PSYC 2020 Notes PDF

**PSYC 2020 Notes** \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- **Rundown** - **Historical background of psych** - **Researc...

**PSYC 2020 Notes** \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- **Rundown** - **Historical background of psych** - **Research, assessment, and diagnosis** - **Mental health & related disorders** - **DSM-5-TR; mental illness "bible"** **Section 0: INTRO TO PSYCH AND CAREERS** **Clinical** **Psychology**: branch of psych that involves researching, diagnosing, and treating mental, emotional, and behavioral issues **Psychological Disorders**: a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected - Mental illness often times is invisible **Psychological** **Dysfunction**: a breakdown in cognitive, emotional, or behavioral functioning; symptoms - Exists on a continuum, everyone experiences some symptoms at some level at some point - Distress or impairment causes problems in one or more important area of life - And/or requires enduring significant stress **Why Diagnose?** - Increased access to community identity - Increased access to services and support **Clinical Psychologist (Career)** Usually PhD in Clinical Psych (PhD, C. Psych); sometimes PsyD - 6-7 years of grad school, 1 year res, 1-year supervised practice - Controlled acts: diagnosis, psychotherapy Clinical psychologists have the responsibility of being a scientist practitioner, meaning: 1. Keep up with science as it relates to their discipline 2. Contribute to evaluation of practice 3. Create new scientific knowledge via research Evaluation - Some practitioners support research - Others generate new ideas for treatments or tools, test them, etc. **Presenting Problems**: not just a diagnosis; it is how a diagnosis (or challenge) is showing up for a particular person, and how that challenge affects their daily life **Disorder Components** Disorder Statistics - **lifetime prevalence**: how many people ever? - **incidence**: how many this year? - **sex ratio**: males vs females - **age of onset**: when people are most often diagnosed Features of Disorders - **chronic vs episodic**: temporary vs permanent - **acute vs. insidious onset** - **prognosis**: how it will progress - severity of distress and/or impairment **Section 1: HISTORICAL CONTEXT OF PSYCHOPATHOLOGY** **The Supernatural Tradition**: Middle Ages and beyond, psychological disorders were often thought to indicate that a person was possessed - These individuals were blamed for many bad things that happen, in turn, mistreated - Some believed passion was punishment for bad behavior - Some believed possession was not the person's fault - Some believed that psychological disorders were natural and resulted from stress - **Treatment**: Existed on a spectrum; well meaning and harmless to painful/traumatizing - Treatment included rest, sleep, baths, etc. - **Astrology: a**nother theory was psychological functioning was impacted by the movements of the moon and stars **The Biological Tradition**: Hippocrates suggested psychological disorders could be treated like any other disease - He linked functioning to 4 bodily fluids: block, black bile, yellow bile, phlegm - **4 Humors** - Too much black bile: depression - Too much blood: delirium - Too much phlegm: apathy/sluggishness - Too much yellow bile: hot temper - In the 19^th^ century: advanced syphilis looks similar to psychosis - One of the first evidence that convinced professionals that psychological disorders are directly treatable - **Treatment** - Insulin shock therapy - Electroconvulsive therapy - Tranquilizers (benzos) **The Psychological Tradition**: - **Plato**: ancient Greek philosopher who believed maladaptive behavior was a result of social/cultural influences - **Treatment**: Educating people towards rational thought - **Asylums**: Often house people with mental illness as well as those in poverty - Early asylums often functioned like prisons vs hospitals **Section 2: FREUD AND BREUER** - Influenced by ideas around hypnosis, began looking for ways to access the "unconscious" mind - Noticed that people benefited from processing emotional trauma and understanding its connection to their present - **Psychanalytic Model**: while not in line with current evidence, this models remains influential - **3 components** - The structure of the mind - Defence mechanisms - Psychosexual development - **Defense Mechanisms**: thought to come out when there is too much conflict between id and superego - **Projection**: attributing own's own unacceptable feelings or thoughts to someone else - **Psychosexual Development**: considers development to be a process of resolving sexual conflicts/seeking pleasure - Where Freud's theories break down - Infamous Oedipus Complex **Humanistic Theory**: tends to be more positively oriented - Focused on self-actualization - Carl Rodger oriented a client-centered approach - Theorized an unconditionally positive relationship would provide space for people to handle their own challenges **Behavioral Approach**: unlike psychoanalytic and humanistic