic event, dissociative reactions (e.g., flashbacks), and intense psychological or physiological responses when exposed to cues (internal or external) that resemble the trauma ​ Criterion C ⇒ The individual must also exhibit at least one of the avoidance symptoms: effortful avoidance of internal cues ​ Criterion D ⇒ The individual must exhibit two or more of the negative cognitions and mood symptoms; these symptoms reflect the range of affect, from numbing and amnesia (and inability to have positive feelings) to strong negative emotions such as guilt, anger, or fear; distorted self-blame or erroneous blame of others who did not cause or intend the event; and negative beliefs about self, others, and the world as a consequence of the traumatic event ​ Criterion E ⇒ The individual must also meet at least two of the arousal and reactivity symptoms, which include sleep difficulties, concentration impairment, exaggerated startle response, and hypervigilance, but also irritable or aggressive behaviors and reckless or self-destructive behavior GENDER DIFFERENCES ​ Women nearly three times as likely as men to have a lifetime diagnosis (9.7% to 3.6%; Kessler et al., 2005) ​ When type of trauma is controlled, women still appear to exhibit higher rates of PTSD, suggesting that risk of exposure to particular types of trauma only partially explains the differential PTSD rates in men and women. COMORBIDITY ​ PTSD had the highest and most diverse rate of comorbid disorders (over 90%) ​ Most frequent: ○​ i. Major depressive disorder (77%) ○​ ii. Generalized anxiety disorder (38%) ○​ iii. Alcohol abuse/dependence (31%) ​ Substance abuse disorders and antisocial personality load on the externalizing dimension ​ Mood and anxiety disorders load on the internalizing dimension HYPOTHALAMIC-PITUITARY-ADRENAL (HPA) AXIS ​ Corticotropin-releasing factor (CRF) promotes the release of norepinephrine from the locus coeruleus as well as the release of corticotropin (ACTH) from the pituitary gland 9  ​ This promotes release of cortisol and other glucocorticoids from the adrenal cortex ​ Vietnam veterans with PTSD have been shown to have elevated resting levels of cerebrospinal fluid CRF (Baker et al., 1999; Bremner et al., 1997), and enhanced hypothalamic release of CRF BIOLOGICAL FACTORS: BRAIN STRUCTURES ​ Brain regions implicated in PTSD are also associated with fear conditioning and extinction: ○​ i. Amygdala ○​ ii. Medial prefrontal cortex (mPFC) ○​ iii. Anterior cingulate cortex (ACC) ○​ iv. Hippocampus ​ Positive association between PTSD severity and increased amygdala responsivity, such that individuals with PTSD demonstrate hyperresponsivity to both trauma-related and trauma- unrelated emotional material (Shin, Rauch, & Pitman, 2006) ​ Memory based disorder because it is focused on that memory EMOTIONAL FACTORS ​ Two types of emotional responses involved in PTSD ○​ Primary emotions ⇒ Conditioned during the traumatic event (e.g. fear, helplessness, horror) ○​ Secondary emotions ⇒ Result from post hoc consideration of the traumatic event (e.g. anger, shame, sadness) – thinking back – survivors guilt ​ Secondary is what produces the block COGNITIVE AND EMOTIONAL FACTORS ​ Ehlers and Clark (2000) have focused on the apparent paradox of memory in PTSD, such that someone with PTSD may have trouble intentionally accessing his or her memory of the event but have involuntary intrusions of parts of it ​ Since memory encoded at the time of the trauma is poorly elaborated and integrated with other memories, this might explain why people with PTSD may have poor autobiographical memory and yet may be triggered to have memory fragments that have a here-and-now quality ○​ If you don't have a clear memory – you have biases that might play a role in filling in memory ​ In response to the perceptions of threat, people with PTSD adopt various maladaptive coping strategies, depending on their appraisals ​ These maladaptive strategies, most often avoidance behaviors, may: ○​ 1. Increase symptoms ○​ 2. Prevent change in negative appraisals ○​ 3. Prevent change in the trauma memory. ​ Social-cognitive theorists have observed that traumatic events dramatically alter basic beliefs about the self, the world, and others SCHEMAS ​ Shorthand for processing what happened – can be an accurate reflection or biased reflection → somewhat related to