Psychopathology: Mental Disorders - Overview, Etiology, and Treatment - PDF

1/13 18% of all people who can be currently diagnosed with a mental disorder - Point prevalence 50% of all people who can be diagnosed with a mental disorder at some time in their life - Lifetime prevalence 1/15 Psychological Disorder - A psychological dysfunction within an individual that...

1/13 18% of all people who can be currently diagnosed with a mental disorder - Point prevalence 50% of all people who can be diagnosed with a mental disorder at some time in their life - Lifetime prevalence 1/15 Psychological Disorder - A psychological dysfunction within an individual that is associated with significant distress or impairment and a response that is not typical or culturally expected o Something is going awry § Psychological function = sensation and perception systems When awry, you see things when nothing is there and hear things when there is no sound (hallucinations) o Most common hallucination is auditory hallucinations (schizophrenia) o Visual hallucination = drug overdose or something aNecting their brain o Fear can be a disfunction within an emotion system § Anxiety and depression o Sleep disfunctions Typical sadness/distress o Grief response, watching an accident occur/something traumatic, loss of a loved one § PTSD occurs when trauma is in their far past but still aNects them every day Know what DSM stands for (Diagnostic and Statistical Manual of Mental Disorders) o Put out by American Psychiatric Association Tourette’s Disorder - Involuntary sudden bodily movements that are diNerent than tremors - People must have multiple motor tics o Only motor tics – seen by neurologist not psychiatrist o Vocal and motor tics fits DSM criteria to be seen by psychiatrist § Involuntary vocal movement that does not represent their thoughts o Tics have persisted for more than one year § Frequency/how long its occurring o Significant impairment o Onset before age 18 § If beyond age 18, not diagnosed as having Tourette’s DiNerent neurological condition that’s hindering their ability to think Associated features - present within some individuals that have a diagnosis that you want to be aware of for your client. Not required or aNects everyone with the disorder - seen in diagnosis more than gen pop but not needed for diagnosis o have obsessions and compulsions § more often seen in those with Tourette’s but not required to have it § OCD o Only 10% of people with tourettes have coprolalia § Uncontrollable swearing or vocalizing obscenities o Copropraxia – motor tic § Uncontrollable obscene gestures o Echolalia § Uncontrollable repetition of another person’s spoken words Diagnostic criteria - required for diagnosis of disorder - without this, they will not have disorder course for tourettes - typical onset (age 4-6) - peak severity (age 10-12) prevalence - children: 3-8 per 1,000 (.3 -.8%) rare sex - males 3 times more aNected than females diNerences in sex presentations for disorders are descriptive most adults have less severe symptoms than when they were children most people that have diagnostic criteria for disorder barely meet the case and have it mild - as a clinician its more frequent to see mild cases than severe cases risks for Tourette’s disorder - some genetic influence on risk o genetic risk usually interacts with environmental factors to be uncovered low birth weight maternal smoking during pregnancy increased paternal age § risk is increased likelihood not destined risk factor does not mean having disorder - environemtnal factors are usually broad to the disorder treatment for tourette’s - 60-80% improve with specific drugs o Haloperidol, pimozide, clonide  § Anti psychotic medications can be benefical for those with Tourette’s and show a clinical benefit (THIS IS NOT A CURE) They are symptom management (medication when working – less frequency, duration, and severity of symptoms but they are still there - Behavioral techniques are not eNective o When under stress, their ticking behavior is increased § Stress exacerbates symptoms generally - Psychotherapy helps life management o Stress management (less stress = fewer symptoms) o Stigma and self-esteem Trying to suppress the tics will add additional stress and therefore increase the frequency of symptoms - Execution of singing vocal movements don’t intrude, athletic behavior motor movements don’t intrude Should tourette’s b considered a physical illness or a mental disorder? - Displays physical signs (tics) - Shows genetic influence on risk - Responds to medications o No clear dividing line between physical illness and mental disorder As a clinical psychologist you want to ask when their last physical was - Depression could be linked got hypothyroidism and psychotherapy won’t help 1/22 Models of Psychopathology - Focuses on certain individual or situation individual is in 1. Clinical Description and Assessment 2. Explanation and Understanding (etiology) a. Gives you explanation that leads you