PSY 183 Midterm Study Guide PDF

PSY183 Fall 2024 Midterm Exam Fair-Game Sheet * will NOT need to know numerical percentages or prevalences History and Basic Concepts Ways of defining psychopathology (e.g., “four D’s”) Deviant: behaviors, thoughts, and emotions that are different from those that are considered “normal”...

PSY183 Fall 2024 Midterm Exam Fair-Game Sheet * will NOT need to know numerical percentages or prevalences History and Basic Concepts Ways of defining psychopathology (e.g., “four D’s”) Deviant: behaviors, thoughts, and emotions that are different from those that are considered “normal” ○ Can vary across cultures and societies ○ Just because something is common doesn’t mean it is normal Distressful: behaviors, ideas, emotions that cause distress Dysfunctional: inability, efficiency, maladaptation; interferes with daily functioning ○ Upsets, distracts, confuses so that people cannot care for themselves properly, interact socially, or work productively Dangerous: behavior is dangerous to oneself or others ○ Consistently, careless, hostile, placing themselves or others around them at risk Characteristics of “eccentrics” and whether they have mental disorders Eccentrics: people who deviate from common behavior patterns or displays odd or whimsical behavior Characteristics include: nonconformity, creativity, strong curiosity, idealism, extreme interests and hobbies, lifelong awareness of being different, high intelligence, outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others’ opinion/company, mischievous humor, nonmarriage, eldest or only child, poor spelling skills Behaviors are chosen freely and provides pleasure → they do not have mental disorders (typically) Trephination A primitive surgical procedure of boring a hole into the head; done to “release the demons from their brains” Humoral theory Hippocrates believed that we had 4 main bodily fluids in which an excess determined our state Blood: an excess of blood makes someone cheerful; sanguine temperament Yellow bile: an excess of yellow bile means someone is trigger happy or easily provoked to anger; choleric temperament Black bile: an excess of black bile means someone is melancholic, dark, brooding; melancholic temperament Phlegm: phlegmatic temperament, or non-reactive, calm Asylums In the middle of the 16th century, people with mental disorders were warehoused in asylums with filthy conditions and cruel care  The mentally ill were treated like animals, provided “treatment” such as being restrained in a crib until they calmed down Demonological view The idea that those who acted strangely or were abnormal were actually possessed by demons in their brain during the Middle Ages Demonic possession was treated by trephination or baking the head in the oven Witches were also individuals who had been possessed by demons ○ Women were less intelligent and fickle, thus more susceptible ○ Diagnosed by dipping witches in water to see if the purity of the water would reject her, or simply torturing them until they confessed ○ Witches were executed Moral treatment Introduced by Philippee Pinel, the idea of moral treatment was to help patients with sympathy and kindness ○ Provide them with medical care, good food, ensuring they get exercise, etc. ○ Led patients on walks through the countryside Dorothea Dix also started a movement towards legal rights and protection for those with mental disorders + to establish state hospitals Types of treatments for mental disorders in early 20th century The State Hospital Era: people with mental disorders were housed in state hospitals, in which they took part in maintaining the grounds ○ Self-serving idea of putting people to work as therapy ○ The mentally ill were called lunatics Pyrotherapy: inducing malaria in patients with dementia paralytica to produce a fever, curing mild to moderate cases as well as halting disease in severe cases → fever chambers Insulin Coma therapy: patients were induced with a coma to be kept at the state of being at the brink of death Metrazol Shock therapy: convulsions were induced in patients, since it was observed that patients with depression, mania, or psychosis were better for a period of time after their seizures Electroconvulsive therapy (ECT): a remarkable treatment for depression done by humanely inducing a seizure, while monitoring and controlling it Prefrontal Lobotomy: inducing grand mal seizures by digging holes and taking portions out of the prefrontal brain area ○ Patients who came out alive were “calm and more pleasant” → custodian patients ○ Freeman and Watt’s transorbital (icepick) leucotomy: disconnect the prefrontal area by sticking icepick and pounding it into the prefrontal area above the eyes  The Thorazine Era: thorazine, the first major tranquilizer and later used as the first antipsychotic medication, was discovered ○ Used to sedate people and to provide relaxation ○ Put an end to the state hospital era, allowing patients to be maintained as outpatients without continued hospitalization → called a “chemical strait jacket” Somatogenic view Somatogenic view: abnormal psychological function is caused primarily by physical factors Krafft-Ebing’s discovery: syphilis is the cause of general paresis → perhaps physical factors are responsible for mental disorders ○ General paresis: disorder with both mental symptoms (delusions and hallucinations) and physical symptoms (paralysis) Wagner-Jauregg’s treatment for “general paresis”: transfusion from malarial patient to a general paresis patient, inducing a fever to treat dementia paralytica (syphilis in the brain) ○ First biomedical cure of a mental disorder The Treatment of Dementia Paralytica by Malaria Inoculation Psychogenic views of mental disorders Psychogenic view: primary causes of abnormal functioning is psychological Hysteria: hysterical disorders are mysterious bodily ailments that had no apparent physical basis Hypnotism: a mental process of hypnotic suggestion could cause and cure a physical dysfunction ○ Mesmerism: inducing a trancelike state in patients, causing symptoms to disappear Psychodynamic therapies: Sigmund Freund’s approach that unconscious psychological processes are at the root of abnormal and normal psychological functioning ○ Outpatient therapy: psychoanalytic treatment to patients in their offices for hour long sessions ○ Help patients gain insight to overcome psychological problems Biological views of mental disorders Psychotropic medications: drugs that primarily affect the brain and reduce symptoms of mental dysfunction ○ Antipsychotic drugs correct confused and distorted thinking ○ Antidepressant drugs lift the mood of depressed people ○ Antianxiety drugs reduce tension and worry Over-promising of medication effectiveness contributed to deinstitutionalization Deinstitutionalization: rationale and outcome Deinstitutionalization, the release of mentally ill from hospitals, was due to:  ○ The introduction of thorazine and other medications which were promised to be super effective ○ The cost of civil right lawsuits on state hospitals and the cost to run them ○ The overselling of community mental health approach as a cost-cutting solution This resulted in: ○ Massive discharge of severely mentally ill patients to unclear destinations → dumped on the street with no treatment → victimization ○ Shortage of psychiatric hospitals → sent to jail ○ Insufficient budgets allotted to establish community mental health facilities Rationale for multicultural psychology Arose due to shifts in immigration trends and high birth rates among minority groups Important in determining how culture, race, ethnicity, gender, and similar factors affect behavior and thought As well as how people of different backgrounds differ psychologically Types of professions in mental health Mental health practitioners: involved in direct patient care Mental health researchers Mental health advocacy groups Possible contributors to recent decline in young people’s mental health Increased social media use undermines self esteem because of social comparison Climate anxiety: towards the future state of our planet and environment Helicopter parents pressuring children’s experience of competition/failure/disappointment Education that disregards competitions leaving students unprepared for college Family and self imposed pressures to attend college rather than pursue alternatives Overpathologizing of normal reactions Decreased stigma surrounding mental disorders Managed care Dominant form of insurance consists of managed care programs: company determines which therapists its clients can choose, the cost of sessions, and the number of sessions they will be reimbursed for Therapists and clients dislike programs ○ Fear that programs shorten therapy, unfairly favor treatments with results that are not lasting, and treatments determined by company rather than by the therapist Reimbursements tend to be lower for mental disorders than physical disorders Research Methods in Psychopathology Advantages/disadvantages of: Clinical case studies (case histories): a detailed description of a person’s life and psychological problems ○ Advantages:  Provides individual information Source of new ideas about behavior, offers tentative support for a theory, serves to challenge a theory’s assumptions, shows the value of new therapeutic techniques, offers opportunities to study unusual problems ○ Disadvantages: Reported by biased observers, researchers who have stake in seeing their treatments succeed Relies on subjective evidence → low internal validity Provides little basis for generalization → low external validity Correlational methods: systematically observe the degree to which events or characteristics vary together; determine the co-relationship between variables and use statistical analysis ○ Advantages: Better generalizability to the general population → high external validity Provides causal information Replicable ○ Disadvantages: Correlations do not explain the relationship → lacking in internal validity Correlation ≠ causation Experimental methods: procedure in which a variable is manipulated and the manipulation’s effect on another variable is observed ○ Advantages: Provides general information → high external validity Provides causal information Replicable ○ Disadvantages: Prone to biases Liabilities of correlation in clinical studies Correlations in clinical studies allow researchers to describe the relationship