Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders PDF

CH8: Anxiety, Obsessive- Compulsive, and Trauma- and Stressor-Related Disorders The Nature of Anxiety Disorders -The essential feature of anxiety disorders is the experience of a chronic & intense feeling of anxiety. Anxiety disorders are characterized by excessive fear and anxiety, and related dis...

CH8: Anxiety, Obsessive- Compulsive, and Trauma- and Stressor-Related Disorders The Nature of Anxiety Disorders -The essential feature of anxiety disorders is the experience of a chronic & intense feeling of anxiety. Anxiety disorders are characterized by excessive fear and anxiety, and related disturbances in behavior. Anxiety: A future-oriented response which involves a sense of dread about what might happen to you in the future. -Involves both cognitive and emotional components, in which an individual is inordinately apprehensive, tense, and uneasy about the prospect of something terrible happening. -People with anxiety disorders also experience fear, which is the emotional response to real or perceived imminent threat. -The most highly prevalent of all psychological disorders With the exception of substance use disorders lifetime prevalence 28.8% Past-Year Prevalence of Any Anxiety Disorder among U.S. Adults (2001–2003) à Separation Anxiety Disorder -Individuals with separation anxiety disorder have intense and inappropriate anxiety about leaving home or being left by their attachment figures, the people close to them in their lives. Children with this disorder may cling so closely to a parent they will not let the parent out of their sight. -Adults who meet the criteria for this disorder have intense anxiety about lasting at least 4 weeks, concerning being separated from the person to whom they are most emotionally attached. -Prior to the DSM-5, the condition of separation anxiety disorder was considered specific to children. However, recognizing that there are a significant number of adult-onset cases, DSM- 5 lifted the disorder’s age restriction to make it diagnosis applicable to adults as well as children. Theories and Treatment: -Swedish researchers suggested that anxiety is passed down from parents to children through environmental, rather than genetic, mechanisms. children with anxious parents learn to develop anxiety through modeling -Sociocultural factors also play a role in predisposing certain individuals to developing this disorderà symptoms of the disorder seem to be more severe in countries that promote an individualistic, independent culture than in those with a more collectivist set of cultural norms -For children, both behavioral and cognitive-behavioral therapies (CBT) seem to have the greatest promise. Behavioral techniques include systematic desensitization, prolonged exposure, and modeling. Contingency management and self-management are also useful in teaching the child to react more positively and competently to a fear-provoking situation. Selective Mutism à A disorder originating in childhood in which the individual consciously refuses to talk. -Refusing to talk in specific situations. Children are capable of using normal language, but they become completely silent under certain circumstances, most commonly the classroom. Prevalence: 0.2%-2%. Beginning btw ages of 3-6. Frequency equal among boys & girls. 1 -Children with selective mutism seem to respond well to behavioral therapy. The clinician devises a hierarchy of desired responses, beginning by rewarding the child for making any utterances and then progressing through words and sentences, perhaps moving from the home to the clinic and eventually to the school. Another behavioral approach uses contingency management, in which children receive rewards if they engage in the desired behavior of speaking. Contingency management seems particularly well suited for use in the home by parents. -CBT is another method that produces improvement in children with selective mutism. Specific Phobias Specific phobia: An irrational and continuous fear of a particular object, activity, or situation. The fear or anxiety is so intense that it becomes incapacitating. People go to great lengths to avoid object or situation that is the target of their fear Must be present for at least 6 months to get diagnosis. Lifetime prevalence for specific phobia in is 12.5 percent -Any object or situation, from the act of driving to syringes, can form the target of a phobia Major Categories: Insects and animals Natural environment (storms or fires) Blood-injection-injury (seeing blood, having an invasive medical procedure) Engaging in activities in particular situations (riding an escalator, flying) Variety of miscellaneous stimuli (e.g. fear of vomiting) Theories -The fact that phobias are grouped together suggests an underlying theme or element at the root cause. Biological perspective: Anxiety associated with specific phobias may relate to abnormalities in the anterior insular cortex à Associated with emotion & self- awareness Amygdala à Moderates the fear response. Play a role in specific phobias. Particularly those acquired through learning in which people associate a stimulus with the emotion of fear. Biological perspective - Treatment: -Focuses on symptom management -Clinicians prescribe medications, benzodiazepines à But only if their clients do not respond to other treatments & interferes with individual’s ability to function on daily basis Psychological perspective: Emphasized the conditioning that Occurs when the individual learns to associate unpleasant physical sensations with a stimulus or situation. There may be some Adaptive value to having such reactions, because the situations may truly be ones we should fear (e.g. poisonous snakes) The symptoms become Maladaptive as individuals begin to generalize an appropriate fear reaction to all stimuli in that category, including harmless ones. Developmental aspects to specific phobias: Very young children tend to fear objects or situations they can see. As they get older, feared objects become more abstract in nature (such as “the bogeyman”) 2 Psychological perspective - Treatment: Behavioral perspective: Rely on positive reinforcement for symptom relief E.g. In exposure therapy — positive reinforcement is used to lead clients to substitute adaptive responses (relaxation) for maladaptive ones (fear or anxiety). Systematic desensitization: presents the client with progressively more anxiety-provoking images while at the same time the client is being trained to relax. Flooding: clients are totally immersed in the feared situation, where they feel the anxiety with full force. In vivo flooding: exposes the client to the actual feared situation, such as the top floor of a tall building for a client who fears heights. Imaginal flooding: in which the clinician exposes the client virtually to the feared situation. Graded in vivo: method in which clients initially confront situations that cause only minor anxiety and then gradually progress toward those that cause greater anxiety. -Clients gradually expose themselves or immersed through imagination to increasingly challenging anxiety-provoking situations -Immersed in the sensation of anxiety by being exposed to the feared situation in its entirety Cognitive Behavioral perspective: individuals with specific phobias have overactive alarm systems for danger, and they perceive things as dangerous because they misinterpret harmless stimuli. E.g., the mistaken perception of an object or a situation as: uncontrollable, unpredictable, dangerous (e.g. spider phobia), disgusting (e.g. blood-injection-fear of contamination) is correlated with feelings of vulnerability Treatment: -Helping the client learn adaptive ways of thinking about previously threatening situations and objects by challenging their irrational beliefs about the feared stimuli. -For example, a therapist may show a young man with an elevator phobia that the disastrous consequences he believes will result from riding in an elevator are unrealistic and exaggerated. The client can also learn the technique of “talking to himself” while in this situation, telling himself that his fears are ridiculous, that nothing bad will really happen, and that he will soon reach his destination. Social Anxiety Disorder à fear of becoming humiliated or embarrassed in front of other people. Social anxiety disorder is characterized by intense, fear of anxiety of social situations in which the individual may be scrutinized by others -The anxiety the person experiences is centered on a desire to avoid humiliation or embarrassment. -The fear is not of other people (it is not a phobia) but rather of what other people may think of the individual. -The lifetime prevalence of is 12.1 % in the USA -The 2nd most common form of anxiety disorder Theories and Treatment Biological perspectives: -The biological underpinnings may be related to partly heritable mechanisms. 3 - The intense anxiety experi- enced by an individual with social anxiety disorder, from this perspective, is essentially a form of intense shyness combined with the personality trait of neuroticism. -Caused by alterations in areas of the brain responsible for attention -Individuals with social anxiety disorder become excessively self-focused and therefore exaggerate the extent to which others look critically upon them. Treatment: selective serotonin or norepinephrine reuptake inhibitors (SSRIs and SNRIs) -Benzodiazepines have significant potential for abuse -MAOIs, which can also effectively manage social anxiety symptoms, have potentially dangerous side effects Psychological perspectives - Treatment: Cognitive-behavioral approach à regards people with social anxiety disorder as unable to gain a realistic view of how others really perceive them. -View social anxiety as reflecting a core fear of interacting with new people in new situations - the clinician working from this perspective attempts to reframe the client’s thoughts in combination with real or imagined exposure. Treatment Challenges -Clients may tend to isolate themselves socially and therefore have fewer opportunities to expose themselves to challenging situations in the course of their daily lives. Their impaired social skills may then lead them to experience negative reactions from others, thus confirming their fears. -For clients who do not respond to psychotherapy or medication, there are promising signs about the benefits of alternate methods: motivational interviewing, acceptance and commitment therapy, and mindfulness/meditation. Their common element, also present in CBT, is the practice of stepping back from situations to identify and challenge automatic thoughts. Panic Disorder -People with panic disorder experience periods of intense physical discomfort known as panic attacks. -During a panic attack, the individual feels overwhelmed by unpleasant physical sensations: -Respiratory distress Shortness of breath Hyperventilation Feeling of choking -Autonomic disturbances Sweating Stomach distress Shaking or trembling Heart palpitations -Sensory abnormalities Dizziness Numbness Tingling -People may also feel that they are going crazy or losing control during a panic attack. -Apprehension & worry about recurring attacks - Having an occasional panic attack is not enough to justify a diagnosis of panic disorder. To meet the diagnostic criteria, the panic attacks have to occur on a repeated basis and be 4 accompanied by fear of having another. People with this disorder also might engage in avoidance behaviors, staying away from situations in which another panic attack might occur. Agoraphobia Intense fear or anxiety triggered by the real or anticipated exposure to situations such as o Using