to understand what is happening to the individual 3. Treatment a. Changes that can be made to make the person suNer less Traditional model 1. Psychodynamic model o Comes out of Freud model o What drives people’s behavior comes from some unconscious wishes/desires that can come in conflict with each other that can lead to suNering and impaired behavior 2. Phenomenological model a. Comes out of philosophy b. Focuses on how people understand broader meaning of life that relates how you influence other people  c. Give limited insight on what’s going on for psychopathology 3. Behavioral (environmental-learning) model a. Abnormal behavior is not very diNerent that normal behavior, they just have a diNerent learning history b. Help them relearn how to react to something in their environment 4. Cognitive Theoretical cause 1. Unconscious conflicts 2. Lack of meaning or distortion of life experiences 3. Maladaptive learning 4. Faulty thinking Theoretical cure 1. Insight into unconscious conflicts a. Hard to achieve because there is resistance at the unconscious level 2. Develop life meaning and mature relationships 3. Unlearning, learning, or relearning 4. Learn new ways of interpreting life experiences Classical conditioning (ivan pavlov) - He was not a psychologist o Unconditioned (unlearned) § Stimulus = meat (US) Anything an animal can detect in its environment § Response = salvation (UR) o Conditioned § (neutral) Stimulus = tone (CS) § Response = salvation (CR) Extinction - Repeated presentation of the CS alone will result in the elimination of the CR - Used in anxiety and fear disorders because most are learned through classical conditioning Classical Conditioning of Fear and Anxiety - Operant Conditioning (B.F. Skinner) o Skinner Boxes § Where birds are trained § At eye level there is a key – translucent disk to indicate diNerent conditions for that bird Can detect how much the bird pecks on the key for food delivery. o Consequences that follow the behavior will determine how often the bird will peck (if hurt, no) o A (antecedent) § Green light § Red Light  § Blue Light + Shock § Orange Light + Grain o B (Behavior) § Peck § Peck § Peck § Peck o C (consequent) § Grain § Shock § Ends Shock § End access to grain o ENect § Increases pecking behavior § Decrease pecking behavior § Increase pecking behavior § Decrease pecking behavior o Contingency Name § Positive Reinforcement (anything that will encourage behavior) Positive – giving a stimulus Negative – removing a stimulus o Praise § Positive Punishment (decreases likelihood of behavior) Spanking § Negative Reinforcement (When you remove a response – negative) Buckling seatbelt, taking medicine for a headache o The removal of the headache is a negative reinforcer that encourages you to take medicine. § Negative punishment (stimulus is removed) Timeout is an example Token economies - Tokens given following desirable behavior - Token taken away following undesirable behavior - Tokens used to “purchase” items o Cigarettes, passes - Can modify how people interact with better social skills Cognitive model Antecedent (specific life event) -> Belief -> Consequent (emotion & behavior) Failed exam -> I’m a failure at life -> depressed and low self-esteem Dispute the belief in Cognitive Behavioral Therapy Cognitive Contributions to Depression (Aaron T. Beck) Dysfunctional Core Beliefs - Automatic negative thoughts that are not conscious until activated by stressor Depressive Cognitive Triad - I am no good - My world is bleak - My future is hopeless Depressive Types - Helpless type (“I am inadequate”) [introjective] - Unlovable type (“I am unattractive/unworthy”) [anaclitic] 1/27 Classification and Diagnosis Cognitive Behavioral Triangle Thoughts Behavior. Emotions This is a triangle because they all aNect each other - Thoughts: I am unlovable - Behavior: Withdraw from social events - Emotions: Depressed Thoughts and Behaviors that impact emotions - Intervention will be at the thoughts and behaviors - This is what is manipulated to eNect emotions CBT Treatment Steps - Detection o What is happening in the person’s life in terms of their cognitions, behaviors and emotions § Record what they are doing, what they are thinking, and what they are feeling Always homework involved in CBT because memories get distorted easily  o Ex: CBT 7 Column Thought Record CBT Thought Record Where were Emotion or Negative automatic Evidence that supports Evidence that does not Alternative thought Emotion or you? feeling thought the thought support the thought feeling What experiences indicate that this thought is not completely true all of the time? Emotions can be If my best friend had this thought what Where were you? described with one What thoughts were going would I tell them? How do you feel What were you word. E.g.: through your mind? Are there any small experiences which Write a new thought which takes about the situation doing? angry, sad, scared What memories or images were What facts support the