theories - Came from Pavlov's dog experiment **Integrated Approach to Psych** 2 Types of Approaches: - **One-Dimensional**: too little depression = depression - **Multi-Dimensional**: several factors work together to cause depression **Key Takeaway**: psychopathy is neither caused nor treated effectively by only one thing **Section 3: BIOPSYCHOSOCIAL MODEL** **Bio**: genetics, neuroscience, the brain **Psych**: thoughts, emotions, behaviours **Social**: culture, family, friends **Bio** **Genetics**: long molecules of DNA passed down by our bio parents - Estimated that about half of individual differences in psychological disorders are related to genetic influence - This genetic influence is usually **polygenic** - **Polygenic**: traits or characteristics that are controlled by multiple genes (2 or more) - Can also be influenced by environment; e.g. specific presentations of genes can be "turned on" or "turned off" depending on different factors - Some environmental factors are so influential they can essentially overrule genetic influence **Diathesis-Stress Model**: theory that genetic vulnerability and life stressors essentially add together to reach (or not reach) threshold for developing a psychological disorder **Gene-Environment Correlation**: notes that some genetics seem to make people more likely to seek out certain environments -- so environment can influence gene expression -- but genetics can also influence environment - Again, remember that cause of psychological disorder is extremely complex -- these theories are just giving us a taste of what is actually likely going on **Structure of the Brain** - **Forebrain**: mostly made up of the cerebral cortex - responsible for thinking, perceiving, and remembering - Emotion regulation happens kind of between the fore and midbrain - **Midbrain**: responsible for coordination and movement - **Hindbrain**: responsible for automatic activities - **Cerebral Cortex**: divided into 4 lobes - **Temporal Lobe**: sights, sounds, long-term memory - **Parietal Lobe**: sensations of touch - **Occipital Lobe**: integrating and making sense of visual input - **Frontal Lobe**: thinking and reasoning, memory and social connection **Psych** **Learned Helplessness**: when you have no control over your environment - Or **believe** you have no control over your environment **Learned Optimism**: when you maintain a positive attitude despite significant stress and challenge **Social Learning Theory**: the idea that people can learn by watching others - Also called "modelling" or "observation learning" - Relies on making decisions about when we are similar or different from others **Prepared Learning**: genetics influence what we learn - More likely to learn to fear things that have historically been dangerous -- even without direct experience - One-trial learning: food and poison **Implicit Cognition**: unconscious processes -- somewhat less salacious than Freud thought - **Stroop colour-naming paradigm**: words that are important draw more attention - Thus, making people slower to name the colour **Intro to the CBT (Cognitive Behavioral Therapy) Triangle** **Cognitive Behavioral Therapy:** a form of psychological treatment that has been demonstrated to be effective for a range of problems - Built on a 2-way relationship between thoughts ("cognitions") and behaviours **Behaviour**: how we act **Psychology**: how our body reacts **Cognition**: how we think and perceive **Emotions and Psychopathy** - **Reminder**: emotions are natural, they serve a function - Many disorders involve disproportionate emotions - Either too little or too much - Depends on context and culture **Social** **Question**: What kind of social and cultural factors can you see playing a role in psychological disorders? **Section 4: RESEARCH BASICS** **Hypothesis**: an educated guess; an idea you can test **Research Design**: the specifics of how you will test your hypothesis **Variables** **Independent Variable**: the thing doing the influencing - E.g. a stressor, a type of therapy, or a specific medication **Dependent Variable**: the thing being influenced - E.g. a thought, behaviour, feeling, or bodily symptom **Validity** **Internal Validity**: the likelihood that the IV is actually what is causing change in the DV - Randomization can help prevent confounding variables from distorting data **External Validity**: how well your findings describe/predict what happens outside of the lab or study - We want to think how we make our study similar to real life **Understanding Significance** **Statistical Significance**: just the math; is there an effect? **Clinical Significance**: does the effect matter in real life? The problem with Average - Who is being tested? - Who is being missed - What happens if you aren't "average"? **Correlational Research** **Correlation**: refers to the relationship between 2 variables - One variable **might** be the IV and one **might** be the DV but we don't know which is which - It also might be the case that **both** variables are dependant - In this case, we are