Abnormal Notes PDF

Chapter 1: Overview What is meant by “abnormality”? - Statistical deviance - Violation of standards of society - Social discomfort - Irrationality and unpredictability - Dangerousness “Abnormal Behavior” can be diagnosed following three criteria of symptoms: - Ps...

Chapter 1: Overview What is meant by “abnormality”? - Statistical deviance - Violation of standards of society - Social discomfort - Irrationality and unpredictability - Dangerousness “Abnormal Behavior” can be diagnosed following three criteria of symptoms: - Psychological Dysfunction: breakdown in cognitive, emotional, or behavioral functioning - Personal distress/impairment in functioning - Atypical or unexpected cultural response Pros and Cons of Classification Systems Pros: - Provides nomenclature - Define the domain of what is considered pathological - Help in insurance reimbursement Cons: - Loss of specific information and personal details due to simplification - Stigma - Labeling/stereotyping CULTURE AND ABNORMALITY Culture affects the way abnormality is defined and can shape the clinical presentation of disorders PREVALENCE AND INCIDENCE OF MENTAL DISORDERS Prevalence: number of active cases in a population during given period of time, expressed in percentages or different types of prevalence estimates Incidence: number of new cases in population over given periods of time; typically lower than prevalence figures - If a cure for certain disease/disorder is discovered, incidence will stay the same while prevalence will decline Comorbidity: the presence of two or more disorders in the same person - Estimations of prevalence in large groups done by screening measures/questionnaires/surveys can be unreliable. Elevated scores can be incorrectly extrapolated to mean mental illness It is unclear with any real certainty how many people suffer from mental illness in a population due to ambiguous diagnostic criteria. Even if insurance records were to be pulled and evaluated, anyone paying out of pocket or anyone undiagnosed or simply not seeking treatment would not be counted - There has been a recent increase in mental health treatment administered by family physicians as opposed to mental health professionals (mostly with anxiety and depression) - Vast majority of mental health treatment is done outpatient APPROACHES TO THE SCIENTIFIC STUDY OF PSYCHOLOGICAL DISORDERS Mental health professionals all use the “scientist-practitioner framework” which emphasizes the dual role of clinicians being both scientists and practitioners, integrating research and evidence-based practices with real-work therapy - Mental health professionals have a responsibility to stay up to date with the latest scientific findings in psychology and integrating their findings into their clinical practice. Practitioners should be using the scientific method to assess the effectiveness of these treatments, ensuring they are using interventions that are supported by empirical evidence Chapter 3: Causal Factors and Viewpoints Etiology: causal patterns of abnormal behavior What determines how different people respond to different scenarios? HISTORICAL CONCEPTIONS OF ABNORMAL BEHAVIOR Major psychological disorders have existed throughout time and universally but the way humans have viewed the causes and treatments of these disorders have greatly varied over time falling under three dominant traditions 1. Supernatural a. Deviant behavior is a battle between “good” and “evil” b. Causes include demonic possession, witchcraft, sorcery, movement of moon and stores c. Treatments include crude surgeries, exorcism, torture, beatings 2. Biological Tradition a. Hippocrates: abnormal behavior as a physical disease i. Linked abnormality with brain chemical imbalance b. General Paresis (Syphilis) bolstered view that mental illness = physical illness since it could lead to severe psychological symptoms like delusions and paralysis c. 1930’s: Insulin Shock Therapy, ECT, Lobotomy d. 1950’s: antipsychotic and antidepressant medications become increasingly available shifting treatments to more minimalist and humane approaches 3. Psychological Tradition  a. The psychological tradition focuses on environmental, social, and psychological factors as the causes of abnormal behavior. This approach considers emotions, thoughts, and learned experiences as key contributors to mental health Today’s integrative model includes a holistic view of psychological, biological, social, and environmental factors RISK FACTORS AND CAUSES OF ABNORMAL BEHAVIOR (important to consider the time frame in all cases) 1. Distal Risk Factors: occurs early in life, but effects won’t reveal themselves for several years 2. Proximal Risk Factors: an event that occurs shortly/immediately before the onset of symptoms 3. Reinforcing Contributory Cause: a condition that reinforces or maintains a maladaptive behavior that is already occurring a. Ex: compliments post weight loss can reinforce disordered eating FEEDBACK AND BIDIRECTIONALITY IN ABNORMAL BEHAVIOR Bidirectional Influence: many causes of abnormal behavior are interacting and cyclical making clear cause-and-effect relationships difficult. DIATHESIS-STRESS MODELS Diathesis-Stress Model: framework used to explain the development of mental disorders as a result of the interaction between a person’s diathesis: inherent vulnerability, and significant stressors they encounter Diathesis: an individual’s predisposition/vulnerability toward developing a disorder. Can arise from - Biological Factors: genetics, brain abnormalities. Neurotransmitter imbalance - Psychological Factors: cognitive styles, personality traits (like a tendency towards pessimistic thinking, high neuroticism - Sociocultural Factors: environmental influences like cultural stress, discrimination, early life adversity Stress: external pressures/challenges that tax an individual’s coping resources, potentially triggering a mental disorder in someone with a diathesis - Examples include job loss, divorce, trauma, any other taxing demand - The interaction between diathesis and stress determines whether symptoms will manifest Ex: an individual with a genetic predisposition for anxiety may remain symptom-free until they experience a major life stressor PROTECTIVE FACTORS AND RESILIENCE Protective Factors: conditions/attributes that reduce the risk of negative mental health