truthfulness contradict this thought? into account the evidence for and now? Who were you with? Rate 0-100% in my mind? of this thought or image? Could I be jumping to conclusions? against the original thought Rate 0 - 100% PSYCHOLOGYT LS http://psychology.tools What evidence supports validity of thought or lack thereof Discover along with the client what is going on in their life - Analysis o How are the cognitions, emotions, and behaviors connected. Look for ongoing patterns of influence. - Change o Challenge beliefs and change behaviors to accomplish goals of therapy Features of CBT - Very collaborative and transparent o Work with client to identify relationships between components of the thoughts. Get them to identify the patterns of thought. We do this to get them to build thoughts for themselves. - Empirical o CBT is an eNective intervention compared to others. Patients often improve in terms of emotions and patterns of behaviors. o Come up with patterns to see how thoughts, behaviors, and emotions are related. Need to test out whether pattern is correct or not; we do this by having client think about themselves diNerently and see how they react/feel  about themselves after. Have them engage in diNerent behavior and see how it eNects thoughts/emotions. - Time limited o 12-24 sessions to get the job done. Psychodynamic therapy is unlimited. We want to build a set of skills as fast as possible with complete focus. - Skill focused o Making suggestions about changing skills/building skill set on their own - Very symptom-focused o How to change symptoms to make them feel better - Present focused o What are they doing, thinking, feeling on a day-to-day basis? o CBT triangle, then personality, then (maybe) relationship dynamics o Not focused on parents, how they grew up - Therapeutic relationship o Best predictor of how therapy is going o If you don’t click with client, you will not be eNective for them Biomedical Model - Deviant behaviors, thoughts, and feelings are symptoms of an underlying disease - Disease: o A condition of an organ system in the body in which its functions are disturbed Disorder or Disease 1. Symptom complex (syndrome) a. Patterns of signs and symptoms that show they have a particular disease/disorder i. Sign: objectively observable behaviors or could be measured 1. Limping while walking, grimacing while body is touched, taking temperature to see how old, taking white blood cell count ii. Symptom: something someone must report to you that isn’t objectively observed 1. My leg hurts, my leg hurts right here in this specific spot, its pins and needs. I have ruminative thoughts, I’m depressed. b. We tend to focus more on symptoms c. We look at the natural course of each disorder or disease 2. Characteristic natural course a. How it starts i. Onset 1. Acute (fast) versus gradual a. Active phase of Schizophrenia (hearing voices that others aren’t hearing and delusion thoughts) vs brief psychotic disorder (sudden onset and oNset of delusions and voices)  2. Typical age a. Tourette’s ticks and motor disorders prior to age 18 vs. ticks and motor disorders at age 60 are neurological disorders 3. Typical circumstances a. Can’t recall anything that happened last weekend (blackout, head trauma) vs. dissociative amnesia ii. Temporal pattern 1. Episodic (or single episode) a. Depressive 2. Chronic a. Schizophrenia i. Problems for the rest of their life iii. Outcome (prognosis) 1. Untreated 2. Treated 3. Specific pathophysiology (physiological mechanism) a. Disorder – don’t know pathophysiology b. Disease indicates that you know more DiNerential diagnosis is important for: - Accurate prediction - ENective treatment selection o DiNerential diagnosis § Two syndromes that have overlapping symptoms to see what disease/disorder someone actually has Appendicitis vs. constipation Biological Contributions to understanding abnormal behavior - Psychopharmacology: o Neuronal and synaptic functioning - Cognitive neuroscience: o Brain behavior relationships - Behavior genetics: o Family, twin, and adoption studies Advantages of Classifying Abnormal behavior - Facilitates communication and record keeping o ENective communication and record keeping require clinicians, researchers, and health care systems to use explicit and consistent terminology. o DiNerent disorders take diNerent times to treat, payment is diNerent - Advances clinical prediction o Predict the course of the disorder § Time span of symptoms  § Expected features o Select an eNective treatment - Advances the discovery of causes o Homogeneous subject groups § Using highly similar subjects in a study is more eNective for diNerentiating causes and associations o Replication of research § Increases reliability across research studies (helps identify similar subjects across studies) 1/29 Construction of Classification System - Clinically derived categories o Appeal to consensus among authorities - Statistically derived categories o Use of statistical procedures § Factor analysis § Multidimensional scaling (MDS) Mapping technique looking at spacial relationships on a multidimensional map § Cluster analysis Hierarchical taxonomy of psychopathology (HiTOP) Used in research more than clinical settings - Theoretically derived categories o Validated abstract theoretical concepts are used to form categories in more mature sciences  o Cognitive behavioral neuroscience can understand normal and abnormal behavior o Using CBN to understand how the brain works o Research Domain Criteria (RDoC) Main organizing principle is circuits (one blacked out) - This is not ready for use in clinics yet Clinically derived Classification Systems - Diagnostic and Statistical Manual of Mental Disorders (DSM) 5th Edition o More descriptive and has no theoretical causes - American Psychiatric Association - International Classification of Disease – world health organization o This is for all of medicine, not just psychiatry o This will probably replace the DSM because this is what people base it oN of - Psychodynamic Diagnostic Manual (PDM)  o Reaction to removing psychoanalytic and psychodynamic from DSM o This has then both o Not used as often because most insurance companies do payments based on codes found in DSM and ICD - All based on consensus of authority figures DSM Revisions - All psychiatrists in US make use of this classification system Edition Year Diagnoses - DSM-I 1952 Descriptive categories - DSM-II 1968 - DSM-III 1980 Specific Diagnostic criteria - DSM-IV 1992 - DSM-5 2013 Big revision in 1980 to use more applicable terms Diagnosis using the DSM (III, IV, and 5) Specific diagnostic criteria a) Inclusion criteria a. What you need to have b) Diagnostic rules a. How to apply the criteria i. How many symptoms, how long a duration c) Exclusion criteria a. what would keep you out i. exclude if drug induced or due to a medical condition explicit symptom definition Growth of DSM Diagnostic Categories Edition Year Diagnoses - DSM-I 1952 106 - DSM-II 1968 182 - DSM-III 1980 265 - DSM-IV 1992 297 - DSM-5 2013 ? Why “New” Disorders are Added to the DSM - Identifying new problems that did not exist before o Phencyclidine Use Disorder (DSM-IV) o Internet Gaming Disorder (DSM-5) § Appendix includes new diagnostic categories - Recognizing old problems that were oNicially acknowledged before o Post-Traumatic Stress Disorder (DSM-III)  o CaNeine Withdraw (DSM-5) - Splitting broader categories into narrower more homogeneous groups o Schizophrenia (DSM-II) à 6 separate psychotic disorders (DSM-III) Challenges to Categorical Approaches to Psychiatric Classification - High co-morbidity between specific diagnostic categories (half-rule) o (simultaneous and longitudinal) - Many clinically significant “subthreshold” conditions o Give a diagnosis of unspecified [disorder family] (DSM-5) - Symptoms form a continuous dimension of frequency or severity Prevalence rates are based on current category cuts not physics Consequences of Delineating Categorical Disorders from Continuous Symptom Dimensions 2/3 Fear Anxiety Definition Emergency or alarm Apprehensive anticipation reaction to an immediate or of a future uncertain imminent danger danger Time Orientation Present oriented Future oriented Normal Activation US for punishment and CS CS for uncertain for certain punishment punishment Physiological Change Massive autonomic Increased muscle tension; (sympathetic) nervous muscle pain; headaches; system activity fatigue - Sweat, pupils dilate (prepares you for vigorous activity) Behaviors Freeze, Flight (escape) or Inhibition of ongoing Fight (defense) behavior behavior; vigilant scanning for danger; increased startle; rumination; insomnia Subjective Feeling Terror or doom Apprehensive worry Anxiety is not related to sympathetic arousal Fear Anxiety Brain system Fight/Flight System (FFS) Behavioral Inhibition System (BIS) aka Anxiety system Brain Activation Amygdala (emotions – fear Bed nucleus of the stria response), ventromedial terminalis (BNST), septal, hypothalamus, hippocampus, anterior ventromedial prefrontal cingulate, amygdala, cortex hypothalamic-pituitary- axis, CRF, cortisol Symptom of Disorder Panic Attack (when no true Maladaptive anxiety (when danger) uncertain signals of danger) Anxious People Exhibit - Increased attention to threats o See world as a more dangerous place than it actually is - Deficient discrimination of threat and safety - Heightened reactivity to that threat uncertainty - Inflated estimates of threat likelihood and consequences - Disrupted cognitive and behavioral control in the presence of threats  - Underestimate their ability to cope eNectively - Increased avoidance of possible threats Uncertain Likelihood of Negative Event Uncertainty about a bad thing happening to you is what drives anxiety Uncertain Severity of Negative Event Uncertain Timing of Negative Event Perceived Control Reduces Anxiety - In these uncertainty studies, people who are told that they can control the shock intensity with a knob show less