missing the IV that is causing both variables to change - E.g.: do sharks like the taste of people who have eaten ice cream? - Do people who are attacked by sharks comfort themselves by eating ice cream? - No\... when it is hot, people buy ice cream, and they also try to cool off in the water Correlation vs Causation - Misunderstanding correlation vs. causation can lead to a lot of stigmas and harm - E.g. LGBTQ+ people and mental illness **Experimental Research** 1. Measure the DV 2. Change the IV 3. Measure the DV 4. Compare scores Issues with Experimental Research Can Include: - Researcher Bias - Confounding variables - Attrition: - Withholding treatment - Self-selection - Typical change - Not every variable can be manipulated - The placebo effect **Strengthening Experimental Research** - Use a control group; could receive no intervention, a different intervention, typical intervention (TAU, or placebo - Randomize participants to control - Choose a double-blind study **Single-Case Experiments** **Repeated Measure**: measure several times before manipulation **Withdrawal**: measure several times -\> implement treatment -\> measure several more times -\> remove treatment -\> measure several more times **Multiple Baseline**: implement treatment in one setting at a time, or targeting one issue at a time - **Reminder**: Even if we can find causation, it doesn't necessarily mean we **understand** the cause **Outcome**: does the IV impact the DV **Process**: how/why does this happen? **Case Study** Felix thinks that small acts of self-care might be able to reduce feelings of loneliness. They recruit 57 undergraduate students and randomly assign them to the experimental or control group. The experimental group is assigned to make themselves their favourite breakfast every day for a week. Both the experimental and control groups answer a questionnaire about loneliness at the beginning and end of the experiment week. **Hypothesis**: Small acts of self-care can reduce feelings of loneliness in individuals **Research Design**: Experimental; participants are randomly assigned to either an experimental group (self-care) or control group (probably no self-care) **IV**: The self care (making their favourite breakfast everyday for a week) **DV**: Loneliness **Concerns About Validity**: - Self-report bias - Generalizability: the study only features undergrad students, but is being applied not individuals of all ages/walks of life - Confounding Variables: other factors may be influencing loneliness - Differences in baseline loneliness levels; overlooked due to random assignment **Section 5: RESEARCH BASICS 2** **Studying Genetic Influence** **Genotype**: the genes you have from your bio parents **Phenotype**: the observable characteristics/behaviors; how genes are expressed - **Reminder**: usually we aren't looking for a single genes, but genes that work together **Family Studies**: examine a particular trait (e.g. disorder) in the context of the family - Confounds/ ethical concerns: - **Adoption**: when family members are raised in different homes but share a disorder; more likely the disorder has genetic basis - **Twins**: can compare monozygotic (all DNA shared) and dizygotic (same amount of shared DNA as other siblings) twins to look at genetic contribution **Types of Research Over Time** **Cross-Sectional Research**: a type of correlational research - Understanding the score of the disorder helps inform if and how to intervene - Compares groups of people within different age brackets - We also want to understand the course of healthy development; what is similar about people who do not develop disorders? **Longitudinal Research**: follows the same group of people over time and measures the variables of interest at multiple timepoints - Allows for measuring individual change/group change, rather than just comparing what is different at different ages **Research Challenges** - We need cross-cultural research, and it is really challenging to do - Different expectations makes direct comparison difficult **The Replication Crisis** - Across fields studies are not being replicated - Why might this cause issues? - Why might it be happening? **Section 6: CLINICAL ASSESSMENT** **Assessment** - Systematic - Evaluation and measurement - Psychological, biological, and social factors - In an individual - Usually related to concerned about a possible disorder - Often results in diagnosis but not always **Evaluating an Assessment Tool** **Reliability**: how consistent is the measure? - Inter-rater reliability - Test-retest reliability **Validity**: is it measuring what it says? - Concurrent validity - Predictive validity **Standardization**: is it administered in the same way every time? - Are we comparing the right **norms**? - E.g. different cultures have different norms **Screening: The First Meeting** Typical First Session - Informed consent - Clinical interview - Understanding current concerns - Collecting background information - Initial plan for next steps - \*\*possibly questionnaires\*\* ***\*Steps are true for therapy or