outcomes even in individuals at high risk. Act as buffers, mitigating the impact of stressors on mental health  - Social Support: research highlights that quality of supportive relationships is more protective than quantity - Healthy Coping Skills: effective problem-solving and emotional regulation strategies can prevent stress from escalating into a mental health crisis Resilience: the ability to adapt successfully and maintain well-being in the face of adversity, the ability to successfully adapt to difficult circumstances BIOLOGICAL PERSPECTIVE The biological perspective views mental disorders as issues extant within the Central Nervous System (CNS), Autonomic Nervous System (ANS), and Endocrine System. These issues can either be inherited/caused by certain pathological processes (diseases or other malfunctions within the body) Key Categories of Biological Factors in Mental Disorders: 1. Genetic Vulnerabilities a. Polygenic Vulnerabilities: result from a combination of multiple genes. This complexity makes genetic contributions harder to pinpoint b. Behavioral Genetics: heritability of mental disorders i. Methods for studying Genetic Influences: 1. Family History Method: researchers examine whether a disorder appears more frequently within a family compared to the general population across multiple generations a. If a disorder is common among first-degree relatives, this suggests a genetic link. But since families share environments, isolating genetic influence is difficult 2. Twin Method: analyzes concordance rates in monozygotic twins vs dizygotic twins a. Since identical twins share 100% of their genes, higher concordance rates will indicate a genetic influence b. Method is advantageous since both sets of twins typically grow up in the same environment, isolating genetic influences more effectively 3. Adoption Method: compares mental health outcomes with those of adopted children’s biological and adoptive parents a. If a mental disorder is more similar between the adopted individual and biological parent, points to a genetic influence. b. Since adopted children share environments with adoptive parents but genetics with biological parents, this method helps separate genetic and environmental influences  c. Together these methods offer insights into the genetic contributions to mental disorders, but cannot establish causation directly because genes aren’t manipulated in the study d. Separating Genetic and Environmental Influences i. Shared Environmental Influences: make family more similar to each other. Can be due to shared family dynamics, traditions, or other common external influences ii. Nonshared Environmental Influences: unique factors that affect family members differently, such as personal experiences outside the home, unique friendships, different schools 2. Brain Dysfunction and Neural Plasticity a. Neural Plasticity: the brain’s ability to change structurally and functionally in response to environmental experiences. Neural pathways can change, meaning both positive and negative experiences can reshape the brain i. Supports the effectiveness of psychotherapy as an alternative to medication, challenges the idea that psychotropic medication is necessary to change behavior 3. Imbalance in Neurotransmitter Systems and Hormones a. Neurotransmitter imbalances can arise from: i. Excessive production and release of neurotransmitters ii. Dysfunction in deactivation causing too brief or too prolonged an impact iii. Receptor Problems with a neuron receptor being hypersensitive or insensitive affecting how the neurotransmitter message is received and processed b. Chemical circuits: neurons sensitive to a particular neurotransmitter often group together, forming neural pathways that link different brain regions. Psychotropic medication aims to adjust these circuits c. Notable Neurotransmitters for Psychopathology: i. Norepinephrine: linked to stress responses and anxiety ii. Dopamine: associated with reward pathways; imbalances are linked to conditions like schizophrenia iii. Serotonin: implicated in mood regulation and behaviors associated with anxiety and depression d. Hormonal Imbalances: hormones are produced by endocrine glands and serve as messengers that regulate body functions i. HPA Axis (Hypothalamic-Pituitary-Adrenal Axis) plays a crucial role in stress response: 1. Hypothalamus releases corticotropin-releasing hormone (CRH), prompting the pituitary gland to release adrenocorticotropic hormone (ACTH) 2. ACTH signals the adrenal glands to release cortisol, the primary stress hormone  3. This system has a feedback loop: cortisol signals the hypothalamus and pituitary to reduce CRH and ACTH release, lowering cortisol production. a. If this feedback loop malfunctions, it can lead to a prolonged stress response, contributing to conditions like depression and PTSD 4. Temperament: a child’s natural ways of reacting emotionally and self-regulating. Seen as a basis from which personality develops, shaping how individuals interact with the world a. Different temperaments affect sensitivity to stress, adaptability, and emotional reactions, which can contribute to mental health outcomes over time PSYCHOLOGICAL PERSPECTIVE Addresses mental health by exploring internal psychological processes. It focuses on how thoughts, feelings, and unconscious motives shape behavior, both adaptive and maladaptive 1. Psychoanalytic Perspective: pioneered by Sigmund Fried, emphasized the role of unconscious motivations in determining behavior a. The belief that many psychological issues arise from unresolved unconscious conflicts, often originating in childhood b. Suggests that mental health issues stem from internal struggles among different parts of the psyche c. Structure of the Psyche: i. Id: source of instinctual drives and unconscious desires, pleasure principle ii. Ego: mediates between demands of id, superego, and reality iii. Superego: moral conscience, often shaped by cultural and parental standards which govern what is considered right and wrong d. Defense Mechanisms: ego employs defense mechanisms to cope with the anxiety that arises from conflicts between id, ego, and superego including repression, projection, denial, rationalization etc which protect the individual from experiencing distress but can also lead to distorted perceptions and maladaptive behavior e. Criticism: i. Lack