anxiety even when the knob not used - Control helps people manage anxiety o Build a skill set so people can have control over the world around them DSM-IV vs DSM-5 - Anxiety disorders, obsessive-compulsive and related disorders, and trauma and stressor related disorders stem from anxiety disorders DSM-5 Anxiety Disorders Divides thee into three separate families - Separation Anxiety Disorder o Most are children o Inappropriate fear or anxiety concerning separation from those whom the individual is attached o The fear, anxiety or avoidance of separation is persistent for more than § 4 weeks in children or adolescence § 6 months in adults  o Prevalence § Children: 4% § Adolescence: 2% § Adults: 1-2% - General Anxiety Disorder o Excessive, uncontrollable anxiety and worry about a number of events or activities o More days than not for a least 6 months o 3 or more of these symptoms: § Restlessness (not a feature of depression so this is big) § Easily fatigued § DiNiculty concentrating § Irritability § Muscle tension (not a feature of depression so this is big) § Sleep disturbance o Prevalence: 5.7% o Sex: female (~60%) > male (~40%) o Onset: 50% before adolescence (?) o Course: chronic but fluctuating o Family pattern: anxiety proneness runs in families for genetic reasons o Co-morbidity: GAD increases genetic risk for major depressive disorder o Treatment § Benzodiazepines (Xanax, Librium, Valium, Ativan) Short-term ( male ~33% § PD+A: Female ~75%> male ~25% o Onset: early adulthood (19-32, mean 26.5) o Course: chronic but fluctuating o Family patterns: § Frist degree biological relatives: 8-20 times more at risk § Twin concordance: 15% Dizygotic (DZ) 50% Monozygotic (MZ) o SuNocation alarm theory of panic disorder § When suNocating, CO2 levels in the blood and acidity in body go up § When CO2 and acidity levels are high respiration increases (hyperventilation) and escape behavior is activated § People with panic disorder are genetically predisposed for hypersensitivity to changing CO2 and acidity in the body o Anxiety sensitivity theory of panic disorder § High trait levels of anxiety sensitivity Hypersensitive interoceptive awareness Bodily sensations interpreted as signs of danger § Panic becomes conditioned to symptoms of sympathetic arousal (increased heart rate) or anxiety (muscle tension) § Worry about uncued panic attacks increases likelihood of more attacks o Treatment § SSRIs and SNRIs (60% responsive) § Panic control therapy (PCT) Cognitive reframing to learn that panic attacks to not indicate danger - Panic (Alarm Reaction) Patterns o Cued § Expected response to a specific stimuli or situation (specific phobias) o Uncued § Not tied to any stimuli, unexpected (panic disorder, agoraphobia) o Situationally predisposed § More likely to happen in some situations, but not always (social anxiety disorder, PTSD) - Agoraphobia o Panic disorder with Agoraphobia § Anxiety about being in places or situations where escape would be diNicult (or embarrassing) if having an unexpected panic attack § Situations are Avoided (stays at home) Endured with marked distress Always requires a companion  - Specific Phobia o Marked fear or anxiety about a specific object or situation o The phobic object or situation provokes immediate fear or anxiety o The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation o The phobic object or situation is actively avoided o Symptoms are present for more than 6 months § Specific phobia subtypes Animal type (dogs, snakes, insects) o This is the most common phobia and it begins in childhood Natural environment type (heights, water, storms) Situational type (airplanes, elevators) Blood-injection injury type o Fear of injection and other medical procedures § Increased sympathetic arousal o Fear of blood and ijury § Reduced sympathetic arousal (decreased heart rate and blood pressure) § Genetic influence § Responsive to drug treatments (monoamine oxidase inhibitors, MAOIs) Other types (fear of choking) o Prevalence: female 16% male 7% § Blood injection injury 60% female o Onset: most begin in childhood o Course: chronic past childhood o Family pattern: many aggregate in families § Blood injection injury runs in families for genetic reasons o Etiology § Classical conditioning from experiencing a personal traumatic event § Classical conditioning from observing a ta evetn - Social Anxiety Disorder 20% of population can be diagnosed with an anxiety disorder Stress exacerbates symptoms - When treating someone, make sure they have good stress coping skills 2/10 Most common type of phobia is animal phobia Phobic stimuli Common - Animals (snakes, insects, dogs, etc.) - Heights - Fire - Water Uncommon - Automobiles - Firearms - Electrical appliances and outlets Prepared Learning - We are genetically equipped through evolution to easily learn to fear certain objects or situations (animals, heights, water, etc.) that were dangerous for our evolutionary ancestors. Specific Phobia Treatment - High success rate of