Psychiatric clinical disorders.pdf

Chapter 2 Behavioural + cognitive science Behavioural perspective Views abnormal behaviour as responses learned in the same ways other human behaviour is learned Classical conditioning Operant conditioning Cognitive perspective Regard the le...

Chapter 2 Behavioural + cognitive science Behavioural perspective Views abnormal behaviour as responses learned in the same ways other human behaviour is learned Classical conditioning Operant conditioning Cognitive perspective Regard the learner as an active interpreter of a situation Learner's past knowledge imposing a perceptual tunnel on their new experiences Schemas Cognitive sets New information may fit the schema but if it doesn't, the learner reorganises the schema Conditioning + cognitive processes Classical + operant conditioning facilitate learning relationships among events We make judgements based on this relationship Learned helplessness E.g. Seligman Encountering conditions over which we have no control Giving up attempting to cope Leads to depression Learned optimism Positive psychology Social learning E.g. Bandura Bobo doll experiment Organisms can learn simply by watching others in their environment (modelling or observational learning) and our interactions with other people around us Attention Retention Reproduction Motivation Prepared learning The recognition that biology + genetics influence what we learn + how readily we do so Learning behaviours that protect us Cognitive science + the unconscious E.g. Freud Unconscious cognitive processes Blind sight - unconscious vision  Implicit memory - uses past experiences to remember things without thinking about them E.g. Driving Implicit cognition / implicit cognitive processes - unobservable unconscious processes Stroop task - methods to study implicit cognition Cognitive behavioural psychotherapy approaches (CBT) Cognitive restructuring CBT Rational emotive behavioural therapy Self-instructional training (meichenbaum) Focuses on modifying what clients say to themselves about the consequences of their behaviour Emotions Tendency to behave in a certain way elicited by an external event and a feeling state accompanied by a characteristic physiological response Emotional States - emotion, mood, affect Emotions - usually short lived, temporary states lasting several minutes to several hours Mood - a more persistent period of affect or emotionality Affect - usually refers to the momentary emotional tone that accompanies what we say or do Cognitive component Involves subjective feelings that have an evaluative aspect Physiological component Activation of the autonomic nervous system Behavioural component Emotions are expressed through body language + facial expressions Emotions + psychopathology Emotion disruption (dysregulation) interferes with behaviour possibly resulting in psychological disorders E.g. Panic attack, bipolar disorder Cultural, social + interpersonal factors Culture bound disorders Gender roles Cultural expectations of men's + women's roles Gender differences exist in rates of mood disorders Two thirds with major depression are women Rumination Males more likely to get involved in other activities Form of self medicating Women respond better to treatment: emotional processing Eating disorders more prevalent in women: pressure to be thin Social effects on health + behaviour Life expectancy + richness of life are related Strong social support system / network = positive impact on life expectancy Social phobia + depressive disorder related to (low) interpersonal contacts Psychological disorders may look different from one culture to another Social stigma Psychological disorders carry societal stigma Stigma is different in different cultures Lifespan development Experiences at different periods of development influence vulnerability to: Stress Other psychological problems Erikson's psychosocial theory The principle of equifinality The fact that a number of paths can lead to the same outcome Reminds us that we must consider the various paths to a particular outcome, not Just the result  Chapter 5 Anxiety What is anxiety? A common emotion characterised by physical symptoms, future orientated thoughts + escape or avoidance behaviours Occurs when people encounter a new situation or anticipate a life changing event Usually is time limited + ends when the event is over Components of anxiety Physiological - heightened level of arousal + physiological activation Cognitive - subjective perception of anxious arousal + associated cognitive processes Behavioural - 'saftey' behaviours; escape / avoidance Normal anxiety vs abnormal anxiety Feeling anxious occasionally is normal Situational factors - truly upsetting situations or actual threats -> normal to feel anxious Chronically anxious people - tendency to perceive threat + to be worried when there is no objective threat or the situation is ambiguous Anxiety must be chronic, relatively intense + causing impairment + significant distress for self + others Anxiety, fear + panic All related but different Anxiety: Negative mood state characterised by bodily symptoms of physical tension + apprehension about the future Fear: Immediate alarm reaction to dangerous or life threatening situations Panic attack: Abrupt experience of intense fear or acute discomfort accompanied by physical symptoms Expected panic attack - know something will cause one Unexpected panic attack - comes out of nowhere, no warning Causes of anxiety Biological contributions People inherit the tendency to be anxious or highly emotional Anxiety is associated with: Neurotransmitter systems Low levels of GABA; not a direct relationship Noradrenergic system is also implicated Other body circuits disc associated with anxiety Corticotropin releasing factor (CRF) system CRF activates the HPA axis when released  Also directly related to the GABA - serotonergic + noradrenergic neurotransmitter systems The limbic system - mediator between the brain stem + cortex Anxiety is a mood state = limbic system controls emotional regulation Behavioural inhibition system (BIS) In animals -> tendency to freeze, experience anxiety + apprehensively evaluate the situation to confirm the presence of danger This circuit leads from the septal + hippocampal areas in the limbic system to the frontal cortex BIS is activated by: Signals from the brain stem or unexpected events, such as major changes in body functioning that might signal danger Danger signals from the cortex to the septal- hippocampus area Distinct from the fight / flight system - immediate alarm + escape response Involved in panic Psychological contributions Anxious behaviour starts in childhood Overprotective + overintrusive parents Affects children's ability to cope with stressors Feeling of no control over environment Personality traits Anxiety sensitivity Tendency to fear the physiological symptoms of anxiety E.g. Rapid heartbeat, sweating Behaviourists view Anxiety a product of conditioning or modelling Social contributions Focus on the relation between stressful life events as triggers for biological + psychological vulnerabilities for anxiety + panic Stressful life events Social + interpersonal Friendship issues, marriage, work life Physical Illness + injury Comorbidity The occurrence of two or more disorders in a single person Major depression + anxiety disorders most commonly comorbid 57% of people diagnosed with one anxiety disorder also have another anxiety disorder or depression Additional diagnoses of depression, alcohol, drug abuse, make recovering from anxiety difficult Comorbidity with physical disorders Anxiety disorders co-occur with several physical conditions Thyroid disease, respiratory disease, arthritis, migraine headaches, allergies Anxiety develops before physical disorder Both together lead to poor quality of life Suicide Not only associated with mood disorders 20% of panic disorder patients attempt suicide Comparable to people with depression Suicidal ideation common Suicide attempts comman More likely by those who inflict self harm Anxiety disorders A group of disorders characterised by heightened physical arousal, cognitive distress a behavioural avoidance of feared objects / situations / events Most common psychological disorders More common in women Generalized anxiety disorder Features: Uncontrollable, unproductive worrying about everyday events Feeling impending catastrophe even after successes Inability to stop the worry Has low physiological arousal E.g. Panic attacks Characterized by: Muscle tension, mental agitation, susceptibility to fatigue, irritability, difficulty sleeping, difficulty concentrating Statistics 12 month prevalence rate aged 15+ - 5.2% More common in women than men Most of the studies conducted in developed countries Relatively few people with GAD come for treatment, compared with patients with panic disorder Stressful life events play role in onset Most common in people 45 + Earlier + more gradual onset than most other anxiety disorders Difficult to treat successfully Difficult to achieve a full remission of symptoms Causes Possibility of a genetic cause GAD runs in families Greater risk for monozygotic twins (identical) Anxiety sensitivity Learning theories Anxiety regarded as having been classically conditioned to external stimuli but with a broader range of conditioned stimuli Cognitive theories Focus on control + helplessness Emphasize the perception of not being in control as a central characteristic of all forms of anxiety Attentional bias The attention of people with GAD is easily drawn to stimuli that suggest possible physical harm or social misfortune Interpreting ambiguous stimuli as threatening Intolerance of uncertainty Positive beliefs about worry  Worrying helps solve a problem Poor problem orientation (threats to be avoided) Cognitive avoidance (avoiding negative affect associated with the threat ) Treatment Drugs Benzodiazepines Highly addictive