public transportation o Being in an enclosed space (theater) or in an open space (parking lot) o Being outside the home alone -People with agoraphobia aren’t fearful not of the situations themselves but of the possibility that they can’t get help or escape if they have panic-like or other embarrassing/incapacitating symptoms when in those situations. -Their anxiety is out of proportion to the actual danger involved in the situation. Diagnosis: § Symptoms must persist at least 6 months § Cause considerable distress § Not be due to another psychological or medical disorder -Panic attacks are somewhat common in that they are estimated to occur in 20% or more of adults -Panic disorder has a much lower lifetime prevalence of between 3 and 5%. Theories and Treatment of Panic Disorder and Agoraphobia Biological perspectives: High levels of norepinephrine: Neurotransmitter involved in preparing the body to react to stressful situations àHigher levels, make the individual more likely to experience fear, anxiety, and panic -Serotonin may also play a role in increasing a person’s likelihood of developing panic disorder, as deficits in serotonin are linked to anxiety. -anxiety sensitivity theory: people who develop panic disorder have heightened responsiveness to the presence of carbon dioxide in the blood. Hence, they are more likely to panic due to the sensation that they are suffocating. Treatment: Effective antianxiety medications for panic disorder & agoraphobia are: -Benzodiazepinesà increase the availability of GABA. BUT may lead to dependency & abuse. -Clinicians may prefer SSRIs or SNRIs. Psychological perspectives: -Classical conditioning perspective à panic disorder results from conditioned fear reactions: individual associates bodily sensations such as difficulty breathing with memories of the last panic attack, causing a full-blown panic attack to develop. -Cognitive behavioral model à people with panic disorder, upon feeling the unpleasant sensations of the panic attack begin (loss of breath), believe it is unpredictable and uncontrollable and that they will not be able to stop it. 5 Personality traits that exacerbate & maintain symptoms: -High neuroticism -Low levels of extraversion - Their tendency to ruminate, to prefer not to experience strong emotions, and to keep to themselves may serve to maintain their symptoms above and beyond whatever was their prior exposure to anxiety-provoking situations. Psychological perspectives - Treatment: Behavioral technique Relaxation training: Used to help clients gain control over the bodily reactions involved in panic attack. After training, the client should be able to relax the entire body when confronting a feared situation. Focus on Breathing: client is instructed to hyperventilate intentionally and then to begin slow breathing, a response that is incompatible with hyperventilation. -In addition to changing the response itself, this method allows clients to feel that they can exert voluntary control over the development of a panic attack. panic-control therapy (PCT): the therapist combines breathing retraining, psychoeducation, and cognitive restructuring to help individuals recognize and ultimately control the bodily cues associated with panic attacks. Generalized Anxiety Disorder -An anxiety disorder characterized by anxiety and worry that is not associated with a particular object, situation, or event but seems to be a constant feature of a person’s day-to- day existence. -Doesn’t have a particular focus. à People with generalized anxiety disorder feel anxious for much of the time, even though they may not be able to say exactly why they feel this way. -They worry a lot, apprehensively expecting the worst to happen to them. -Symptoms: general restlessness, sleep disturbances, feelings of fatigue, irritability, muscle tension, and trouble concentrating, to the point where their mind goes blank. -There is no particular situation they can identify as lying at the root of their anxiety, and they find it difficult to control their worrying. -Lifetime prevalence: 5.7% Theories and treatment: Biological perspectives: -Disturbances in GABA, serotonergic, and noradrenergic systems. - overlap in genetic vulnerability with the personality trait of neuroticism. à people who are prone to developing this disorder have inherited an underlying neurotic personality style. Cognitive-behavioral perspective: the anxiety people with this disorder experience results from cognitive distortions in their interpretation of the minor inconveniences of life -Clinicians using this approach attempt to break the cycle of negative thoughts and worries by helping clients learn how to recognize anxious thoughts, to seek more rational alternatives to worrying, and to take action to test these alternatives. -Another compounding factor in generalized anxiety disorder may be the individual’s inability to tolerate uncertainty or ambiguity. à CBT can be of benefit in helping individuals with the disorder come to accept such ambiguities - Cognitive-behavioral therapy à considered the method of choice in treating individuals with generalized anxiety disorder, particularly because it avoids the potentially negative side effects of antianxiety medications. 6 -Acceptance and commitment therapy (ACT) is thought to have similar mechanisms to CBT and is gaining evidence as a stand-alone treatment for various anxiety disorders. Obsessive-Compulsive Disorder (OCD) -An obsession is a recurrent & persistent thought, urge, or image experienced as intrusive and unwanted. Causes significant distress or impairment in their ability to work and live. -The thought or action the person uses to try to neutralize the obsession is known as a compulsion à a repetitive behavior or mental act the person feels driven to carry out according to rigid rules. - Compulsions need not, however, be paired with obsessions. - obsessive-compulsive disorder (OCD): individuals experience either obsessions or compulsions to such an extent that they find it difficult to conduct their daily activities. -Lifetime prevalence 1.6% in US. Common compulsions Repeated behaviors such as: washing and cleaning counting items putting items in order checking requesting assurance -These compulsions may also take the form of mental rituals, such as counting up to a certain number every time the individual has an unwanted thought. Some individuals with OCD experience tics, which are uncontrollable motor movements such as twitches, vocalizations, and facial grimaces. Four major dimensions of OCD: -Obsessions associated with checking compulsions -Need for symmetry and order -Obsessions about cleanliness associated with washing compulsions -Hoarding-related behaviors Theories and treatment Biological perspective: -Abnormalities in the basal ganglia, which are subcortical areas of the brain active in motor control. -Failure of the prefrontal cortex to inhibit unwanted thoughts, images, or urges (hyperactivation). -Brain scan evidence shows heightened levels of activity in the brain’s motor control centers of the basal ganglia and frontal lobes. Biological treatments: Treatment with clomipramine (a tricyclic anti-depressant) Treatment with other SSRIs medications such as Fluoxetine (Prozac) and Sertraline (Zoloft) -Treated with psychiatric neurosurgery in extreme cases. E.g. Deep-brain stimulation to areas active in motor control can help relieve symptoms by reducing the activity of the prefrontal cortex, which in turn may help reduce the frequency of obsessive-compulsive thoughts. 7 Psychological treatments: Cognitive-behavioral perspective: -Proposes that maladaptive thought patterns contribute to the development & maintenance of symptoms. -Individuals with OCD may be primed to overreact to anxiety-producing events in their environment -For people with OCD, these experiences become transformed to disturbing images which they then try to suppress or counteract by engaging in compulsive rituals. -Additionally, people withOCD may be high in the personality trait of perfectionism, a component of neuroticism, that can be thought of as a cognitive vulnerability unique to this disorder. -CBT is currently regarded as the most effective treatment for OCD. -Exposure with ritual prevention. 8 Body Dysmorphic Disorder Body dysmorphic disorder: A disorder in which individuals are preoccupied with the idea that a part of their body is ugly or defective. -Individuals may check themselves constantly, groom themselves to an excessive degree, or constantly seek reassurance from others about how they look. -They don’t necessarily see themselves as fat or excessively heavy, both of which are common concerns in Western cultures, but they may believe that their body build is too small or not muscular enough. -Prevalence: 2.5% of women, 2.2% of men. -BDD is frequently accompanied by major depressive disorder, social anxiety disorder, obsessive-compulsive disorder, and eating disorders. -Clients’ distress clearly can become intense. -Completed suicides are 45 times more common among people with this disorder than in the general U.S. population Theories and Treatment Biological perspective: medications, particularly SSRIs à that can reduce the associated symptoms of depression and anxiety as well as the more obsessive symptoms of distress, bodily preoccupations, and compulsions. Psychosocial perspective: people with BDD may have experienced being teased about their appearance or made to feel sensitive in some other way during a time when their identities were in a critical period of formation. -Once they start to believe that their bodily appearance is defective or deviates from the ideal to which they aspire, they become preoccupied with this belief, setting off a series of dysfunctional thoughts and repetitive behaviors. Cognitive-behavioral perspective: Clinicians focus on helping them to understand that appearance is only one aspect of their total identity, while at the same time challenging them to question their assumptions that their appearance is, in fact, defective. -In one hands-on cognitive technique, clinicians encourage clients to look at themselves in a mirror and change their negative thoughts about what they see. -Interpersonal therapy can also help people with BDD develop improved strategies for dealing with the distress they feel in their relationships with others, as well as addressing their low self-esteem and depressed mood. Hoarding Disorder -In the compulsion known as hoarding, people have persistent difficulties discarding or parting with their possessions, even if they are not of much value. -These difficulties include any form of discarding, including putting items into the garbage. -People with hoarding disorder believe these items have utility or aesthetic or sentimental value, but in reality they often consist of old newspapers, bags, or leftover food. 9 - When faced with the prospect of discarding the items, these individuals become distressed. -Prevalence: 2-6% of adults. - A substantial percentage of adults with hoarding disorder also have comorbid depressive symptoms. Theories and Treatment -biopsychosocial approach appears to be the most effective treatment. -Biological treatments have traditionally included SSRIs, but researchers believe the disorder may also have a neurocognitive component that would warrant treatment through addressing cognitive function. E.g. people with hoarding disorder may have a form of ADHD in which they lack the ability to focus their attention on specific details. -Hoarding disorder is also becoming understood from a developmental perspective as reflecting attachment difficulties and growing up in a household that lacked warmth. -Home visits in which the therapist