treatment - Easy to treat  - Real (in vivo) exposure o Break behavioral avoidance and do exposure therapy § Flooding – massive exposure Not used anymore § Gradual – incremental exposure Could be done in 4/5 hours - Simulated exposure o Imaginal – exposure to self-created imagery o Virtual reality – exposure to computer-generated imagery - Modeling o Based on observational learning o If they can handle the snake, I can do it too o Not exactly like breaking behavioral avoidance - Cognitive restructuring o Modify catastrophic beliefs o Change expectations Social Anxiety Disorder - DSM-IV: Social Phobia - A marked fear or anxiety of social or performance situations in which the person is exposed to possible scrutiny by others - Individual fears/worries that he or she will be negatively evaluated - This is not anxiety about all social situations only those with an evaluative component - These social situations provoke fear or anxiety - These social situations are avoided or endured with intense distress - The above last more than 6 months Social Anxiety Disorder - Lifetime prevalence 12% - 12 months prevalence o U.S. 7% but older (>45) adults 2 to 5% o Other countries:.5 – 2.0% - Sex: o Community samples: female > male o Clinical samples: female = male o Males are less likely than females to ever be married - Onset: mid-teens - Course: chronic, but impairment declines with age and worsens with increasing social demands (dating, job requiring contact with the public) - Family pattern: more frequent among first-degree biological relatives - Comorbidity: 46% also have another mental disorder, usually an anxiety or mood disorder Treatment - SSRIs - Cognitive therapy with social exposure (especially to social mishaps) Trauma and Stressor Related Disorders - Reactive attachment disorder o Extreme neglect as a child o Social deprivation during childhood: § Extreme social neglect during early childhood, such that needs for comfort, stimulation and aNection are not met by caregivers § Repeated changes of primary caregivers that limit the opportunity to from stable attachments o Persistent social and emotional disturbance indicated by: § Minimal social and emotional responsiveness with others § Rarely seeks or responds to comfort when distressed § Rarely expresses positive emotions o Onset: disturbance must begin before age 5 o Risk factors: rearing in institutions with very high child-to-caregiver ratios OR frequent changes in foster care o Prevalence: unknown, but rare § Most tend to be resilient - Disinhibited social engagement disorder o Social deprivation during childhood: § Extreme social neglect during early childhood, such that needs for comfort, stimulation and aNection are not met by caregivers § Repeated changes of primary caregivers that limit the opportunity to from stable attachments o Behavioral disturbance during childhood indicated by: § No hesitation in venturing away from adult caregivers, even in unfamiliar settings § Actively approaches and readily interacts with unfamiliar adults § Willingness to go oN with an unfamiliar adult with little or no hesitation o Onset: disturbance must begin before age 5 - Posttraumatic stress disorder o Traumatic event exposure § Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: Directly experience traumatic event(s) Witnessing, in person, the event(s) as it occurs to others Learning that the traumatic event(s) occurred to a close family member or close friend Experiencing extreme exposure to the aversive details of the traumatic event(s) § Traumatic event is persistently re-experienced in one (or more) of the following ways:  Recurrent and involuntary intrusive distressing memories of the traumatic event(s) – imagery or its negative consequences o Thoughts persist for months and months on end Recurrent distressing dreams of the event(s) Dissociative reactions in which the individual feels as if the event(s) were reoccurring Marked physiological reactions to internal and external cues that symbolize or resemble an aspect of the traumatic events o Internal cues = thought or memory of the event o Intrusion symptoms o Avoidance symptoms § Persistent avoidance of trauma-related stimuli as evidenced by one or both of the following: Avoidance or eNorts to avoid external reminders that arouse distressing memories, thoughts and feeling associated with the traumatic event(s) Avoidance or eNorts to avoid distressing memories, thoughts, and feeling associated with the traumatic event(s) o Try to suppress them but when you try not to think about it you do § Deep cut doesn’t heal when you don’t stop touching it o Negative alterations in mood and cognition § Inability to remember important aspects of the trauma § Persistent and exaggerated negative beliefs about oneself, others, or the world “the world is a completely dangerous place” “no one can be trusted” “my future is completely ruined” § Persistent distorted cognitions that blame self for the event § Persistent negative emotional state § Persistent