between 2 variables, but they do not explain the relationship There may be outside factors or confounding variables that cause the result observed Correlations must be tested with a statistical analysis of their data: ask “how likely is it that these findings occurred by chance?” ○ p ≤ 0.05 Problems with current research practices WEIRD participants: a vast majority of research has been done on WEIRD populations (Western, Educated, Industrialized, Rich, Democratic) ○ Cultural differences and minorities are not studied Biases include experimenter bias and the Rosenthal effect  Conflicts of interest Replication issues Correlational studies: Epidemiological (cross-sectional): reveals how often a problem occurs in a particular population Longitudinal (developmental): researcher observe the same individuals on many occasions over a long period of time ○ Cannot directly manipulate the IV or randomly assign participants to conditions → can’t pinpoint causes ○ Reporting order of events → clues about which events are more likely to be causes vs. consequences Experimental studies: Experimental groups: the group receiving treatment or manipulation, exposed to the IV under investigation Control groups: the group not exposed to the IV; used to better determine the effect of the IV Participant assignment: selection procedures are used to ensure that participants are randomly assigned to either the experimental or control group Blind (masked) designs: an experimental strategy in which individuals are kept unaware of their assigned group to minimize participant and experimenter bias Experimenter bias: when experimenters’ expectations unintentionally transmit to participants in their studies ○ Rosenthal effect: unconscious bias exhibited by experimenters, such as confidence when administering the real drug versus hesitation when administering the placebo Naturalistic experiments: nature itself manipulates the independent variable; experimenter observes the effects ○ Used to study the psychological effects of unusual and unpredictable events Analogue experiments: inducing lab participants to behave in ways that seem to resemble real-life abnormal behavior and conduct experiments on them ○ Limitation: uncertain that phenomena observed in the lab are the same as the actual disorder being studied Single-subject experiments: a single subject is observed before and after the systematic manipulation of the IV ○ Rely first on baseline data gathered before manipulation ○ Limitation: unsure if participant reaction is typical or applicable to general population Epidemiological studies: Information is obtained though broad-population studies, such as through extensive surveys  Prevalence: the total number of cases of a disorder occurring in a population over a specific period of time Incidence: the number of new cases of a disorder occurring in a population over a specific period of time IRB’s, basic rights of research participants, and problems with “informed consent” Institutional Review Board (IRB): an ethics committee in a research facility that is empowered to protect the rights and safety of human research participants ○ Conduct risk-benefit analysis; the benefits of the study must outweigh its costs/risks Basic rights of research participants: ○ Participants enlist voluntarily and can end their participation in the study at any time ○ Participants are protected from physical and psychological harm ○ Participants have access to information about the study ○ Participants privacy is protected; confidentiality or anonymity Issues with informed consent: forms are too lengthy, as well as written at an advanced college level that makes them incomprehensible to many Assessment and Diagnosis DSM-5-TR conception of “mental disorder” A mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual Is associated with present distress, disability and dysfunction, and a significantly increased risk of suffering death, pain, loss of freedom Must not be merely an expectable and culturally sanctioned response to a particular event Mental disorders span brain diseases, behavior patterns, and troublesome or disagreeable conditions Philosophical viewpoints and their relevance for different conceptions of mental disorder Monism: the idea that the world is made of one stuff ○ Idealism: all “mental” ○ Materialism: all “physical” ○ Reductive materialism: all mental events are knocked down to material events Mental events are reduced to events in the brain → everything is understandable as the result of physiological mechanisms Mental disorders are brain disorders, identified by pathology and tissue damage Dualism: the idea that the physical and mental worlds are separate domains ○ The mind is different from the brain → mental disorders are not a part of the brain, but rather, an output from the brain ○ Mental disorders change the way we act and perceive, not the brain itself  The mind is to brain as a radio station is to a radio box ○ Mental disorders are disorders of mental processes, and don’t have to have a basis in the brain or out bodily processes Most psychiatrists doing psychopharmacology act as monists Most psychotherapists act as dualists Kraepelinian view on mental disorder nosology and his card sorting method Emil Kraepelin believed that all mental disorders were brain disorders; thus, should be treated like physical disorders Held an objective view, rather than using the content of people’s thinking Devised a method of using index cards to track characteristics of patients’ disorders, such as symptoms, course, how long they stayed, whether they recovered or not, etc. → scientific view of psychiatry Observed commonalities in how cards stacked up Relationship between nosology and diagnosis Nosology provides the framework and terminology that helps researchers systematically describe, categorize, and study diseases This classification system (nosology) offers standard definitions and criteria, which help in diagnosing conditions DSM (nosology) is used to match patient symptoms to disorder categories (diagnosis) Phenotypic vs. Genotypic diagnosis Phenotypic: the physical manifestations, including what we see and hear from the patient ○ Such as signs, symptoms, course, outcome, response to treatment Genotypic: the true causes, the causal change that leads to a mental disorder ○ Causes such as genes, germs, tissue abnormalities, etc. In physical medicine, the process consists of moving from phenotypic to genotypic diagnosis In mental health, nearly all diagnosis is phenotypic, with some endophenotypic evidence emerging Endophenotypic signs in diagnosis Endophenotypic signs: internal markers that suggest and tip you off to something genotypic going on Can be found through lab tests, subclinical biomarkers, behavioral tests, etc. Advantages and disadvantages of psychodiagnosis Advantages: ○ Prognosis to forecast outcome ○ Treatment implications ○ Communication among professions ○ Establish prospects for contagion or transmissions, and possible prevention ○ Legal reasons: claim competence, or insanity determination ○ Financial reasons: insurance, compensation to patient and/or treatment provider  ○ Research Disadvantages: ○ Sacrificing the uniqueness of individual patient ○ Can falsely imply etiology or cause: assuming [event] had to have happened because one has a certain disorder Ex: you have borderline personality → must have been assaulted as a kid ○ Drawing false causations: assuming that [event] caused a certain disorder ○ Rigidifies treatment alternatives Ex: your borderline personality is a result of you being assaulted as a kid ○ Iatrogenic illness: the act of being diagnosed results in the patient stigmatizing him or herself ○ Stigmatization from others around you, being trivialized for seeking mental health help ○ Secondary gains: aiming to get payoff from one’s disorder; can be both unconscious or conscious/strategic Kinds of information that go into a psychodiagnosis Symptoms, signs, course of illness, age of onset, family history (response to medication!!!), recent events and behaviors, psychological tests (sometimes), laboratory tests, and info on prior/current response to treatments Diagnosis is based on a pattern of signs and symptoms (a syndrome) ○ No single sign or symptom is pathognomonic (indicative) of a mental disorder → it’s always a pattern Clinical interview: kinds of information solicited or observed (signs and symptoms) Assess the patient’s current and past symptoms (onset, intensity) Observe signs from patient’s presentation, such as: ○ Physical characteristics: attire and grooming, posture, skin tone/complexion, weight/stature, symmetry/atrophy/bodily anomalies ○ Behavior: mannerisms, spasms or tics ○ Speech: articulation (is it crisp or slurred) and prosody (tone of voice) ○ General attitude Ex: defiant, compliant, guarded, defensive, sincere, resistant, apathetic, etc. ○ Emotional state: are they upbeat, hopeless, frustrated, etc. ○ Mental state: consciousness, such as level of alertness, fogginess, hypervigilance Thought content, which can be solicited by free inquiry Thought processes: delusions (false beliefs), hallucinations (false perceptions) Thought boundary violations: broadcasting, removal, insertion General knowledge Abstract thinking  Social judgment Insight Cognitive functioning: current mental status via brief screening Obtain personal and family history, such as parenting, early childhood events, education, abuse/neglect, substance use, any medical, social, occupational, or financial problems ○ Family history is important in diagnosis, as it influences the risk of specific mental disorders Obtain history of mental health involvement Obtain history of treatments (including psychotherapy and medications) that have worked/not worked in the past Done to assess suitability and readiness for psychotherapy → are they insightful and can they articulate that there is a problem? ○ Determine if there is a need for further referrals towards psychotropic medication, medical evaluation, neurological testing, etc. Assessment and Diagnosis (Cont’d) Basic diagnostic concepts: Nosology: science or scheme of disease categorization and classification, such the DSM-5-TR Diagnosis: the act of assigning a nosological category to a patient Signs: the observable markers, what you are able to see Symptoms: the patient reports, what the patient tells you Syndromes: signs + symptoms Prognosis: the ultimate