Understanding Psychopathology PDF

**Understanding Psychopathology** Psychological Disorder- or abnormal behavior is a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected. Three Criteria: 1. **Psychological Dysfunction** - -...

**Understanding Psychopathology** Psychological Disorder- or abnormal behavior is a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected. Three Criteria: 1. **Psychological Dysfunction** - -refers to a breakdown in cognitive, emotional, or behavioral functioning. 2. **Personal Distress or Impairment** -this criterion is satisfied when the individual is extremely upset. 3. **Atypical or not culturally expected** response **An Accepted definition** - It is difficult to define "Normal" and "Abnormal" behavior. - DSM-V --defines abnormal behavior/psychological disorder as behavioral, psychological, or biological dysfunctions that are unexpected in their cultural context and associated with present distress and impairment in functioning or increased risk of suffering, death, pain, or impairment. - **Prototype**- the typical profile of a disorder. **Clinical Description** - **Presents**- is a traditional shorthand way of indicating why the person came to the clinic. - The **presenting problem** is the first step in determining an individual's **Clinical Description**, which represents the unique combination of behaviors, thoughts, and feelings of an individual that make up a particular disorder. **Statistical Data** - **Prevalence**- how many people in the population as a whole have the disorder - **Incidence**- how many cases occur during a given period, such as a year. - **Sex ratio**- what is the percentage of males and females of the disorder. - **Typical age of onset** **Differences in Course** - **Chronic course**- tends to last a long time. (sometimes a lifetime) - **Episodic course**- individuals recover within a few months only to suffer a recurrence of the disorder at a later time. (may repeat throughout a person's life) - **Time-limited course**- the disorder will improve without treatment in a relatively short period. **Differences in Onset** - **Acute onse**t- begins suddenly - **Insidious onset**- develops gradually over an extended period - **Prognosis**- is the anticipated course of a disorder. - **Developmental Psychology**- refers to the study of changes in behavior over time. - **Developmental psychopathology**- refers to the study of changes in abnormal behavior. - **Lifespan developmental psychopathology**- is the study of abnormal behavior across the entire age span. - **Etiology**- study of origins, deals with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions. **Anxiety** - **Anxiety - is a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future.** - **Anxiety is a future-oriented mood state, characterized by apprehension because we cannot predict or control upcoming events whereas 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.** - **Howard Lidel called anxiety the "shadow of intelligence"** - **He thought that the human ability to plan some detail for the future was connected to that gnawing feeling that things could go wrong and we had better be prepared for them.** - **Fear- is an immediate alarm reaction to danger. It protects us by activating a massive response from the autonomic system.** - **Levels of Anxiety** - **Mild - focused attention on many things including learning, solving problems, and protecting the self. Associated with tensions of every day events. Experience of fidgeting, irritability, sweaty palms, and heightened senses.** - **Moderate - Person is focused exclusively on the stressful situation while ignoring other tasks. Experience of faster heartbeat, dry mouth, sweating and stomach pain or nausea. Nervous habits may be exhibited.** - **Severe - symptoms intensify such as vomitting, scattered thoughts, erratic behavior and a sense of dread. Ability to focus and solve problems is impaired. Person is not ale to recognize or take care of own needs.** - **Panic - overwhelms capacity to function normally, inability to move or speak. Thinking rationally is impaired and perceptions are distorted.** **Panic** - **Panic Attack - an abrupt experience of intense fear of acute discomfort, accompanied by physical symptoms that usualy include heart palpitations, chest pains, shortness of breath, and possibly, dizziness.** - **Expected (cued) Panic attacks** - **If you know you are afraid of it and might have a panic attack in known situations but not anywhere else** - **More common in specific phobias or social phobia.** - **Unexpected (uncued) Panic attacks** - **If you don't have a clue when or where the next attack will occur.** **Anxiety disorders** **Includes:** - **Generalized anxiety disorder** - **Panic disorder** - **Agoraphobia** - **Specific phobia** - **Social anxiety disorder** **Two new disorders:** - **Separation anxiety disorder** - **Selective mutism** **Generalized Anxiety Disorder** - **Indiscriminate and unproductive worrying.** - **The state of not being able to stop worrying, even if you know it is doing you no good and probably making everyone else around you miserable.** - **People with GD mostly worry about minor, everyday life events.** - **For children, only one physical symptom is required for a diagnosis of GAD.** - - - - **Some people with GAD report onset in early adulthood usually in response to a life stressor. It is associated with an earlier and more gradual onset than most other anxiety disorders.** - **Once it develops, GAD is chronic.** **Differential diagnosis** - **Social anxiety disorder -- individuals with it often have anticipatory anxiety focused on upcoming social situations in which they must perform or be evaluated, people with GAD worry, whether or not they are being evaluated.