of Scientific Rigor: reliance on subjective personal reports doesn’t meet scientific standards, cannot be objectively verified ii. Limited Empirical Support: can’t observe or measure any of these theoretical structures 2. Behavioral Perspective: to understand human behavior, focus should be exclusively on observable behaviors, environmental stimuli, and the reinforcement patterns that shape them. Behavior is shaped through learning and conditioning processes rather than internal mental processes  a. Focus on environmental influence: environmental stimuli and reinforcers play a central role in acquiring, modifying, and even eliminating behavioral responses. (both adaptive and maladaptive behaviors). b. Classical Conditioning: where a neutral stimulus becomes associated with a natural response (neutral stimulus repeatedly paired with unconditioned stimulus which elicits an unconditioned response. Over time the neutral stimulus becomes a conditioned stimulus, eliciting a conditioned response on its own) i. Extinction: when CS is repeatedly presented without the US, the conditioned response gradually weakens, eventually disappears c. Operant Conditioning: individuals learn to achieve desired goals by associating certain behaviors with positive/negative outcomes due to positive and negative reinforcement. i. Positive Reinforcement: delivering reward/pleasant stimulus to increase likelihood of a behavior ii. Negative Reinforcement: involves removal of aversive stimulus to increase behavior’s occurrence d. Observational Learning/Modeling: allows individuals to acquire behaviors without directly experiencing reinforcement or stimuli. 3. Cognitive Behavioral Perspective: examines how thoughts, beliefs, and information processing can become distorted and lead to maladaptive emotions and behaviors. Highlights the powerful role of cognition: how people interpret and think about their experiences in shaping psychological health a. Thought Distortions: cognitive behavioral theorists suggest that abnormal behavior arises from negative or irrational thought patterns. The distorted thinking leads to problematic emotions and behaviors which fuels a cycle of maladaptive responses b. Attribution/Attributional Style: the cognitive process of assigning causes to events. Attributional style refers to a habitual way of explaining life events i. Nondepressed individuals tend to have self serving/protective bias, they are most likely to attribute positive events to internal, stable, and global causes while attributing negative events to external, unstable, and specific causes ii. Depressed individuals often exhibit a negative attributional style, interpreting negative events with internal, stable, and global explanations. This perpetuates depressive episodes by reinforcing feelings of helplessness and low self worth CULTURAL, SOCIAL, AND INTERPERSONAL FACTORS IN PSYCHOPATHOLOGY Cultural Factors: - Cultural norms and values influence what is considered “normal” or “abnormal” behavior, impacting how mental health symptoms are displayed and diagnosed - Cultural backgrounds often determine how people experiences and express emotions, how they cope with stress, and what kinds of symptoms they might report  - Stigma and acceptance: heavy stigmatization of mental illness can lead individuals to hide symptoms, avoid seeking help, or experience shame. This cultural factor may delay treatment and increase the risk of worsening symptoms Gender Effects: - Gender impacts both emotional experience and expression, influencing the types and prevalence of psychological disorders seen among men and women - Difference in Expression: women are more likely to seek social support for distress and openly express feelings of sadness and anxiety. Men more likely to express psychological distress through irritability, anger, risk-taking behavior (both can be at least partially the result of the self fulfilling prophecies of how society expects them to express and react emotionally) - Disorder Prevalence: depression and anxiety more common in women (maybe more women seek diagnosis and treatment), antisocial personality disorder and substance abuse disorder more common in men. Social Supports Effects on Health and Behavior: - Frequency and quality especially important - strong social connections are associated with better health outcomes and reduced mortality - Plays protective role in mental health (resilience communities, people take turns being resilient for each other) - Cultures that foster resilience vs fragility Chapter 4: Clinical Assessment and Diagnosis Psychological Assessment: a systematic process where clinicians use psychological tests, interviews, and observations to gather information on a client’s symptoms, behaviors, and cognitive function resulting in a summary profile of the client’s mental status/health Clinical Diagnosis: after assessment, clinicians synthesize findings into a diagnosis using classification systems like the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) or the ICD-11 (International Classification of Diseases) FUNDAMENTAL ASSESSMENT CONCEPTS Reliability: the consistency of an assessment tool over time - Test-Retest Reliability: ensures that the test results are stable when administered at different times - Inter-Rater Reliability: measures agreement among clinicians using the same assessment tool, promoting consistency in diagnosis Validity: refers to how well a test measures what it claims to measure Standardization: tests are administered, scored, and interpreted uniformly, allowing comparison of an individual’s score to a broader population or normative sample NATURE AND GOALS OF CLINICAL ASSESSMENT Presenting Problem: identifying the client’s main symptoms and concerns - Important to assess client’s cultural background, including environmental demands, support systems, and stressors which may influence mental health symptoms and coping strategies Clinician-Client Trust and Rapport: establishing a trusting relationship is vital for effective assessment. Clients need to feel comfortable with the clinician, especially given the confidentiality limits in therapeutic settings METHODS OF PSYCHOLOGICAL ASSESSMENT 1. Clinical Interviews: involves face-to-face interactions with clinicians a. provides first hand information about client’s situation, behavior, and personality b. Mental Status