No more than a week or two Long term use effectiveness has not been empirically supported Antidepressants Paxil Psychological CBT Focus on the worry process and avoidance of feelings of anxiety + negative affect Strong support when testing effectiveness long term Effective with children + older adults Mindfulness based approaches Panic disorder & agoraphobia Panic disorder Sensation of dying or losing control, unexpected panic attacks Person suffers a sudden and often inexplicable attack of alarming symptoms Rapid or laboured breathing, heart palpitations, nausea and chest pain, feelings of choking, dizziness and trembling, intense apprehension and feeling that disaster is imminent Person may also experience Depersonalisation Derealisation In many cases, PD is accompanied by agoraphobia Agoraphobia Fear and avoidance of situations - unsafe and inescapable A cluster of fears cantering on public places and being unable to escape or find help should one become incapacitated Safe place or safe person People develop agoraphobia as they never know when the panic like or other embarrassing symptoms may occur Diagnosis requires anxiety in at least 2 of the 5 situations: Public transportation Open spaces Enclosed spaces Lines/crowds Being out of the house alone Many people with agoraphobia are unable to leave the house or do so with great distress Many people with PD go on to develop agoraphobia but not everyone with PD has agoraphobia Avoidant behaviours are displayed Could lead to drug and alcohol abuse/dependance Interoceptive avoidance: Removing self from situations/activities leading to arousal Statistics: For PD 4% of Canadians will experience PD in their lifetime Canadian women higher (4.6%) rate than men (2.8%) Mean age of onset: 25-29 years Most initial attacks begin at or after puberty Gender differences Cultural explanation Accepted for women to report fear - Men to be stronger and braver Women - more fearful of anxiety Males - turn to alcohol Cultural influences PD exists worldwide Lowest rates in Asian and African countries Expression of PD varies Latin America - Susto - a fright disorder Inuit of Northern Canada & west Greenland - Kayak angst Nocturnal panic Panic attacks most frequently occur between 1:30am and 3:30am Delta (slow wave) sleep Causes Biological theories PD runs in families Identical twin pairs vs fraternal twins An increased risk of 5-16% among relatives of those with PD Genetic diathesis Noradrenergic activity theory Panic is caused by over activity in the noradrenergic system Simulation of the locus coeruleus causes monkeys to have ‘panic attack’ Drugs that block firing in the locus coerulus have not been found o be very effective in treating panic attacks The role of gamma-a!inobutryric acid (GABA) in panic GABA generally inhibit noradrenergic activity PET study found fewer GABA receptor binding sites in people with PD Psychological theories Misinterpretation of physiological arousal symptoms Overly active ANS + psychological tendency to become very upset by these sensations -> danger signal A vicious cycle in PD - panic attack -> fear -> fearing another panic attack -> increased autonomic activity -> catastrophic ways of interpreting these symptoms -> raise the anxiety level -> full blown panic attack Anxiety sensitivity  Treatment Medication Most widely used drugs - benzodiazepines, SSRIs, SNRIs Relapse closer to 90% if medication stopped Benzodiazepines adversely affect cognitive and motor functions to some degree Psychological Intervention Exposure based therapies - concentrated on reducing agoraphobic avoidance Exposure to feared situation Gradual exposure exercises combined with relaxation or breathing retraining CBT Panic control treatment (PCT) Therapists creates ‘mini’ attacks - exposing patients with PD to the cluster of interoceptive sensations that remind them of their panic attacks Identify and modify the basic attitudes and perceptions concerning the dangerousness of the feared but objectively harmless situations Combined psychological drug treatments Research - no advantage to combining drugs and CBT initially Psychological treatments perform better in the long term Stepped care approach - adding another treatment to existing treatment (CBT, drugs) Specific phobia Clinical description An irrational fear of a specific object or situation that markedly interferes with an individual’s ability to function Unwarranted fears caused by the presence or anticipation of a specific object or situation The fear and avoidance is out of proportion to the danger actually posed The fear is recognised by the sufferer as groundless To name a specific phobia, the suffix ‘phobia’ is preceded by a Greek work for the feared object or situation New phobias tend to emerge in keeping with societal changes Nomophobia A pathological fear of remaining out of touch with technology that is experienced by people who have become overly dependant on us in their mobile phones or personal computers