comprehensive assessment*** **The Clinical Interview** Textbook talks about a funnel, and this is kind of true; but could also think of it as more of a diamond - **Step 1**: usually start with "why are you here" (narrow) - **Step 2**: then collect tons of info and life, family history (broad) - **Step 3**: then take all of that and start to narrow back down Typical Therapists Notes - Why here? Why now? - History of problem - What tried? - Development? - Behavior - Transitions - Learn - Social - Hopes/fears - Strengths **Variations on Clinical Interviews** Semi-Structured - Questions/prompts that are generally followed but can be modified - May be more or less scripted - May include scoring criteria to help with diagnosis Mental Status Examination - Systematic observation tool I. Appearance/behaviors II. Thought process III. Mood/affect IV. Intellectual functioning V. Sensorium (awareness of surroundings) **Additional Considerations**: Need to have some awareness of other things that make look like disorders - E.g. physical illness, poor eyesight, poor hearing **Section 7: COMPREHENSIVE ASSESSMENT** **Cognitive Assessment**: diverse set of tasks looking at thinking reasoning, and problem-solving as well as working memory and processing speed - Results in "IQ" score; however, we don't really have a consensus on what intelligence is - Evaluates cognitive abilities that generally underlie academic skills **Academic Assessment**: generally looks more at school tasks - Typically get overall measures of reading, writing and math - Follow-ups examine why any areas ow weakness/strength are happening **Diagnostic Interviews** - Can be structured or semi-structured - Often ae directly based on DSM diagnostic criteria - Can be broad or specialized (e.g. focusing on anxiety disorders) - Even wi9th scores, still relies on clinical judgement to make diagnosis **Questionnaires** - Can assess behaviors, emotions, social skills, etc. - Can be self report or other report (e.g. parents, teachers) - Often most useful to have questionnaires from multiple sources - Personality inventories are one example **The ABC's: Antecedents, Behaviors, Consequences** **Projectives:** originally inkblot tests - Intended to reveal unconscious processes - Now more often used to starts convos - Rarely scored **Specialized Testing**: neuropsychological testing; can screen for brain dysfunction or even specific brain damage - **Neuroimaging**: CAT/CT scan, MRI, fMRI, PET scan - Psychophysiology: EEG, electrodermal responding **Section 8: CLINICAL DIAGNOSIS** **Diagnostic & Statistical Manual of Mental Disorders (DSM-5-TR)** Again, the "bible" of diagnosis (at least in North America) - Worldwide (e.g. Europe), the ICD-11 is more commonly used (International Classification of Diseases) - CD has many of the same diagnoses, but sorts them a bit differently and does not use symptom counts in the same way +-----------------------------------+-----------------------------------+ | **DSM-5-TR** | **ICD-11** | +===================================+===================================+ | **Major Depressive Disorder** | **Recurrent Depressive Disorder** | | | | | - At least two weeks | - At least two weeks | | | | | - At least 5 total symptoms | - Essential features: at least | | (from list) | one of depressed mood OR | | | diminished interest/pleasure | | - At least one symptom must be | in pleasurable activities | | depressed mood OR diminished | | | interest/pleasure in | - Additional features: | | pleasurable activities | insomnia, fatigue, weight | | | gain/loss, etc. | | - Other symptoms can be any of | | | insomnia, fatigue, weight | | | gain/loss, etc. | | +-----------------------------------+-----------------------------------+ **Types of Classification** **Categorical Classification**: must meet all criteria - Often works well in medical system - Works quite poorly in psych **Dimensonal Classification**: thoughts, moods, and behaviors ranked on a scale (as opposed to present, not present) - Difficult to classify - Unclear which dimensions and what level of severity needed for which disorders **Prototypical Classification**: diagnosis evaluated in relation to what we think the average presentation of a disorder is - Includes essential characteristics (must have x/y/z) and non-essential (can have a/b/c/d) **Evaluating Diagnostic Standards** - Guess who's back? Our friends: reliability and validity - **What would reliability in diagnosis look like?** - **What would validity in diagnosis look like?