Exam: assesses cognitive, emotional, and behavioral functioning in a structured manner  c. Types of Interviews: i. Structured Interview: follows specific format to quantify responses for standardized evaluation ii. Semi-Structured Interviews: has a set order of questions with flexibility to ask follow-ups, enhancing accuracy iii.Unstructured Interview: no predetermined questions, allows for open ended, subjective approach to gather information 2. Behavioral Observation: a. Direct Observation: observing a client’s appearance and behavior in various contexts to gather insights into their psychological functioning b. Role Playing: controlled scenarios where clients act out situations to reveal patterns in behavior c. Self-Monitoring: clients record their thoughts, feelings, and behaviors in real-time, helping clinicians assess natural responses i. Reactivity: changes in behavior as a result of being observed or self-monitores d. Rating Scales: help organize systematically and improve reliability and objectivity 3. Psychological Tests a. Intelligence Tests/Wechsler Adult Intelligence Scale (WAIS): measures both verbal and performance skills, X = 100, STDV = 15 b. Projective Personality Tests: unstructured, rely on various ambiguous stimuli as opposed to specific questions i. Rorschach Inkblot Tests: uses inkblots to elicit responses that reveal underlying thoughts and feelings ii. Thematic Apperception Test (TAT): clients create stories based on pictures, revealing themes in their cognition and emotions iii. Sentence Completion Test: particularly for younger clients; requires them to finish sentences, revealing thoughts and emotional patterns c. Objective Personality Tests: structures, questionnaire, self-report inventories, rating scales i. Minnesota Multiphasic Personality Inventory (MMPI): widely used tool for personality assessment with scales for clinical symptoms and validity, offering a standardized measure of personality traits and potential psychological issues 4. Physical Exams: essential for disorders with physical symptoms like panic (recurrent, unexpected panic attacks) and conversion disorders (where psychological stress manifests as physical symptoms like paralysis, tremors, or sensory loss with the absence of any neurological condition or apparent physical cause - a type of somatic symptom disorder)  a. Physical exams help by ruling out physical causes as well as establishing a baseline of physical health that can help determine if physical symptoms are likely due to a psychological condition rather than underlying medical issue 5. Neuropsychological Examination: can provide important clues about the extent and location of brain damage/abnormal functioning a. MRI (Magnetic Resonance Imaging): provides detailed images of brain structure and anatomy i. Used for spotting structural abnormalities like lesions, tumors, of atrophy which can be linked to psychological symptoms or behavior changes ii. Ex: in conversion disorder, an MRI can rule out structural issues like MS or a brain tumor as a cause of physical symptoms b. fMRI (Functional Magnetic Resonance Imaging): shows areas of the brain that are active during specific tasks by measuring changes in blood flow i. Allows clinicians to see which brain regions are active during decision making, emotional processing ii. Ex: fMRI can show heightened amygdala activity (related to fear response) in people with panic disorder, helping confirm diagnosis c. PET (Positron Emission Tomography) Scan: uses radioactive tracers to show how organs and tissues function at a cellular level i. Particularly helpful in observing metabolic activity (how much energy certain brain regions are using) which can reveal abnormal patterns associated with mental health conditions ii. Ex: can reveal differences in areas related to mood regulation and perception in people with depression of schizophrenia d. Electroencephalogram (EEG): assess brain wave patterns/electrical activity in the brain providing real-time monitoring; changes in the brain can be recorded almost immediately after they occur i. Can detect abnormal electrical activity like epilepsy or sleep disorder ii. Ex: for someone with conversion disorder, an EEG could rule out epilepsy if seizures are part of their symptoms e. Computer Tomography (CT) Scan: allows for cross-sectional images of brain structures, showing physical changes or abnormalities i. Useful for identifying brain injuries ii. Ex: CT scan can reveal structural changes in the brain of someone experiencing cognitive symptoms, ruling out or confirming a cause like a traumatic brain injury Chapter 6: Panic, Anxiety, Obsession, and their Disorders Anxiety: a future-oriented state where a person feels apprehension/worry about potential threats or dangers - Often involves physical and cognitive symptoms that prepare the body and mind to deal with a perceived threat - Cognitive Component: worrying about future threats, focusing on “what if”s and potential negative outcomes - Physiological Component: chronic over-arousal, muscle tension, restlessness - Behavioral Component: tends to lead to avoidance behaviors to escape situations perceived to be dangerous/uncomfortable - Anxiety at mild or moderate levels is a beneficial adaptive response as it increases focus and preparedness, improving response to potential threats and boosting performance Fear: an immediate response to a clear and present danger. Unlike anxiety, fear is typically focused on a specific, identifiable source - Cognitive Component: thoughts focused on imminent danger - Physiological Component: triggered by the ANS, resulting a “fight-or-flight” response, includes increased heart rate, rapid breathing, sweating, and other physiological changes - Behavioral: an urgent need to escape or confront the danger - Fear allows quick responses to dangerous situations such as fleeing or defending oneself, which are essential survival mechanisms Panic Attack: a sudden, intense burst of fear/discomfort, usually without an obvious external threat. Can occur spontaneously and can even wake a person from sleep - Cognitive Component: often accompanied by catastrophic thoughts like, “I’m going to die,” or “I’m losing control” - Physiological Component: intense bodily sensations, rapid heart rate, shortness of breath, dizziness, sweating, tremors. Symptoms mimic those of a heart