uses cognitive-behavioral methods seem to hold the most promise, particularly in encouraging clients to discard their hoarded items. Trichotillomania (Hair-Pulling Disorder) -Individuals who pull out their hair in response to an increasing sense of tension or urge. -After they pull their hair, they feel temporary relief, pleasure, or gratification. -People with trichotillomania are upset by their uncontrollable behavior and may find that their social, occupational, or other areas of functioning are impaired because of the disorder. -They feel unable to stop the behavior, even when it results in bald patches and lost eyebrows, eyelashes, armpit hair, and pubic hair. -Psychologically, they may suffer low self-esteem, shame and embarrassment, depressed mood, irritability, and argumentativeness. -Their impairments appear early in life and continue through to middle and late adulthood -Prevalence: 0.6% -Genetics seems to play an important role in trichotillomania, with an estimate of 80 percent heritability of the disorder. -The neurotransmitters serotonin, dopamine, and glutamate are thought to play a role in the development of trichotillomania. -Brain imaging studies of individuals with trichotillomania suggest that they may also have abnormalities in brain regions active in attentional control, memory, and the ability to suppress automatic motor reactions. -The regulation model of trichotillomania suggests that individuals with this disorder seek an optimal state of emotional arousal, providing them with greater stimulation when they are understimulated and calming them when they are overstimulated. -Pharmacological treatments for trichotillomania include antidepressants, atypical anti- psychotics, lithium, and naltrexone. Naltrexone seems to have shown the most promising results. -The behavioral treatment of habit reversal training (HRT) is regarded as the most effective approach to treating trichotillomania. à the individual learns a new response to compete with the habit of hair pulling, such as fist clenching. Excoriation (Skin-Picking) Disorder -Recurrent picking at one’s own skin. à they repeatedly pick at their own skin, perhaps as much as several hours a day. - When they are not picking their skin, they think about picking it and try to resist their urges to do so. 10 -They may attempt to cover the evidence of their skin picking with clothing or bandages, and they feel ashamed of and embarrassed about their behavior. -Prevalence: 1.4% of adults. - share causes and effective treatment approaches with trichotillomania. Reactive Attachment Disorder (RAD) à trauma- and stressor-related disorder -A disorder involving a severe disturbance in the ability to relate to others in which the individual is unresponsive to people, is apathetic, and prefers to be alone rather than to interact with friends or family. -diagnosis given to children who literally “react against” attachment to others. -Their symptoms include becoming withdrawn and inhibited. They tend not to show positive affect, but they also lack the ability to control their emotions. -Unlike normal children, when they become distressed, they do not seek comfort from adults. Disinhibited Social Engagement Disorder -An opposite situation in which a child with a history of trauma engages in culturally inappropriate, overly familiar behavior with people who are relative strangers. - found in children who have experienced an abuse pattern of social neglect, repeated changes of primary caregivers, or rearing in institutions with high child-to-caregiver ratios. -Consequently, such children are significantly impaired in their ability to interact with other children and adults. Acute Stress Disorder and Post-Traumatic Stress Disorder -A trauma is said to occur when an individual is exposed, either once or repeatedly, to circumstances that are harmful or life threatening and that have lasting adverse effects on the individual as harmful or life individual’s functioning and mental health. -When people are exposed to the threat of death, or to actual or threatened serious injury, or sexual violation, they risk developing acute stress disorder. -Being exposed to the death of others, or to any of these events, real or threatened, adverse effects on the individual’s to others can also lead to the development of this disorder. -Symptoms: intrusion of distressing reminders of the event, dissociative symptoms such as feeling numb or detached from others, avoidance of situations that might serve as reminders of the event, and hyperarousal including sleep disturbances or irritability. -The symptoms may persist for a few days to a month after the traumatic event. -The events that can cause acute stress disorder may lead to the longer-lasting disorder known as post-traumatic stress disorder (PTSD). -If the individual experiences acute stress disorder symptoms for more than a month, the clinician assigns the PTSD diagnosis. -The intrusions, dissociation, and avoidance seen in acute stress disorder are also present in PTSD. Symptoms also include loss of memory of the event, excessive self-blame, distancing from others, and inability to experience positive emotions. -Lifetime prevalence: 6.8% Theories and Treatment -A traumatic experience is an external event that impinges on the individual and hence does not have biological “causality.” -However, they do lead to changes in the brain that make certain regions primed or hypersensitive to possible danger in the future. 11 -Individuals with PTSD experience alterations in the hippocampus (responsible for consolidating short-term memory). As a result, these individuals become unable to distinguish relatively harmless situations (like fireworks) from the ones in which real trauma occurred (like combat). -SSRI antidepressants are the only FDA-approved medications for people with PTSD. Psychological perspective: people with PTSD have a biased information-processing style that, due to the trauma they experienced, causes their attention to be highly attuned toward potentially threatening cues. -Personality and coping style also predict responses to trauma, including high levels of neuroticism and extreme sensitivity to internal cues of anxiety. -Cognitive-behavioral therapy combines some type of exposure (in vivo or imaginal) with relaxation and cognitive restructuring. (Generally considered the most effective psychological treatment for PTSD). -Specific trauma-focused psychotherapy that focuses on memory of the traumatic event or its meaning is gaining support as a first-line treatment. CH9: Dissociative and Somatic Symptom Disorders Major Forms of Dissociative Disorders Dissociative Identity Disorder (DID): A dissociative disorder in which an individual develops more than one self or personality. Formerly called multiple personality disorder. -The separate personalities seem to have their own unique characteristic ways of: Perceiving, Thinking, and Relating to others. -People with DID have at least two distinct identities and, when inhabiting the identity of one, are not aware that they also inhabit the other. As a result, their experiences lack continuity. -They have large gaps in important memories about themselves and their lives, often memories of a traumatic nature such as being victimized or abused. Dissociative amnesia: An inability to remember important personal details and experiences; usually associated with traumatic or very stressful events. -Unable to remember information about an event or set of events in their lives. -Their amnesia may even invoke a fugue state: an episode of amnesia that leaves them unable to recall some or all of their past and identity, along with either bewildered wandering or travel that seems focused on a particular purpose. Depersonalization/derealization Disorder: Condition in which ppl have the experience of depersonalization, derealization, or both. -A dissociative disorder in which the individual experiences recurrent and persistent episodes of: Depersonalization: condition in which people feel their identities have become detached from their bodies. -They may have experiences of unreality, of being an outside observer, and of emotional or physical numbing. Derealization: condition in which people feel a sense of unreality or detachment from their surroundings. -Individuals experiencing derealization may report perceiving the world around them as foggy, dreamlike, surreal, and/or visually distorted. 12 Theories of Dissociative Disorders -In normal development, people integrate the perceptions and memories they have of them- selves and their experiences. à you can remember many of the events from your past, which give you a sense of continuity over time. -In a dissociative disorder, the individual loses this continuity, trying to block out or separate from conscious awareness events that caused extreme psychological, if not physical, pain. -By doing so, they can distance themselves psychologically from pain. -To an extent, dissociation permits the child to move through life without constant reminders of distressing events. For example, a child who experiences ongoing sexual abuse can think: “It’s too overwhelming to feel such fear. It’s too dangerous to feel such anger. It’s too real to know what is happening to my body. That’s not me. That’s someone else.” By doing this, they displace: “Overwhelming thoughts, feelings, and memories onto different, personified aspects of self & separate from their painful circumstances”. à This ‘not me’ experience is the cornerstone of DID. -DID often allows children to maintain attachments, creativity, the capacity for humor, reflection under extremely difficult circumstances. -However, as dissociation continues into adulthood when the danger no longer exists, it can interfere with—or even prevent—recovery from trauma. Treatment of Dissociative Disorders DID is best treated with a three-phased approach that involves: 1) Focusing on safety & stability - Reinforce the safety of the person with a focus on more serious symptoms like self- harm or suicidal ideation. - Replace any harmful coping techniques they use with healthier options - Start the process of teaching ways to understand that dissociated identity states represent important feelings, thoughts, and memories that, while very difficult to accept, are part of a whole self. 2) Focus on identifying, addressing, & working through traumatic memories. -Doing this under clinical care helps the patient build distress tolerance and manage reactions to traumatic memories in a safe environment. -As symptoms of PTSD and co-occurring issues stabilize, DID patients begin to integrate compartmentalized experiences. -They begin to understand that painful thoughts, emotions, and memories they mentally packed away as children—really do belong to them 3) Being able to go through life without dissociating. -As new and different coping methods are used successfully, they will likely experience greater confidence, increased self- awareness, stronger self- regulation skills, and more emotional stability. 