** **Criticisms of Psychological Disorder Diagnosis** - **Comorbidity**: the existence of 2 or more unique disorders (or diseases) in a person at the same time - Reliability - Validity - Labelling/Stigma **Section 9: ANXIETY AND PANIC DISORDERS** Anxiety Fear ----------- ---------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- Helpful **Can motivate proactive behaviors like studying for a test** **Can ready you to escape from or defend against danger** Unhelpful **(e.g. anxiety disorders) often restricts functioning; e.g. so anxious/worried you cannot study** **(e.g. panic disorder) likely overemphasizes possible danger; promotes avoidance and distress** **Anxiety vs. Fear** Anxiety Key Features - Future oriented - Physical tension - Feelings of worry/apprehension - Often promotes freeze behaviours Fear Key Features - Happening in the present - Immediate reaction to real or perceived danger - Tends to promote fight or flight **Causes of Anxiety and Fear** Biological - Tendency towards both anxiety and panic seme to run in families, but have distinct underlying systems - Neurotransmitters implicated include: GABA, dopamine, noradrenaline, and serotonin Behavioural Inhibition System (BIS) - Limbic System: mediates between brain stem and cortex -- anxiety associated with an overly responsive limbic system - BIS is a specific circuit within the brain that seems to promote freezing and anxiety in the face of this overly responsive limbic system Fight/Flight System (FFS) - Distinct from BIS - Originates in the brainstem but travels through much if the midbrain - Produces an immediate alarm reaction ***\*Environmental factors (e.g. smoking) can impact how sensitive these systems are*** Psychological - Many factors and experiences can come together to promote anxiety - Specifically, seems to be related to learning that life is not in your control; and a feeling that life is unpredictable Neglectful vs Helicopter Parenting - On one hand... - Parenting that is absent, neglectful, or abusive results in child's needs not being met - Let's child know that they cannot expect the world to be stable, safe, a predictable - On the other hand - Parenting that involves too much support can set a child up for a big shock when "real life" sets in - In these cases, the child has not had the opportunity to practice coping with uncertainty or adversity Social - Stressful life events can trigger underlying vulnerabilities - For example, big changes like starting university, moving into a new city, or oping with a divorce - Ongoing stressful situations can also add up; e.g. overwhelm at school + going through a breakup **Some Fun Statistics** - As of 2016, Stats Canada reported 8.6% of Canadians age 12+ had a diagnosed anxiety disorder -- similar for First Nations - Higher rates for women vs. men (**this *can* be misleading since due societal norms/stigma, men are less likely to reach out for help, in turn leading to lower rates od diagnosis**) - Anxiety disorders increase suicidal ideation and suicide attempts - Nearly 30% of people with anxiety disorder report it causes severe disability disorder **Anxiety and Mood** - Anxiety disorders frequently co-occur with mood disorders and certain physical disorders (e.g. migraines) - Specifically, roughly 50% of those with anxiety also have another anxiety disorder and/or mood disorder - When an individual has an anxiety disorder **and** mood disorder their rates of severe disability rise from 30% to 50% **Treatment of Anxiety Disorders** Medication - Benzodiazepines - Pros: very effective and fast acting - Cons: extremely addictive/ easy to become dependent - Anti-depressants (e.g. SSRIs) - Pros: reasonably effective, not typically addictive - Cons: various side effects; typically need to reduce slowly Cognitive Behavioural Therapy (CBT) - Mighty use thought records or evaluations - Might specifically learn about "thinking traps" or cognitive distortions - Might engage in behavioral experiments or "exposures" - Tends to focus on disproving anxious thoughts and creating more balanced thoughts Acceptance and Commitment Therapy (ACT) - Focuses on flexible thinking and letting anxious thoughts pass rather than actively fighting them - Often incorporates mindfulness practices -- activities designed to support non-judgemental awareness of the present moment Panic Control Treatment - A type of exposure that involves inducing panic-related symptoms (e.g. elevated heart rate) within a session -- then using cognitive therapy to support clients in recognizing that the symptoms we not catastrophic or unliveable Additional options - Group Therapy - Can help normalize anxiety - Can be especially helpful for Social Anxiety Disorder - Meds and Therapy - In many cases meds work faster and therapy works longer - Can be the case that using both is the most useful, especially in crisis or if the person is not responding quickly to therapy **Subsection 1: ANXIETY DISORDERS** 1. **GENRALUZEE ANXIETY DISORDER** 2. **SOCIAL ANXIETY DISORDER** 3. **SEPARATION ANXIETY DISORDER** 4. **SELECTIVE MUTISM** **Generalized Anxiety Disorder** **Characterized by**: - Worrying a lot - Worrying about a lot of things - Not being able to "turn off worry" - Incredibly exhausting - Distressing and/or impairing **DSM Criteria** A. Excessive anxiety and worry more days than not for at least 6 months about many events or activities B. Individual finds it difficult to control the worry C. Anxiety and worry associated with 3 or more of the following symptoms (with at least some present more days than not for the past 6 months) - Restlessness/being on edge - Being