attack, making the panic attack even more distressing - Behavioral: a strong urge to escape or flee the situation is common, especially if the person perceives the setting as dangerous. Component Fear Anxiety Cognitive/Subjective “I am in danger” “I am worried about what might happen” Physiological Increased heart rate/sweating Tension, chronic overarousal Behavioral Urge to escape/run General avoidance TRAIT VS STATE ANXIETY Trait Anxiety: a personality characteristic describing a person’s general tendency towards anxiety. Some people naturally experience more anxiety than others and are often characterized as “worriers” State Anxiety: linked to a specific event or situation. A high state of anxiety can be experienced before a major exam or life event - Ex: “White Coat Hypertension” - blood pressure rising in the doctor’s office due to the anxiety surrounding visiting the doctor. Can lead to misinterpretations of blood pressure health ANXIETY DISORDERS Anxiety Disorders: defined by persistent, unrealistic or irrational fears that cause significant distress/impair functioning 1. Specific Phobias: an irrational fear of a specific subject or object (spiders, heights). The person goes to great lengths t avoid said object/situation a. DSM-5 Criteria: the phobic object almost always provokes an immediate anxiety, is avoided or endured with immense anxiety, the fear is out of proportion to the actual danger, it lasts for more than 6 months, it causes clinically significant distress/impairment b. Lifetime Prevalence Rate: 12% c. Certain phobias more common in men d. Psychological Causal Factors: i. Classical conditioning - NS is paired with frightening experience ii. Vicarious learning - observing someone else’s fearful reaction iii. Evolutionary Preparedness: biologically predisposed to fear objects that historically posed survival threats - snakes, heights, enclosed spaces e. Treatments: i. Exposure Therapy ii. D-Cycloserine (DCS): medication that can enhance the effects of exposure therapy by facilitating learning and reducing the anxiety response when administered prior to the exposure session f. The 4 Categories of Specific Phobias i. Animal Phobias ii. Natural Environment Phobias iii. Situational Phobias iv. Blood-Injection-Injury Phobias (runs in families!) 2. Social Anxiety Disorder: the intense fear of social situations a. DSM-5 Criteria: individual fears they will act in a way that will be negatively evaluated, social situations almost always provoke a fear and are avoided, the anxiety is out of proportion to the actual threat posed by the sociocultural context, fear lasts 6+ months b. Lifetime Prevalence Rate: 12%  c. Most common in women, emerges in adolescence/early childhood d. Psychological Causal Factors: i. Direct or vicarious conditioning ii. Perceptions of uncontrollability/unpredictability iii. Cognitive biases: tendency to believe they will be negatively evaluated by others, interpret ambiguous social information as negative or threatening e. Biological Causal Factors: moderate genetic influence f. Treatments: i. CBT to challenge and change maladaptive thoughts, challenge assumptions, reduce anxiety ii. Medications: antidepressants 3. Panic Disorder: characterized by recurrent, unexpected panic attacks a. 4.7% Lifetime Prevalence b. Comorbidity: over 80% of those with panic disorder have at least one other disorder, with increased risk of suicide c. Biological Causal Factors: i. Moderate genetic contribution ii. Increased amygdala activity iii. Neurotransmitter malfunction 1. Noradrenergic System (triggers cardiovascular symptoms) 2. Serotonergic System (can be treated with SSRIs) 3. GABA iv. Treatments: CBT, SSRIs, Benzodiazepines 4. Agoraphobia: fear of places/situations where escape may be difficult or help unavailable if panic-like symptoms occur. Can lead to avoidance of large crowds, open spaces, even leaving home a. Psychological Causal Factors: i. classical conditioning ii. Cognitive biases: heightened attention to potential threats and misinterpretation of ambiguous situations as dangerous iii. Perceived lack of control in triggering situations b. Treatments: exposure therapy (CBT), SSRIs and benzos 5. Generalized Anxiety Disorder: excessive, uncontrollable worry about various aspects of life a. DSM-5: restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance b. 5.7% lifetime prevalence c. More common in women, often comorbid with anxiety and mood disorders d. Psychological Causal Factors: i. History of uncontrollable/unpredictable life events  ii. Cognitive Biases: attention to threatening cues, interpreting ambiguous information negatively e. Biological Causal Factors: i. Modest genetic heritability ii. GABA deficiency, dysregulation of serotonin/norepinephrine iii. Increased cortisol release in response to stress f. Treatments: i. SSRIs for long term use, benzodiazepines as needed ii. CBT - relaxation techniques, cognitive restructuring, guided imagery 6. Obsessive-Compulsive Disorder (OCD) a. Presence of obsessions (recurrent intrusive thoughts) and/or compulsions (repetitive actions aimed at reducing anxiety) b. 2-3% Lifetime Prevalence, often comorbid with anxiety and depressive disorders c. Psychological Causal Factors: i. Learned behavior/classical conditioning with avoidance maintaining the disorder d. Biological Causal Factors: i. High concordance in identical twins, suggesting genetic component ii. Brain abnormalities: basal ganglia (affects motor and cognitive processes) e. Treatments: i. CBT: exposure and response prevention ii. SSRIs iii. Neurosurgery as a last resort 7. Body Dysmorphic Disorder (BDD) a. Preoccupation with perceived physical flaws, repetitive behaviors, and significant distress/impairment b. 1-2% LIfetime Prevalence, high rates of suicidal ideation and attempts c. Causal Factors: i. Moderate genetic contribution, biased attention, interpretation of ambiguous stimuli as relating to perceived attractiveness d. Treatments: i. CBT ii. SSRIs iii. Plastic surgery is ineffective, often it is the plastic surgeon who will refer the patient to a psychologist 8. Hoarding Disorder: a. Difficulty discarding possessions, excessive attachment to items b. 3-5% Lifetime Prevalence c. Treatment:  i. CBT ii. SSRIs 9. Trichotillomania: a. Compulsive hair pulling (tension before, relief afterwards) b. Visible hair loss leading to distress Causal