13 Somatic Symptom Disorder -People with somatic symptom disorder have physical symptoms that may or may not be accounted for by a medical condition; they also have maladaptive thoughts, feelings, and behaviors. à These symptoms disrupt their everyday lives. -People with this disorder think to a disproportionate degree about the seriousness of their symptoms, feel extremely anxious about them, and spend a great deal of time and energy on the symptoms or their concerns about their health. -The somatic symptoms individuals experience may include pain as the primary focus. -A diagnosable medical condition may exist, but it cannot account for the amount and nature of the pain clients report. -It is relatively rare, but it is present with higher than expected frequency among patients seeking treatment for chronic pain. -In one study, over half the patients referred to cardiologists for heart palpitations or chest pain were found not to have heart disease. Illness Anxiety Disorder à Formerly called hypochondriasis -A somatic symptom disorder characterized by the misinterpretation of normal bodily functions or reactions as signs of serious illness. -Preoccupied with their mistaken beliefs about the seriousness of their symptoms. -They may turn to nonmedical abuse of prescription drugs, which in turn can expose them to harmful side effects as well as to dependence on the medications themselves. Functional Neurologic Disorder (Conversion Disorder) -Involves nervous system (neurological) symptoms that can't be explained by a neurological disease or other medical condition. -individual experiences a change in a bodily function that is not due to an underlying medical condition. The forms the disorder can take range from movement abnormalities such as paralysis or difficulty walking to sensory abnormalities such as inability to hear or see. -Related to how the brain functions, rather than damage to the brain's structure (such as from a stroke, multiple sclerosis, infection or injury). The forms the disorder can take range : Disorders of movement Paralysis Weakness Blindness and other sensory disorders Inability to hear or see Pseudoseizures à not real seizures, but appearing as such Disturbances of speech Cognitive impairment -Symptoms can be so severe make it impossible to work -Over half are bedridden or require assistive device -Affecting 1-3% of those whom clinicians refer for mental health care -Often runs in families -Appears between ages 10-35 -More frequently observed in women & people with less education -Half of individuals with conversion disorder also suffer from a dissociative disorder 14 Conversion: Refers to the transformation of psychological conflict to physical symptoms presumed to underlie the disorder -Historic roots in Freudian psychoanalysis Malingering: consists of deliberately feigning the symptoms of physical illness or psychological disorder for an ulterior motive such as receiving disability or insurance benefits. primary gain: The relief from anxiety or responsibility due to the development of physical or psychological symptoms. factitious disorder imposed on self: A disorder in which people fake symptoms or disorders not for the purpose of any particular gain but because of an inner need to maintain a sick role. factitious disorder imposed on another: A condition in which a person induces physical symptoms in another person who is under that person’s care. secondary gain: The sympathy and attention that a sick person receives from other people. Theories and Treatment of Somatic Symptom and Related Disorders Psychodynamic approach: Aim to identify and bring into conscious awareness the underlying conflicts that we associate with the individual’s symptoms. -Through this process, the client gains insight/self-awareness and becomes able to express emotion directly, rather than through physical manifestation. Cognitive behavioral perspective: Dissociative, somatic symptom, & related disorders are viewed in terms of the thoughts linked to their physical symptoms. -People with these disorders are subject to cognitive distortions that lead them to misinterpret normal bodily sensations -Once they start to exaggerate the importance of their symptoms, they become even more sensitized to internal bodily cues, which in turn leads them to conclude that they are truly ill. -CBTà Clinicians help their clients gain a more realistic appraisal of their body’s reactions E.g. clients who have no cardiac illness but complain of palpitations or chest pain can be exposed to exercise while being taught to interpret their raised heartbeat as a normal reaction to exertion, not disease. Theories and Treatment of Functional Neurologic Disorder -CBT à Predisposing factors can be analyzed, and patients should focus on improving their communication and ability to express emotions properly. -Hypnotherapy (may be helpful for speech symptoms or sensory loss): Therapist instructs hypnotized client to move paralyzed limb. Then makes posthypnotic suggestion to enable client to sustain movement after therapist brings them out of hypnotic trance. -Family therapy (improve communication) -Antidepressants, anxiolytics, or mood stabilizers psychological factors affecting other medical conditions: Conditions in which clients have a medical disease or symptom that appears to be exacerbated by psychological or behavioral factors. à Mental disorders, stress, emotional states, personality traits, and poor coping skills are psychological factors that can affect an individual’s physical health and well-being. Stress and Coping Stress: the unpleasant emotional reaction a person has when perceives an event to be threatening. 15 -Emotional reaction à Heightened physiological arousal (↑ reactivity sympathetic nervous system) -A stressful life event à a stressor that disrupts the individual’s life -A person’s efforts to reduce stress is called coping. The cognitive model of stress: Places greater emphasis on the way you interpret events than on whether you experienced a given event. -Proposes that the appraisal of an event as stressful determines whether it will have a negative impact on your emotional state -The circumstances surrounding the event also important (e.g. late in class) Hassle: A relatively minor event that can cause stress. Uplifts: events on a small scale that boost your feelings of well-being. you can balance your hassles with them. Coping strategies for stress Problem-focused coping: Attempt to reduce stress by acting to change whatever it is that makes the situation stressful. e.g. If you’re always late for class, then take the earlier bus Emotion-focused coping: You don’t change the situation but instead change the way you feel about it. e.g. professor doesn’t care if you’re a little bit late, so don’t be hard on yourself. -Avoidance is another emotion-focused strategy (similar to the defense mechanism of denial) e.g. rather than think about a stressful experience, you put it out of your mind. Which is the better of the two ways of coping? à It depends! -In changeable situations, use problem-focused coping (e.g. low grades) -But, if you’re stressed because you lost your cell phone & you truly cannot find it, use emotion-focused coping such as: Tell yourself you need a newer model anyhow CH11: Paraphilic Disorders, Sexual Dysfunctions, and Gender Dysphoria Paraphilic Disorders -Para meaning “faulty” or “abnormal” -Philia meaning “attraction” Literally means: Deviation from the norm in terms of the object of a person’s sexual attraction. -Paraphilias are behaviors in which an individual has recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving: 1. Nonhuman objects 2. Children or other non-consenting persons 3. The suffering or humiliation of self or partner Clinicians diagnose paraphilic disorder when the paraphilia: ▪ Causes intense distress & Impairment ▪ Has lasted for at least 6 months -A person’s nonnormative sexual behavior is not pathological in & of itself. -The symptoms of a paraphilia must include fantasies, urges, or behaviors to bring about “recurrent and intense sexual arousal” that cannot be achieved in another fashion. -Neither the DSM nor the ICD regard deviation from heterosexual intercourse as a criterion for a paraphilic disorder. 16 -The essential feature: People with one of these disorders are so psychologically dependent on the particular form or target of desire à results in inability to experience sexual arousal without target. -Even if people do not actually fulfill their urges or fantasies, they are obsessed with thoughts about acting upon them -They lose sight of any goals other than achieving sexual fulfillment in this specific way -Having a paraphilic disorder is not illegal but acting on paraphilic urges may be. -As a result, the person who reports having such a disorder runs the risk of being: o Arrested o Convicted o Required to register as a sex offender -Difficult to diagnose & self-reports more informative Pedophilic Disorder -A paraphilic disorder in which an adult is sexually aroused by children or adolescents -Clinicians use this diagnosis for adults who are: At least 18 years of age & At least 5 years older than the children to whom they are attracted -The key feature of this disorder: The individual experiences an intensity of sexual arousal when with children equal to or greater than sexual arousal of a physically mature individual. Diagnosis includes: -People who have acted upon these urges. -Those who have not act on those urges but views Internet pornography -It is difficult to obtain prevalence data given the illegality Online Surveys -Stated that they would have sex with a child if they could be assured of not getting caught: 6 % men, 2 % women -Stated they would view child pornography: 9% men, 3% women -For both men & women interest in sex with children was associated with: ▪ Higher rates of antisocial or criminal behavior ▪ Abuse in childhood Reports of sexual assault of children to approximate the prevalence of pedophilia: -This measure yields an estimate of 2/3s of children under the age of 18. The most frequent form of sexual assault is: o Forcible fondling (45 percent) o Forcible rape (42 percent) -More likely to be victimized in a residence 17 -Nearly all offenders reported to the law (96 %) are male -Their most frequently reported ages range from 15 to 20 years Exhibitionistic Disorder -A person has intense sexual urges & fantasies involving the exposure of genitals to a stranger. They derive sexual arousal from exposing their genitals. -These fantasies, urges, & behaviors cause significant distress or impairment. -Begins early in adulthood & persists throughout life. -Comorbidity with other disorders. E.g. Major depressive disorder, Substance abuse. -Over half experienced suicidal thoughts -The existence of comorbid conditions such as major depressive disorder and substance abuse, along with the reluctance of people with the disorder to come forward, present numerous challenges both for developing an understanding of the causes of the disorder and for planning its treatment. Voyeuristic Disorder -Individual has a compulsion to derive sexual gratification from observing the nudity or sexual activity of others who are unaware of being watched. -Voyeurism is related to exhibitionism -The most common of the paraphilic disorders. -People with either of these disorders, also likely to engage in sadomasochistic behaviors & cross-dressing. Law officials are unlikely to apprehend individuals with this disorder These individuals are even less likely to seek treatment Fetishistic Disorder -People with fetishistic disorder are aroused by an object not specifically intended to be used in a sexual context. -There is a wide range of objects to which people with fetishistic disorder can develop attachments. However, they do not include articles of clothing associated with cross-dressing or objects such as vibrators that people use in tactile genital stimulation. -In a related disorder, partialism, the individual is sexually aroused by the presence of a specific body part. -As with all paraphilic disorders, the attraction to objects or body parts must be recurrent, intense, and have lasted at least 6 months. Frotteuristic Disorder à From French frotter (“to rub”) -The individual has recurrent, intense sexual urges and sexually arousing fantasies of rubbing against or fondling a nonconsenting