easily fatigued - Difficulty concentrating/mind going blank Irritability - Muscle tension - Sleep disturbance D. Symptoms cause clinically significant distress and/or impairment E. Symptoms are not the direct effect of a substance or another medical condition F. Symptoms are not better explained by another mental disorder **Statistics** - In 2012, 3% of Canadians currently met criteria - 9% had met criteria in their lifetime - 50% also had symptoms of major depressive episode - 2/3 people diagnosed are female (this may be specific to developed countries - In the US, seems to be more common in white people than people of colour - Onset tends to be gradual and occur over late adolescence to early adulthood - GAD is often chronic -- re-occurring or flaring up throughout life - Anxious *tendencies* appear to have a large genetic component -\> but this does not guarantee developing a disorder **Common Patterns** - Intolerance of uncertainty - Problems = threats -\> not challenges - Belief that worry is effective - Many worries prevent working through worry **Social Anxiety Disorder** **Characterized by**: - Not just "being shy" - Worrying a lot in or about social situations (or performance situations) - Worrying about being embarrassed or negatively evaluated **DSM Criteria** A. Marked fear or anxiety about one or more situations in which the individual is exposed to possible scrutiny by others B. The individual fears that they will act in a way or show anxiety symptoms that will be negatively evaluated C. The social situations almost always provoke fear or anxiety D. The social situations are avoided or endured with intense fear or anxiety E. The fear or anxiety is out of proportion to the actual threat F. The fear, anxiety, or avoidance is persistent (6 months or more) G. Causes clinically significant distress or impairment in major areas of functioning H. Is not attributable to a substance or another medical condition I. Is not better explained by another mental disorder J. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive - ***\*\*Specify if: performance only*** **Statistics** - As many as 13.3% of people experience Social Anxiety Disorder at some point in their lives - Higher in women than men, but less of a difference compared to GAD - Usually begins in adolescence and is more prevalent in younger undereducated, single, and low-income individuals - **Cross-Culturally** - Common across ethnic and cultural groups, however, presentations may look a bit different - For example, in more collectivist cultures, the worry may be less about being embarrassed and more about embarrassing someone else - Some evidence suggests that cultures that re more accepting towards socially withdrawn behaviors also have more social anxiety **Underlying Factors** - Tendency towards shyness - Sensitivity to negative evaluation - **Specific Stressors** - Traumatic social event(s) - Perception of negative evaluation - Belief that one has poor social skills ***92% of those with SAD (anxiety) report severe teasing/bullying in childhood compared to 35-50% for other anxiety disorders*** **Separation Anxiety Disorder** **Characterized**: by extreme distress about being away from major attachment figures DSM Criteria A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached -- evidenced by at least 3 of the following - Excessive distress when anticipating or experiencing separation from home or from major attachment figures - Excessive worry about losing major attachment figures or about possible harm to them - Excessive worry about experiencing an untoward event that results in separation reluctance or refusal to go out/away from home - Excessive fear or reluctance to be alone at home or elsewhere - Excessive reluctance or refusal to sleep away from home or go to sleep without being near attachment figure - Repeated nightmares with a theme or separation - Repeated complaints of physical symptoms when separation occurs or is anticipated B. Fear, anxiety, or avoidance is persistent (at least 4 weeks in children/adolescents and typically 6 months or more in adults) C. Causes clinically significant distress or impairment in important areas of functioning D. Is not better explained by another mental disorder Extra Info - Previously had to have begun before age 18 - Mya have been highly overlooked in adults - Can carry over from childhood if not treated (approximately 35% of the time) **Selective Mutism** **Characterized**: by a rare childhood disorder involving lack of speech in one or more settings **DSM Criteria** A. Consistent failure to speak in specific social situations in which there is an expectation for speaking, despite speaking in other situations B. Disturbance interferes with educational or occupational achievement or social communication C. Lasts at least one month (and not only the first month of school) D. Failure to speak is not attributable to a lack of knowledge or comfort with the spoken language required E. Not better explained by a communication disorder and does not occur only within autism, schizophrenia or