inability to experience positive emotions § Marked diminished interest or participation in significant activities § Feeling of detachment or estrangement from others o Arousal and reactivity symptoms § Marked alterations in arousal and reactivity as evidence by two (or more) of the following: Hypervigilance Sleep disturbance Problems with concentration Exaggerated startle response Irritable behavior or outbursts of anger Recklessness or self-destructive behavior  o These symptoms must last more than one month o Duration > 1 month - Acute stress disorder - Adjustment disorders o Most common is someone experiences a negative life event and has a depressed mood. This is important for diNerential diagnosis of depression disorder and adjustment disorder PTSD Specifiers - Additional aspects of the disease that are useful for treatment or predicting the course o With dissociative symptoms § Depersonalization – feeling detached from one’s body or mental processes § Derealization – experiences surroundings as unreal Feels unreal but knows the experiences are real o With delayed expression § Full symptoms are not met until at least 6 months after the event Someone has experienced a trauma; they are continuously upset by the trauma, but their symptoms are below what one would experience for the trauma. Not totally free from the negative consequences of the trauma – some thoughts but not overwhelming until one day it does Complex PTSD - ICD only, not DSM - Person has experienced prolonged or repeated trauma over a period of months or years o Ex: § Repeated domestic abuse § Repeated sexual abuse associated with human traNicking § Being a prisoner of war § Repeated combat or war atrocities - These are people doing things to other people o These are harder to process than natural events like tornadoes or hurricanes - Compared to non-complex PTSD o Generally, shows more severe symptoms § Especially distrust of others and negative worldviews o Possibly diNicult to treat PTSD - U.S. Prevalence: o 8.7% (lifetime) o 3.5% (12-month prevalence) - Sex: female (10%) > Male (5%)  - Onset: within first 3 months after trauma - Course: 50% recover in 3 months, otherwise chronic PTSD Etiology - Classically conditioned alarm reaction to stimuli present at the trauma - Amygdala increases in size and hyper-reactivity - BIS arousal à hypervigilance for trauma cues o Behavioral Inhibition System - External and internal avoidance of processing information related to the trauma - Avoidance prevents learning to emotionally cope with the trauma – PTSD suNerers are frozen in a state of denial and numbness PTSD Risk Factors - Prior mental disorder o Mood or anxiety disorder - High neuroticism - Negative attributional style o Say things with extreme descriptions - Trauma is interpersonal o Assault, rape, combat - Prior trauma o Especially during childhood - Lack of social support Acute stress disorder - Traumatic event - 9 or more symptoms from any of these 5 symptom groups o Intrusion symptoms (4 symptoms) o Negative mood (1) o Dissociative symptoms (2) o Avoidance symptoms (2) o Arousal and reactivity symptoms (5) - Duration of disturbance: o 3 days to 1 month after trauma exposure - Prodrome PTSD - Prevalence after trauma: o Interpersonal § Assault, rape, mass shootings 20-50% o Non-interpersonal § Auto and industrial accidents, fires, weather < 20 % - Course: o 80% of people with ASD have PTSD six months later  o 4-13% who do not get ASD in the first month after a trauma will get PTSD in later months or years - Risk factors: o Same as PTSD o Previous mental disorders o High neuroticism o Avoidant coping style PTSD treatment - Selective Serotonin Reuptake Inhibitors (SSRIs) o Prozac, paxil o Only 60% show a clinical response, not immediate eNect § Decrease in severity, frequency, duration of symptoms. It is a way to manage symptoms not get rid of them - Cognitive behavioral therapy - Exposure therapy o Gradual imagery exposure followed by actual exposure if possible - Group therapy with other trauma survivors - Eye movement desensitization and reprocessing (EMDR) o Client recall distressing images and then does bilateral sensory input, such as side-to-side eye movements or hand tapping o Research shows it can be beneficial PTSD is one of the highest risk factors for suicide - Vulnerability for Suicide in PTSD o Symptoms have been experienced for more than one year o The adult has also experienced childhood trauma o There is a depressive component to the syndrome o They are self-medicating with alcohol or cannabis PTSD Prevention - Debriefing and immediate social support - Reduce exposure to trauma (better safety) Obsessive-Compulsive and Related Disorders - Obsessive-compulsive disorder o Obsessions: recurrent and persistent thoughts, urges, or images that § Are intrusive and unwanted § Cause distress or anxiety § The person attempts to ignore or suppress or neutralize with another action § Are time consuming (>1 hour per day) or cause clinically significant