outcome of the disorder Course of illness: the trajectory that the disorder takes Etiology: cause of disorder Comorbidity: experience or having 2 or more different disorders; illnesses that co-occur Cognitive tasks commonly used in the clinical interview Montreal Cognitive Assessment (MOCA) is used to scan for dementia, MCI, AD’s ○ Visuospatial/executive functioning, naming, memory, attention, language, abstraction, delayed recall, orientation, etc. ○ Cutoff score: Normal controls (NC): greater than or equal to 26 Mild cognitive impairment (MCI): less than 26 Alzheimer’s Disease (AD): less than 26 Clinical tests: nature of projective tests vs. personality/response inventories Clinical tests: used for gathering information about a person’s psychological functioning Projective tests: general, free response ○ Require clients to interpret vague stimuli or follow open-ended questions  ○ General clues and instructions → people “project” aspects of their personality onto the task ○ Used to gain supplementary insight, lacks reliability and validity ○ Biased against minority groups (ex: issues with representation of members in TAT pictures) Personality/response inventories: specific detailed information about oneself ○ Personality: patients are assessing themselves, answering questions about their behavior, beliefs, and feelings Indications of which statements apply to them → use responses to draw conclusions about their personality and psychological functioning Standardized Great test-retest reliability than other projective tests More validity than projective tests, but still not highly valid Cultural limitations between the implications of a response (is this a disorder or is it normal?) ○ Response inventories: focused on one specific area of functioning Used to determine the role these specific factors play in a person’s disorder Many have not been standardized or tested for reliability and validity Reliability / validity of diagnosis or assessment Reliability: measures the consistency of results ○ Test-retest reliability: how consistent are results every time it is administered ○ Interrater reliability: how consistent are results among different judges of scoring and interpretation Validity: measures the accuracy of results ○ Face validity: appearing to be valid because it makes sense/seems reasonable ○ Predictive validity: a tool’s ability to predict future characteristics or behavior ○ Concurrent validity: degree to which the measures of one tool agree with the measures of other assessments Overview of TAT and Rorschach administration, interpretation, and value Rorschach test: inkblots → what do they see, what it seems to be, what it reminds them of ○ Perceived images corresponds to their psychological condition ○ Attention should be paid to the themes and images seen, as well as the style of responses (are they focusing on the whole or details?) Thematic Apperception test (TAT): pictorial test showing black and white pictures of individuals in vague situations → tell a dramatic story ○ What is happening, what led up to this, what the people are feeling and thinking, what the final outcome is ○ Belief that people always identify with one of the characters on the card  ○ Stories reflect their own circumstances, needs, emotions General makeup of MMPI-2 (not specific scales) 500+ self-statements to be labeled “true,” “false,” “cannot say” Covers issues of physical concerns, to mood, sexual behaviors, and social activities Together, statements make up 10 clinical scales scored from 0-120 (in which a score of 70+ = deviant) Scale scores considered side by side reveal a pattern called a profile; indicates the person’s general personality Psychophysiological tests & polygraphy Psychophysiological tests: measure physiological responses as possible indicators of psychological problems Polygraph: electrodes attached to the body measure changes in breathing, perspiration, and heart rate while the person answers questions ○ Control questions (known yes or no) establish baseline → observe physiological reactions to test questions and compare Limitations in tuning and maintaining equipment ($$$) Lab equipment itself might arouse nervous system and change responses → can be inaccurate and unreliable Physiological responses tend to change with repeated measurements Major types of brain imaging (neuroimaging) Electroencephalogram (EEG): measures brain waves that result from electrical activity when neurons fire Computerized axial tomography (CT or CAT scan): x-rays of brain’s structure are taken at different angles and combined Positron emission tomography (PET scan): computer-produced motion picture of chemical activity throughout the brain Magnetic resonance imaging (MRI scan): magnetic property of hydrogen atoms creates a detailed picture of brain structure ○ Functional MRI (fMRI scan): MRI pictures are converted to neuron activity → picture of the functioning brain IQ testing and use of IQ Intelligence tests play a key role in diagnosis of intellectual disability Intelligence tests: series of tasks that require people to use verbal and nonverbal skills ○ Standardized on large groups of people → good idea of how each individual’s score compares with the population ○ High reliability: people receive approximately the same score years later ○ High validity: IQ scores correlate with other measures (academic achievement) Other factors that have nothing to do with intelligence can influence performance ○ Low motivation, high anxiety, cultural biases in language of tasks, etc. IQ: the general score derived from these assessments Neuropsychological tests Neuropsychological tests: measure cognitive, perceptual, and motor performances on certain tasks → abnormal performances are indicators of underlying brain problems ○ Brain damage is most likely to affect visual perception, memory, and visual-motor coordination → neuropsychological tests focus on these areas History, development and construction of DSM-5-TR – general principles and organization 1883: Emil Kraepelin developed first modern classification system → foundation for DSM Entries describe the criteria for diagnosing the disorder and key clinical features ○ Inclusion criteria: signs/symptoms that, if present, support the diagnosis ○ Exclusion criteria: signs/symptoms that, if present, counter the diagnosis Background information and research findings, age, culture, gender trends Prevalence, risk, course, complications, predisposing factors, and family patterns Organized into: ○ Categorical information: which disorder(s)? Can be diagnosed with more than one ○ Dimensional information: how extensive, how severe are symptoms? Mild, moderate, severe, etc. ○ Additional information: special psychosocial problems Z-codes are used to specify psychosocial situations Each diagnosis in the DSM-5-TR has a corresponding numerical code that is listed in the ICD-10 → state it! DSM-5-TR ≠ effective classification system Dimensional and ancillary information in DSM-5-TR Dimensional information: a rating of how severe a client’s symptoms are and how dysfunctional the client is across various dimensions of personality and behavior Ancillary information: additional information to support diagnoses ○ Info from family members: family history influences the risk of specific mental disorders ○ Info from physicians, employers ○ Medical record/chart if available ○ Previous psychological testing, and case summaries from previous therapists ○ Discharge summaries from hospital stays Evidence-based treatment guidelines Empirically supported or evidence-based treatment: a movement to help clinicians becomes more familiar with and apply research findings ○ Seeks to identify which therapies have received clear research support for each disorder ○ Propose corresponding treatment guidelines  Determining effectiveness of treatment requires defining success, measuring improvement, and considering the variety and complexity ○ People differ in problems, personal styles, motivations ○ Therapists differ in skill, experience, orientation, personality ○ Therapies differ in theory, format, and setting Psychotherapy: general effectiveness and meta-analysis Psychotherapy is more helpful than no treatment or than placebos Meta-analysis found that the average person who received treatment was better off than 75% of untreated persons ○ Many others have found similar relationships between treatment and improvement Common factors in effective psychotherapy, and the “rapprochement movement” Rapprochement movement: to identify a set of common factors or strategies that are present in all effective therapies Highly successful therapists: ○ Give feedback to clients ○ Help clients focus on their own thoughts and behavior ○ Pay attention to the way they and their clients are interacting ○ Promote self-mastery in their clients Pharmacogenomics Pharmacogenomics: how our genes affect the way we respond to medications Comorbidity Many people experience 2 or more different disorders Almost half of people in the US qualify for a DSM diagnosis during their lives ○ 18.7% one disorder ○ 10.4% two disorders ○ 17.3% three or more disorders If symptoms of another disorder are not at that level, diagnosis can also specify that they are experiencing features of another disorder Major Depression Cognitive/motivational vs. neurovegetative signs/symptoms of Major (Unipolar) Depression, and cultural specificity Cognitive signs/symptoms: ○ Pervasive sadness, tearfulness, excessive or inappropriate guilt, feelings of helplessness, emptiness, worthlessness ○ Recurrent thoughts of death (not just a fear of dying), suicidal ideation, or a suicide attempt or plan ○ Complaints about poor intellectual ability: not being able to remember things, easily distracted, unable to solve small problems  Motivational signs/symptoms: ○ Pervasive anhedonia: not feeling pleasure in doing things you enjoy ○ Loss of the desire to pursue their usual activities ○ A lack of drive, initiative, spontaneity ○ Have to force oneself to go to work, talk with friends, eat meals, have sex Neurovegetative (physical) signs/symptoms ○ Significant change in weight due to decreased or increased appetite Females likelier to experience increased appetite ○ Sleep disturbance: insomnia (insufficient) or hypersomnia (always sleepy) Females likelier to experience hypersomnia ○ Psychomotor agitation (can’t sit still) or retardation (inertia, leaden paralysis, can’t