** - **OCD- In GAD, the focus of the worry is about forthcoming problems and it is the excessiveness of the worry about future events that is abnormal. In OCD, obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts, urges, or images.** - **PTSD- Anxiety is invariably present in PTSD, GAD is not diagnosed if the anxiety and worry are better not explained by symptoms of PTSD.** **Panic Disorder and Agoraphobia** - **A type of panic attack is nocturnal panic attack. Waking up from sleep in a state of panic.** - **Median onset is 20-24** - **Only a minority of individuals recover without remission without subsequent relapse within a few years.** - **If the disorder is untreated, it is chronic but waxing and waning.** - **Risk and prognostic Factors:** - **Temperamental- (negative affectivity/neuroticism and anxiety sensitivity are risk factors for the onset of panic attacks.** - **Environmental- reports of childhood experiences of sexual and physical abuse are more common in panic attacks and panic disorder.** - **Genetic and physiological** **Agoraphobia** - **Fear and avoidance of situations in which a person feels unsafe or unable to escape to get home or to a hospital in thee event of a developing panic symptoms or other physical symptoms.** - **Coined by Karl Westphal, a german physician and in the original Greek, refers to fear of the marketplace.** - **Shopping mall** - **Panic disorder and agoraphobia were integrated into one disorder called panic disorder with agoraphobia in DSM IV. It was discovered however that people may experience panic disorder without developing agoraphobia and some may develop agoraphobia without an accompanying panic disorder.** **Differential diagnosis** - **Specific phobia, situational type- if it is limited to one agoraphobic situation then it is specific phobia. Cognitive ideation.** - **Separation anxiety- the thoughts are about detachment from significant others and home-environment, in agoraphobia, the focus is on panic-like symptoms or other incapacitating or embarrassing symptoms in the feared situations.** - **Social phobia- differentiation from the situational clusters that trigger fear, anxiety, or avoidance and other cognitive ideation.** - **Panic disorder- when criteria for PD are met, agoraphobia should not be diagnosed if the avoidance behaviors related with PD do not extend avoidance of two or more agoraphobic situations.** - **PTSD and acute stress disorder- can be differentiated from agoraphobia by examining whether the fear, anxiety, or avoidance is related only to the situations that remind the individual of the traumatic event.** - In PD, anxiety and panic are combined in an intricate relationship that can become devastating. - To meet criteria for PD, a person must experience an unexpected panic attack and develop substantial anxiety of having another attack or about tAnxiety is diminished for individuals with agoraphobia if they think a location or person is "safe" - Agoraphobic avoidance is simply one way of coping with unexpected panic attacks - Some individuals do not avoid agoraphobic situations but endure them with "intense dread" - The DSM-5 notes that agoraphobia may be characterized either by avoiding the situations or by enduring them with intense fear and anxiety. - he implications of the attack or its consequences. - **Interoceptive avoidance**- removing oneself from situations or activities which might produce the physiological arousal resembling the beginning of panic attacks. - A large portion of males with unexpected panic attacks cope in a culturally acceptable way: consuming large amounts of alcohol, though they become dependent. **Specific phobia** - It is the irrational fear of a specific object or situation that markedly interferes with an individual's ability to function. - In the earlier versions of the DSM, this category was called "simple phobia" to distinguish it from the more complex agoraphobia Condition - The fear and anxiety is out of proportion to the actual danger posed by the specific object or situation. - The phobic situation is actively avoided or endured with intense fear or anxiety **Classifications of specific phobia** - **Blood-injection-injury phobia** - Runs in families more strongly than any phobic disorder - **Situational phobia** - Planes, elevators, or enclosed places - The main difference between this and panic disorder is that people with situational phobia never experience panic attacks outside the context of their phobi object or situation. People with panic disorder might experience unexpected, uncued panic attacks at any given time. - **Natural environment phobia** - Heights, storms, and water - **Animal Phobia** - **"Other" types** **Social Anxiety Disorder\ (Social Phobia)** - An experience of marked fear or anxiety focused on one or more social or performance situations. - It is more than exaggerated shyness. - It may be just accompanied by performance anxiety which is a subtype of SAD, usually have no difficulty with social interaction, but when they must do something specific in front of people anxiety takes over and they focus on the possibility that they will embarrass themselves. - Public speaking **New anxiety disorders** **Separation anxiety disorder** - Characterized by children's unrealistic and persistent worry that something will happen to their parents or other important people in their life or that something will happen to the children themselves that will separate them from their parents. - If left untreated can extend to adulthood (35%). The focus of anxiety in adults is the same (the harm may befall loved ones during separation). **School phobia** - It differs from separation anxiety because the fear is clearly focused on something specific to the school situations. The