a psychotic disorder **Extra Info** - Strongly related to social anxiety -\> many or most children with SM meet criteria for SAD (anxiety) - Occurs in \~0.5% of children, higher in girls than in boys **Subsection 2: PANIC DISORDERS** **Panic Disorder** **Characterized**: by repeated panic attacks and persistent worry about having future panic attacks **DSM Criteria** A. Having recurrent unexpected panic attacks -- an abrupt surge of intense fer or discomfort that peaks within minutes and includes four (or more) of the following symptoms - Heart palpitations - Sweating - Trembling/shaking B. At least one of the attacks has been followed by 1 moth (or more) of one or both of the following - Persistent concern/worry about additional panic attacks or their consequences - A significant maladaptive change in behaviour related to the attacks C. Not attributable to a substance or another medical condition D. Not better explained by another mental disorder **Statistics** - About 3.7% of Canadian population meet criteria at some point during their lives -- higher in women than in men - Panis disorder typically occurs somewhere around age 25 - In the US, white people appear to have the highest rates of panic disorder -- but when BIPOC individuals have panic disorder it is often associated with racial discrimination (due to) - Women with panic disorder seem to be much more likely compared to men with panic disorder to also have agoraphobia - However, men with panic disorder are not unbothered -- instead, they seem to be more likely to turn to alcohol to cope... **Panic Disorder and Sleep** - Roughly 60% of people with panic disorder have experienced panic attacks in their sleep -- especially between 1:30-3:30 am - People who experience overnight panic attacks may be afraid to go to sleep at night - It seems that entering the deepest stage of sleep may trigger feelings of "letting go" which makes the person anxious - When these people awake, they often fear they are dying **Causes** - Some people are genetically more likely to have a panic reaction when facing a stressful event - Once a person has had a panic attack, they may generalize those symptoms as if they are always related to panic - Then they must also believe that these physical sensations are hinting at danger -- it turns out this often because that has been their experience in the past (e.g. they have previously had physical disorders) **Subsection 3: PHOBIAS** 1. **AGOROPHOBIA** 2. **SPECIFIC PHOBIA** **Agoraphobia** **Characterized**: by avoidance of certain public situations due to fear of developing a panic attack and being embarrassed or not having access to support **DSM Criteria** A. Marked fear or anxiety about 2 or more of the following - Using public transportation - Being in open spaces - Being in enclosed paces - Standing in line or being in a crowd - Being outside of the home alone B. the individual fear or avoid these situations due to concern that escape may be difficult or help may be unavailable if panic symptoms or other embarrassment occurs C. These situations almost always provoke fear or anxiety D. The situations are actively avoided, require the presence of a companion or are endured with intense fear or anxiety - Companion can be person, support animal. They don't actually have to be useful E. Fear is out of proportion to actual danger F. Typically lasting for 6 months or more G. Distress or impairment H. If another medical condition -- reaction is excessive - I. Not better explained by another mental disorder (e.g. OCD, PTSD) People with agoraphobia can stay agoraphobic even years after their last panic attack for multiple reasons, with the most common one being that their method of protection is working (staying inside, not taking the bus, etc.) and they fear if they stop, the panic attacks will resurface **Specific Phobia** **Characterized**: characterized by strong and persistent fear of specific object or situation -- which causes distress or impairment in functioning **DSM Criteria** A. Marked fear or anxiety about a specific object or situation B. Object or situation almost always provokes immediate fear or anxiety C. Object or situation is actively avoided or endured with intense fear or anxiety D. Fear or anxiety is out of proportion to any danger E. Fear is persistent (6 months or more) F. Causes clinically significant distress or impairment G. Not better explained by a mental disorder Many people with a phobia have more than one. People with Phobias may often not seek treatment and will instead orient their life around avoiding the phobia Some phobias are harder to cope with than others -- for example, it's hard to avoid storms but for most people fairly easy to avoid planes. Most people have specific fear -- but only 6.4% will meet full criteria for a "specific phobia" **Causes** - Traumatic event - Vicarious experience - Informational transmission Phobias are reported way more in women than in men - Maybe because men work to overcome fear, more likely they simply hide them more intensely... **Section 10: OCD AND