Abnormal Psychology Midterm Coverage 2024-2025 PDF

Topic 1: INTRODUCTION, HISTORICAL ROOTS OF ABNORMAL BEHAVIOR AND METHODS OF RESEARCH Learning Objectives: Understand the historical roots of abnormal behavior. Understand and learn the criteria of abnormal behavior. Recognize the fixated beliefs and apply scientific method to cure the fixa...

Topic 1: INTRODUCTION, HISTORICAL ROOTS OF ABNORMAL BEHAVIOR AND METHODS OF RESEARCH Learning Objectives: Understand the historical roots of abnormal behavior. Understand and learn the criteria of abnormal behavior. Recognize the fixated beliefs and apply scientific method to cure the fixation. Understand the ethical principles and cultural considerations in determining psychological disorders. Mental Disorder defined: A difficult fundamental task facing those in the field of psychopathology is to define mental disorder. The best current definition of mental disorder is one that contains several characteristics. The definition of mental disorder presented in the 5th edition of the American diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was released in May 2013, includes a number of characteristics essential to the concept of mental disorder (Stein et al., 2010), including the following: The disorder occurs within the individual. It involves clinically significant difficulties in thinking, feeling, or behaving. It involves dysfunction in processes that support mental functioning. It is not a culturally specific reaction to an event (e.g., death of a loved one). It is not primarily a result of social deviance or conflict with society. 4Ds of abnormal behavior Psychological disorder, a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected. Psychological dysfunction refers to a breakdown in cognitive, emotional, or behavioral functioning. That the behavior must be associated with distress to be classified as abnormal adds an important component and seems clear: the criterion is satisfied if the individual is extremely upset. The concept of impairment is useful, although not entirely satisfactory. For example, many people consider themselves shy or lazy. This doesn’t mean that they’re abnormal. But if you are so shy that you find it impossible to date or even interact with people and you make every attempt to avoid interactions even though you would like to have friends, then your social functioning is impaired. Atypical or not culturally expected. At times, something is considered abnormal because it occurs infrequently; it deviates from the average. The greater the deviation, the more abnormal it is. The Mental Health Professions ▪ Although there is a great deal of overlap, counseling psychologists tend to study and treat adjustment and vocational issues encountered by healthy individuals, and clinical psychologists usually concentrate on more severe psychological disorders. ▪ Also, programs in professional schools of psychology, where the degree is often a Psy.D., focus on clinical training and de-emphasize or eliminate research training. In contrast, Ph.D. programs in universities integrate clinical and research training. ▪ Psychiatrists first earn an M.D. degree in medical school and then specialize in psychiatry during residency training that lasts 3 to 4 years. Psychiatrists also investigate the nature and causes of psychological disorders, often from a biological point of view; make diagnoses; and offer treatments. ▪ Psychiatric social workers typically earn a master’s degree in social work as they develop expertise in collecting information relevant to the social and family situation of the individual with a psychological disorder. Social workers also treat disorders, often concentrating on family problems associated with them. ▪ Psychiatric nurses have advanced degrees, such as a master’s or even a Ph.D., and specialize in the care and treatment of patients with psychological disorders, usually in hospitals as part of a treatment team. ▪ Finally, marriage and family therapists and mental health counselors typically spend 1–2 years earning a master’s degree and are employed to provide clinical services by hospitals or clinics, usually under the supervision of a doctoral-level clinician.  Psychopathology Terms to Remember Prevalence- is the figure that shows how many people in the populations have the disorder. E.g., In 2017, there were an estimated 46.6 million adults aged 18 or older in the United States with any mental illness (AMI). This number represented 18.9% of all U.S. adults. The prevalence was higher among women (22.3%) than men (15.1%). Incidence- is the statistics on how many new cases occur during a given period, such as a year. E.g., The overall incidence rate of depression was 9.47/1000 person-years (PYs) (10.72/1000 PYs for women and 8.27/1000 PYs for men). Chronic course- disorders that tend to last a long time, sometimes a lifetime. E.g. Schizophrenia. Episodic course- the individual is likely to recover within a few months only to suffer a recurrence of the disorder at a later time. E.g. mood disorders Time-limited course- the disorder will improve without treatment in a relatively short period. E.g. acute stress Prognosis- is the anticipated course of a disorder. So, we might say, “the prognosis is good”, meaning the individual will probably recover, or “the prognosis is guarded”, meaning the probable outcome doesn’t look good. Etiology- the study of origins, has to do with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions.  HISTORICAL CONCEPTIONS OF ABNORMAL BEHAVIOR The Supernatural Tradition ▪ Humans have always supposed that agents outside our bodies and environment influence our behavior, thinking, and emotions. These agents—which might be divinities, demons, spirits, or other phenomena such as magnetic fields or the moon or the stars—are the driving forces behind the supernatural model. ▪ Although many have thought that the mind can influence the body and, in turn, the body can influence the mind, most philosophers looked for causes of abnormal behavior in one or the other. This split gave rise to two traditions of thought about abnormal behavior, summarized as the biological model and the psychological model. ▪ During the last quarter of the 14th century, religious and lay authorities supported these popular superstitions and society as a whole began to believe more strongly in the existence and power of demons and witches. The Catholic Church had split, and a second center, complete with a pope, emerged in the south of France to compete with Rome. In reaction to this schism, the Roman Church fought back against the evil in the world that it believed must have been behind this heresy. ▪ During these turbulent times, the bizarre behavior of people afflicted with psychological disorders was seen as the work of the devil and witches. ▪ Treatments included exorcism, in which various religious rituals were performed in an effort to rid the victim of evil spirits. ▪ Other approaches included shaving the pattern of a cross in the hair of the victim’s head and securing sufferers to a wall near the front of a church so that they might benefit from hearing Mass. ▪ Mental depression and anxiety were recognized as illnesses, although symptoms such as despair and lethargy were often identified by the church with the sin of acedia, or sloth. ▪ Common treatments were rest, sleep, and a healthy and happy environment. Other treatments included baths, ointments, and various potions. ▪ In the 14th century, one of the chief advisers to the king of France, a bishop and philosopher named Nicholas Oresme, also suggested that the disease of melancholy (depression) was the source of some bizarre behavior, rather than demons. ▪ As we see in the handling of the severe psychological disorder experienced by late-14th-century King Charles VI of France, both influences were strong, sometimes alternating in the treatment of the same case. King Charles VI of France was under a great deal of stress, partly because of the division of the Catholic Church. A variety of remedies and rituals of all kinds were tried, but none worked. High-ranking officials and doctors of the university called for the “sorcerers” to be discovered and punished. ▪ With a perceived connection between evil deeds and sin on the one hand and psychological disorders on the other, it is logical to conclude that the sufferer is largely responsible for the disorder, which might well be a punishment for evil deeds. ▪ In the Middle Ages, if exorcism failed, some authorities thought that steps were necessary to make the body uninhabitable by evil spirits, and many people were subjected to confinement, beatings, and other forms of torture. ▪ Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in which the experience of an emotion seems to spread to those around us. ▪ Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the devil, suggesting instead that the movements of the moon and stars had profound effects on people’s psychological functioning. ▪ The Roman Catholic Church requires that all healthcare resources be exhausted first before spiritual solutions such as exorcism can be considered. The Biological Tradition ▪ The Greek physician Hippocrates is considered to be the father of modern Western medicine. He and his associates left a body of work called the Hippocratic Corpus, written between 450 and 350 B.C., in which they suggested that psychological disorders could be treated like any other disease. ▪ Hippocrates considered the brain to be the seat of wisdom, consciousness, intelligence, and emotion. Therefore, disorders involving these functions would logically be located in the brain. ▪ Hippocrates also recognized the importance of psychological and interpersonal contributions to psychopathology, such as the sometimes-negative effects of family stress; on some occasions, he removed patients from their families. ▪ The Roman physician Galen, later adopted the ideas of Hippocrates and his associates and developed them further, creating a powerful and influential school of thought within the biological tradition that extended well into the 19th century. ▪ One of the more interesting and influential legacies of the Hippocratic-Galenic approach is the humoral theory of disorders. Hippocrates assumed that normal brain functioning was related to four bodily fluids or humors: blood, black bile, yellow bile, and phlegm. Blood came from the heart, black bile from the spleen, phlegm from the brain, and choler or yellow bile from the liver. Physicians believed that disease resulted from too much or too little of one of the humors; for example, too much black bile was thought to cause melancholia (depression). The humoral theory was, perhaps, the first example of associating psychological disorders with a “chemical imbalance”, an approach that is widespread today. Terms derived from the four humors are still sometimes applied to personality traits. For example, sanguine (literal meaning “red, like blood”) describes someone who is ruddy in complexion, presumably from copious blood flowing through the body, and cheerful and optimistic, although insomnia and delirium were thought to be caused by excessive blood in the brain. Melancholic means depressive (depression was thought to be caused by black bile flooding the brain). A phlegmatic personality (from the humor phlegm) indicates apathy and sluggishness but can also mean being calm under stress. A choleric person (from yellow bile or choler) is hot tempered. King Charles VI’s physician moved him to the less stressful countryside was to restore the balance in his humors. ▪ In addition to rest, good nutrition, and exercise, two treatments were developed. In one, bleeding or bloodletting, a carefully measured amount of blood was removed from the body, often with leeches. The other was to induce vomiting; indeed, in a well-known treatise on depression published in 1621, Anatomy of Melancholy, Robert Burton recommended eating tobacco