schemas that are present before the traumatic event – can reinforce the previous bad schema (i'm a whore that's why i was assaulted) ​ Information-processing structures that allow one to make sense of the world ​ Difficulties with adaptation following traumatic events result if previously positive schemas are disrupted by the experience or if previous negative schemas are seemingly confirmed by the experience. ​ 3 major assumptions that may be shattered in the face of a traumatic event: ○​ 1. Personal invulnerability, ○​ 2. The world as a meaningful and predictable place ○​ 3. The self as positive or worthy ​ McCann, Sakheim, and Abrahamson (1988) proposed six major areas of functioning, either self- or other-focused, that can be disrupted by traumatic victimization: (1) agency, (2) safety, (3) trust, (4) power/control, (5) esteem, and (6) intimacy ​ Resick (1992) proposed that when traumatic events conflict with prior beliefs, those affected have three possibilities: 10  ○​ 1. Altering their interpretations of the event in an attempt to maintain previously held beliefs (assimilation) ○​ 2. Altering their beliefs just enough to accommodate the new information (accommodation) ○​ 3. Changing their beliefs drastically (overaccommodation) ​ Others proposed that cognitions of people with PTSD fall into two classes: ○​ 1. The world is dangerous ○​ 2. The person himself or herself is completely incompetent BEHAVIORAL FACTORS ​ Avoidance behaviors have been implicated in maintenance of PTSD symptoms ​ Many of the symptoms and disorders that develop along with PTSD may develop as attempts to avoid the intrusive images and strong emotions ​ Many traumatic events elicit anger, sadness, guilt, and horror, which are overwhelming, which may trigger escape, avoidance, and numbing PSYCHOSOCIAL TREATMENT ​ Research suggests that psychotherapy is effective for the treatment of PTSD ​ Meta-analyses have indicated large effect sizes overall ​ Cognitive-behavioral therapy (CBT) has the most evidence supporting its efficacy and has demonstrated the largest effect size COGNITIVE BEHAVIORAL THERAPY ​ Exposure interventions include exposure to the trauma memory, as in imaginal exposure, or through exposure to trauma-related stimuli in the environment (in vivo exposure) ​ For recovery from trauma to occur, the affected person must be able to activate his or her trauma memory, block the negative reinforcement that occurs with escape and avoidance behavior, habituate to anxiety, and disconfirm erroneous beliefs ​ Exposure to both trauma memories and real-life situations, teaches the individual to discriminate true danger cues from false alarms and past experiences from the present ​ Prolonged exposure also addresses the cognition and memory issues theorized to underlie PTSD by helping patients organize their trauma memory in a coherent way → forces you to confront the memory of that trauma different forms – audio, rhythmic, talking ​ Cognitive processing therapy targets unhelpful and inaccurate ways of thinking (schemas) that occur following trauma, including assimilation and over-accommodation ​ CPT also targets five cognitive content areas that tend to be affected in PTSD: safety, trust, power/control, esteem, and intimacy ​ CPT has established efficacy in the treatment of PTSD and depression in a variety of traumatized populations ​ Both CPT and PE are considered trauma-focused therapies EYE MOVEMENT DESENSITIZATION AND REPROCESSING ​ Goal of EMDR is to help the patient process trauma-related information, with the use of side-to-side eye movements (or other forms of stimulation such as hand tapping or auditory stimuli) that are theorized to help enhance information processing ​ Several studies have shown that eye movement desensitization and reprocessing (EMDR) is more effective than wait-list control conditions in treatment of PTSD ​ Although EMDR may lead to improvements in PTSD symptoms, there is much debate surrounding the active ingredients of EMDR that are considered responsible for improvements PHARMACOLOGICAL TREATMENT ​ Class of antidepressant: sertraline and paroxetine (FDA approved) are selective serotonin reuptake inhibitors (SSRIs) ​ SSRIs are considered to be the front-line pharmacological treatment for PTSD in various clinical practice guidelines ​ Generally effective, however not all are equally effective 11