similarities across anxiety disorders include: - Genetic Vulnerability - Brain Structure: the limbic system (involved in emotional processing) and parts of the cortex are commonly implicated in anxiety disorders - Neurotransmitters Irregularity: GABA, norepinephrine, serotonin (regulate mood, fear, arousal) - Lack of Perceived Control, leading to heightened stress and anxious responses Chapter 7: Mood Disorders and Suicide Depression: characterized by intense sadness, low energy, feelings of dejection that affect daily life and functioning. Includes lack of interest in previously enjoyable activities and persistent low mood Mania: involves extreme levels of excitement, energy, euphoria which may result in impulsive decisions or risky behavior. Distinct from happiness - this is intense, often unrealistic, and prolonged Types of Mood Disorders: 1. Unipolar Depressive Disorder: individuals experience only depressive episodes without any manic or hypomanic phases a. Symtoms: persistent sadness, anhedonia (lack on interest in activities), sleep disturbances, thoughts of death or suicide b. Often emerges in late adolescence or young adulthood and can recur without treatment 2. Bipolar Disorder: cycle between depressive and manic episodes, experiencing significant mood swings that impact functioning a. Manic Episode: requires at least one week of abnormally elevated, expansive, or irritable mood i. Inflated self esteem, decreased need for sleep, increased talkativeness, racing thoughts, easily distracted, increase in goal-directed activities (work, social, sexual) or psychomotor agitation, engaging in risky behavior b. Hypomanic Episode: a milder form of mania lasting at least four days. Similar symptoms to mania but less severe, often without significant disruption to daily life 3. Cyclothymic Disorder: chronic form of bipolar disorder with milder symptoms over an extended period of at least 2 years a. Involves repeated hypomanic and depressive episodes but without reaching the full criteria for either a manic or major depressive episode CAUSAL FACTORS IN BIPOLAR DISORDERS 1. Strong Genetic Influence a. 80-90% of variance in the risk of Bipolar I Disorder attributed to genetics b. Polygenic nature - complex inherited condition 2. Neurochemical Factors a. Increased dopamine levels correlate with manic symptoms b. Serotonin is generally low during both depressive and manic phases, affects mood regulation 3. Hormonal Dysregulation a. Abnormalities in HPA axis are common. Thyroid hormones can trigger manic episodes in susceptible individuals b. Cortisol levels are high during depressive states but not typically during manic episodes, showing influence of stress response systems 4. Sleep and Biological Rhythms: a. Sleep and Biological Disturbance: manic episodes involve reduced sleep, while depressive episodes involve hypersomnia b. Life stressors: can precipitate mood swings and often linked to onset of episodes TREATMENT - Mood stabilizers: lithium is most studied and effective for stabilizing mood swings, especially for manic episodes - Anticonvulsants are used when lithium is ineffective or poorly tolerated. They stabilize mood by affecting neurotransmitter levels and brain activity UNIPOLAR DEPRESSIVE DISORDERS Major Depressive Disorder (MDD) - At least 5 symptoms including persistent low mood, anhedonia, weight changes, sleep disturbances, fatigue, feelings of worthlessness and suicidal ideation - Commonly recurrent, 40-50% experience multiple episodes - Specifers: (different patterns of symptoms): - MDD Episode with Melancholic Features: least common, significant loss of interest, not reacting to usually pleasurable stimuli or desired events - Severe Major Depressive Episode with Psychotic Features: hallucinations, delusions - Differential diagnosis - when someone is experiencing both mood and psychotic symptoms, difficult to diagnose - MDD Episode with Catatonic Features: unusual psychomotor behaviors, characterized by extreme lack of movement or unusual posturing  - Recurrent Major Depressive Episode with a Seasonal Pattern/”Seasonal Affective Disorder” (SAD): depression occurs at specific times of the year, often in winter due to reduced sunlight exposure Postpartum Depression: temporary mood swings, sadness, and irritability shortly after childbirth, affecting 50-70% of new mothers - Full depression may develop weeks after post-birth, with symptoms severe enough to meet criteria for MDD CAUSAL FACTORS FOR UNIPOLAR MOOD DISORDERS - Genetic Influence: unipolar depression is 2-3 times more likely among blood relatives - Serotonin-transporter gene: variations in this gene are implicated in depression - Hormonal and Immune System Dysregulation: - HPA Axis monitors stress hormones. Dysregulation can secrete excess stress hormones, are associated with depression - Hypothalamic-Pituitary-Thyroid Axis: Dysregulation of thyroid function can mimic or contribute to depressive symptoms - Drugs used to increase thyroid hormones and lower depression show dysregulation of this axis - Hyperthyroidism can imitate a manic episode - Hypothyroidism would result in low energy/enthusiasm - Gender: - Women more frequently diagnosed than men, potentially due to hormonal influences, social stressors, and willingness to seek help - Men may express depression in ways we don’t know to recognize - may self medicate more (higher rates of substance abuse in men) - Unclear if women have a greater genetic vulnerability - Theory that hormonal factors like normal flux in ovarian hormones are the cause is so far supported by inconsistent scientific results Cognitive and Behavioral Theories: - Beck’s Cognitive Theory: dysfunctional beliefs (depressogenic schemas) lead to a Negative Cognitive Triad (negative thoughts about the self, the world, the future) - Lack of Reinforcement: depression may develop when people’s actions no longer bring pleasure or positive reinforcement, leading to withdrawal and avolition. TREATMENTS AND INTERVENTIONS Pharmacotherapy: - Antidepressants: SSRIs, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs)  - Electroconvulsive Therapy (ECT): effective for severe depression; induces seizures under medical supervision, side effects can include memory loss and confusion - Transcranial Magnetic Stimulation (TMS): non-invasive brain stimulation without the side effects of ECT - Bright Light