and a half-boiled cabbage to induce vomiting. ▪ In ancient China and throughout Asia, a similar idea existed. But rather than “humors,” the Chinese focused on the movement of air or “wind” throughout the body. Unexplained mental disorders were caused by blockages of wind or the presence of cold, dark wind (yin) as opposed to warm, life-sustaining wind (yang). Treatment involved restoring proper flow of wind through various methods, including acupuncture. ▪ Hippocrates also coined the word hysteria to describe a concept he learned about from the Egyptians, who had identified what we now call the somatic symptom disorders. In these disorders, the physical symptoms appear to be the result of a medical problem for which no physical cause can be found, such as paralysis and some kinds of blindness. ▪ Behavioral and cognitive symptoms of what we now know as advanced syphilis, a sexually transmitted disease caused by a bacterial microorganism entering the brain, include believing that everyone is plotting against you (delusion of persecution) or that you are God (delusion of grandeur), as well as other bizarre behaviors. ▪ Louis Pasteur’s germ theory of disease, developed in about 1870, facilitated the identification of the specific bacterial microorganism that caused syphilis. ▪ John P. Grey’s position was that the causes of insanity were always physical. Therefore, the mentally ill patient should be treated as physically ill. The emphasis was again on rest, diet, and proper room temperature and ventilation, approaches used for centuries by previous therapists in the biological tradition. Under Grey’s leadership, the conditions in hospitals greatly improved and they became more humane, livable institutions. But in subsequent years, they also became so large and impersonal that individual attention was not possible. ▪ In the 1930s, the physical interventions of electric shock and brain surgery were often used. Benjamin Franklin made numerous discoveries during his life with which we are familiar, but most people don’t know that he discovered accidentally, and then confirmed experimentally in the 1750s, that a mild and modest electric shock to the head produced a brief convulsion and memory loss (amnesia) but otherwise did little harm. ▪ Emil Kraepelin was the dominant figure during this period and one of the founding fathers of modern psychiatry. He was extremely influential in advocating the major ideas of the biological tradition, but he was little involved in treatment. His lasting contribution was in the area of diagnosis and classification. The Psychological Tradition ▪ During the first half of the 19th century, a strong psychosocial approach to mental disorders called moral therapy became influential. The term moral actually referred more to emotional or psychological factors rather than to a code of conduct. Its basic tenets included treating institutionalized patients as normally as possible in a setting that encouraged and reinforced normal social interaction. ▪ Moral therapy as a system originated with the well-known French psychiatrist Philippe Pinel and his close associate Jean-Baptiste Pussin. When Pinel arrived in 1791, Pussin had already instituted remarkable reforms by removing all chains used to restrain patients and instituting humane and positive psychological interventions. Pussin persuaded Pinel to go along with the changes. ▪ After William Tuke followed Pinel’s lead in England, Benjamin Rush, often considered the founder of U.S. psychiatry, introduced moral therapy in his early work at Pennsylvania Hospital. ▪ Asylums had appeared in the 16th century, but they were more like prisons than hospitals. It was the rise of moral therapy in Europe and the United States that made asylums habitable and even therapeutic. ▪ Unfortunately, after the mid-19th century, humane treatment declined because of a convergence of factors. First, it was widely recognized that moral therapy worked best when the number of patients in an institution was 200 or fewer, allowing for a great deal of individual attention. ▪ A second reason for the decline of moral therapy has an unlikely source. The great crusader Dorothea Dix campaigned endlessly for reform in the treatment of insanity. A schoolteacher who had worked in various institutions, she had firsthand knowledge of the deplorable conditions imposed on patients with insanity, and she made it her life’s work to inform the American public and their leaders of these abuses. Her work became known as the mental hygiene movement. In addition to improving the standards of care, Dix worked hard to make sure that everyone who needed care received it, including the homeless. Through her efforts, humane treatment became more widely available in U.S. institutions. As her career drew to a close, she was rightly acknowledged as a hero of the 19th century. ▪ Franz Mesmer suggested to his patients that their problem was caused by an undetectable fluid found in all living organisms called “animal magnetism”, which could become blocked. Mesmer is widely regarded as the father of hypnosis, a state in which extremely suggestible subjects sometimes appear to be in a trance. ▪ Many distinguished scientists and physicians were interested in Mesmer’s powerful methods of suggestion. One of the best known, Jean-Martin Charcot. A distinguished neurologist, Charcot demonstrated that some techniques of mesmerism were effective with a number of psychological disorders, and he did much to legitimize the fledgling practice of hypnosis. ▪ A close second was their discovery that it is therapeutic to recall and relive emotional trauma that has been made unconscious and to release the accompanying tension. This release of emotional material became known as catharsis. Chapter Summary ▪ Psychopathology the field concerned with the nature, development, and treatment of mental disorders. ▪ The 4Ds of abnormal behavior are: dysfunction, deviance, distress, and dangerous behaviors. All these characteristics represent an abnormal behavior. ▪ Prevalence rate is the figure that shows how many people in the populations have the disorder. ▪ Incidence rate is the statistics on how many new cases occur during a given period, such as a year. ▪ Chronic course disorders that tend to last a long time, sometimes a lifetime. ▪ Episodic course is where the individual is likely to recover within a few months only to suffer a recurrence of the disorder at a later time. ▪ Time-limited course suggests that the disorder will improve without treatment in a relatively short period. ▪ Prognosis- is the anticipated course of a disorder. ▪ Etiology is the study of origins, has to do with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions. Topic 2: CONTEMPORARY PERSPECTIVES ON ABNORMAL BEHAVIOR AND METHODS OF TREATMENT Learning Objectives: ▪ At the end of this chapter, you should be able to identify the contemporary perspectives and distinguish it from forces of psychology. ▪ Be familiarized with different perspectives and utilize them in the analysis of cases. ▪ Understand the methods of treatment. An Integrative Approach to Psychopathology No influence operates in isolation. Each dimension—biological or psychological—is strongly influenced by the others and by development, and they weave together in various complex and intricate ways to create a psychological disorder. ▪ Huntington’s disease, a degenerative brain disease that appears in early to middle age, usually the early 40s. This disease has been traced to a genetic defect that causes deterioration in a specific area of the brain, the basal ganglia. It causes broad changes in personality, cognitive functioning, and, particularly, motor behavior, including involuntary shaking or jerkiness throughout the body. ▪ Phenylketonuria (PKU), which can result in intellectual disability (previously called “mental retardation”). This disorder, present at birth, is caused by the inability of the body to metabolize (break down) phenylalanine, a chemical compound found in many foods. Like Huntington’s disease, PKU is caused by a defect in a single gene, with little contribution from other genes or the environmental background. ▪ In linkage studies, scientists study individuals who have the same disorder, such as bipolar disorder, and also share other features, such as eye color; because the location of the gene for eye color is known, this allows scientists to attempt to “link” known gene locations (for eye color, in this example) with the possible location of a gene contributing to the disorder. ▪ The environment may occasionally turn on certain genes. This type of mechanism may lead to changes in the number of receptors at the end of a neuron, which, in turn, would affect biochemical functioning in the brain. ▪ The brain and its functions are plastic, subject to continual change in response to the environment, even at the level of genetic structure. ▪ For years, scientists have assumed a specific method of interaction between genes and environment. According to this diathesis–stress model, individuals inherit tendencies to express certain traits or behaviors, which may then be activated under conditions of stress. Each inherited tendency is a diathesis (vulnerability), which means, literally, a condition that makes someone susceptible to developing a disorder. When the right kind of life event, such as a certain type of stressor, comes along, the disorder develops. The smaller the vulnerability, the greater the life stress required to produce the disorder; conversely, with greater vulnerability, less life stress is required. ▪ There was reason to believe, from prior work with animals, that individuals with at least two copies of the long allele (LL) were able to cope better with stress than individuals with two copies of the short allele (SS). ▪ Gene–environment correlation model or reciprocal gene–environment model. Some evidence now indicates that genetic endowment may increase the probability that an individual will experience stressful life events. For example, people with a genetic vulnerability to develop a certain disorder, such as blood–injection– injury phobia, may also have a personality trait—let’s say impulsiveness— that makes them more likely to be involved in minor accidents that would result in their seeing blood. In other words, they may be accident prone because they are continually rushing to complete things or to get to places without regard for their physical safety. ▪ Neither nature (genes) nor nurture (environmental events) alone, but rather a complex interaction of the two, influences the development of our behavior and personalities. The Central Nervous System ▪ The human nervous system includes the central nervous system, consisting of the brain and the spinal cord, and the peripheral nervous system, consisting of the somatic nervous system and the autonomic nervous system. ▪ Dendrites have numerous receptors that receive messages in the form of chemical impulses from other nerve cells, which are converted into electrical impulses. ▪ The other kind of branch, called an axon, transmits these impulses to other neurons. ▪ Neurons are not actually connected to each other. There is a small space through which the impulse must pass to get to the next neuron. The space between the axon of one neuron and the dendrite of another is called the synaptic cleft. ▪ The biochemicals that are released from the axon of one neuron and transmit the impulse to the dendrite receptors of another neuron are called neurotransmitters. ▪ The brain stem is the lower and more ancient part of the brain. Found in most animals, this structure handles most of the essential automatic functions, such as breathing, sleeping, and moving around in a coordinated way. ▪ The forebrain is more advanced and evolved more recently. ▪ The lowest part of the brain stem, the hindbrain, contains the medulla, the pons, and the cerebellum. The hindbrain regulates many automatic