person. -Among men diagnosed with paraphilic disorders approximately 10-14% have committed acts of frotteurism. -Men with frotteuristic disorder seek out crowded places where they can safely rub up against their unsuspecting victims. Sexual Masochism Disorder masochismà act of seeking pleasure from being in pain. -People with sexual masochism disorder are sexually aroused by being: Beaten Bound Otherwise made to suffer 18 Sexual Sadism Disorder -Involves sexual arousal from the physical or psychological suffering of another person -DSM-5 does not classify Bondage, Domination & Sadomasochism (BDSM) as a disorder in & of itself. Little scientific research exists for both sexual sadism & sexual masochism disorders. People do not often seek out treatment. Do not feel the need to change because their behaviors occur in a consensual relationship. Preference for Bondage, Domination, And Sadomasochism (BDSM) activities: -46.8 % performed at least 1 BDSM-related activity -22 % have or have had fantasies about it -12.5% perform at least 1 BDSM-related activity on a regular basis Transvestic Disorder (Cross-dressing) -Behavior of dressing in the clothing of the other sex. -Commonly displayed by men. -A clinician would diagnose an individual with transvestic disorder only if he showed the symptoms of a paraphilic disorder, namely distress or impairment. -Psychologists would consider a man who frequently cross-dresses and derives sexual pleasure from this behavior as a transvestite, but they would not diagnose him with a disorder. -DSM-IV-TR limited this behavior to heterosexual males, but DSM-5 opened the diagnosis to women or gay men who have this sexual interest. Theories and Treatment of Paraphilic Disorders -Deciding what is normal in sexuality is fraught with controversy -Critics argued against including several of these disorders in DSM-5 - The main point to keep in mind is that by defining the disorders in this area as accompanying intense distress or impairment, authors of the DSM-5 hoped to avoid judging a behavior’s normality and instead to base the criteria for a disorder on an individual’s subjective experience of distress or degree of impairment in everyday life. Challenges To Understand The Causes: -Most of the people we can study for disorders involving criminal acts & are likely to have been arrested -Self-selection can determine who decides to participate in research -Prevalence estimate data are likely to be biased Biological perspectives: emphasizes altered genetic, hormonal, and sensory factors in paraphilic disorders. -For men, the male sex hormone testosterone is the focus of theories and treatment, but dopamine and serotonin also play roles in male sexuality. -World Federation of Societies of Biological Psychiatry advocates treatment of paraphilic disorders in men that includes SSRIs, antiandrogens, and luteinizing hormone-release hormone (LHRH). LHRH: Acts as a suppressor in men for the production of testosterone. Reduces testosterone below the level achieved by castration. Side effects of LHRH: Loss of bone mineral content, Cardiovascular disease, Fatigue, Sleep disorders, Hot flashes à Not recommended for lifelong treatment 19 Castration: Destroy the body’s production of testosterone through surgical castration Chemical castration: Individual receives medications that suppress the production of testosterone Psychotherapeutic: Medications alter the individual’s neurotransmitter levels Psychological perspectives: -John Money à Regarded paraphilias as the expressions of lovemaps Lovemap: internal representations of an individual’s sexual fantasies & preferred practices -People form lovemaps in late childhood, when they first begin to discover sexuality -“Misprints” in this process can result in sexual habits & practices that deviate from the norm -The individual, in this sense, is programmed to act out fantasies that are socially unacceptable & harmful. -The majority of the psychological literature on paraphilic disorders focuses on pedophilic disorder. -A common theme in this literature is the idea of a “Victim-to-abuser cycle” or “abused- abusers phenomena’. -Arguing against these explanations is the fact that most abuse victims do not go on to abuse or molest children. -On the other hand, some people with pedophilic disorder who were abused as children show an age preference that matches their age when they were abused, suggesting that they are replicating behaviors that were directed toward them as children. Treatments: Most effective when combining individual with group therapy In the group context: -Empathy training can help these individuals understand how their victims are feeling -Clinicians may also help clients learn how to control their sexual impulses -Relapse prevention à Helps clients accept that even if they slip, this does not mean that they cannot overcome their disorder -Clinicians no longer recommend aversion training in which clinicians teach clients to associate negative outcomes with sexual attraction toward children -Psychotherapy is the recommended treatment, particularly CBT à Useful in helping clients recognize their distortions and denial -Another focus of treatment may be clinicians themselves à clinicians may be less willing to offer them treatment -In one intervention, researchers presented therapists in training with a 10-minute video that effectively challenged typical myths about pedophilia, such as the idea that it is a choice and that people with this disorder act upon their urges. Sexual Dysfunctions sexual dysfunction: a marked divergence in an individual’s response in the sexual response cycle, along with feelings of significant distress or impairment. -To consider it a sexual dysfunction, clinicians must not be able to attribute this divergence to a psychological disorder, effects of a substance such as a drug of abuse or medication, or a general medical condition. Arousal Disorders People whose sexual disorders occur during the initial phases of the sexual response cycle have low or no sexual desire or are unable to achieve physiological arousal. As a result, they may avoid having or be unable to have sexual intercourse. 20 male hypoactive sexual desire disorder: A sexual dysfunction in which the individual has an abnormally low level of interest in sexual activity. female sexual interest/ arousal disorder: A sexual dysfunction characterized by a persistent or recurrent inability to attain or maintain normal physiological and psychological arousal responses during sexual activity. erectile disorder: Sexual dysfunction in which a man cannot attain or maintain an erection during sexual activity that is sufficient to allow him to initiate or maintain sexual activity. female orgasmic disorder: A sexual dysfunction in which a woman experiences problems having an orgasm during sexual activity. delayed ejaculation: A sexual dysfunction in which a man experiences problems having an orgasm during sexual activity; also known as inhibited male orgasm. premature (early) ejaculation: A sexual dysfunction in which a man reaches orgasm well before he wishes to, perhaps even prior to penetration. genito-pelvic pain/ penetration disorder: A sexual dysfunction affecting both males and females that involves recurrent or persistent genital pain before, during, or after sexual intercourse. Gender Dysphoria Distress that may accompany the incongruence between: Person’s experienced/expressed gender and that person’s biological sex. Gender identity: a person’s inner sense of maleness or femaleness Biological sex: the sex determined by a person’s chromosomes -An individual’s identification with a sex other than the biologically assigned one need not be a disorder. Current criteria: -The feeling of being “in the wrong body” causes feelings of discomfort -Sense of inappropriateness about the person’s assigned gender -Thus, the clinical problem is the dysphoria, not the individual’s gender identity. -Another term that relates to cross-gender identification is Transsexualism: describes the inner feeling of belonging to the other sex. -The term is generally considered equivalent to transgender identity. -Some people with gender dysphoria wish to live as members of the other sex, and they act and dress accordingly. -Unlike individuals with transvestic disorder, these people do not derive sexual gratification from cross-dressing. -Some individuals with gender dysphoria may choose to pursue gender-affirming medical procedures. These range from taking hormones to a variety of surgical procedures such as facial feminization surgery, chest reconstructive surgery (“top” surgery), and genital reconstructive surgery (“bottom” surgery). Theories and Treatments -Emphasize a more fluid view of gender than the binary male-female dichotomy -New DSM-5 terminology reflects a theoretical perspective that does not focus on what is “wrong” -Clinicians can begin by using the gender terminology the client prefers -They can avoid using terms like real or biological gender 21 Through this approach, often referred to as affirmative psychotherapy: à Clinicians can provide education about medical options & help and connect with sources of social support -Clients will still likely struggle with transphobia à the negative stereotyping and fear of transgender individuals. New therapeutic approaches: Encourage clients to create their own gender identities, which can result in an improved sense of well-being -Through this process, transgender individuals can explore more openly & without bias their multiple, intersecting identities. CH13: Neurocognitive Disorders Characteristics of Neurocognitive Disorders Many sources of insult or injury can affect an individual’s brain, such as: trauma, disease, exposure to toxic substances including drugs. -Ppl can develop delusions, hallucinations, mood disturbances, personality changes as a result of these influences on the brain. -Neurocognitive disorders involve decline in one or more domains of cognition associated with alterations in the brain. -Diagnosis based upon: ▪ Neuropsychological testing à Does it fit to known disease profiles? ▪ Neuroimaging à Helps connect symptoms with specific illnesses or injuries ▪ Individual’s medical history à Do symptoms fall into the category of a neurocognitive disorder? -In DSM-5, the term neurocognitive disorder replaces dementia. -Dementia used in DSM-IV-TR to refer: Progressive loss of cognitive functions severe enough to interfere with their normal daily activities & social relationships. -Using interviews with the client & family members or significant others, they rate the client as showing major or mild neurocognitive disorder. 22 Diagnosis of Major neurocognitive disorders: -Significant cognitive decline (2 SDs below) from a previous level of performance in the 6 domains (in the table) - Cognitive deficits must interfere with the individual’s ability to perform necessary tasks in everyday living (e.g., feeding, dressing). -Not occur exclusively with delirium à mental state in which you are confused, disoriented, and not able to think or remember clearly. It usually starts suddenly. It is often temporary and treatable. -Lack a better explanation as another disorder Diagnosis of Mild neurocognitive disorders: -Disorders involving modest cognitive decline -Declines are not severe enough to interfere with the individual’s capacity for living independently. -Difficulties with only activities of daily living such as housework, or managing money -After diagnosing level of cognitive impairment clinician must specify which disease is responsible for cognitive symptoms: Alzheimer’s disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication use HIV infection, prion disease Parkinson’s disease Huntington’s disease Other medical conditions Multiple etiologies, or unspecified Delirium A neurocognitive disorder that is: Temporary in nature Involve disturbances in attention, awareness, cognitive processing Acute state of confusion Symptoms appear abruptly Fluctuate over the course of the time that they have the disorder To receive a diagnosis of delirium: -The individual must show changes in consciousness over a very short period of time, on the order of hours or days. -A general medical condition must cause the disturbance. -Clinicians need to specify the cause (e.g., substance intoxication, substance withdrawal, a medication, or other medical condition(s)) - The clinician also rates the delirium as acute (occurring a few hours or days) or persistent (occurring over weeks or months). 