Coronaphobia An excessive triggered response of fear of contracting the virus causing Covid-19 leading to: Accompanied excessive concern over physiological symptoms Significant stress about personal and occupational loss Increased reassurance and safety seeking behaviours Avoidance of public places and situations Marked impairment in daily life functioning Major subtypes Blood injury injection phobia  Situational phobias Natural environment phobias Animal phobias Other phobias Statistics The lifetime prevalence around the world - 3 to 15% Fears and phobias concerning heights and animals - the most common 6.4% of Canadian population 8.9% of women, 4.1% of men Paradox - common and treatable yet goes untreated Most work around their phobias - only the most severe cases seek treatment Causes: Traumatic experiences/ traumatic conditioning Prepared learning Vicarious experience Info transmission Panic attack ( false alarm) - phobia of that situation Anxiety over the possibility of another traumatic event or false alarm Social and cultural factors Most reported specific phobia occur in women Treatment: Exposure based exercises Change brain functioning by modifying neural circuitry in amygdala, insula, cingulate cortex Virtual reality exposure therapy, a newer approach, is effective Purely cognitive approach is not reccomended Separation anxiety disorder Child’s unrealistic and persistent worry something will happen to parents or other people important to child Afraid to go to school - has nightmares 35% can extend into adulthood if not treated in childhood Adults with this disorder have been overlooked Sometimes the onset is in adulthood rather than carrying over from childhood Causes: Biological vulnerability Parent child attachment - insecure or anxious attachment styles Traumatic events and significant life changes Parental loss, separation, divorce, death of a loved one, major life transitions Treatment: Gradual exposure - gradual exposure to the separation situations in a controlled manner Cognitive restructuring - challenging and changing irrational thoughts about separation Relaxation training - teaching coping strategies and relaxation techniques to manage anxiety  Parent child interaction therapy - to improve parent child interactions and reinforce positive behaviours Social anxiety disorder (social phobia) Clinical description Persistent, irrational fears of being judged by other people Tend to avoid situations in which they might be evaluated Concerns that blushing, shaking and sweating (physiological signs of anxiety) will be observed by others Social situations: Speaking or performing in public Social interactions Being observed in public Statistics: 12 month prevalence rate - 7.1% of Canadians SAD usually begins during adolescence (peak age 15) More prevalent in young, less educated, single, economically disadvantaged individuals Females are slightly more represented than males Causes: Prepared learning (angry faces) - react to angry faces with greater activation of the amygdala and less cortical control than people without anxiety Biological vulnerability to develop anxiety and/or to social inhibition Panic attack in a social situation Anxiety - additional panic attacks in the same/similar social situation Experience of a real social trauma -> true alarm -> anxiety in the same/similar social situations Childhood experiences (bullying, difficult periods in childhood 12-15 yrs) Cognitive characteristics Attentional bias to focus on negative social info Perfectionist standards for accepted social performances High degree of public self consciousness Post event processing of negative social experiences Alden’s interpersonal transaction cycle Individual’s interaction with people in the social environment contribute to or maintain social anxiety Biases social perceptions -> maladaptive behaviour in social situations -> elicits negative reactions from others Upward and downward social comparisons Treatment: CBT Cognitive behavioural group therapy - includes cognitive restructuring as well as rehearsal or role play of feared situations in a group setting More effective than psycho education Social mishap exposure CBT -> changes in the brain activity associated with emotional processing SSRIs (Paxil, Zoloft) CBT and SSRI - both effective but the combination was no better than the two  individual treatments Selective mutism DSM-5 TR includes SM with anxiety disorders Rare childhood disorder characterised by lack of speech in settings where public speech is expected Related to social anxiety Speechlessness in selective situations only (school) Lack of speech must be more than one month and cannot be limited to the first month of school Causes: Genetic contribution Traumatic life events Overprotective parents Treatment: Emphasize activities that promote verbal participation and spontaneous speaking Behavioural techniques - modelling, shaping combined with reinforcement for participation in the treatment