activities, such as breathing, the pumping action of the heart (heartbeat), and digestion. The cerebellum controls motor coordination, and recent research suggests that abnormalities in the cerebellum may be associated with the psychological disorder autism, although the connection with motor coordination is not clear. ▪ Also located in the brain stem is the midbrain, which coordinates movement with sensory input and contains parts of the reticular activating system, which contributes to processes of arousal and tension, such as whether we are awake or asleep. ▪ At the top of the brain stem are the thalamus and hypothalamus, which are involved broadly with regulating behavior and emotion. These structures function primarily as a relay between the forebrain and the remaining lower areas of the brain stem. ▪ At the base of the forebrain, just above the thalamus and hypothalamus, is the limbic system. Limbic means border, so named because it is located around the edge of the center of the brain. The limbic system, which figures prominently in much of psychopathology, includes such structures as the hippocampus (sea horse), cingulate gyrus (girdle), septum (partition), and amygdala (almond), all of which are named for their approximate shapes. This system helps regulate our emotional experiences and expressions and, to some extent, our ability to learn and to control our impulses. It is also involved with the basic drives of sex, aggression, hunger, and thirst. ▪ The basal ganglia, also at the base of the forebrain, include the caudate (tailed) nucleus. Because damage to these structures may make us change our posture or twitch or shake, they are believed to control motor activity. ▪ The largest part of the forebrain is the cerebral cortex, which contains more than 80% of all neurons in the central nervous system. This part of the brain provides us with our distinctly human qualities, allowing us to look to the future and plan, to reason, and to create. The left hemisphere seems to be chiefly responsible for verbal and other cognitive processes. The right hemisphere seems to be better at perceiving the world around us and creating images. Each hemisphere consists of four separate areas, or lobes: temporal, parietal, occipital, and frontal. ❖ The temporal lobe is associated with recognizing various sights and sounds and with long-term memory storage. ❖ The parietal lobe is associated with recognizing various sensations of touch and monitoring body positioning. ❖ The occipital lobe is associated with integrating and making sense of various visual inputs. ❖ The frontal lobe is the most interesting from the point of view of psychopathology. The front (or anterior) of the frontal lobe is called the prefrontal cortex, and this is the area responsible for higher cognitive functions such as thinking and reasoning, planning for the future, as well as long-term memory. This area of the brain synthesizes all information received from other parts of the brain and decides how to respond. The Peripheral Nervous System ▪ The peripheral nervous system coordinates with the brain stem to make sure the body is working properly. ▪ Its two major components are the somatic nervous system and the autonomic nervous system. The somatic nervous system controls the muscles, so damage in this area might make it difficult for us to engage in any voluntary movement, including talking. The autonomic nervous system includes the sympathetic nervous system and parasympathetic nervous system. ❖ The primary duties of the autonomic nervous system are to regulate the cardiovascular system (for example, the heart and blood vessels) and the endocrine system (for example, the pituitary, adrenal, thyroid, and gonadal glands) and to perform various other functions, including aiding digestion and regulating body temperature.  The sympathetic nervous system is primarily responsible for mobilizing the body during times of stress or danger by rapidly activating the organs and glands under its control. When the sympathetic division goes on alert, three things happen. The heart beats faster, thereby increasing the flow of blood to the muscles; respiration increases, allowing more oxygen to get into the blood and brain; and the adrenal glands are stimulated. One of the functions of the parasympathetic system is to balance the sympathetic system. In other words, because we could not operate in a state of hyperarousal and preparedness forever, the parasympathetic nervous system takes over after the sympathetic nervous system has been active for a while, normalizing our arousal and facilitating the storage of energy by helping the digestive process. ▪ The endocrine system works a bit differently from other systems in the body. Each endocrine gland produces its own chemical messenger, called a hormone, and releases it directly into the bloodstream. The adrenal glands produce epinephrine (also called adrenaline) in response to stress, as well as salt- regulating hormones; The thyroid gland produces thyroxine, which facilitates energy metabolism and growth; The pituitary is a master gland that produces a variety of regulatory hormones; and the gonadal glands produce sex hormones such as estrogen and testosterone. ▪ The hypothalamus connects to the adjacent pituitary gland, which is the master or coordinator of the endocrine system. The pituitary gland, in turn, may stimulate the cortical part of the adrenal glands on top of the kidneys. As we noted previously, surges of epinephrine tend to energize us, arouse us, and get our bodies ready for threat or challenge. When athletes say their adrenaline was really flowing, they mean they were highly aroused and up for the competition. The cortical part of the adrenal glands also produces the stress hormone cortisol. This system is called the hypothalamic–pituitary–adrenocortical axis, or HPA axis. Neurotransmitters ▪ Research on neurotransmitter function focuses primarily on what happens when activity levels change. We can study this in several ways. We can introduce substances called agonists that effectively increase the activity of a neurotransmitter by mimicking its effects; substances called antagonists that decrease, or block, a neurotransmitter; or substances called inverse agonists that produce effects opposite to those produced by the neurotransmitter. ▪ After a neurotransmitter is released, it is quickly drawn back from the synaptic cleft into the same neuron. This process is called reuptake. Some drugs work by blocking the reuptake process, thereby causing continued stimulation along the brain circuit. Amino-acid neurotransmitters ▪ Glutamate is an excitatory transmitter that “turns on” many different neurons, leading to action. ▪ Gamma-aminobutyric acid, or GABA for short, which is an inhibitory neurotransmitter. Thus, the job of GABA is to inhibit (or regulate) the transmission of information and action potentials. ▪ Because these two neurotransmitters work in concert to balance functioning in the brain, they have been referred to as the “chemical brothers”. ▪ GABA was discovered before glutamate and has been studied for a longer period; its best-known effect is to reduce anxiety. Scientists have discovered that a particular class of drugs, the benzodiazepines, or minor tranquilizers, makes it easier for GABA molecules to attach themselves to the receptors of specialized neurons. Thus, the higher the level of benzodiazepine, the more GABA becomes attached to neuron receptors and the calmer we become (to a point). ▪ The GABA system rides on many circuits distributed widely throughout the brain. GABA seems to reduce overall arousal somewhat and to temper our emotional responses. ▪ In addition to reducing anxiety, minor tranquilizers have an anticonvulsant effect, relaxing muscle groups that may be subject to spasms. Furthermore, the GABA system seems to reduce levels of anger, hostility, aggression, and perhaps even positive emotional states such as eager anticipation and pleasure, making GABA a generalized inhibiting neurotransmitter, much as glutamate has a generalized excitatory function. Monoamine Neurotransmitters Serotonin The technical name for serotonin is 5-hydroxytryptamine (5HT). Serotonin is believed to influence a great deal of our behavior, particularly the way we process information. The serotonin system regulates our behavior, moods, and thought processes. Extremely low activity levels of serotonin are associated with less inhibition and with instability, impulsivity, and the tendency to overreact to situations. Low serotonin activity has been associated with aggression, suicide, impulsive overeating, and excessive sexual behavior. Several classes of drugs primarily affect the serotonin system, including the tricyclic antidepressants such as imipramine (known by its brand name, Tofranil). However, the class of drugs called selective-serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), affects serotonin more directly than other drugs, including the tricyclic antidepressants. SSRIs are used to treat a number of psychological disorders, particularly anxiety, mood, and eating disorders. Norepinephrine A third neurotransmitter system in the monoamine class important to psychopathology is norepinephrine (also known as noradrenaline). We have already seen that norepinephrine, like epinephrine (referred to as a catecholamine), is part of the endocrine system. Norepinephrine seems to stimulate at least two groups (and probably several more) of receptors called alpha-adrenergic and beta-adrenergic receptors. In the central nervous system, a number of norepinephrine circuits have been identified. One major circuit begins in the hindbrain, an area that controls basic bodily functions such as respiration. Another circuit appears to influence the emergency reactions or alarm responses that occur when we suddenly find ourselves in a dangerous situation, suggesting that norepinephrine may bear some relationship to states of panic. More likely, however, is that this system, with all its varying circuits coursing through the brain, acts in a more general way to regulate or modulate certain behavioral tendencies and is not directly involved in specific patterns of behavior or in psychological disorders. Dopamine Dopamine is a major neurotransmitter that is in the monoamine class and that is also termed a catecholamine because of the similarity of its chemical structure to epinephrine and norepinephrine. Dopamine has been implicated in the pathophysiology of schizophrenia and disorders of addiction. Some research also indicates it may play a significant role in depression and attention deficit hyperactivity disorder. Remember the wonder drug reserpine that reduced psychotic behaviors associated with schizophrenia? This drug and more modern antipsychotic treatments affect a number of neurotransmitter systems, but their greatest impact may be that they block specific dopamine receptors, thus lowering dopamine activity. Dopamine circuits merge and cross with serotonin circuits at many points and therefore influence many of the same behaviors. For example, dopamine activity is associated with exploratory, outgoing, pleasure- seeking behaviors, and serotonin is associated with inhibition and constraint; thus, in a sense they balance each other.  One of a class of drugs that affects the dopamine circuits specifically is L-dopa, which is a dopamine agonist (increases levels of dopamine). One of the systems that dopamine switches on is the locomotor system, which regulates ability to move in a coordinated way and, once turned on, is influenced by serotonin activity. Because of these connections, deficiencies in dopamine have been associated with disorders such as Parkinson’s disease, in which a marked deterioration in motor behavior includes tremors, rigidity of muscles, and difficulty with judgment. L-dopa has been successful in reducing some of these motor disabilities. Cognitive science, which is concerned with how we acquire and process information and how we store and ultimately retrieve it (one of the processes involved in memory). Along similar lines, Martin Seligman, and his colleague Steven Maier, also working with animals, described the phenomenon of learned helplessness, which occurs when rats or other animals encounter conditions over which they have no control.  