23  -The Delirium Rating Scale– Revised (DRS-R-98) is a widely used measure that has been translated into several languages and has well-established validity and reliability. Most common causes: from most frequent to least frequent 1. Infection: Respiratory infections Urinary tract Kidney infections 2. Central nervous system disorder: Cancer Stroke Seizure 3. Metabolic disorders, cardiovascular disease, and orthopedic procedures 4. Drug-induced delirium -People of any age can experience delirium, but more common among medically or psychiatrically hospitalized older adult patients. Treatment: -Pharmacological approach that relies on antipsychotics like Haloperidol & Risperidone. -Resolved symptoms in 84% of cases over a period of 4-7 days -Instead of using medications as a prevention for the development of delirium, clinicians can provide high-risk patients with cognitively stimulating activities such as discussions of current events or word games. Neurocognitive Disorder Due to Alzheimer’s Disease -This is a neurocognitive disorder associated with progressive, gradual declines in: Memory, learning & At least one other cognitive domain (see table 3). -The first symptoms of memory loss precede a cascade of changes that eventually ends in death due to the development of medical illness resulting from infection or failure of vital bodily organs. 24 Prevalence of Alzheimer’s Disease -The WHO (2001) estimates prevalence of 5% of men & 6 % of women worldwide -The incidence rate of new cases is less than 1% a year in those ages 60–65, or possibly as high as 6.5% in those 85 & older. -55 percent of neurocognitive disorders can be caused by disease processes other than Alzheimer’s E.g., Vascular dementia, Dementia with Lewy body, Frontotemporal dementia Theories and Treatment of Alzheimer’s Disease -All theories regarding the cause of AD focus on biological abnormalities of the nervous system. However, approaches to treatment may incorporate other perspectives. -The biological theories of Alzheimer’s disease attempt to explain the devel- opment of two characteristic abnormalities in the brain: neurofibrillary tangles and amyloid plaques. Neurofibrillary tangles: Made up of a protein tau, plays a role in maintaining microtubule stability. Microtubules: Supporting the axon’s internal structure. Guide nutrients from the cell body down to the axon’s ends In AD: Tau changes chemically & loses its ability to support the microtubules -Tubules begin to wind around each other and can no longer perform their function. -This collapse of the transport system within the neuron may first result in malfunctions in communication between neurons and may eventually lead to the neuron’s death. -The development of neurofibrillary tangles appears to occur early in the disease process and may progress substantially before the individual shows any behavioral symptoms. Amyloid plaques: Collections of clusters outside the neuron made up of abnormal protein fragments called beta amyloid. -A characteristic of Alzheimer’s disease in which clusters of dead or dying neurons become mixed together with fragments of protein molecules. -Although researchers are testing various theories to identify the causes of Alzheimer’s dis- ease, the most probable is that an underlying defect in the genetic programming of neural activity triggers the formation of tangles and plaques. 25 Genetics The apoE gene on chromosome 19 has three common forms: e2, e3, and e4 -Each produces a corresponding form of apolipoprotein E (apoE) called E2, E3, and E4 E4 form of apoE, is associated with ↑risk -Damages the microtubules within the neuron Behavioral Strategies Target both patient and caregiver to: ▪Maximize the daily functioning ▪Provide social support for caregivers to manage the emotional stress that occurs with their role Tips for Everyday Care for People With Dementia -Buy loose-fitting, comfortable, easy-to-use clothing, such as clothes with elastic waistbands, fabric fasteners, or large zipper pulls instead of shoelaces, buttons, or buckles. -Use a sturdy shower chair to support a person who is unsteady and to prevent falls. You can buy shower chairs at drug stores and medical supply stores. -Be gentle and respectful. Tell the person what you are going to do, step by step while you help them bathe or get dressed. -Serve meals in a consistent, familiar place and give the person enough time to eat. Neurocognitive Disorders Due to Neurological Disorders Other than Alzheimer’s Disease -The symptoms of neurocognitive disorder can have a number of causes that include degenerative neurological conditions other than Alzheimer’s disease. -Each of these disorders has a separate diagnosis associated with it. Figure shows the overlap among symptoms of these neurological disorders. 26 Frontotemporal Neurocognitive Disorder: Neurocognitive disorder that involves the frontotemporal area of the brain. -Symptoms are reflected in personality changes (rather than decline in memory like AD) such as apathy, lack of inhibition, obsessiveness, and loss of judgment -Neglect of personal habits and loss of the ability to communicate eventually occurs -The onset of the disorder is slow and insidious à Proceeding in a gradual, subtle way, but with very harmful effects -On autopsy, brain shows atrophy in frontal & temporal cortex, but no amyloid plaques or arterial damage. Neurocognitive disorder with Lewy bodies: characterized by progressive loss of memory, language, calculation, and reasoning, as well as other higher mental functions. T -disorder gets its name from the presence in the brain of Lewy bodiesà abnormal deposits of a protein called alpha-synuclein. -These deposits affect dopamine and norepinephrine, which in turn affect motor functioning and memory. -Individuals with neurocognitive disorder with Lewy bodies experience alterations in mood and movement in addition to cognitive changes. Vascular Neurocognitive Disorder: -Affects the supply of blood to the brain (e.g. causes deprivation) -Highly prevalent and linked to a variety of cardiovascular risk factors -The most common is Multi-infarct dementia (MID): caused by transient attacks in which blood flow to the brain is interrupted by clogged or burst artery. -Each infarct is too small to be noticed at first, but over time the progressive damage leads the individual to lose cognitive abilities -Memory impairment appears to be similar to that observed in AD. But there are some significant differences. -People with VND show physical abnormalities: Walking difficulties Weakness in the arms & legs Distinct pattern of cognitive functioning from AD (patchy deterioration; sudden loss) -As is true for Alzheimer’s disease, there is no treatment to reverse the cognitive losses in vascular neurocognitive disorder. Pick’s disease: A relatively rare degenerative disease that affects the frontal and temporal lobes of the cerebral cortex and that can cause neurocognitive disorders. à memory problems, individuals become socially disinhibited à either acting inappropriately and impulsively or appearing apathetic and unmotivated. neurocognitive disorder due to Parkinson’s disease: A neurocognitive disorder that involves degeneration of neurons in the subcortical structures that control motor movements (basal ganglia). -Parkinson’s disease is usually progressive, with various motor disturbances being the most striking feature of the disorder. E.g. at rest, the person’s hands, legs, or head may shake involuntarily. -The muscles become rigid, and it is difficult for the person to initiate movement, a symptom called akinesia. -A general slowing of motor activity, known as bradykinesia, also occurs, as does a loss of fine motor coordination. 27 neurocognitive disorder due to Huntington’s disease: A hereditary condition causing neurocognitive disorder that involves a widespread deterioration of the subcortical brain structures and parts of the frontal cortex that control motor movements. -Can affect personality and cognitive functioning. neurocognitive disorder due to prion disease (Creutzfeldt- Jakob disease): A neurological disease transmitted from animals to humans that leads to neurocognitive disorder and death resulting from abnormal protein accumulations in the brain. -Initial symptoms include fatigue, appetite disturbance, sleep problems, and concentration difficulties. As the disease progresses, the individual shows increasing signs of neurocognitive loss and eventually dies. Neurocognitive Disorder Due to Traumatic Brain Injury Traumatic brain injury (TBI): Damage to the brain caused by exposure to trauma. Neurocognitive disorder due to traumatic brain injury: A disorder in which there is evidence of impact to the head. -Results in an alteration or loss of consciousness, or -Post-traumatic amnesia -Disorientation and confusion -Cognitive & Neurological symptoms (e.g. seizures) - The symptoms must occur immediately after the trauma or after recovery of consciousness, and past the acute postinjury period. -In 2013, there were an estimated 2.8 million TBI-related hospitalizations, emergency department visits, & deaths. The greatest risk of TBI have: Children aged 0 to 4 years Adolescents and young adults aged 15 to 24 years Adults 75 years and older (highest rates of hospitalization and death) -20% of U.S. veterans of Iraq & Afghanistan have experienced TBIs - Most of these cases are relatively mild in severity, - Involved loss of consciousness for 30- min or less - Post-traumatic amnesia of 24-h or less - Most victims recover within 6 months -Veterans who experienced TBI are at higher risk of developing: PTSD, Anxiety, Adjustment disorders -People undergoing mild TBI may experience a related condition known as postconcussion syndrome (PCS) in which they continue to have symptoms such as fatigue, dizziness, poor concentration, memory problems, headache, insomnia, and irritability. -Individuals most at risk of developing PCS are those who had an anxiety or depressive disorder prior to their injury and acute post-traumatic stress for approximately 5 days after their injury. 28 Neurocognitive Disorders Due to Substances/Medications and HIV Infection 1. Infectious Diseases: Conditions like neurosyphilis, encephalitis, tuberculosis, meningitis, HIV, and localized brain infections can lead to neurocognitive disorders. 2. Kidney Failure: Toxic buildup in the blood due to kidney failure may cause symptoms of neurocognitive disorder. 3. Brain Tumors: Certain types of brain tumors can impair cognitive functioning. 4. Anoxia (Oxygen Deprivation): Anoxia, occurring during surgery, carbon monoxide poisoning, or other situations, can lead to severe brain damage, affecting cognitive and emotional functions, including planning and memory. 5. Substance/Medication-Induced Disorder: Exposure to drugs, environmental toxins (e.g., house paint fumes, plastics chemicals, petroleum fuels), can cause brain damage and cognitive impairments. 