EATING DISORDERS** **Subsection 1: OBSESSIVE-COMPULSIVE DISORDER (OCD)** 1. **OBSESSIVE-COMPULSIVE DISORDER** 2. **BODY DYSMORPHIC DISORDER** 3. **HOARDING DISORDER** **OCD** **Characterized**: by persistent intrusive unwanted thoughts or impulses that are ignored when possible or directly resisted via intense focus on alternate thought/behaviours **DSM Criteria** A. Presence of obsessions, compulsions, or both: - Obsessions 1. Recurrent and persistent thought/impulses/images that are intrusive and unwanted and cause anxiety and distress 2. Individual attempts to ignore or supress the above or to neutralize them with alternate thought/actions (compulsions) - Compulsions 3. Repetitive behaviors or mental acts that feel necessary to neutralize an obsession or to meet rigid internal rules 4. Behaviors or mental acts are intended to prevent or reduce stress or to prevent a dreaded situations -- but are not realistically connected or are clearly excessive B. Obsessions are compulsions are time-consuming (e.g. take more than 1 hour a day) or cause clinically significant distress or impairment C. Not attributable to physiological effects of a substance D. Not better explained by another mental disorder ***\*\*Specify Insight*** - ***Good or fair*** - ***Poor*** - ***Absent/delusional*** ***\*\*Specify if*** - ***Tic related*** **4 Types of OCD** 1. Symmetry/Exactness (27%) - Obsessions: making things symmetrical/aligned, doing things over and over until they feel "just right" - Compulsions: putting things in a certain order, repeating rituals 2. Forbidden Thought/Actions (21%) - Obsessions: fear of urges to harm self or others in some way (sexual, aggressive), fear of offending God (religious - Compulsions: checking, avoidance, reassurance-seeking 3. Hoarding (16%) - Obsessions: fear of germs/contaminants - Compulsions: repetitive or excessive washing, using gloves/masks when not needed 4. Cleaning/Contamination (15%) - Obsessions: fear or throwing anything away - Compulsions: collecting and/or saving objects with little to no actual sentimental value **Statistics** - 1.6%-2.3% lifetime prevalence - Up to 13% of people may have moderate obsessions or compulsions that do not reach diagnostic level - Boys seem to develop OCD earlier (13-15) than girls (20-24) but women are more likely to have OCD in their lifetime - OCD tends to be chronic - OCD seems to be pretty consistent across cultures -- with some areas having a higher amount of religious obsessions **Underlying Factors** **Thought-action fusion**: belief that thoughts and actions are the same/similar -- or that thinking something is as bad as doing it - Belief that some thoughts are unacceptable - Otherwise, similar to anxiety **Treatment** - Anti-depressants (SSRIs) seem to work pretty well for many -- but relapse is common if they are discontinued - Most effective therapy approach tends to be Exposure and Response Prevention - In rare cases, psychosurgery may be used -- but usually involves severe side effects **Exposure and Response Prevention**: a very specialize type of CBT - OCD tends to be very sticky in both thoughts and behaviours -- ERP targets both - Often looks similar to a fear hierarchy and with the "fear" being the obsessions/compulsions - For example, an early step in a cleaning type OCD might be watching a video about germs and not washing your hands or using sanitizer for 5 minutes **Body Dysmorphic Disorder** **Characterized**: by feeling like there is something objectively wrong with how you look -- even thought others do not see the same thing DSM Criteria A. Preoccupation with one or more perceived body defects that are either not observable to others or appear slight B. At some point the individual has performed repetitive behavior or mental acts in response to their concern C. Clinically significant distress or impairment D. Not better explained by concerns with weight related to an eating disorder ***\*\*Specify Insight*** - ***Good or fair*** - ***Poor*** - ***Absent/delusional*** ***\*\*Specify if*** - ***With muscles dysmorphia*** Lack of insight is very high -- 33-50% fall in absent/delusional category - Used to be thought of as somatic (related to physical) -- but turns out it is more similar to OCD - Common perceived defects: skin, hair, nose, stomach, teeth **Statistics** - Likely quite common -- and often not diagnosed or treated - In adolescence, girls more likely to have BDD than boys -- but by adulthood it is equal - Age of onset peaks at 16-17 - Men tend to have more severe BDD - Women more likely to also have eating disorder **Causes and Treatment** - Mostly what we know is that it seems quite similar to OCD in onset, course, and treatment -- so it is likely the causes are similar - Plastic surgery is common -- but usually doesn't work at all **Hoarding Disorder** Characterized: different than OCD (hoarder specifier) because it tends to get worse and worse, rather than waxing and waning in times of stress - Involves a very strong emotional attachment to possessions -- rather than simply a fear of getting rid of them