Another influential psychologist, Albert Bandura, observed that organisms do not have to experience certain events in their environment to learn effectively. Rather, they can learn just as much by observing what happens to someone else in a given situation. This fairly obvious discovery came to be known as modeling or observational learning. According to the concept of prepared learning, we have become highly prepared for learning about certain types of objects or situations over the course of evolution because this knowledge contributes to the survival of the species. The alarm reaction that activates during potentially life-threatening emergencies is called the flight or fight response. Emotion scientists now agree that emotion is composed of three related components—behavior, physiology, and cognition. The principle of equifinality is used in developmental psychopathology to indicate that we must consider a number of paths to a given outcome. Clinical Assessment and Diagnosis ▪ Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder. ▪ Diagnosis is the process of determining whether the particular problem afflicting the individual meets all criteria for a psychological disorder, as set forth in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. ▪ Affect refers to the feeling state that accompanies what we say at a given point. Usually our affect is “appropriate”; that is, we laugh when we say something funny or look sad when we talk about something sad. ▪ The first neuroimaging technique, developed in the early 1970s, uses multiple X-ray exposures of the brain from different angles; that is, X-rays are passed directly through the head. As with any X-ray, these are partially blocked or attenuated more by bone and less by brain tissue. Detectors in the opposite side of the head pick up the degree of blockage. A computer then reconstructs pictures of various slices of the brain. This procedure, which takes about 15 minutes, is called a computerized axial tomography (CAT) scan or CT scan. This gives an image of the brain structure. ▪ Several more recently developed procedures give greater resolution (specificity and accuracy) than a CT scan without the inherent risks of X-ray tests. A now commonly used scanning technique is called nuclear magnetic resonance imaging (MRI). The patient’s head is placed in a high-strength magnetic field through which radio frequency signals are transmitted. These signals “excite” the brain tissue, altering the protons in the hydrogen atoms. This gives an image of the brain structure. ▪ Subjects undergoing a positron emission tomography (PET) scan are injected with a tracer substance attached to radioactive isotopes, or groups of atoms that react distinctively. This substance interacts with blood, oxygen, or glucose. When parts of the brain become active, blood, oxygen, or glucose rushes to these areas of the brain, creating “hot spots” picked up by detectors that identify the location of the isotopes. Thus, we can learn what parts of the brain are working and what parts are not. This gives an image of the brain functioning. ▪ A second procedure used to assess brain functioning is called single photon emission computed tomography (SPECT). It works much like PET, although a different tracer substance is used, and this procedure is somewhat less accurate. It is also less expensive, however, and requires far less sophisticated equipment to pick up the signals. Therefore, SPECT is used more often than PET scans. This gives an image of the brain functioning. ▪ Functional Magnetic Resonance Imaging (fMRI) procedures have largely replaced PET scans in the leading brain-imaging centers because they allow researchers to see the immediate response of the brain to a brief event, such as seeing a new face. ▪ In an electroencephalogram (EEG), electrodes are placed directly on various places on the scalp to record the different low-voltage currents. ▪ When brief periods of EEG patterns are recorded in response to specific events, such as hearing a psychologically meaningful stimulus, the response is called an event-related potential (ERP) or evoked potential. ▪ If we want to determine what is unique about an individual’s personality, cultural background, or circumstances, we use what is known as an idiographic strategy. ▪ But to take advantage of the information already accumulated on a particular problem or disorder, we must be able to determine a general class of problems to which the presenting problem belongs. This is known as a nomothetic strategy. ▪ The term classification itself is broad, referring simply to any effort to construct groups or categories and to assign objects or people to these categories on the basis of their shared attributes or relations—a nomothetic strategy. ▪ If the classification is in a scientific context, it is most often called taxonomy, which is the classification of entities for scientific purposes, such as insects, rocks, or—if the subject is psychology—behaviors. ▪ If you apply a taxonomic system to psychological or medical phenomena or other clinical areas, you use the word nosology. All diagnostic systems used in healthcare settings, such as those for infectious diseases, are nosological systems. ▪ The term nomenclature describes the names or labels of the disorders that make up the nosology (for example, anxiety or mood disorders). ▪ The classical (or pure) categorical approach to classification originates in the work of Emil Kraepelin and the biological tradition in the study of psychopathology. Emil Kraepelin was one of the first psychiatrists to classify psychological disorders from a biological point of view. ▪ Kraepelin first identified what we now know as the disorder of schizophrenia. His term for the disorder at the time was dementia praecox. Dementia praecox refers to deterioration of the brain that sometimes occurs with advancing age (dementia) and develops earlier than it is supposed to, or “prematurely” (praecox). The Diagnostic and Statistical Manual of Mental Disorders (DSM) ▪ The first Diagnostic and Statistical Manual (DSM-I), published in 1952 by the American Psychiatric Association. Only in the late 1960s did systems of nosology begin to have some real influence on mental health professionals. ▪ In 1968, the American Psychiatric Association published a second edition of its Diagnostic and Statistical Manual (DSM-II). ▪ The year 1980 brought a landmark in the history of nosology: the third edition of the Diagnostic and Statistical Manual (DSM-III). Under the leadership of Robert Spitzer, DSM-III departed radically from its predecessors. Three changes stood out. 1. First, DSM-III attempted to take an a theoretical approach to diagnosis, relying on precise descriptions of the disorders as they presented to clinicians rather than on psychoanalytic or biological theories of etiology. 2. The second major change in DSM-III was that the specificity and detail with which the criteria for identifying a disorder were listed made it possible to study their reliability and validity. 3. Third, DSM-III (and DSM-III-R) allowed individuals with possible psychological disorders to be rated on five dimensions, or axes. This framework, called the multiaxial system, allowed the clinician to gather information about the individual’s functioning in a number of areas rather than limiting information to the disorder itself. ❖ Axis I. The disorder itself, such as schizophrenia or mood disorder, was represented only on the first axis. ❖ Axis II. What were thought to be more enduring (chronic) disorders of personality were listed on Axis II. ❖ Axis III consisted of any physical disorders and conditions that might be present. ❖ Axis IV the clinician rated, in a dimensional fashion, the amount of psychosocial stress the person reported. ❖ Axis V. And the current level of adaptive functioning was indicated on Axis V.  The fourth edition of the DSM (DSM-IV) was published in 1994. Perhaps the most substantial change in DSM-IV was that the distinction between organically based disorders and psychologically based disorders that was present in previous editions was eliminated. The multiaxial system remained in DSM-IV, with some changes in the five axes. Specifically, only personality disorders and intellectual disability were now coded on Axis II. DSM IV Axes ✓ Axis I. Pervasive developmental disorders, learning disorders, motor skills disorders, and communication disorders, previously coded on Axis II, were now all coded-on Axis I. ✓ Axis II. Only personality disorders and intellectual disability were now coded on Axis II. ✓ Axis III. Consisted of any physical disorders and conditions that might be present. ✓ Axis IV. The new Axis IV is used for reporting psychosocial and environmental problems that might have an impact on the disorder. ✓ Axis V. Axis V was essentially unchanged. It indicates the current level of adaptive functioning. ▪ In 2000, a committee updated the text that describes the research literature accompanying the DSM-IV diagnostic category and made minor changes to some of the criteria themselves to improve consistency. This text revision (DSM-IV-TR) helped clarify many issues related to the diagnosis of psychological disorders. ▪ In the almost 20 years since the publication of DSM-IV our knowledge has advanced considerably and, after over 10 years of concerted effort, DSM-5 was published in the spring of 2013. The manual is divided into three main sections. The first section introduces the manual and describes how best to use it. The second section presents the disorders themselves, and section 3 includes descriptions of disorders or conditions that need further research before they can qualify as official diagnoses. Perhaps the most notable change is the removal of the multiaxial system since the former axes I, II, and III have been combined into the descriptions of the disorders themselves, and clinicians can make a separate notation for relevant psychosocial or contextual factors (formerly axis IV) or extent of disability (formerly axis V) associated with the diagnosis. The use of dimensional axes for rating severity, intensity frequency, or duration of specific disorders in a relatively uniform manner across all disorders has also been substantially expanded in DSM-5, as previously proposed. In DSM-5 the term “mental retardation” has been dropped in favor of the more accurate term “intellectual disability”, which is consistent with recent changes by other organizations. ▪ Individuals are often diagnosed with more than one psychological disorder at the same time, which is called comorbidity.  