get going) Females likelier to experience retardation ○ Pervasive fatigue or loss of energy → difficulty thinking, concentrating, or making decisions Differences between cultures in expression of unipolar depression ○ Depressions differ between less-Westernized societies vs. more Westernized countries ○ All people show neurovegetative and cognitive signs ○ Western societies: predominance of feelings of guilt and “wretchedness” Differences may relate to early views of depression among Western religions: depression as a moral failing ○ Non-Western societies: more reference to physical complaints, or somatization → treated like they have an illness Differences between cultures ○ Differences between ethnic/racial groups largely arise concerning the recurrence of depression Limited treatment → minority groups in the US are more vulnerable to repeated experiences of depression ○ Depression is more common among Hispanic and African Americans who were born in the US compared to immigrants Psychodynamic account of Major Depression w/ problems Psychodynamic view: major losses, especially those suffered in early life, set the stage for later depression Sigmund Freud and Karl Abraham noted similarity between clinical depression and grief of those who lost a loved one ○ Regression to oral stage of development → mourning their own identity with the person they lost → introjection: direct sadness and anger toward themselves Symbolic or imagined loss: equating of other kinds of events with the loss of a loved one  ○ Ex: failure of a calculus class as loss of parents, believing parents only love them when they get good grades Object relations theorists propose that depression results when relationships leave people feeling unsafe, insecure, and dependent Those whose childhood needs were poorly met are particularly likely to become depressed after experiencing loss BUT less than 10% of all people who have had major losses experienced depression → more research on the loss-depression link is needed Postpartum depression vs. “baby blues,” incl. possible etiologies of postpartum depression “Baby blues” ○ Very common, with about 50-80% of females experiencing weepiness, lethargy ○ Usually resolves by 2 weeks ○ Results from attempting to cope with new lifestyle, rattled emotions, and stressors that accompany a new baby Postpartum depression: occurs within 4 weeks of giving birth or even during pregnancy ○ 10-20% have persistent postpartum depression: symptoms from “baby blues” are more severe, and may last up to a year or more ○ Extreme sadness, tearfulness, insomnia, anxiety, intrusive thoughts, compulsions, panic attacks, inability to cope, suicidal thoughts ○ 1-2 per 1000 have psychotic symptoms that may be lethal to mother and child Ex: thinking your baby is evil, your baby isn’t yours ○ Women who have an episode have a 25-50% chance of developing it again with a subsequent birth Possible etiologies of postpartum depression: ○ Hormonal changes accompanying childbirth may trigger postpartum depression; estrogen and progesterone levels drop sharply after birth ○ Some women have a genetic predisposition, especially those who have a family history of mood disorders ○ Enormous psychological and social change in relationships, routines, and roles ○ Sleep and relaxation decrease, financial pressures increase → pileup of stress ○ Infants who are sick or have difficult temperaments can contribute too Treatments: self-help support groups and other approaches used in treating other forms of depression Many women do not seek help because they feel ashamed and are scared of judgment about being sad after childbirth Rates of postpartum depression are declining with improved depression screening and antidepressant use during pregnancy Patterns of Major Depression occurrence (episodes, persistence, recurrence, etc.) Episodes ○ Episodes can occur at any point throughout the lifespan  Exogenous (reactive) depression: follows clear-cut stressful events Endogenous depression: response to internal factors ○ 80% of all severe episodes occur within a month or 2 of a significant negative event ○ Average age of onset: 19 years ○ Peak age of onset: late adolescence or early adulthood ○ Higher rates (twice as much) among adults under 65 years than 65 year or above at any given point in the year Tied to depression and health: those who are depressed have more medical problems → higher mortality rate → less likely to live until old age Persistence ○ 85% of people with unipolar depression recover within 6 months, some without treatment Recurrence ○ More than half of those who suffered from unipolar depression and recover have at least one other episode later in their lives Odds are > 50% of 1st recurrence, > 75% of 2nd recurrence, etc. ○ Each recurrence tends to be longer and leaves the person with greater disability → depression is often progressive ○ Depression that is aggressively controlled early (by high doses and multiple, or multiple-action, medications) predicts less recurrence ○ Minorities are more likely to have recurrences: no access to treatment → more likely to reoccur Major depressive disorder: major depressive episodes with no history of mania Variations include: ○ Seasonal: disorder changes with the seasons ○ Catatonic: marked by immobility or excessive activity ○ Peripartum: occurs during pregnancy or within 4 weeks of giving birth ○ Melancholic: person is almost totally unaffected by pleasurable events ○ Premenstrual Dysphoric Disorder: signs and symptoms in the majority of menstrual cycles Sex ratios in prevalence of Major Depression, possible explanations, and implication of Amish findings Females are diagnosed with MDD twice as much as males (2:1 F:M ratio) Exceptions include Western University students, some non-Western societies, and elderly Explanations: ○ X-linked depression gene(s): females have twice the load of depressive genes ○ Premenstrual symptoms are concurrent with MDD surveys ○ Quality of female vs. male life in Western societies: men hold more power and freedom compared to females who hold responsibilities  ○ Freund’s theory of female masochism: females feel penis envy and are inferior → difficulty in accepting so leads to depression ○ Cognitive style: females are more likely to dwell or ruminate on problems, while males tend to ignore or escape them Specific names of theories: ○ Artifact theory: both men and women are equally prone to depression, but clinicians often fail to detect depression in men ○ Hormone explanation: hormone changes triggers depression, particularly during puberty, pregnancy, and menopause ○ Life stress theory: women are more subject to more stress than men → depression ○ Body dissatisfaction theory: females are taught to fulfill unreasonable, unhealthy, and unattainable body goals ○ Lack-of-control theory: women feel less control than men over their lives (learned helplessness) ○ Rumination theory: women are more likely than men to ruminate when their mood darkens → vulnerable to onset of depression Old order Amish people are prohibited from drinking and drugs, and it was found in this culture that the prevalence of MDD was of 1:1 ratio in females to males ○ → implies that females are diagnosed with MDD twice as males likely because male depression is often masked by alcohol / drug abuse Genetic evidence on prevalence of depression Family pedigree studies show that a proband’s relatives have a higher rate of depression than the population at large ○ As many as 30% of those relatives are depressed, compared with less than 10% in the general population Twin studies show that there are larger number of cases among the close relatives (similar genetic makeup) of a proband ○ Identical twin with unipolar depression = 38% chance of other twin having ○ Fraternal twin with unipolar depression = 20% chance of other twin having Gene studies have shown that unipolar depression may be tied to genes on certain chromosomes ○ Ex: 5-HIT gene on chromosome 17 responsible for serotonin activity → a predisposition to unipolar depression can be inherited “Kindling” and depression risk Kindling: each major depressive episode increases the risk of later depression, regardless of life stress 50% chance that depression will come back later on Likelihood there was a trigger for the first depressive episode, something to attribute the depression to  Every episode after that, it is harder to show a precipitating event ○ Implies that the more depressive episodes that are being had, the more likely they are to have caused themselves ○ Each repeat depressive episode → less clear of cause ○ With every depressive episode → likelier to have another Persistent depressive disorder and “double depression” Persistent depressive disorder: chronic unipolar depression; MDD that lasts 2 or more years ○ Between 3:2 and 2:1 F:M ratio ○ Persistent depressive disorder with major depressive episodes: repeated major depressive episodes ○ Persistent depressive disorder with dysthymic syndrome: less severe less disabling symptoms Double depression: overlay of an MDD on persistent depressive disorder ○ Can have a chronically depressed baseline + experience a dramatic worsening Psychotic features in severe Major Depression, e.g., hallucinations and delusions Extreme cases of major depression may include psychotic symptoms, marked by a loss of contact with reality ○ Delusions: bizarre ideas without foundation ○ Hallucinations: perceptions of things that are not actually present Types of psychotherapy for Major Depression – rationales, evidence for effectiveness Psychodynamic therapy: helps by bringing underlying issues to consciousness and working them through ○ Free association, dream interpretation, reviewing past events and feelings ○ Goal: to gain awareness of the losses in their lives, cope with those losses effectively, become less dependent on others, and make corresponding changes in functioning ○ Continues to be used widely for depression, even though strong evidence of effectiveness has not been offered ○ Long-term psychodynamic therapy is only occasionally helpful in cases of unipolar depression ○ Seems most effective in modest or moderate levels of severity + clear history of childhood loss or trauma Cognitive Behavioral Therapy (CBT): focuses on uncovering automatic self-defeating thinking patterns ○ Develop new ways to interpret setbacks → normalization, analyzing logically, de-catastrophizing ○ Behavioral