child can leave the parents or attachment figures to go somewhere other than school. **Selective Mutism** - A rare childhood disorder characterized by a lack of speech in one or more settings in which speaking is socially expected. - Clearly driven by social anxiety, since the failure to speak is not because of a lack of knowledge of speech or any physical difficulties, nor is it due to another disorder in which speaking is rare or can be impaired such as autism spectrum disorder. - Must occur more than one month and cannot be limited to the first month of the school. **Trauma and stressor related disorders** - PTSD - Adjustment disorders - Attachment disorders - Reactive attachment disorders - Disinhibited social engagement disorder **Posttraumatic stress disorder (PTSD)** - 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, or actual or threatened serious injury, or actual or threatened sexual violation. - Learning that the traumatic event occurred to a close family member or friend, or enduring repeated exposure to details of a traumatic event are also settling events. - Difficulty sleeping and recurring intrusive dreams of the event are prominent features of PTSD. Diagnosis cannot be made until at least one month after the occurrence of the traumatic event **Delayed onset posttraumatic stress disorder** - 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 **Acute stress disorder** - Occurs within the first month after the trauma, but the different name emphasizes the severe reaction that some people have immediately **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. - 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." **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. **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. - Reactive attachment disorder of infancy or early childhood is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. - The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults. - When distressed, they show no consistent effort to obtain comfort, nurturance, or protecton from caregiers. **Disinhibited Social Engagement Disorder** - The essential feature is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. This overly familiar behavior violates the social boundaries of the culture. - A diagnosis should be made before the children are developmentally able to form selective attachments. For this reason, the child must have a developmental age of at least 9 months. **Obsessive-Compulsive and Related Disorders** - Hoarding disorder - Body dysmorphic disorder - Trichotillomania - Excoriation - Obsessive-compulsive Disorder **Obsessive-Compulsive Disorder** - Among clients suffering from anxiety and related disorders, a client who needs hospitalization is likely to have OCD. - A client referred for psychosurgery (neurosurgery for a a psychological disorder) because every psychological and pharmacological treatment has failed and the suffering is unbearable probably has OCD. - The devastating culmination of the anxiety disorders. - It is not uncommon for someone w/ OCD to experience severe generalized anxiety, recurrent panic attacks, debilitating avoidance, and major depressive disorder, all occurring simultaneously with OCD symptoms. - In anxiety disorders, the danger is usually in an external object or situation, or at least in the memory of one. In OCD, the dangerous event is a thought, image, or impulse that the client attempts to avoid as completely as someone with a snake phobia avoids snakes. **Obsessions** - recurrent and intrusive thoughts that are typically unwanted and tough to get out of your brain. These causes anxiety and usually they lead to compulsions. - Intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate. **Compulsions** - Are actions that might be performed to try and reduce the anxiety associated with obsessions. - These thoughts and rituals can have a serious impact on someone's daily life. - Thoughts or actions used to suppress the obsessions and provide relief - Compulsions can be either behavioral or mental which is believed to reduce stress or prevent a dreaded event; often "magical" in that they may bear no logical relation to the obsession. **4 Major types of obsessions** - **Symmetry obsessions /Exactness/"just right"** - **Obsession** - Needing things to be symmetrical/aligned just so; Urges to do things over and over again until they feel "just right" - **Compulsio**n - Putting things in a certain order; Repeating rituals - **Forbidden thoughts or actions (aggressive/sexual/religious)** - **Obsession** - Fears, urges to harm self or others; Fears of offending god - **Compulsion** - Checking; Avoidance; Repeated requests for reassurance - **Cleaning and contamination** - **Obsession** - Germs; Fear of germs or contaminants; - **Compulsio**n -Repetitive or excessive washing; Using gloves, masks to do daily tasks - **Hoarding** - **Obsessio**n - Fears of throwing away anything - **Compulsion** - Collecting/saving objects with little or no actual or sentimental value such as food wrappings **Tic Disorder and OCD** - It is common for tic disorders, characterized by involuntary movement (sudden jerking of limbs, for example), to co-occur in patients with OCD (particularly children) or in their families. - Tourette's disorder- more complex tics with involuntary vocalizations. - In some cases, involuntary movements are not tics but compulsions. - Obsessions in tic-related OCD are almost always related to symmetry **Body Dysmorphic Disorder** - Some relatively normal-looking people think they are so ugly they refuse to interact with others or otherwise function normally for fear that people will laugh at their ugliness - It has been referred to as "imagined ugliness" - BDD was considered a somatoform disorder but increasing