RESEARCH METHODS IN PSYCHOPATHOLOGY ▪ Kiesler labeled the tendency to see all participants as one homogeneous group the patient uniformity myth. Comparing groups according to their mean scores (“Group A improved by 50% over Group B”) hides important differences in individual reactions to our interventions. ▪ One type of correlational research that is much like the efforts of detectives is called epidemiology, the study of the incidence, distribution, and consequences of a particular problem or set of problems in one or more populations. ▪ Epidemiologists study the incidence and prevalence of disorders among different groups of people. ▪ Like other types of correlational research, epidemiological research can’t tell us conclusively what causes a particular phenomenon. Knowledge about the prevalence and course of psychological disorders is extremely valuable to our understanding, however, because it points researchers in the right direction. ▪ When behavior changes as a result of a person’s expectation of change rather than as a result of any manipulation by an experimenter, the phenomenon is known as a placebo effect (from the Latin word placebo, which means “I shall please”). ▪ As an alternative to using no-treatment control groups to help evaluate results, some researchers compare different treatments. In this design, the researcher gives different treatments to two or more comparable groups of people with a particular disorder and can then assess how or whether each treatment helped the people who received it. This is called comparative treatment research. ▪ One of the more important strategies used in single-case experimental design is repeated measurement, in which a behavior is measured several times instead of only once before you change the independent variable and once afterward. ▪ Endophenotypes are the genetic mechanisms that ultimately contribute to the underlying problems causing the symptoms and difficulties experienced by people with psychological disorders. In the case of schizophrenia, for example, researchers are not looking for a “schizophrenia gene” (genotype); instead, they are searching for the gene or genes responsible for the working memory problems characteristic of people with this disorder (endophenotype), as well as the genes responsible for other problems experienced by people with this disorder. The basic principle of genetic linkage analysis is simple. When a family disorder is studied, other inherited characteristics are assessed at the same time. These other characteristics—called genetic markers—are selected because we know their exact location. If a match or link is discovered between the inheritance of the disorder and the inheritance of a genetic marker, the genes for the disorder and the genetic marker are probably close together on the same chromosome. ▪ The second strategy for locating specific genes, association studies, also uses genetic markers. Whereas linkage studies compare markers in a large group of people with a particular disorder, association studies compare such people to people without the disorder. Prevention Intervention Strategies ▪ Health promotion or positive development strategies involve efforts to blanket entire populations of people—even those who may not be at risk—to prevent later problems and promote protective behaviors. The intervention is not designed to fix existing problems but, instead, focuses on skill building, for example, to keep problems from developing. ▪ Universal prevention strategies focus on entire populations and target certain specific risk factors (for example, behavior problems in inner-city classrooms) without focusing on specific individuals. ▪ The third approach to prevention intervention—selective prevention—specifically targets whole groups at risk (for example, children who have parents who have died) and designs specific interventions aimed at helping them avoid future problems. ▪ Finally, indicated prevention is a strategy for those individuals who are beginning to show signs of problems (for example, depressive symptoms) but do not yet have a psychological disorder. ▪ A variation of correlation research is to compare different people at different ages. For a cross- sectional design, researchers take a cross section of a population across the different age groups and compare them on some characteristic. In cross-sectional designs, the participants in each age group are called cohorts; Brown and Finn studied three cohorts: 12-year-olds, 15-year-olds, and 17-year-olds. The members of each cohort are the same age at the same time and thus have all been exposed to similar experiences. Differences among cohorts in their opinions about alcohol use may be related to their respective cognitive and emotional development at these different ages and to their dissimilar experiences. This cohort effect, the confounding of age and experience, is a limitation of the cross-sectional design. ▪ Rather than looking at different groups of people of differing ages, researchers may follow one group over time and assess change in its members directly. The advantages of longitudinal designs are that they do not suffer from cohort effect problems and they allow the researchers to assess individual change. ▪ Longitudinal designs can suffer from a phenomenon similar to the cohort effect on cross-sectional designs. The cross-generational effect involves trying to generalize the findings to groups whose experiences are different from those of the study participants. Chapter Summary ▪ Dopamine is a major neurotransmitter that is in the monoamine class and that is also termed a catecholamine because of the similarity of its chemical structure to epinephrine and norepinephrine. ▪ Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder. ▪ The first Diagnostic and Statistical Manual (DSM-I), published in 1952 by the American Psychiatric Association. ▪ Endophenotypes are the genetic mechanisms that ultimately contribute to the underlying problems causing the symptoms and difficulties experienced by people with psychological disorders. Topic 3: CLASSIFICATION AND ASSESSMENT OF ABNORMAL BEHAVIOR Learning Objectives: At the end of this chapter, you should be able to: Identify and appreciate the significance, benefits, and limitations of diagnostic and statistical manual of mental disorders. Apply the knowledge learned in this chapter for sample cases of psychological disorders.  Clinical Case: Aaron Hearing the sirens in the distance, Aaron realized that someone must have called the police. He didn’t mean to get upset with the people sitting next to him at the bar, but he just knew that they were talking about him and plotting to have his special status with the CIA revoked. He could not let this happen again. The last time people conspired against him, he wound up in the hospital. He did not want to go to the hospital again and endure all of the evaluations. Different doctors would ask him all sorts of questions about his work with the CIA, which he simply was not at liberty to discuss. They asked other odd questions, such as whether he heard voices or believed others were putting thoughts into his head. He was never sure how they knew that he had those experiences, but he suspected that there were electronic bugging devices in his room at his parents’ house, perhaps in the electrical outlets. Just yesterday, Aaron began to suspect that someone was watching and listening to him through the electrical outlets. He decided that the safest thing to do was to stop speaking to his parents. Besides, they were constantly hounding him to take his medication. But when he took this medication, his vision got blurry and he had trouble sitting still. He reasoned that his parents must somehow be part of the group of people trying to remove him from the CIA. If he took this medication, he would lose his special powers that allowed him to spot terrorists in any setting, and the CIA would stop leaving messages for him in phone booths or in the commercials on Channel 2. Just the other day, he found a tattered paperback book in a phone booth, which he interpreted to mean that a new assignment was imminent. The voices in his head were giving him new clues about terrorist activity. They were currently telling him that he should be wary of people wearing the color purple, as this was a sign of a terrorist. If his parents were trying to sabotage his career with the CIA, he needed to keep out of the house at all costs. That was what had led him to the bar in the first place. If only the people next to him wouldn’t have laughed and looked toward the door. He knew this meant that they were about to expose him as a CIA operative. If he hadn’t yelled at them to stop, his cover would have been blown. Introduction Diagnosis and assessment are the critically important “first steps” in the study and treatment of psychopathology. In the case of Aaron, a clinician may begin treatment by determining whether Aaron meets the diagnostic criteria for a mood disorder, schizophrenia, or perhaps a substance-related disorder. Diagnosis can be the first major step in good clinical care. Having a correct diagnosis will allow the clinician to describe base rates, causes, and treatment for Aaron and his family, all of which are important aspects of good clinical care. Diagnosis enables clinicians and scientists to communicate accurately with one another about cases or research. Without agreed-on definitions and categories, our field would face a situation like the Tower of Babel (Hyman, 2002), in which different scientists and clinicians would be unable to understand each other. Diagnosis is important for research on causes and treatments. Sometimes researchers discover unique causes and treatments associated with a certain set of symptoms. For example, autism was only recognized in the Diagnostic and Statistical Manual in 1980. Since that time, research on the causes and treatments of autism has grown exponentially. DIAGNOSIS AND CLINICAL ASSESSMENT What is a Diagnosis (Dx)? It is the label or name given for a syndrome. Syndrome defined: (1) Disease or disorder that involves a particular group of signs and symptoms. (Merriam-Webster) (2) A collection or set of signs and symptoms that characterize or suggest a particular disease. (3) Combination of signs and symptoms. Signs- are objective observation of the syndrome by a physician or clinician; signs are visible externally. (e.g. weight loss, skin rash) Symptoms- are subjective. It is the patient’s observation of the syndrome. It can only be described by the person feeling them. (e.g. pain, dizziness, numbness, fatigue, vision disturbance, lightheadedness) Why is diagnosis important? (1) It allows the clinician to describe base rates, causes, and treatment (2) Often, a diagnosis can help a person begin to understand why certain symptoms are occurring, which can be a huge relief. (3) It enables clinicians and scientists to communicate accurately with one another about cases or research. (4) It is important for research on causes or treatments. Disease vs. Disorder Disease- resulting from a pathophysiological response to external or internal factors. It is mostly: (1) Organic in nature or has an organic cause (2) Observed because of structural changes to patients. Physical changes may be seen in patients. (3) Can be confirmed through laboratory tests. Disorder- a disruption to the normal or regular functions in the body or a part of the body. The effect of disorder is mostly: (1) Functional; there is an interference with the person’s daily life (e.g. to hold a job or form relationships.) (2) The detection of a disorder is dependent to the symptoms. (3) Not confirmed by laboratory tests. Clinical Assessment Is the process of collecting information about an individual for understanding and arriving at an informed decision. It is a systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder. Cornerstones of Diagnosis and Assessment Three basic concepts that help determine the value of clinical assessments: (1) Reliability (2) Validity (3) Standardization Reliability- is the degree to which a measurement is consistent; producing same results. Types of reliability that is most central to assessment and diagnosis: (1) Interrater Reliability- degree to which two independent observers agree on what they have observed. (2) Test-retest Reliability- extent to which people being observed twice or taking the same test twice, perhaps several weeks or months apart, receive similar scores. Note: This only makes sense when we can assume that people will not change appreciably between test sessions on the underlying variable being measured. (3) Alternate-form reliability- extent to which scores on the two forms of the test are consistent. (4) Internal consistency reliability- assesses whether the items on a test are related to one another. (e.g. items in an anxiety inventory should be interrelated, or correlated with one another, if they truly tap anxiety.) Validity- related to whether a measure measures what it is supposed to measure. (e.g. If a questionnaire is supposed to measure a person’s hostility, does it do so?) NOTE: Validity is related to reliability—unreliable measures will not have a good validity. Types of Validity: (1) Content Validity- refers to whether a measure adequately samples the domain of interest. (2) Criterion Validity- evaluated by determining whether a measure is associated in an expected way with some other measure (the criterion). ✓ Concurrent validity- if both variables are measured at the same point in time. ✓ Predictive validity- assessed by evaluating the ability of the measure to predict some other variable that is measured at some point in time in the future. (3) Construct Validity- viewed as an overarching concept that encompasses all other forms of validity. Construct- is an idea of an attribute or characteristics inferred. Standardization- process by which a certain set of standards or norms is determined for a technique to make its use consistent across different measurements. EXAMPLE: Your score on a particular psych test should be compared only to the norms of Asians and not to the scores of different people, such as African-American males.  