6. Nutritional Deficiencies: Severe undernourishment, particularly folate deficiency, can lead to cerebral atrophy, depression, and cognitive impairments like poor memory and reasoning. 7. Reversibility of Cognitive Losses: Early medical intervention can reverse cognitive losses caused by physical disorders or toxins, but delayed treatment may result in irreversible brain damage. 8. HIV/AIDS and Neurocognitive Disorders: Prior to antiretroviral therapies, AIDS dementia complex was common in late-stage HIV/AIDS. Improved treatments have reduced prevalence, but undiagnosed/untreated cases remain significant, particularly in developing countries. Neurocognitive Disorders Due to Another General Medical Condition Amnesia: Inability to recall information that was previously learned or to register new memories. major neurocognitive disorder due to another medical condition: Cognitive disorders involving the inability to recall previously learned information or to register new memories. - This disorder is due either to the use of substances or to medical conditions such as head trauma, loss of oxygen, and herpes simplex. -The most common cause of this form of neurocognitive disorder is chronic alcohol use. -The memory loss must persist over time for the clinician to assign the diagnosis of neurocognitive disorder due to another general medical condition. CH14: Personality Disorders Personality disorders: ingrained patterns of impairments relating to: -An individual’s self-understanding -Ways of relating to other people -situations, events -Personality traits (e.g. extreme rigidity) -Characterized by a rigid & maladaptive pattern of inner experience and behavior -Dating back to adolescence or early adulthood - As conceptualized in the DSM-5, the personality disorders represent a collection of distinguishable sets of behavior falling into 10 distinct categories (plus one additional “not otherwise specified” diagnosis). -Fitting the general definition of a psychological disorder, a personality disorder deviates markedly from the individual’s culture and leads to distress or impairment. 29 -The types of behavior that personality disorders represent can be, for example, excessive dependency, overwhelming fear of intimacy, intense worry, exploitive behavior, or uncontrollable rage. -To fit the current diagnostic criteria, these behaviors must manifest themselves in at least two of four areas: (1) cognition (2) affectivity (3) interpersonal functioning (4) impulse control. -As a result of these behaviors, the individual experiences distress or impairment. -Prevalence: 9 to 10 % -Personality disorders are highly comorbid with drug dependence. What’s in the DSM-5: Dimensionalizing the Personality Disorders -The history of Personality disorders which are not so much illnesses but characteristics of an individual’s core ways of relating to others & experiencing the self reflects the tension between those who support categorical diagnoses and those who prefer a system of personality trait ratings. Dimensional approach: We cannot summarize the many complex facets of personality into a discrete set of units. Categorical approach: Diagnoses are a more legitimate way to capture the essence of a personality disorder à It is more convenient to describe clients as fitting into the “borderline” diagnostic category rather than to list all the personality traits that particular individuals display (according to clinicans) -To satisfy proponents of both approaches, the DSM-5 authors wanted to include: § Categorical diagnoses § Dimensional rating system of pathological personality traits -These changes were not implemented DSM-5 Personality Disorder Clusters -The DSM-5 groups 10 diagnoses into three clusters based on shared characteristics: § Cluster A — The odd & eccentric behaviors (e.g. paranoid, schizotypal, schizoid personality disorders) § Cluster B — The overdramatic, erratic/unpredictable & emotional behaviors (e.g. antisocial, borderline, narcissistic personality disorders) § Cluster C — The anxious & fearful behaviors (e.g. avoidant, dependent, OCD personality disorders) -The 11th personality disorder à Reserved for individuals who do not clearly meet one of the other 10 diagnostic criteria. It receives the label “not otherwise specified” Cluster A Personality Disorders -Include those disorders characterized by odd and eccentric behavior. -People with these disorders have qualities suggesting they feel: Different Unlikable Unable to fit into the social world (of their friends, families, fellow students, and co- workers) -This leaves them with a preference for avoiding interpersonal relationships 30 Cluster A - Paranoid Personality Disorder The individual is: -Extremely suspicious of others and are always on guard against potential danger or harm. -Their view of the world is narrowly focused, in that they seek to confirm their expectations that other people will take advantage of them, making it virtually impossible for them to trust even their friends and associates. E.g. believes a spouse or partner to be unfaithful, even if no substantiating evidence exists. -with their guarded behavior and suspiciousness, those with paranoid personality disorder are known to have difficulty establishing the type of interpersonal closeness that helps maintain the quality of a long-term intimate relationship -inability to take blame for mistakes, seeing others as being at fault instead. à Project blame onto others - perception that there is hidden meaning in innocent comments or glances. - may be relatively successful in certain kinds of jobs requiring that they be on the lookout for threats to themselves, co-workers, or the public. - do not see themselves as the source of their problems, they refuse to seek professional help. Cluster A - Schizoid Personality Disorder Characterized by: -An indifference to social & sexual relationships -With a limited range of emotional experience and expression, individuals with this disorder prefer to be by themselves rather than with others, and they appear to lack any desire for acceptance or love, even by their families. -They are not even interested in becoming sexually involved with others. -In turn, others perceive them as cold, reserved, withdrawn, and seclusive. -Throughout their lives, they seek out situations that require only minimal interaction with others. (e.g. jobs in which they spend all their work hours alone) -choose to live alone, guarding their privacy and avoiding any but the most superficial dealings with neighbors. Paranoid & Schizoid Personality Disorder -Paranoid & schizoid personality disorders would have been eliminated in the DSM-5 -Research does not support their continued inclusion because they cannot be uniquely identified. -Also, their names are somewhat misleading à They sound as if they refer to a variant of schizophrenia. However, individuals with these qualities have not lost touch with reality. Cluster A - Schizotypal Personality Disorder -It primarily involves odd or eccentric beliefs, behavior, appearance, and interpersonal style. The term schizotypal implies a connection with schizophrenia. à people who fit this diagnosis are vulnerable to developing a full-blown psychosis if exposed to difficult life circumstances that challenge their coping ability. -People may have bizarre/eccentric ideas or preoccupations E.g. Magical or superstitious thinking – belief that unrelated events are causally connected. -Difficulty forming accurate perceptions & cognitions about their world à Leading to more negative views about themselves than are warranted by objective data -Also show a tendency to be high on the personality trait of openness to experience, specifically, openness to unusual ideas. 31 Cluster B Personality Disorders -People behave in ways that are best described as: Dramatic Emotional Erratic -These individuals: § Act impulsively § Seem to have an inflated view of their own importance/self-esteem § High in the desire to seek stimulation Cluster B - Antisocial Personality Disorder A disorder characterized by: -Lack of regard for society’s moral & legal standards -Impulsive and Risky lifestyle -They engage in impulsive and aggressive acts, take risks despite experiencing negative consequences, and fail to conform to social or ethical norms. -Their antisocial lifestyle may also include a history of early behavioral problems or juvenile delinquency. -Individuals are high in the quality of psychopathy: à defined as being able to exploit others, extremely ego-centric and incapable of love, unreliable and deceptive, charming but insincere, and unable to feel remorse. 1. Lack of remorse for harmful acts committed to others 2. Poor judgment & failure to learn from experience 3. Extreme egocentricity & incapacity for love 4. Lack of emotional responsiveness to others 5. Impulsivity 6. Absence of “nervousness” 7. A combination of unreliability, untruthfulness & insincerity -Personality researchers coined the fitting term dark triad to reflect the makeup of individuals high in psychopathy who are also highly self-centered and regard other people as objects to be exploited. In the DSM-5, an individual show 3 of these behaviors: 1. Failure to conform to social norms 2. Deceitfulness 3. Impulsivity 4. Aggressiveness 5. Disregard for safety of self or others 6. Irresponsibility 7. Lack of remorse Treatment of Antisocial Personality Disorder Problems of working with these individuals: -Lack of motivation to change -Tendency toward deception and manipulation -Inability to see the world from the others’ perspective -Do not learn from the negative consequences of their behaviors -Lack of deep or lasting emotion 32 -Reflecting the many difficulties in both working with the population and defining reasonable goals of therapy, at present no one accepted method of treatment has been shown to be effective in reducing the core features of the disorder. -Nevertheless, therapists can take a pragmatic approach to helping clients satisfy their needs through prosocial ways, such as cooperation rather than exploitation and manipulation. -Motivational interviewing, focused on providing clients with opportunities to connect to core values and the need for fulfillment, can also be of value as a means to help these clients make better life decisions. Cluster B - Borderline Personality Disorder Pervasive pattern of: -Poor impulse control -Instability in mood, interpersonal relationships, and self Diagnosis, at least 5 of 9 possible behaviors, including: 1. Frantic efforts to avoid abandonment 2. Unstable and intense relationships 3. Identity disturbance 4. Impulsivity in areas such as sexuality, spending, or reckless driving 5. Recurrent suicidal behavior 6. Unstable affect 7. Chronic feelings of emptiness 8. Difficulty controlling anger 9. Occasional feelings of paranoia or dissociative symptoms -Their insecurity reaches such an extreme that they rely on other people to help them feel “whole.” -Even after they have passed through the customary time of identity questioning that most people experience in adolescence, these individuals remain unsure and conflicted about their life’s goals. -The way that people with BPD relate to others is termed “splitting”. àAll-good versus all- bad dichotomy: Preoccupation with feelings of love, attention can turn to extreme rage, hatred when that love object rejects them -The intense despair into which they can be thrust may also lead them to perform suicidal gestures, as a way to either gain attention or derive feelings of reality from the physical pain the action causes. -Parasuicide: Attempted suicide, often a call for help à clinicians detect that the act was, in fact, a gesture