distress or impairment  o Compulsions: repetitive behaviors (ex: hang washing, checking) or mental acts (ex: counting) that § the person feels driven to perform in response to an obsession § or according to rules that must be applied rigidly § are aimed at reducing distress or preventing a dreaded event § are not connected in a realistic way (or clearly excessive) to what they are intended to prevent - Hoarding disorder o Persistent diNiculty discarding or parting with possessions, regardless of their actual value o This diNiculty is due to perceived need to save the items and distress associated with discarding them o Result in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use o Prevalence: 2-6% (current prevalence) o Sex: § Community: females = males § Clinic: females > males o Onset: mid-adulthood o Course: chronic for some, 3 times more prevalent in older adults (55-94) and younger adults (34-44) o Pathophysiology: disruptions in ventromedial prefrontal cortex and anterior cingulate o Treatment: SSRIs, gradual exposure with CBT - Body dysmorphic disorder o Preoccupation with an imagined defect or flaw in physical appearance o Performs repetitive behaviors (mirror checking, excessive grooming) or mental acts (comparing self to others) in response to appearance concerns o Significant distress or impairment o Not better accounted for by another mental disorder (anorexia nervosa) § Insight specifiers: With good or fair insight: o Recognizes BDD beliefs are definitely (good) or probably (fair) not true With poor insight: o Thinks BDD beliefs are probably true With absent insight or delusional beliefs o Convinced that BDD beliefs are probably true § With muscle dysmorphia: Preoccupied with being insuNiciently muscular § Prevalence: 2.4% (point prevalence) 6-15% (patients for cosmetic surgery, dermatology, orthodontia) § Sex: female = male § Onset: most begin in adolescence (median onset 15)  § Course: chronic with varying symptom intensity § Etiology: serotonin dysfunction; consistent with an OCD-spectrum disorder § Treatment: SSRIs, anti-psychotics, exposure with response prevention, and CBT - Hair-pulling disorder (trichotillomania) o Diagnostic features § Recurrent pulling out one’s own fair resulting in hair loss § Repeated attempts to stop pulling hair § Clinically significant distress or impairment o Associated features § Pulling often preceded by anxiety or boredom § Pulling provides gratification or relief from tension § Majority have other body-focused repetitive behaviors (nail biting, skin picking, lip chewing) § Prevalence: 1-2% (12-month prevalence) § Gender: Adults: Females > Males Children: Females = males Males with hair-pulling behavior may not be distressed by the behavior. Therefore, they do not qualify for the disorder. § Onset: early adolescence § Course: chronic for some, episodic for others § Treatment: responds to SSRIsses - Skin-picking disorder (excoriation) 2/17 Obsessive-Compulsive Disorder (OCD) Common Obsessions and Compulsions Obsession Compulsion Symmetry/exactness/numbers Arranging, Repeating, Counting Forbidden/frightening thoughts or actions Checking and avoidance Contamination Hand washing, cleaning, purification Insight Specifiers - With good or fair insight o Recognizes OCD beliefs are definitely (good) or probably (fair) not true - With poor insight o Thinks OCD beliefs are probably true - With absent insight or delusional beliefs o Convinced that OCD beliefs are true Tic-Related Specifier - Has current or past history of tic disorder Obsessive-Compulsive Disorder (OCD)  - Prevalence: 1.6% - Sex: o Adults: Male = Female o Children: male > female - Onset: o Males: 6-15 years of age § Unclear why an earlier age of onset o Females: 20-29 years of age - Course: chronic but fluctuating - Family pattern: OCD aggregates in families for genetic reasons, and aggregates with other OCD spectrum disorders SSRIs are used in most emotional disorders What maintains a specific phobia? - Act of avoidance of the phobia Sit with anxiety that comes with obsessive thought for 2 minutes and work its way up to overcome the obsessive thought - Try to build a set of skills that will allow them to overcome obsessive behavior - Never say don’t do this behavior Brain Areas Dysfunctional in OCD Thought-Action Fusion Thought-reality confusion - Likelihood Thought-Action fusion o Simply thinking about an event, increases the likelihood that the event will happen o Did I shut the garage door? I mustve not - Moral thought-action fusion o Simply thinking an unacceptable thought is equivalent to performing the action o Want to slap roommate, thought is just as bad as the action OCD Treatment - Medications o SSRIs – selective serotonin reuptake inhibitors § Clomipramine (Anafranil) - Cognitive Behavioral Therapy (CBT) o Gradual exposure with ritual prevention (ERP) o Modify irrational thoughts of threat or danger - Cingulotomy o Lesion the cingulate bundle. Benefits some (30%) treatment non-responsive OCD patients.