CLASSIFICATION AND DIAGNOSIS Classification System aka Nomenclature- set of definitions of syndromes and rules for determining when a patient’s symptoms are part of each syndrome. Classification Systems presently used by clinicians: (1) Diagnostic and Statistical Manual of Mental Disorders 5th Edition by the American Psychiatric Association (2) International Statistical Classification of Diseases and Related Health Problems (ICD-10) by the World Health Organization 2 Essential Strategies in the Study and Treatment of Psychopathology (1) Idiographic Strategy- used to determine what is unique about an individual’s personality, cultural background, or circumstances. (2) Nomothetic Strategy- taking advantage of the information already accumulated on a particular problem or disorder by determining a general class of problems to which the presenting problem belongs. In other words, we are attempting to name or classify the problem. Issues in Classification 1. The subject of classification becomes controversial in humans unlike classifications in the field of biology or geology courses. 2. Some people have questioned whether it is proper or ethical to classify human behavior. (E.g. the use of terms such as “normal” and “abnormal”) 3. Some would prefer to talk about behavior and feelings on a continuum from happy to sad or fearful to non-fearful rather than to create categories as mania, depression, and phobia. Ways of Classifying Human Behavior (1) Categorical Approach or Classical (Pure)- originates in the work of Emil Kraepelin and the biological tradition in the study of psychopathology. Here we assume that every diagnosis has a clear underlying pathophysiological cause, such as bacterial infection or malfunctioning endocrine system, and that each disorder is unique. A categorical system defines a threshold for treatment that helps demarcate a point where treatment is recommended. Although the cutoffs are likely to be somewhat arbitrary, they can provide helpful guidance. (e.g. Does the patient have schizophrenia or not?) NOTE: Despite some debate, DSM-5 preserves a categorical approach to diagnosis. A dimensional approach to personality traits has been included in the appendix, but other diagnoses are based on categorical classification. As with DSM-IV-TR, the DSM-5 includes the category “unspecified” to be used when a person meets many but not all of the criteria for a diagnosis. NOTE: A categorical system forces clinicians to define one threshold as “diagnosable”. Categorical diagnoses foster a false impression of discontinuity (Widiger, 2005). Indeed, up to half of the people seeking treatment have mild symptoms that fall just below the threshold diagnosis. Many of these people with sub-threshold symptoms of a diagnosis still receive extensive treatment. (2) Dimensional Approach- describes the degree of an entity that is present (e.g. a 1-to-10 scale of anxiety, where 1 represents minimal and 10, extreme). (3) Prototypical Approach- identifies certain essential characteristics of an entity so that clinicians can classify it but it also allows certain nonessential variations that do not necessarily change the classification. When this is used in classifying psychological disorder, many possible features or properties of the disorder are listed and any candidate must meet enough of them to fall into that category. Example: Consider diagnostic criteria defining a major depressive episode. The criteria include many nonessential symptoms, but if you have either depressed mood or marked loss of interest or pleasure in most activities and at least four of the remaining symptoms, you come close enough to the prototype to meet the criteria for a major depressive episode. One person might have: (1) depressed mood (2) significant weight loss (3) insomnia (4) psychomotor agitation (5) loss of energy Whereas, another person who also meets the criteria for major depressive episode might have: (1) Marked diminished interest or pleasure in activities (2) Fatigue (3) Feelings of worthlessness (4) Difficulty thinking or concentrating (5) Ideas of committing suicide NOTE: Although both have the requisite five symptoms that bring them close to the prototype, they look different because they share only one symptom.  CREATING A DIAGNOSIS/DIAGNOSTIC IMPRESSION How does a clinician arrive at a diagnosis? Requirements for diagnosis: 1. Minimum number of symptoms according to the DSM 5. 2. Minimum duration. 3. Clinical significance of the symptom that brings distress or cause impairment to the patient. Levels of Disorders Sub-threshold- 1 or 2 requirements are not met. Sub-syndromal - number or duration of symptoms are lacking. Subclinical- symptoms do not cause clinically significant distress or impairment. NOTE: Essentially, these terms are used interchangeably to refer to symptoms, not full-blown or not severe enough. At times, all the symptoms are there but in “too mild form” to impair functioning. The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM 5, 2013) Features: 1. Descriptive, not explanatory 2. Categorical vs Dimensional/Continuum 3. Atheoretical What are the Sections of DSM-5? Section I: DSM-5 Introduction/Use of Manual Section II: Diagnostic Criteria and Codes Section III: Emerging Measures and Models Appendix What are the innovations observed in DSM-5? (1) Multiaxial system of diagnosis (DSM-IV-TR) has been removed. Now, diagnosis only includes the clinical syndrome (or syndromes if co-morbid) and the general medical condition. (2) There is an ICD/DSM harmony. (3) Chapters are reorganized in this new edition to reflect patterns of comorbidity and shared etiology (4) New Diagnoses- such as Disruptive Mood Dysregulation Disorder for children and adolescents who are falsely labeled with Bipolar Disorder because no category seemed to fit their symptoms. They do not meet the full criteria for mania (defining feature of bipolar). Other diagnoses include: Language Impairment Disorder, Premenstrual Dysphoric Disorder, Somatic Symptom Disorder, and Illness Anxiety Disorder) (5) Combining Diagnoses- some DSM-IV-TR diagnoses were combined because there is not enough evidence for differential etiology, course, or treatment response to justify the labeling. Example: DSM-IV-TR dx of Substance Abuse and Dependence are replaced in DSM-5 as Substance Use Disorder; Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder are replaced with Female Sexual Interest/Arousal Disorder. (6) Present DSM puts greater emphasis on the influence of age, gender, and culture in diagnosis. Use of the New DSM Manual In the illustration, we can see that: (1) DSM-5 combines Axes I-III which are: Mental Disorders, Medical Disorders, Other Medical conditions that may be the focus of Clinical Attention (2) Expanded V codes of the DSM and Z codes of ICD-10 can be used to determine contextual or situational factors (Also, you may consider including the reason for visit, factors that affect the diagnosis, prognosis, or treatment). It was intentionally changed to be more similar with other classification systems such as the ICD. (3) In noting disability or impairment, the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), Section III is used (also included in the DSM-5 appendix of assessment measures). Note: This is not required for a diagnosis. How to write a correct DSM-5 diagnosis? 1. Determine the disorder that meets the criteria. 2. Write the name of the disorder. 3. Add any subtype or specifiers of the disorder. 4. Add the ICD-10 code found at the top of the diagnostic criteria (Starting October 2014, ICD-10 codes should be used) REMEMBER! In case of multiple diagnosis or comorbidity, the principal diagnosis is listed first, followed by the other diagnoses in descending order of clinical importance.  CULTURAL CONCEPTS OF DISTRESS ❑ This formerly called Culture Bound Syndromes are ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions (APA, 2013). ❑ The term culture bound was used to describe patterned behaviors of distress or illness whose phenomenology appeared distinct from psychiatric categories and were considered unique to particular cultural settings. 3 Main Types of Cultural Concepts (1) Cultural Syndromes- are clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience. (2) Cultural Idioms of Distress- are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns. (e.g. “nausog”) (3) Cultural Explanations or Perceived Causes- are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress. Why are Cultural Concepts important? (1) To avoid misdiagnosis: Cultural variation in symptoms and in explanatory models associated with these cultural concepts may lead clinicians to misjudge the severity of a problem or assign the wrong diagnosis (e.g., unfamiliar spiritual explanations may be misunderstood as psychosis) (2) To obtain useful clinical information: Cultural variations in symptoms and attributions may be associated with particular features of risk, resilience, and outcome. (3) To improve clinical rapport and engagement: “Speaking the language of the patient” (4) To improve therapeutic efficacy: Cultural influences the psychological mechanism of disorder, which need to be understood and addressed to improve clinical efficacy. For example, culturally specific catastrophic cognitions can contribute to symptom escalation into panic attacks. (5) To guide clinical research: Locally perceived connections between cultural concepts may help identify patterns of comorbidity and underlying biological substrates. (6) To clarify cultural epidemiology. Examples of Culture Bound Syndromes 1. Amok- “murderous frenzy”, is a dissociative episode that is characterized by a period of depression followed by an outburst of violent, aggressive, or homicidal behavior. Patients return to premorbid states following the episode. It seems to be prevalent only among males. The term “amok” originated in Malaysia, but similar behavior patterns can be found in Laos, Philippines, Polynesia (cafard or cathard), Papua New Guinea, and Puerto Rico (mal de pelea), and among the Navajo (iich’aa). Precipitants: Feelings of loss, shame, anger, or lowered self-esteem although specific triggers were very diverse in nature and presentation. 2. Ataque de Nervios- is an idiom of distress principally reported among Latinos from the Caribbean, but recognized among many Latin American and Latin Mediterranean groups. Commonly reported symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression. A general feature of an ataque de nervios is a sense of being out of control. 3. Possession Syndrome- involuntary possession trance states are very common presentations of emotional distress around the world. 