activation: therapist helps systematically increase the number of constructive and pleasurable activities and events in a client’s life  ○ Contingency management approach: therapist systematically ignores depressive behaviors while praising or reward constructive statements and behavior More helpful when combined with cognitive techniques ○ Beck’s cognitive theory: help people identify and change the maladaptive assumptions and ways of thinking that caused it in the first place ○ Replacing old “automatic” thoughts with new ones ○ Focus is on the patient’s view of him/herself, important life events, and the future ○ Depressed adults receiving this therapy improve more than placebo or no treatment ○ 50-60% show significant improvement in eliminating symptoms Interpersonal Therapy (IPT): sources of insufficient social connection and support ○ Any 4 interpersonal problem areas may lead to depression → must be addressed! ○ Interpersonal loss/grief: delayed mourning, developing replacement relationships ○ Interpersonal disputes/fights: building skills in communication, negotiation, assertiveness ○ Interpersonal role transition: reevaluating the lost role, building a new role, developing new social supports ○ Interpersonal social deficits: using role playing to learn new behavior in relationships ○ 50-60% show significant improvement in eliminating symptoms Natural remission of Major Depressions and relevance for theories of depression Remission: no longer in the diagnosable range of depression Most first episodes of major depression remit with no treatment within 3-4 months Although first episodes of Major Depression are somewhat related to life events, social support, etc., recurrences seem weakly related or not at all Problems with psychogenic theories of the causation and treatment of Major Depression Despite very different explanations of causation, and different kinds of therapies based on those explanations, the different depression therapies appear equally effective Perhaps improvement results from nonspecific factors in therapy ○ Having a friend, someone who is an ally in life, building a trusting and accepting relationship with the therapist ACT and MBCT: “third-wave” variants of Cognitive Behavior Therapy Acceptance and Commitment Therapy (ACT) Mindfulness-Based Cognitive Therapy (MBCT) Help clients recognize and accept their cognitions as just streams of thinking Accept their thoughts for what they are, rather than completely discarding or trying to banish their negative thoughts Helpful in preventing recurrences Insufficient evidence of superior effectiveness compared to standard CBT Brain changes (including BDNF, neocortical and neurotransmitter disturbances) in depression, and possible mechanisms of action of major classes of antidepressant drugs Neurotrophic theory: reduced activity of neuronal growth factors that promote axonal and dendritic sprouting → death of neuronal connections, rather than just neurons ○ Brain-derived neurotrophic factor (BDNF) and other growth factors are reduced in depression ○ Thinning of the cortex in brains of those with depression Endocrine theories: HPA-axis overactivity equates depression with stress reaction ○ Hypothalamus-pituitary dysfunction, thyroid dysfunction, adrenal gland dysfunction ○ Altered levels of activity in the limbic system, prefrontal area, and other brain regions, observable by neuroimaging ○ Reduced gray matter volume in neocortex seen in chronic depression Appears to be restored with successful antidepressant therapy Neurotransmitter theory: insufficient neurotransmitter turnover in the depressed brain ○ Norepinephrine, epinephrine, dopamine, serotonin ○ Neurotransmitter abnormalities in depression represent just one part of the neurobiological changes in depression ○ They account for the side effects of antidepressant medications more than the main effects Inflammatory theory: over-secretion (or under) of substances related to stress and inflammatory responses in brains with depression ○ Individuals with higher levels of the inflammatory blood marker C-Reactive Protein (CRP) are likelier to develop depression within 5 years ○ Neurosteroids are reduced in depression, which normally inhibit signals of brain inflammation (to control swelling) Regardless of the mode of action, remission of depression with antidepressant medication results in restoration of normal levels of BDNF and neurosteroids, and return of normal neural activity Types of antidepressant medications: uses in depression and other disorders, side effects, precautions, and general drug classes General use ○ Work best for moderate-to-severe depression ○ Does not cure it, only relieves symptoms for as long as they are taken ○ Typically takes 2-3 weeks after first dose to produce an antidepressant response A fast response is an indicator of mania → depression is part of larger bipolar disorder pattern ○ Antidepressant discontinuation or changing must be tapered or cross-tapered slowly to avoid rebound symptoms  ○ Discontinuation Syndrome: symptoms associated with abruptly stopping any antidepressant Dizziness, tremor, anxiety and panic, nausea and vomiting, and confusion ○ Continuation or maintenance therapy: patients should be kept on drugs for at least 5 months after being free of symptoms Monoamine Oxidase (MAO) Inhibitors: stop the destruction of NTs → rise in NT activity level → reduction of depressive symptoms ○ Limitation: eating foods containing tyramine at the same time leads to dangerous rising blood pressure Tricyclics: 3 ring molecular structure acts on the vigorous reuptake seen in depressive patients, blocking reuptake of serotonin and norepinephrine → NTs last in the synapse longer ○ Also improves and corrects the function of the structures involved in the depression brain circuit ○ Must be taken for at least 10 days before seeing improvements ○ 50-60% of those who take are helped ○ High risk of relapsing if discontinued right after relief ○ Some side effects such as dry mouth, constipation, blurred vision Selective Serotonin Reuptake Inhibitors (SSRIs): increase serotonin activity specifically ○ 30-40% of patients on SSRIs suffer from sleep & sexual symptoms ○ Children on Paxil may develop suicidal ideation (but not suicide) ○ People who do not respond to one SSRI have a 40-70% chance of responding to a second one, or one of the atypical antidepressants, or a combination ○ SSRIs may be associated with slightly elevated risks of heart and lung defects in infants Evidence is weak and is under investigation ○ Weak evidence that SSRIs may slightly increase premature birth complications However, there are drastic risks to pregnancies when pregnant mothers are depressed ○ Serotonin syndrome: can occur rarely in people who are taking multiple SSRIs, or SSRIs along with other serotonin-raising drugs Confusion, hallucinations, fever, seizures Atypical Antidepressants: most prescribed class of current antidepressants ○ Fewer sexual side effects; varied in actions and side effects Antidepressants do not work for everyone ○ Publication bias → not as helpful as they seem or come across to be ○ Often, alternatives just keep being prescribed rather than being redirected to psychotherapy or counseling Relationship between antidepressant medication and suicidality, and period of suicide risk in treatment As of 2004, all antidepressants in U.S. must now carry warnings about suicidality ○ 40% of people with major depression make one suicide attempt ○ 50-60% have suicidal ideation Suicidality is associated with improvement from depression, regardless of the presence of antidepressant medication ○ Some studies show that suicidal ideation is increased with antidepressant medication ○ Various studies have shown no link between antidepressant medication and actual suicides Recovery from severe depression is the period of greatest concern for suicide → increased energy to act on suicidal thoughts Electroconvulsive Therapy (ECT): nature of treatment, effectiveness, and side effects ECT treatment: using muscle relaxants + light anesthesia to induce therapeutic seizures ○ 20 electrodes placed on head, 65-140 volts of electricity → brain seizure lasting from 15-70 seconds Bilateral ECT: one electrode on each side of forehead Unilateral ECT: electrodes are placed so current passes through only one side ○ Usually applied only to right hemisphere to minimize speech disturbance ○ May result in memory loss; in most cases clears up within a few months, but potential for permanent distant amnesia too Sometimes causes spotty, episodic memory loss Effective and fast-acting: works fastest of any standard therapy for major depression ○ ECT is primarily used on severely depressed people ○ 50-80% of ECT patients improve, especially when followed up with continuation or maintenance therapy ○ More effective than other brain stimulation approaches or antidepressants Has fewest side effects of any standard therapy for depression; very high satisfaction ratings Relapse within a year, unless initial treatment is followed-up Nature and effectiveness of alternative treatments: Transcranial magnetic stimulation (TMS): a current is sent into the prefrontal cortex to increase neuron activity → improve functioning ○ Areas of the PFC that are underactive are stimulated, improving the function of the depression circuit ○ Weak magnetic field sufficient to produce twitches in fingers ○ Standard treatment is 1-2 weeks of short daily sessions, weak effectiveness  ○ Stanford Neuromodulation Therapy: 10 sessions per day for 5 days shows high rates of depression remission (~80%) for TRD Vagus Nerve Stimulation (VNS): stimulating the brain by electrically stimulating the vagus nerve ○ Electric signals from the pulse generator travels to the vagus nerve, which delivers signals to the brain → significant relief ○ Patients with epilepsy and depression got over their depression after VNS was used for their epilepsy → used on patients with only depression and it worked Ketamine treatment: ○ Patient receives slow infusion of ketamine at sub-anesthetic dose, but sufficient to place in twilight state ○ Mild hallucinations and experience of depersonalization and derealization ○ Side effects are confusion, hangover hallucinations, fuzzy vision; no driving for 24 hrs ○ Experiences antidepressant effect within hours, lasting days to weeks; booster infusions provided as needed ○ Warning: not everyone benefits, and