Therapy: initially for SAD, now shown to be effective in other depressions as well Psychotherapy: - CBT: focuses on modifying dysfunctional thoughts and behaviors “here and now” - Behavioral Activation: aims to increase engagement in rewarding activities and decrease avoidance - Interpersonal Therapy (IPT): addresses relationship issues, improving social functioning, trying to help patient understand and alter maladaptive interaction patterns - Family and Marital Therapy: as effective as CBT in reducing unipolar depression in the depressed spouse SUICIDE: CLINICAL PICTURE AND INTERVENTIONS Depression is the disorder most commonly linked with suicidal behavior Suicial behavior must be distinguished from NSSI = non suicidal self injury which refers to the direct, deliberate destruction of body tissue in the absence of any intent to die - Women are significantly more likely than men to think about suicide and make nonlethal suicide attempts - Men are 4x more likely to die by suicide - Research has found that the brains of suicidal people show greater activation in regions associated with self-referentual thoughts than non suicidal people when thinking about words like “death” Suicide Prevention and Intervention: Crisis Intervention: primary objective is to help person cope with an immediate problem as quickly as possible Suicide Assessmnet Five -Step Evaluation and Traige (SAFE-T): 1. Identify risk factors - understand what factors increase risk of suicide for indivdual by looking for both long term and immediate factors like: a. Prior attempts b. Mental health conditions c. Substance use disorders d. Recent losses/stressors e. Family history of suicide f. Social isolation or lack of support 2. Identify Protective factors, whatever might reduce the risk of suicide by considering: a. Strong social support networks b. Beliefs that discourage suicide  c. Sense of responsibility towards dependants, friends d. Positive coping skills and resilience e. Access to mental health care and willingness to engage in treatment 3. Conduct Suicide Assessment: a. Intent: “have you made a plan?” b. Desire: “what is making you want to end your life?” c. Capability: “do you have the means to carry out your plan?” d. Buffers: 4. Determine Risk Level and Intervention a. Low risk: no specific plan, low intent, protective factors present b. Moderate risk: some intent, potential means, fewer protective factors c. High risk: clear intent, a well-defined plan, and access to means d. Interventions will range from outpatient care and safety planning (low risk) to hospitalization or emergency intervention (high risk) 5. Documentation and Follow Up to create a clear record of assessment and ensure ongoing support No-Suicide Pact: agreement between therapist and client to reach out for help if suicidal thoughts intensify DBT - Dialectical Behavior Therapy: often used with BDD patients, addresses suicidal tendencies with coping strategies and distress tolerance Chapter 13: Schizophrenia and Other Psychotic Disorders SCHIZOPHRENIA Psychosis: defined as a significant loss of contact with reality, hallmark feature of schizophrenia Schizophrenia: chronic mental disorder that severely affects thought processes, perceptions, and emotional responsiveness Epidemiology: Lifetime Prevalence: affects just under 1% of the population Onset: most often begins between the ages of 18 and 30 Gender Differences: generally more common and severe in men than women Clinical Picture: 1. Delusions: Fixed, erroneous beliefs that remain clear despite contradictory evidence a. Paranoid Delusions: beliefs of being persecuted or plotted against b. Grandiose Delusions: inflated sense of self-importance or abilities 2. Hallucinations: Sensory experiences without any external stimulus  a. Can occur in any sensory modality, auditory hallucinations are the most common 3. Disorganized speech a. Represents a disorder in thought form rather than content (delusions) b. Speech may be incoherent, tangential, or involve making connections that don’t logically flow, even though language use appears normal 4. Positive Symptoms: Excesses or distortions in normal functions a. Halunicantions, delusions 5. Negative Symptoms: Diminished abilities in typical functioning, divided into 2 domains: a. Expressive Behavior: limited or flat affect, alogia (minimal speech) b. Motivational Deficits: lack of drive or pleasure in usual activities (avolition: inability to start or persist in goal oriented tasks, anhedonia) c. Negative symptoms often signal a more severe course and poorer prognosis OTHER PSYCHOTIC DISORDERS Schizoaffective Disorder: - Combines features of both schizophrenia and a mood disorder - Experience psychotic symptoms alongside significant mood episodes which can be depressive or manic - Types: - Bipolar Type: includes both manic and depressive episodes - Depressive Type: involves only major depressive episodes - For an accurate diagnosis, psychotic symptoms must occur for at least two weeks without any major mood symptoms. This is what makes schizoaffective disorder different from mood disorders with psychotic features where psychosis only appears during mood episodes - DSM-5 criteria include: uninterrupted period of illness during which a major mood episode is concurrent with schizophrenia symptoms, Psychotic symptoms must also present for at least two weeks in the absence of a major mood episode - Long term treatment is required Schizophreniform Disorder: a short term, schizophrenia-like illness that lasts for 1-6 months. Functions like schizophrenia but not chronic - DSM-5 Criteria include: at least one of the core symptoms of schizophrenia is required (disorganized speech, hallucinations, delusions), episode lasts between 1 and 6 months - With timely intervention, individuals may recover fully within the six-month period, but some may go on to develop schizophrenia Delusional Disorder: characterized by the presence of one of more delusions lasting for at least one month, otherwise normal functioning and no other major psychotic symptoms - Unlike schizophrenia, does not involve disorganized speech or hallucinations - Delusions are usually non-bizarre and involve realistic but incorrect beliefs  - Types of Delusions: - Erotomoanic: belief that another person (often of higher status) is in love with them - Grandiose: belief in having great talent, insight, or