4. Shenjing Shuairuo- “weakness of the nervous system”, is a translation and cultural adaptation of the term “neurasthenia”, lack of nerve strength. It is a syndrome of lassitude, pain, poor concentration, headache, irritability, dizziness, insomnia, and over 50 symptoms. (at about 87% of those who have this actually meets the criteria of major depression.) 5. Koru- reported in South and East Asia, an episode of intense anxiety about the possibility that the penis or nipples will recede into the body, possibly leading to death. 6. Hikikomori (withdrawal)- refers to a syndrome observed in Japan, Taiwan, and South Korea in which an individual, most often an adolescent boy or young adult man, shuts himself into a room (e.g. bedroom) for a period of 6 months or more and does not socialize with anyone outside the room. 7. Taijin Kyofusho- is a Japanese culture-specific syndrome. This is the fear of interpersonal relations. Those who have this are likely to be extremely embarrassed about themselves or fearful of displeasing others when it comes to the functions of their bodies or their appearances. Symptoms of this syndrome overlap with that of social phobia and body dysmorphic disorder. Causal Factors in Abnormal Psychology Etiology- study of origins; causal patterns; it explains why a mental disorder begins and what causes it. It includes psychological, biological, and even social dimensions. (1) Distal/Predisposing Cause- anything that produces a susceptibility or disposition to a condition without actually eliciting it. This includes conditions that occurred relatively early in life but may not show its effect right away. (2) Proximal/Precipitating Cause- factor that initiates the onset of manifestations of a disease process; trigger of the disorder. (3) Reinforcing Cause- a condition that tends to maintain maladaptive behavior that is already occurring. Illustration: Imagine a plant that starts as a seed. The seed is the distal cause. Water and soil in this case, are the proximal causes. Water, soil, sunlight are the reinforcing causes. ❖ Risk Factors- these are factors that increase the possibility of an individual to develop a disorder. ❖ Protective Factors- influences that modify a person’s response to an environmental stressor, lessening the impact of stress. (e.g. resilience of Filipinos)  TREATMENT AND INTERVENTIONS (1) Biologically-based Therapies: a. Electroconvulsive Therapy (ECT)- addresses major depression. b. Neurosurgery- craniotomy c. Psychopharmacotherapy- which drugs work to alleviate the disorders. Before, pharmacological treatments are divided into 4: (1) Antipsychotics (2) Antidepressants (3) Antianxiety/Anxiolytics (4) Mood-stabilizing drugs Now, this is less valid in DSM-5 because: 1.Many drugs of one class are used to treat disorders previously assigned to other class. 2.Drugs from all 4 categories are used to treat disorders not previously treatable by drugs (e.g. eating disorders, impulse-control disorder, panic disorder) 3.Other drugs such as Clonidine (catapres), Propanolol (Inderal), and Verapanil (Isoptin) can effectively treat a variety of disorders and do not fit easily into the aforementioned classification of drugs. (2) Psychological Therapies/Psychotherapies a. Psychodynamic Therapy- aims to facilitate the client to achieve insight; uncovering the contents of the unconscious using different techniques. b. Behavior Therapy- change the maladaptive behaviors learned through the principles of learning. c. Cognitive-Behavioral Therapy- aims to change the distorted thought processes of the patient. d. Humanistic/Existential Therapies- facilitate clients to realize potentials for self-actualization. e. Family Therapy Chapter Summary Diagnosis is the label or name given for a syndrome. Syndrome is a collection or set of signs and symptoms that characterize or suggest a particular disease. Signs are objective observation of the syndrome by a physician or clinician. Symptoms are subjective. It is the patient’s observation of the syndrome. Reliability is the degree to which a measurement is consistent; producing same results. Validity is related to whether a measure measures what it is supposed to measure. Standardization is the process by which a certain set of standards or norms is determined for a technique to make its use consistent across different measurements. Cultural Concepts of Distress, formerly called Culture Bound Syndromes, are ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions (APA, 2013). Cultural Syndromes- are clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience.  Cultural Idioms of Distress- are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns. Cultural Explanations or Perceived Causes are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress. Distal/Predisposing Cause- anything that produces a susceptibility or disposition to a condition without actually eliciting it. This includes conditions that occurred relatively early in life but may not show its effect right away. Proximal/Precipitating Cause- factor that initiates the onset of manifestations of a disease process; trigger of the disorder. Reinforcing Cause is a condition that tends to maintain maladaptive behavior that is already occurring Risk Factors are factors that increase the possibility of an individual to develop a disorder. Protective Factors are influences that modify a person’s response to an environmental stressor, lessening the impact of stress. Topic 4: TRAUMA AND STRESS-RELATED DISORDERS Learning Objectives: You should be able to evaluate the effects of stress. Identify and describe the stages of general adaptation syndrome. Evaluate evidence on the relationship between life changes and psychological and physical health. Identify psychological factors that moderate the effects of stress. Define the concept of adjustment disorder and describe the key features of this disorder. Describe the key features of acute stress disorder and posttraumatic stress disorder. Describe ways of understanding and treating PTSD. What is Stress? Stress is the person’s biological and psychological response to adjustive demands from the environment. Categories of Stressors: 1. Conflict- is the presence of two or more incompatible needs. ❑ Types of Conflict: a. Approach-avoidance conflict- occurs when there is one goal or event that has both positive and negative effects or characteristics that make the goal unappealing and appealing simultaneously. E.g. marriage b. Double-approach conflict- choice between two or more desirable goals. E.g. Where to study? Which cell phone brand do I choose? c. Double-avoidance conflict- choice between undesirable alternatives (If you don’t have any desirable choice so you just choose from whatever is available.) 2. Pressure- a force that requires one to speed up, intensify effort, or change the direction of behavior. E.g. time, demands, deadlines. 3. Frustration- occurs when a person’s strivings toward a goal are blocked or by the absence of an appropriate goal. Trauma and Stressor-Related Disorders ▪ DSM-5 consolidates a group of formerly disparate disorders that all develop after a relatively stressful life event, often an extremely stressful or traumatic life event. ▪ This set of disorders—trauma and stressor-related disorders—include attachment disorders in childhood following inadequate or abusive childrearing practices, adjustment disorders characterized by persistent anxiety and depression following a stressful life event, and reactions to trauma such as posttraumatic stress disorder and acute stress disorder.  POSTTRAUMATIC STRESS DISORDER ▪ DSM-5 describes the setting event for PTSD as exposure to a traumatic event during which an individual experiences or witnesses death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation. ▪ Victims re-experience the event through memories and nightmares. When memories occur suddenly, accompanied by strong emotion, and the victims find themselves re-living the event, they are having a flashback. ▪ Victims most often avoid anything that reminds them of the trauma. ▪ They are sometimes unable to remember certain aspects of the event. It is possible that victims unconsciously attempt to avoid the experience of emotion itself, like people with panic disorder, because intense emotions could bring back memories of the trauma. ▪ Victims typically are chronically over aroused, easily startled, and quick to anger. ▪ New to DSM-5 is the addition of “reckless or self-destructive behavior” under the PTSD E criteria as one sign of increased arousal and reactivity. ▪ Also new to DSM-5 is the addition of a “dissociative” subtype describing victims who do not necessarily react with the re-experiencing or hyper-arousal, characteristic of PTSD. ▪ Since many individuals experience strong reactions to stressful events that typically disappear within a month, the diagnosis of PTSD cannot be made until at least one month after the occurrence of the traumatic event. ▪ In PTSD with delayed onset, individuals show few or no symptoms immediately or for months after a trauma, but at least 6 months later, and perhaps years afterward develop full-blown PTSD. ▪ As we noted, PTSD cannot be diagnosed until a month after the trauma. In DSM-IV a disorder called acute stress disorder was introduced. This is really PTSD, or something very much like it, occurring within the first month after the trauma, but the different name emphasizes the severe reaction that some people have immediately. ***Refer to your DSM 5 for the diagnostic criteria of PTSD. Statistics ▪ In the population as a whole, surveys indicate that 6.8% have experienced PTSD at some point in their life. ▪ The highest rates are associated with experiences of rape; being held captive, tortured, or kidnapped; or being badly assaulted. ▪ What accounts for the discrepancies between the low rate of PTSD in citizens who endured bombing and shelling in London and Beirut and the relatively high rate in victims of assaultive violence? Close exposure to the trauma seems to be necessary to developing this disorder. ▪ Since a diagnosis of PTSD predicts suicidal attempts independently of any other problem, such as alcohol abuse, every case should be taken very seriously. Causes ▪ We know that intensity of exposure to assaultive violence contributes to the etiology of PTSD but does not account for all of it. ▪ A family history of anxiety suggests a generalized biological vulnerability for PTSD. ▪ Nevertheless, as with other disorders, there is little or no evidence that genes directly cause PTSD. ▪ While all experienced the same traumatic experience, specific characteristics of what is referred to as the serotonin transporter gene involving two short alleles (SS) described as increasing the probability of becoming depressed. ▪ Breslau, Davis, and Andreski demonstrated among a random sample of 1,200 individuals that characteristics such as a tendency to be anxious, as well as factors such as minimal education, predict exposure to traumatic events in the first place and therefore an increased risk for PTSD. ▪ Family instability is one factor that may instill a sense that the world is an uncontrollable, potentially dangerous place. ▪ The results from a number of studies are consistent in showing that, if you have a strong and supportive group of people around you, it is much less likely you will develop PTSD after a trauma. ▪ Positive coping strategies involving active problem solving seemed to be protective, whereas becoming angry and placing blame on others were associated with higher levels of PTSD. ▪ A number of studies show that support from loved ones reduces cortisol secretion and hypothalamic– pituitary–adrenocortical (HPA) axis activity in children during stress ▪ It seems clear that PTSD involves a number of neurobiological systems, particularly elevated or restricted corticotropin-releasing factor (CRF), which indicates heightened activity in the HPA axis. Treatment ▪ In psychoanalytic therapy, reliving emotional trauma to relieve emotional suffering is called catharsis. ▪ Unlike the object of a specific phobia, a traumatic event is difficult to recreate, and few therapists want to try. Therefore, imaginal exposure, in which the content of the trauma and the emotions associated with it are worked through systematically, has been used for decades under a variety of names. ▪ At present, the most common strategy to achieve this purpose with adolescents or adults is to work with the victim to develop a narrative of the traumatic experience that is then reviewed extensively in therapy. ▪ Cognitive therapy to correct negative assumptions about the trauma—such as blaming oneself in some way, feeling guilty, or both—is often part of treatment. ▪ Some of the drugs, such as SSRIs (e.g., Prozac and Paxil), that are effective for anxiety disorders in general have been shown to be helpful for PTSD, perhaps because they relieve the severe anxiety and panic attacks so prominent in this disorder.  