the long-term effects are uncertain Comparative effectiveness of medications vs. psychotherapy for different degrees of Major Depression Traditional psychodynamic therapies are less effective than other therapies across all levels of unipolar depression For mild to severe unipolar depression: ○ Cognitive-behavioral, interpersonal, and biological therapies are all effective treatments ○ Drug therapies reduced symptoms more quickly than these, but they matched up by the final 4 weeks in effectiveness Today, antidepressant drugs are more often prescribed for mild to severe unipolar depression Medication vs. psychotherapy: ○ Work equally well ○ Medication: faster ○ Psychotherapy: fewer remissions due to teaching preventative strategies Combinations of psychotherapy and drug therapy are often more helpful than any one approach on its own, particularly in cases of severe depression Overview of SADS and phototherapy SAD: seasonal affective disorder where depressive symptoms changes with the seasons ○ Recommended to be treated in the same way as other types of depression ○ Episodes typically recur in the dark months of the year ○ Related to the amount of sun in the light → phototherapy  Phototherapy exposes patients to light to mimic natural sunlight and boost mood Other disorders associated with depression and frequently treated with antidepressant medications Chronic pain Binge eating disorder Bulimia nervosa Migraine headache Anxiety disorders (panic disorder, OCD) Trichotillomania Compulsive zit popping, shopping, gambling Hypochondria Sexual addiction Premature ejaculation Premenstrual dysphoric disorder Mania and Bipolar Disorder Hypotheses about etiology, including neurochemistry Bipolar disorders appear to be best explain by a focus on biological factors Neurotransmitter activity: low serotonin + high norepinephrine → mania ○ vs. low serotonin + low norepinephrine → depression ○ Overactivity of norepinephrine related to mania Ion activity: ions in charge of relaying messages are transporting irregularly → neuron firing too easily → mania Brain structure: ○ Hippocampus, basal ganglia, and cerebellum tend to be smaller in bipolar patients’ brains ○ Lower amounts of gray matter ○ Structural abnormalities in raphae nuclei, striatum, amygdala, and PFC Genetic factors: possible to inherit a biological predisposition to developing bipolar disorders ○ Compared to the 1-2.6% prevalence in general population: Identical twins have 40-70% chance of developing the same bipolar disorder Fraternal twins, siblings, close relatives: 5-10% ○ Bipolar disorder has also been linked to genes on chromosomes in molecular biology Genes that regulate calcium channel regulation, release of neuroprotective proteins, circadian rhythms, estrogen release Defects in the metabolism of Protein-Kinase C (PKC), an enzyme involved in the calcium metabolism of neurons in specific brain areas  ○ → results in the unstable levels of neurotransmitter release by these neurons ○ PKC activity is increased in manic patients and normalized by anti-manic medications Genetic evidence, sex ratio in prevalence Runs in families: ○ 65% concordance rate in monozygotic (identical) twins ○ 14% in dizygotic (fraternal) twins ○ 10% concordance rate in 1st-degree relatives ○ Family history of BPD in 30% of bipolar patients ○ In 20% of MZ twins in which one has BPD, the other will have major depression, suggesting some common inheritance ~ 1:1 F:M sex ratio (no sex difference in prevalence) Signs/symptoms Mania: experiencing dramatic and inappropriate rises in mood ○ Feeling active and powerful emotions that are out of proportion, euphoria irritability ○ Want constant excitement, involvement, companionship ○ Very active, moving and talking quickly; flamboyant and dangerous even ○ Racing thoughts, “pressured” speech ○ Show poor judgment and planning, feeling too good or moving too fast to think things through ○ Inflated self-esteem / grandiosity ○ Very out of touch with reality ○ Typically getting little sleep, yet feeling very energetic and remaining/acting wide awake Persistent insomnia: historically lethal ○ Involvement in damaging activities Ex: unrestrained buying, foolish investments, sexual indiscretions ○ Sometimes, if accompanied by substance abuse, impulsive assaultiveness or suicidality Many attempt to self-medicate with alcohol and try to bring themselves out of this manic state → really just disinhibits them even more Manic episode: displaying abnormally high or irritable mood, increased activity or energy, and at least 3 other symptoms of mania for at least 1 week ○ May even include psychotic features like delusions and hallucinations ○ Hypomanic episode: a muted form of manic episode, when symptoms are less severe/cause little impairment Bipolar I disorder: experiencing full manic and major depressive episodes Bipolar II disorder: experiencing hypomanic, or mildly manic episodes, that alternate with major depressive episodes over time  With mixed features: displaying both manic and depressive symptoms within the same episode Rapid cycling: 4 or more episodes within a 1 year period Cyclothymic disorder: a disorder marked by numerous periods of hypomanic symptoms and mild depressive symptoms Bipolar disorder associated with high rates of: ○ Alcohol and drug abuse: 40-50% ○ Anxiety disorders: 40% ○ Criminal behavior due to impulsivity Course and prognosis Predominant aspect of bipolar disorder is mood instability, moods that shift without any discernible explanation ○ Bipolar disorder episodes are most often random and not cyclical, may last from a few hours to many months, and may include interviewing stable periods Age of first diagnosis ranges from 15 to 45, with most people diagnosed in their 20’s ○ Sometimes seen in children (pediatric bipolar disorder), even infancy in the form of rages Most cases of Bipolar Disorder first appear as depressed phase ○ 40% of persons with Bipolar Disorder are initially misdiagnosed with Major Depression ○ Mania is revealed when “depressed” patients are administered antidepressants About 10% of people with Bipolar II may change to Bipolar I in their lifetimes Unfortunately, 40% of people do not improve with treatment and just have to let their mania or depression run its course Differences between Major Depression and Bipolar depression Bipolar depressions: ○ Last longer ○ Recur more frequently ○ Are more likely to reach psychotic levels ○ Can take twice as long to obtain remission with treatment Depression is the more problematic state in Bipolar Disorder ○ Sufferers spend up to 1/3 of their adult lives in depression ○ As people age, depressed periods become worse and more frequent and manic episodes lessen More than 10% of people with Bipolar Disorder eventually suicide, mostly in depressed phase Types of antimanic medications (mood stabilizers): side effects, precautions, and general classes of medications Medication is 1st line treatment, but compliance is only ~30%  Acute management (sedating antipsychotic medications), followed by introduction of a mood stabilizer for chronic management Mood stabilizers: ○ Lithium carbonate: strong antimanic but weak antidepressant actions Lithium increases the size of the hippocampus and the amount of gray matter in bipolar patients May be best anti-suicide treatment Requires careful dosing and close blood-level monitoring Long-term use may be toxic to kidneys ○ Anticonvulsants: moderate antimanic and overall weak antidepressant actions Has moderate antidepressant properties, fewest side effects, and is typically weight-neutral Currently preferred Bipolar I/II medication Some types can be used for rapid-cycling Bipolar Disorder ○ “Antipsychotic” agents: moderate antimanic and overall weak antidepressant actions Continued doses of mood stabilizers are important in preventing the return of manic episodes and reducing the risk of future depressive episodes and suicide attempts Less powerful impact on depressant episodes → combine mood stabilizers and antidepressants to treat bipolar disorder Mood stabilizers work by: ○ Correcting biological abnormalities through the second messengers in neurons ○ Increasing the production of brain-derived neurotrophic factor (BDNF) and other proteins whose job is to prevent cell death → increase health and functioning of cells → reduce bipolar symptoms ○ Improving the functioning of or communications between key brain structures Non-medication treatments Psychotherapy or mood stabilizing drugs alone are rarely helpful for bipolar disorder ○ Psychotherapy on its own doesn’t have an effect on the disorder itself Psychotherapy: many clinicals use individual, group, or family therapy as an adjunct to mood stabilizing drugs ○ Usually requires prior medication response to be valuable ○ Builds compliance to medication ○ Helps patient (and family) understand impact of disorder ○ Reduces hospitalizations, improves their social functioning, and increases patients’ ability to obtain and hold a job ○ Psychotherapy plays a more central role in mild, cyclothymic disorder ECT: effective for both mania and bipolar depressions, as well as mixed episodes ○ Used in adjunct to ongoing medication Induced sleep for mania: rarely used, temporary results  ○ Sleep wave cycling is linked to depression and mania ○ Depressive patients who are forced to stay awake for a few days will actually see their symptoms lift General features of pediatric bipolar disorder Occurs in about 1% of children, sometimes as early as infancy Manifested by: ○ Mood instability: periods of rages and despondency (crying in the corner, clinginess) ○ Hyper-sexuality ○ Pressured speech ○ Racing thoughts ○ Impaired judgment ○ Delusions and hallucinations Up to ½ of severe childhood depressions become adult Bipolar Disorder ~ 50% of children treated for depression with SSRIs develop manic or hypomanic episodes Typically a 10-year lag between occurrence of first signs/symptoms and onset of treatment Often confused or co-morbid with Attention Deficit Hyperactivity Disorder (ADHD) ○ ADHD: how you function all the time VS bipolar: episodic Relationship of bipolar disorder and/or depression to creativity Affective disorders may be associated with creativity ○ Cyclothymia: mood and instability below the diagnosis threshold Rate of artists, poets, writers with cyclothymia and manic-depressive disorder in the population are much higher than expected rate in general population Elevated