a special relationship with a deity or celebrity - Jealous: belief that a person is unfaithful - Persecutory: belief that one is being mistreated or conspired against - Somatic: belief in having a physical defect or medical condition - DSM-5 Criteria: delusions must last at least a month, functioning is not impaired otherwise and behavior is not obviously bizarre Brief Psychotic Disorder: brief psychotic episodes that are sudden, short term and last for less than a month, followed by a full recovery - Symptoms include delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior - Symptoms appear suddenly, often in response to a stressful life event (though not necessarily) - DSM-5 Criteria: duration is at least one day but less than one month, with return to previous level of functioning after the episode, symptoms cannot be better explained by other mood/psychotic disorders or substance use GENETIC AND BIOLOGICAL FACTORS OF PSYCHOTIC DISORDERS 1. Genetic Factors: schizophrenia shows genetic linkage, with 10% higher prevalence in first-degree relatives and 3% in second-degree relatives 2. Twin Studies: Concordance rates for identical twins is 28%, ordinary siblings/fraternal twins 6% 3. Adoption Studies: elevated risk among children whose biological parents had schizophrenia even when raised out of the home 4. Prenatal Exposure and Birth Complications: a. Elevated rates of schizophrenia have been noted in those whose mothers were exposed to influence during the second trimester b. Rhesus (Rh) Incompatibility: (Rh-negative mother carries Rh-positive fetus, her immune system may produce antibodies against the fetus’s Rh-positive red blood cells. Potentially leads to hemolytic disease of the fetus and newborn (HDFN) where fetus’s red blood cells are destroyed, leading to hypoxia ) hypoxia can disrupt normal brain development, possible leading to structural changes that are linked to schizophrenia 5. Loss of Brain Volume: enlarged ventricles (particularly in men), are common in schizophrenia and suggest a reduction in brain tissue, Brain volume loss starts early in the illness and may progress over time 6. Structural and functional brain abnormalities: reduced volume in frontal and temporal lobes, particularly in amygdala, hippocampus, and thalamus.  a. Hypofrontality: some patients display low activation in the frontal lobes during challenging tasks, indicating impaired frontal lobe functioning early on or in high-risk individuals 7. Neurochemistry: a. Dopamine Hypothesis: suggests that schizophrenia may involve dopamine dysregulation i. Dopamine antagonist drugs like chlorpromazine alleviate symptoms ii. Dopamine increasers like amphetamines can induce symptoms resembling schizophrenia b. Glutamate Hypothesis: blocking glutamate receptors can lead to schizophrenia like symptoms, suggesting it may also play a role PSYCHOLOGICAL AND CULTURAL ASPECTS - Expressed Emotion (EE) measures family environment based on levels of criticism, hostility, and emotional overinvolvement - High EE environments are associated with doubled relapse rates, particularly in chronically ill patients CLINICAL OUTCOMES - Around 38% of patients show favorable outcomes after 15-25 years - 12% require long term institutional care - Approx ⅓ experience persistent negative symptoms TREATMENTS Pharmacological Approaches: 1. First-Generation Antipsychotics: a. Block dopamine receptors in the brain, particularly in pathway associated with thought and behavior regulation b. Reduction in dopamine activity helps alleviate the “positive symptoms” of schizophrenia, like hallucinations and delusions c. Side effects: extrapyramidal side effects (movement related symptoms that can resemble Parkinson’s - tremors, rigidity, involuntary facial movements) i. Due to discomfort, patient adherence can be low, leading to symptom relapse 2. Second-Generation Antipsychotics: a. Target dopamine receptors but affect additional neurotransmitter systems like serotonin, making them effective for both positive and some negative symptoms b. Fewer extrapyramidal side effects than first generation antipsychotics but side effects still include weight gain, diabetes risk and sedation c. While generally better tolerated than first-generation, the metabolic side effects can still lead to patient discontinuation Therapeutic Interventions: 1. Case Management a. Case managers help patients coordinate their various needs (housing, employment, social services) b. Effective case management has been shown to reduce hospitalization rates, as it ensures continuity of care and helps patients navigate their lives more independently 2. Family Therapy a. Educates and involves the patient's family in the treatment process, fostering a more supportive home environment b. Aims to reduce EE c. Strategies: families learn coping strategies, communication skills, stress management techniques d. Reducing EE in the household has been found to more than double the likelihood of a patient maintaining stability and avoiding relapse 3. Psychoeducation a. Provides patients and their families with essential knowledge about schizophrenia, including understanding symptoms, triggers, and management strategies b. Helps patients recognize early warning signs of relapse and learn about medication compliance and lifestyle adjustments c. This helps families enhance understanding, reduce frustration, build empathy towards patient d. Promotes better adherence to treatment and equips both patients and families to handle symptoms effectively 4. CBT a. For schizophrenia, focuses on identifying and modifying distorted or unhelpful thought patterns and behaviors that exacerbate symptoms b. While CBT can’t fully remove hallucinations or delusions, it helps patients reframe and manage these experiences by challenging irrational thoughts and learning coping strategies c. Patients may learn techniques to deal with auditory hallucinations by changing their reactions to them or learning relaxation techniques to handle stress triggers d. CBT has been shown to reduce the distress and impairment associated with psychotic symptoms, helping patients live more functionally and reducing likelihood of hospitalization With pharmacological support to stabilize symptoms and therapeutic interventions for skill building and social support, patients can achieve a significantly improved quality of life