ADJUSTMENT DISORDER ▪ Adjustment disorders describe anxious or depressive reactions to life stress that are generally milder than one would see in acute stress disorder or PTSD but are nevertheless impairing in terms of interfering with work or school performance, interpersonal relationships, or other areas of living. The stressful events themselves would not be considered traumatic but it is clear that the individual is nevertheless unable to cope with the demands of the situation and some intervention is typically required. If the symptoms persist for more than six months after the removal of the stress or its consequences, the adjustment disorder would be considered “chronic”  REACTIVE ATTACHMENT DISORDER ▪ Attachment disorders refers to disturbed and developmentally inappropriate behaviors in children, emerging before five years of age, in which the child is unable or unwilling to form normal attachment relationships with caregiving adults. These seriously maladaptive patterns are due to inadequate or abusive child-rearing practices. In either case the result is a failure to meet the child’s basic emotional needs for affection, comfort, or even providing for the basic necessities of daily living. ▪ In reactive attachment disorder the child will very seldom seek out a caregiver for protection, support, and nurturance and will seldom respond to offers from caregivers to provide this kind of care. Generally, they would evidence lack of responsiveness, limited positive affect, and additional heightened emotionality, such as fearfulness and intense sadness. ▪ In disinhibited social engagement disorder, a similar set of child rearing circumstances— perhaps including early persistent harsh punishment—would result in a pattern of behavior in which the child shows no inhibitions whatsoever to approaching adults. Such a child might engage in inappropriately intimate behavior by showing a willingness to immediately accompany an unfamiliar adult figure somewhere without first checking back with a caregiver. Chapter Summary Stress is the person’s biological and psychological response to adjustive demands from the environment. Conflict is the presence of two or more incompatible needs. Frustration occurs when a person’s strivings toward a goal are blocked or by the absence of an appropriate goal. Approach-avoidance conflict occurs when there is one goal or event that has both positive and negative effects or characteristics that make the goal unappealing and appealing simultaneously. Trauma and Stress-Related Disorders are sets of disorders—trauma and stressor-related disorders— include attachment disorders in childhood following inadequate or abusive childrearing practices, adjustment disorders characterized by persistent anxiety and depression following a stressful life event, and reactions to trauma such as posttraumatic stress disorder and acute stress disorder.  In the population as a whole, surveys indicate that 6.8% have experienced PTSD at some point in their life. Adjustment disorders describe anxious or depressive reactions to life stress that are generally milder than one would see in acute stress disorder or PTSD but are nevertheless impairing in terms of interfering with work or school performance, interpersonal relationships, or other areas of living. Attachment disorders refers to disturbed and developmentally inappropriate behaviors in children, emerging before five years of age, in which the child is unable or unwilling to form normal attachment relationships with caregiving adults. Topic 5: ANXIETY DISORDERS, OBSESSIVE-COMPULSIVE DISORDERS AND OTHER RELATED DIDOSRDERS Learning Objectives: At the end of this chapter, you should be able to describe the physical, behavioral, and cognitive features of anxiety disorders. Describe the leading conceptual model of panic disorder. Evaluate the methods used to treat panic disorder. Describe the key features and specific types of phobic disorders and explain how phobias develop. Evaluate methods used to treat phobic disorders. Describe the key features of generalized anxiety disorder and ways of treating it. Describe the key features of obsessive-compulsive disorder and ways of understanding and treating it. Describe the key features of body dysmorphic disorder and hoarding disorder and explain why these are classified within the obsessive-compulsive spectrum. Anxiety defined: Anxiety is a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future. Social, physical, and intellectual performances are driven and enhanced by anxiety. Fear is an immediate emotional reaction to current danger characterized by strong escapist action tendencies and, often, a surge in the sympathetic branch of the autonomic nervous system. Panic Attack: In psychopathology, a panic attack is defined as an abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms that usually include heart palpitations, chest pain, shortness of breath, and, possibly, dizziness. Two basic types of panic attacks are described in DSM-5: expected and unexpected. Unexpected attacks are important in panic disorder. (Expected attacks more common in specific phobias or social phobia.) ❑ If you know you are afraid of high places or of driving over long bridges, you might have a panic attack in these situations but not anywhere else; this is an expected (cued) panic attack. ❑ By contrast, you might experience unexpected (uncued) panic attacks if you don’t have a clue when or where the next attack will occur.  ETIOLOGY Biological Contributions As with almost all emotional traits and psychological disorders, no single gene seems to cause anxiety or panic. Instead, contributions from collections of genes in several areas on chromosomes make us vulnerable when the right psychological and social factors are in place. Depleted levels of gamma aminobutyric acid (GABA), part of the GABA–benzodiazepine system, is associated with increased anxiety, although the relationship is not quite so direct. The noradrenergic system has also been implicated in anxiety, and evidence from basic animal studies, as well as studies of normal anxiety in humans, suggests the serotonergic neurotransmitter system is also involved.  But increasing attention in the last several years is focusing on the role of the corticotropin-releasing factor (CRF) system as central to the expression of anxiety (and depression) and the groups of genes that increase the likelihood that this system will be turned on. ❑ This is because CRF activates the hypothalamic– pituitary–adrenocortical (HPA) axis, which is part of the CRF system, and this CRF system has wide-ranging effects on areas of the brain implicated in anxiety, including the emotional brain (the limbic system), particularly the hippocampus and the amygdala; the locus coeruleus in the brain stem; the prefrontal cortex; and the dopaminergic neurotransmitter system. ❑ The CRF system is also directly related to the GABA–benzodiazepine system and the serotonergic and noradrenergic neurotransmitter systems. The area of the brain most often associated with anxiety is the limbic system which acts as a mediator between the brain stem and the cortex. The more primitive brain stem monitors and senses changes in bodily functions and relays these potential danger signals to higher cortical processes through the limbic system.  The late Jeffrey Gray, a prominent British neuropsychologist, identified a brain circuit in the limbic system of animals that seems heavily involved in anxiety. The system that Gray calls the behavioral inhibition system (BIS). ❑ BIS is activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger. Danger signals in response to something we see that might be threatening descend from the cortex to the septal–hippocampal system. ❑ The BIS also receives a big boost from the amygdala. ❑ When the BIS is activated by signals that arise from the brain stem or descend from the cortex, our tendency is to freeze, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present. The BIS circuit is distinct from the circuit involved in panic. Gray and Graeff identified what Gray calls the fight/flight system (FFS). ❑ This circuit originates in the brain stem and travels through several midbrain structures, including the amygdala, the ventromedial nucleus of the hypothalamus, and the central gray matter. ❑ When stimulated in animals, this circuit produces an immediate alarm-and-escape response that looks very much like panic in humans. ❑ The FFS is activated partly by deficiencies in serotonin, suggest Gray and McNaughton. One important study suggested that cigarette smoking as a teenager is associated with greatly increased risk for developing anxiety disorders as an adult, particularly panic disorder, and generalized anxiety disorder. Psychological Contributions Freud thought anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful situation. Behavioral theorists thought anxiety was the product of early classical conditioning, modeling, or other forms of learning. A general “sense of uncontrollability” may develop early as a function of upbringing and other disruptive or traumatic environmental factors. Parents who provide a “secure home base” but allow their children to explore their world and develop the necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of control. Social Contributions Stressful life events trigger our biological and psychological vulnerabilities to anxiety. Most are social and interpersonal in nature—marriage, divorce, difficulties at work, death of a loved one, pressures to excel in school, and so on. Some might be physical, such as an injury or illness. DSM-5 now makes it explicit that panic attacks often co-occur with certain medical conditions, particularly cardio, respiratory, gastrointestinal, and vestibular (inner ear) disorders, even though the majority of these patients would not meet criteria for panic disorder. Based on epidemiological data, Weissman and colleagues found that 20% of patients with panic disorder had attempted suicide.  GENERALIZED ANXIETY DISORDER The DSM-5 criteria specify that at least 6 months of excessive anxiety and worry (apprehensive expectation) must be ongoing more days than not. Whereas panic is associated with autonomic arousal, presumably as a result of a sympathetic nervous system surge (for instance, increased heart rate, palpitations, perspiration, and trembling), GAD is characterized by muscle tension, mental agitation, susceptibility to, fatigue (probably the result of chronic excessive muscle tension), some irritability, and difficulty sleeping. Focusing one’s attention is difficult, as the mind quickly switches from crisis to crisis. ***Refer to your DSM 5 for the full diagnostic criteria of GAD. Statistics About two-thirds of individuals with GAD are female in both clinical samples. But this sex ratio may be specific to developed countries. In the South African study mentioned here, GAD was more co