rates between cyclothymia and manic depressive illness in creativity Other disorders associated with bipolar disorder Anxiety disorders Drug or alcohol abuse Attention Deficit Hyperactivity Disorder (ADHD) Suicide (Text Readings Only) Rates of males vs. females in attempted vs. completed suicides and explanation Attempted suicide: 3 times more women than men Completed (died): 3 times more men than women Men use more lethal, violent methods: hanging, shooting, stabbing themselves Women use methods such as drug overdose Likeliest people to die by suicide in U.S American Indian males ○ Highest rates due to poverty, alcohol use, modeling, availability of guns  ○ Followed by non-Hispanic White Americans Likely reasons for recent increase in deaths by suicide Pro-suicide websites and live-streams broadcasting the action have been on the rise Leading risk factors for suicide Stressful events and situations: combat stress, immediate and major stressors, long term stressors ○ Social isolation, serious illness, abusive or repressive environments, occupational stress, etc. Mood and thought changes: ○ Psychache: a feeling of psychological pain that seems intolerable to the person ○ A sense of hopelessness, dichotomous thinking (keyword ONLY) Alcohol and drug use ○ Alcohol lowers inhibitions, reduces fear, impairs judgment and thinking ○ More intoxicated = more lethal method used Mental disorders: severe depression, chronic alcoholism, schizophrenia ○ Depressed + substance-dependent → particularly prone to suicidal impulses ○ Risk of suicide actually increases when mood improves in major depressive disorder patients, since they have more energy to act on their ideations Interpersonal beliefs of perceived burdensomeness and thwarted belongingness + the psychological capability for suicidal acts ⇒ suicide Strongest suicide predictor = biological abnormalities + key psychosocial factors (i.e. childhood traumas) Protective factors in suicide More thorough belonging in family, religious institutions, and community → lower risk of suicide Stable structures in surrounding social environment Regular serotonin levels and normal functioning brain circuitry Basic interventions to prevent suicide and treat high-risk people Treatment after attempt: ○ Medical care for injuries, brain damage, etc. ○ Psychotherapy or drug therapy follows Systematic follow-up care is crucial in preventing future attempts ○ Dialectical behavior therapy (DBT): assess, challenge, and change negative attitudes, teach better coping and problem solving skills Helps to accept and build tolerance of psychological distress/thoughts, rather than eliminate them Suicide prevention: ○ Suicide prevention programs and crisis intervention: identify and respond to individuals who are at risk of killing themselves ○ In therapy:  Establish positive relationship Understand and clarify the problem Assess suicide potential on lethality scale Assess and mobilize their resources Formulate a plan to make changes and establish no-suicide contract Reduce the public’s access to lethal and common means of suicide General evidence for “contagiousness” of suicide Modeling, in which suicidal acts serve as a model for another Social contagion effect: trauma and a sense of loss increases the risk of suicide among relative and friends of the victim Bizarre cases that are highly publicized have lead to similar suicidal acts ○ Ex: politically motivated self-burning suicide media report → 82 people followed without political motivation Other possible models include celebrities or coworkers Anxiety Disorders Nature of clinical “anxiety”: signs and symptoms Anxiety: the central nervous system’s physiological and emotional response to a vague sense of threat or danger Anxiety disorder: suffering from such disabling fear and anxiety that one cannot lead a normal life Generalized anxiety disorder (GAD): marked by persistent and excessive feelings of anxiety and worry about numerous events and activities ○ Described as free-floating anxiety: anxiety about practically anything ○ Experiencing disproportionate, uncontrollable, and ongoing anxiety and worry about multiple matters → reduced quality of life Cognitive signs and symptoms: ○ Objectless fear or feeling of apprehensiveness; a generalized fear, feeling weary ○ Heightened sense of and vulnerability ○ Worrying and rumination ○ Going blank or spacing out ○ Irritability, impatience, distractibility ○ Hypervigilance Physiological signs and symptoms: ○ Trembling, twitching, feeling shaky ○ Fatigue, restlessness ○ Muscle tension, jitteriness ○ Dizziness, lightheadedness ○ Fast heartbeat, breathing rate ○ Sweating, cold or clammy hands  ○ Dry mouth, nausea, diarrhea ○ Altered appetite and sleep Anxiety can be chronic or acute ○ Chronic: likely that anxiety runs in the family ○ Acute intense anxiety: panic attack Same anxiety symptoms Dissociative experiences (derealization, depersonalization) Fear of dying, losing control or going crazy Paresthesias: numbness or tingling sensations Chills or hot flashes Sociocultural characteristics that affect anxiety GAD is most likely to develop in people who are faced with dangerous ongoing societal conditions ○ Highly threatening environments develop feelings of tension, anxiety, fatigue, sleep disturbances ○ Poverty: high crime rates, poor opportunities, health problem risks Rates of GAD are ~ 2 times higher among low income people vs. high income Wage decreases → GAD rate increases ○ Nervios or ataques de nervios in Hispanic individuals GAD is also more common among members of high-income societies than those from low-income societies ○ Low-income: mind is preoccupied with survival ○ High-income: less demands → mind is free to wander and worry Separation anxiety is a common psychological disorder among kids ○ Trouble being separated from their family for fear of losing them to some circumstance ○ Otherwise, normal functioning when near their parents Can even develop in adulthood, after experiencing trauma with losing someone ○ Become consumed with the concern about another important person in their life → severe distress Brain areas, neurotransmitters and ANS involvement in anxiety Amygdala: registers emotional aspects of situations, hooking up what we are experiencing with the emotional significance of it Locus coeruleus: controls arousal of neocortex, and activated hypothalamic-pituitary axis and autonomic NS Fear circuit in the brain is excessively active, hyperactive, in people with GAD ○ Regions include: prefrontal cortex, anterior cingulate cortex, insula, amygdala ○ Low levels of GABA → hyperactive circuit functioning → GAD ○ Improper functioning of structures and neurons in the fear circuit → GAD  ○ We still need a better understanding: Possibility of 2 separate circuits, one producing physical/behavioral reactions, the other producing cognitive processes GABA (gamma-aminobutyric acid): anxiety-prone people have deficits in GABA ○ Chemically blocking GABA increases anxiety ○ Common anti-anxiety medications bind to GABA receptor areas and mimic GABA GABA and serotonin inhibit anxiety Epinephrine, norepinephrine, and dopamine increase anxiety Anxiety-related actions of the sympathetic NS (fight or flight): ○ Pituitary release of ACTH → triggers release of steroid hormones from adrenal gland → causing increased appetite and anti-inflammatory actions ○ Adrenal gland secretion of epinephrine and norepinephrine ○ Pupillary dilation ○ Drying of mucosal linings: mouth, stomach, intestines ○ Increased sweating ○ Heightened heart rate ○ Constriction of blood vessels in skin and gut, and diversion of blood flow to muscles → raises BP ○ Speeded respiration and airway relaxation ○ Emergency release of glucose into the circulation Physical conditions that can masquerade as anxiety disorders These physical symptoms can all be confused with anxiety disorder Hyperthyroidism: metabolism, heart rate, and blood pressure all increase dramatically Pheochromocytomas: adrenal tumors are over-secreting adrenaline → constant feelings of sympathetic fight or flight Inner ear disease: balance problems → feeling anxious and dizzy Angina pectoris: reduced blood flow to heart → chest pain, harder breathing Hypoglycemia: low blood sugar → feeling weak, dizzy, shaky Mitral valve prolapse: chronic weak oxygenation of brain and body → constant state of panic Cardiac arrhythmias: irregular heartbeats → interfering with heart’s ability to function Drug effects: caffeinism, nic addiction, nasal decongestants, psychostimulants, asthma inhalers Types of symptomatic treatments for anxiety, including classes of anxiolytic medications: differences, precautions, side effects, and general classes of drugs Psychotherapy: ○ Cognitive therapy: normalization, de-catastrophizing, paced metronomic breathing ○ Supportive therapy  ○ Muscle relaxation training ○ Meditation techniques ○ Stress management training ○ Biofeedback: technological meditation, patients are given feedback about physiological activity Anxiolytic: lysing, or cutting off, the anxiety ○ For acute use: benzodiazepines or beta-blockers (rarely, used for stage fright) ○ For chronic use: SSRIs or atypical antidepressants Anticonvulsant (gabapentin): walking around in a fog Atypical anxiolytics Antipsychotics (worth the side effects for very severe anxiety) Drug therapies: ○ Sedative-hypnotic drugs: low doses are calming in effect, high doses help people fall asleep Benzodiazepines: provides relief from anxiety by mimicking GABA at receptors GABA is inhibitory, it stops neurons from firing → excitability stops, fear and anxiety subsides Short-lived effects: when stopped, anxiety returns just as strong Produces undesirable side effects: drowsiness, lack of coordination, memory loss, depression, aggression → one can become physically dependent Mixes badly with other drugs/substances Barbiturates: more addictive ○ Antidepressant medications: increase serotonin and norepinephrine → improved functioning in the fear circuit Able to bring some relief to GAD patients (60%) ○ Antipsychotic medications: altering dopamine activity in the fear circuit → relieve anxiety Can produce serious side effects Major etiological aspects and diagnostic features of, and treatments for: Generalized anxiety disorder (GAD) Generalized anxiety disorder (GAD): a disorder marked by persistent and excessive feelings of anxiety and worry about numerous events and activities 2:1 F:M ratio