and not a true desire to end their lives. -Individuals seem to have an inability to regulate emotions, known as emotional dysregulation, limitations in the ability to withstand distress (distress tolerance), and avoidance of emotionally uncomfortable situations and feelings (experiential avoidance). Perspectives on Borderline Personality Disorder Psychological Have great difficulty handling their anger when something does go wrong Avoidance of emotionally uncomfortable situations and feelings Lack of awareness, understanding, or acceptance of emotions Childhood neglect or traumatic experiences, marital or psychiatric difficulties in the parental home Children who were insecurely attached are also more likely to develop into adults with BPD 33 Treatment of Borderline Personality Disorder: -Dialectical behavioral therapy (DBT), a form of behavioral therapy. -Psychologist Marsha Linehan developed DBT specifically to treat individuals with BPD who might otherwise not respond to conventional psychotherapy. -In DBT, the clinician integrates supportive and cognitive-behavioral treatments with the goal of reducing the frequency of the client’s self-destructive acts and increasing his or her ability to handle emotional distress. § A dialectic is a synthesis or integration of opposites § Dialectical strategies help therapist & client get unstuck from extreme positions § Acceptance strategies are added to the behavioral change strategies in CBT à Through validation & through accepting the client just as he or she is § Too much focus on change results in clients feeling misunderstood & that their suffering is invalid § Working with people with extreme emotional sensitivity requires careful attention to the balance between acceptance & change § “B” stands for “behavioral”à DBT requires a behavioral approach: This means that we assess the situations & target behaviors relevant to clients’ goals to figure out how to solve the problems in their lives. mentalization therapy: clients are helped to identify their feelings by gaining control over their dysfunctional thoughts. transference-focused psychotherapy: uses the client–clinician relationship as the framework for helping clients achieve greater understanding of their unconscious feelings and motives. Cluster B - Histrionic Personality Disorder -Characterized by exaggerated emotional reactions, approaching theatricality, in everyday behavior. -Show extreme pleasure at being the center of attention and who behave in whatever way necessary to ensure that this happens. -The criteria for this disorder include: excessive concern with physical appearance and constant and extreme efforts to draw attention to self. -Flirtatious and seductive, people with this disorder become furious if they don’t get the attention they seek. -They want immediate gratification of their wishes and overreact to even minor provocations, usually in an exaggerated way such as by weeping or fainting. -Their cognitive style is vague and impressionistic, making them easily influenced by others and unable to solve problems on their own. Cluster B - Narcissistic Personality Disorder (NPD) A personality disorder primarily characterized by: -An unrealistic, inflated sense of self- importance -Lack of sensitivity to the needs of other people -extreme form of egocentrism in which they see themselves as the center of the universe. 34 The sense of entitlement is one of NPD’s most prominent symptoms: o Because they see themselves as exceptional o They may set their personal standards unrealistically high o Being satisfied with nothing less than perfection - Entitled, haughty, and unable to see the world from anyone’s perspective but their own, people with NPD seem to show little regard for the people who care about them. Ironically, however, they are highly dependent on the way they believe others perceive them, and as a result they need constant flattery, attention, and reassurance. -Often devote their lives to seeking approval from others -Despite having very little concern for the well-being of other people Grandiose narcissism: The form of NPD in which individuals think of themselves entirely in an inflated & self-aggrandizing way. Vulnerable narcissism: The form of NPD in which individuals have an internally weak sense of self -Become despondent when they feel that someone who is important to them is humiliating or betraying them Theories of Narcissistic Personality Disorder Current Psychodynamic -Approach with empathy - incorporates the object relations view in seeing narcissistic personality disorder as the adult’s expression of childhood insecurity and need for attention. -Clinicians attempt to provide a corrective developmental experience, using empathy to support the client’s search for recognition & admiration -Attempt to guide the client toward a more realistic appreciation that no one is flawless -As clients feel their therapists increasingly support them, they become less grandiose & self- centered Cognitive behavioral -Focus on maladaptive ideas, particularly the view in which they regard themselves as exceptional people (grandiose narcissism) who deserve far better treatment than ordinary humans. - These beliefs hamper their ability to perceive their experiences realistically, and as a result they encounter problems when their inflated ideas about themselves clash with their experiences of failure in the real world. - Rather than simply confronting them with their erroneous beliefs, clinicians working in the cognitive-behavioral perspective structure interventions that work with, rather than against, the client’s self-aggrandizing and egocentric tendencies - This allows the individual to accept the therapist’s help because the intervention seems less threatening. For example, rather than try to convince the client to act less selfishly, the therapist might try to show that there are better ways to reach important personal goals. Most effective approach Provide reassurance and develop a more realistic view of themselves and other people The therapist avoids capitulating to the client’s demands for special favors and attention 35 Cluster C Personality Disorders -Disorders that involve people who appear anxious or fearful -Tend to be extremely restrained -Draw little attention to themselves (in contrast to cluster B disorders) Cluster C - Avoidant Personality Disorder A personality disorder in which people have low estimation of their social skills & are fearful of: Disapproval Rejection Criticism Being ashamed or embarrassed -Stay away almost entirely from social encounters to avoid any situation that could embarrass them - Believe they lack social skills and have no desirable qualities that would make others want to be with them. - They may set unrealistically high standards for themselves, which in turn lead them to avoid situations in which they feel doomed to fail. -Intimate relationships present a severe threat to them because they fear shame or ridicule should they expose their flaws to a partner. Theories of Avoidant Personality Disorder: -APD exists along a continuum extending from the normal personality trait of shyness to social anxiety disorder. à Avoidant personality disorder is a more severe form of social anxiety disorder (according to this view) -The link between social anxiety disorder & avoidant personality disorder is that both are characterized by excessive self-criticism, which in turn leads people with these disorders to expect the same level of criticism from others. Contemporary Psychodynamic approach -Expression of fear of attachment in close relationships -People with this disorder avoid getting close to others because they fear being abandoned or neglected in the same way they were by their caregiver in early childhood. Cognitive behavioral -Individuals are hypersensitive to shame due to parental criticism -Hypersensitivity causes them to misinterpret neutral & even positive remarks -Hurt by perceived rejection, they retreat inward, placing further distance between themselves & others. -Main aim to break the client’s negative cycle of avoidance. - Clients learn to articulate the automatic thoughts and dysfunctional attitudes that interfere with their ability to establish relationships with others. -Clients must learn to trust the therapist rather than see him or her as yet another person who may ridicule or reject them -May also use graduated exposure to present the client with social situations that are increasingly more difficult to confront. 36 Cluster C - Dependent Personality Disorder - A personality disorder whose main characteristic is that the individual is extremely passive and tends to cling to other people, to the point of being unable to make any decisions or to take independent action. -When alone, these clients feel despondent and abandoned. - Their extreme dependence causes them to urgently seek another relationship to fill the void. -Even when with others, they become preoccupied with the fear of being left. -They cannot comfortably initiate new activities on their own because they are hampered by worries that they will make mistakes unless others guide their actions. -Go to extremes to avoid having people dislike them—e.g. by stating that they agree with others even when they do not. -May also seek approval by taking on responsibilities no one else wants, but if anyone criticizes them, they feel shattered. - Cognitive-behavioral treatment appears to be effective, particularly if the clinician alternates as needed between changing behaviors and challenging the client’s faulty beliefs. -Mindfulness training can also be useful in helping individuals with this disorder identify and manage their interpersonal anxiety. Cluster C - Obsessive-Compulsive Personality Disorder -A personality disorder involving intense perfectionism and inflexibility manifested in worrying, indecisiveness, and behavioral rigidity. -defining their sense of self and self-worth in terms of their work productivity. -Find it difficult to complete a task because they can always see a flaw in what they have done. Their work products are never good enough to meet their unrealistic standards. -They can also be overly moralistic because they stick to overly conscientious standards that almost anyone would find difficult to meet. - Because they have such high standards for themselves, people with OCPD are critical of other people who they see as not matching their own expectations. Others, in turn, perceive those with OCPD as rigid and stubborn. - The words obsessive and compulsive as applied to the OCPD personality disorder have a different meaning than in the context of obsessive compulsive disorder (OCD). -Unlike those with OCD, people with OCPD do not experience obsessions and compulsions but instead are rigidly compulsive (such as being fixated on certain routines) and obsessed with the need to be perfect. - Contemporary psychodynamic theorists give more attention to cognitive factors and prior learning experiences as central to the development of OCPD. - Clinicians using cognitive-behavioral treatment for clients with OCPD face challenges due to the characteristic features of this personality disorder. -The person with OCPD tends to intellectualize, to ruminate over past actions, and to worry about making mistakes. -Cognitive-behavioral therapy, with its focus on examining the client’s thought processes, may reinforce this ruminative tendency. -Metacognitive interpersonal therapy can help individuals with OCPD “think about their thinking.” In this procedure, clinicians help their clients take a step back and learn to identify their problematic ruminative thinking patterns in the context of building a supportive therapeutic alliance.