Etiology (psychodynamic, humanistic, cognitive, biological perspectives): ○ Unresolved childhood anxiety: Freund argued that early developmental experiences produce an unusually high level of anxiety in some  People who suffered extreme punishments or overprotectiveness as children have higher levels of anxiety later Extreme punishment → belief that one’s Id impulses are dangerous → feeling anxiety whenever they experience impulses Overprotected children → Ego defense mechanism may be too weak to cope with anxiety of life stressors ○ GAD arises when people stop looking at themselves honestly and acceptingly, building self-judgment Denying/distorting true thoughts, emotions, and behaviors → anxious, unable to fulfill potential as human beings Carl Rogers’ explanation: too much unconditional positive regard from others → overly critical and harsh self-standards, or conditions of worth ○ Maladaptive assumptions: more and more assumptions → develop GAD Albert Ellis holds that people are guided by basic irrational assumptions Basic irrational assumptions: inaccurate/irrational beliefs held by people with various psychological problems that lead them to act and react inappropriately Facing stressful events + making assumptions = interpreting as dangerous, overreacting, feeling fear Aaron Beck argued that people with GAD constantly hold silent assumptions that imply they are in imminent danger ○ Metacognitive theory: people with GAD implicitly hold both positive and negative beliefs about worrying Positive: worrying is a useful way of appraising and coping with threats → they look for and examine all signs Negative: worrying is a bad thing, and that repeated worrying is harmful → meta-worries: worrying about worrying Concerned that they are going crazy or losing out because they keep worrying → GAD ○ Intolerance of uncertainty theory: individuals cannot tolerate the knowledge that negative events may occur, even small possibilities Worry constantly + unbearable uncertainty over the possibility of an unacceptable negative outcome + uncertain attempts to find “correct” solution → vulnerability to developing GAD People with GAD display higher levels of intolerance of uncertainty than people with normal degree of anxiety Develops in early childhood; can be passed on from parents to children ○ Avoidance theory: individuals worry repeatedly in order to reduce or avoid uncomfortable states of bodily arousal  People with GAD have greater bodily arousal, and worrying serves to reduce this arousal People with GAD experience fast and intense body reactions, find these overwhelming, worry more when aroused, and can reduce arousal by worrying ○ GAD patients have deficient GABA production levels or few/broken receptors ○ Abnormally functioning fear circuit in the brain; excessively active, hyperactive ○ Biological relatives of a person with GAD are more likely than nonrelatives to also have GAD 15% of relatives have GAD Diagnostic features: ○ Debilitating worry, fretfulness on most days over at least 6 months ○ Worry is excessive, hard to control or put aside; sometimes justified/maintained by the worrier ○ Varied anxiety symptoms, including: Restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, insomnia Sometimes: nausea, diarrhea and irritable bowel hyperstartle, headaches ○ May emerge at any age ○ Non-Hispanic white Americans are more likely than members of minority groups to develop GAD Treatments: ○ Habit control ○ Anxiolytic (anti-anxiety) medications ○ Psychodynamic therapies: Utilize techniques of free association, resistance, and dreams to help GAD patients becomes less afraid of id impulses and control them Object relations therapists use methods to help patients identify and settle childhood relationship problems ○ Client-centered therapy: show unconditional positive regard for clients and empathize with them Acceptance and caring → allow clients to recognize their true needs, thoughts, emotions → anxiety and symptoms will subside Usually more helpful to anxious clients than no treatment But only sometimes better than placebo therapy ○ Cognitive-behavioral therapies: Rational-emotive therapy: focus on changing maladaptive assumptions Point out irrational assumptions, suggest more appropriate ones, and assign homework to practice this process Brings at least modest relief  Acceptance and commitment therapy (mindfulness-based therapy): “new-wave” cognitive-behavioral therapists aim to guide clients to recognize and change their dysfunctional use of worrying Educate them on the role of worrying in their disorder, have them observe their arousal and responses Learn to appreciate the triggers, misconceptions, and their misguided efforts to control worrying Accept their worries, rather than eliminate → less upset and less influenced by them ○ For mild to moderate anxiety: exercise, support groups Panic Disorder, incl. heightened interoception and “anxiety sensitivity” Panic disorder: occurrence of panic attacks without warning ○ Panic attacks: periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass 5:2 F:M ratio Etiology: ○ Panic attacks are believed to be more prevalent among people who have lots of stressors in their lives → constantly on the edge of breaking down ○ Panic attacks can be triggered in susceptible people by various stimulants, Ex: caffeine, nicotine, marijuana ○ People who suffer from Panic Disorder may be more “interoceptive” than others: more attuned to internal sensations than non-sufferers Feeling the flow of blood through their body, feeling how deeply they’re breathing ○ People who suffer from panic disorder have a hyperactive panic circuit Panic circuit: amygdala, hippocampus, ventromedial nucleus of hypothalamus, central gray matter, locus coeruleus Inherited development of abnormalities in this circuit Close relatives share rates of panic disorder more than distant relatives ○ Locus Coeruleus: panic reactions related to irregularities in norepinephrine activity in the locus coeruleus ○ Panic-prone individuals may experience more frequent or intense bodily sensations ○ Panic-prone individuals have had more trauma-filled events → greater expectations of catastrophe ○ Panic-prone individuals have a high degree of anxiety sensitivity: a tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful Diagnostic features:  ○ One month or more of apprehensiveness about further attacks and their consequences (losing control, having a heart attack, going crazy) ○ Pattern of avoidance and disability as a result ○ Course is typically chronic but waxing and waning ○ Associated with other anxiety disorders, and with Substance Use Disorders ○ Rates of co-morbidity with Major Depression are as high as 60% ○ 25% of people with Panic Disorder have suicidal ideation ○ Typically sets the stage for development of agoraphobia Treatments: ○ Dietary/medication control, such as restrictions on caffeine, nicotine, marijuana ○ Anxiolytic medications ○ Antidepressant medication Mainly SSRIs as a chronic preventative Antidepressants that increase norepinephrine in the brain seemed to alleviate symptoms Antidepressant drugs bring improvement to more than ⅔ of panic disorder patients Improvement lasts as long as the drugs are continued ○ Psychotherapy ○ Cognitive-behavioral therapy: aims to correct misinterpreted bodily sensations Educate clients about the general nature of panic attacks, causes of sensations, and tendency to misinterpret Teach clients to apply more accurate interpretations and ways to cope better with anxiety Biological challenge tests are used to induce panic and provide them with opportunities to apply their skills ⅔ of participants become free of panic through cognitive-behavioral therapy ○ Cognitive-behavioral therapy, drug therapy, or a combination of these approaches, are helpful to those displaying both panic disorder and agoraphobia Derealization / depersonalization Derealization: feelings of unreality Depersonalization: being detached from oneself; observing their own bodies from a different perspective Agoraphobia Agoraphobia: a fear of venturing into public places or situations where escape might be difficult or help may be unavailable if one were to become panicked or incapacitated 2:1 F:M ratio Etiology:  ○ Often develops (30-50% of cases) with prior panic attacks, as ritualized avoidance of situations that might trigger panic attacks, and is then co-diagnosed with Panic Disorder Home, or room within the home, becomes “safety zone” Reluctance to venture outside safety zone without “escape route” ○ Peak ages are in late adolescence and young adulthood More independence, more responsibilities, leaving the safety of the home ○ Cognitive-behavioral models: idea that fears are conditioned and reinforced by processes of classical conditioning and modeling Diagnostic features: ○ Marked fear or anxiety triggered by real or imagined exposure to a range of situations ○ Fear is that escape is impossible or help will be unavailable, especially if a panic attack occurs Self-fulfilling prophecy: begin to avoid more and more places, more and more people ○ The intensity of agoraphobia fluctuates Severe: limited and imprisoned in their homes → social life dwindles, can’t hold a job, become depressed ○ Many experience panic attacks when they enter public places → receive 2 diagnoses of agoraphobia and panic disorder ○ Twice as common among poor people compared to wealthy people Agoraphobia is chronic and persistent without treatment Treatments: ○ Antidepressant medication, typically an SSRI ○ Utilize exposure approaches, offering considerable relief to many people In vivo (in real life) desensitization: exposing them to what they are most anxious about Help clients venture farther and farther from their homes to gradually enter outside places Use support, reasoning, and coaxing to get them to confront the world ○ Support groups: small number of patients go out together for exposure sessions that last several hours, encouraging one another to eventually do tasks on their own ○ Home-based self-help programs: give clients and their families detailed instructions to carry out exposure treatments themselves ○ 70% of agoraphobic clients who receive exposure treatment find it easier to enter public places ○ Improvement persists for years; however, are often partial rather than complete → about half have relapses  Agoraphobia + panic disorder seem to benefit less from exposure therapy alone Socia