evidence indicated that it was more closely related to OCD. - Excessive grooming and skin picking are common. - Many people become fixated on mirrors and often check their presumed ugly feature to see whether any change has taken place. - The prevalence is hard to estimate because it tends to be kept secret. - Woman focus on more varied body areas and are more likely to have an eating disorder. - Individuals are reluctant to seek treatment - We know little about the etiology of BDD, almost no information of whether it runs in families so we can't investigate a specific genetic contribution. - No meaningful information on biological and psychological predisposing factors or vulnerabilities. **Hoarding Disorder** - The three major characteristics are: - Excessive acquisition of things - Difficulty discarding anything - Living with excessive clutter under conditions best characterized as gross disorganization - Individuals experience strong anxiety and distress about throwing anything away, because everything has either some potential use or sentimental value in their minds, or simply becomes an extension of their own identity. - Animal hoarders are a thing btw. This is due to the attribution of human characteristics to their animals. - These individuals usually begin acquiring things during their teenage years and often experience great pleasure even euphoria from shopping or otherwise collecting various items. - Shopping or collecting things may be a response to feeling down or depressed and is sometimes called, facetiously, "retail therapy" - It has similarities and differences with both ocd and impulse control disorders.Therefore it is best considered a separate disorder and now appears as such in the DSM - OCD tends to wax and wane, hoarding behaviors can begin early in life and get worse with each passing decade. **Trichotillomania (Hair Pulling Disorder)** - Urge to pull out one's hair from anywhere on the body including the scalp, eyebrows and arms. - Results in noticeable hair loss, distress, significant social impairments. - 1 and 5% of college students, more females - May have some genetic influence **Excoriation (Skin Picking Disorder)** - Repetitive and compulsive picking of the skin leading to tissue damage. - There can be significant embarrassment, distress, and impairment in terms of social work and functioning. - Largely a female disorder other specified or unspecified schizophrenia spectrum and other psychoticdisorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify current or most recent episode: Hypomanic: If currently (or most recently) in a hypomanic Episode Depressed: If currently (or most recently) in a major depressive episode **Mood Disorders** **Depression and Mania** - An overview of Depression and Mania - Used to be categorized under several general labels such as "depressive disorders," "Affective disorders," or even "depressive neurosis." - Fundamental experiences of depression and mania contribute, either singly or together, to all the mood disorders. - Most commonly diagnosed and severe depression is Major Depressive Episode. **Major Depressive Episode** - Most commonly diagnosed and most severe depression. - Extremely depressed mood state that lasts at least 2 weeks and includes cognitive symptoms (feelings of worthlessness and indecisiveness) and disturbed physiccal functions (altered sleeping patterns, significant changes in appetite and weight, or a notable loss of energy) to the point that even the slightest activity or movement requires an overwhelming effort. - This episode is typically accompanied by a general loss of interest in things and inability to experience any pleasure in life.\ The most central indicators of a full major depressive episode are the physical changes (Somatic or vegetative symptoms) along with behavioral and emotional "shutdown." - **Anhedonia** (loss of energy and inability to engage in pleasurable activities or have any "fun") is more characteristic of the episode more than reports of sadness or distress, the tendency to cry reflect severity or even the presence of a depressive episode. **Mania** - The second fundamental state in mood disorders which is characterized by abnormally exaggerated elation, joy, or euphoria. - Individuals find extreme pleasure in every activity, some even compare the experience with multiple sexual orgasm. - They become extraordinarily active (Hyperactive), requires little sleep, and may develop grandiose plans such as believing they can accomplish anything they desire. - Flight of ideas- characterized by rapid speech which may become incoherent. - Duration of only one 1 week - Hospitalization can occur, if the individual is engaging self-destructive buying spree. - Manic episodes are more common in adolescents. - **Hypomanic episode** -- less severe version of manic episode that does not cause marked impairment in social or occupational functioning and need last only for days rather than a full week. Not really problematic in itself but contributes to the definition of several mood disorders. **Structure of Mood Disorders**. - Unipolar mood disorder- characterized by experience of either depression only or mania only. Their mood remains at one "pole" of the Depression-Mania continuum. Often a chronic condition that waxes and wanes over time but seldom disappears. - Bipolar mood disorder- someone who alternates between depression and mania or from one pole to another of the depression elation continuum and back again. - Depression and elation are not exactly opposites ends of the same mood state, they are related but often relatively independent. - "Mixed Features"- an individual can experience manic symptoms but feel somewhat depressed or anxious at the same time or be depressed with a few symptoms of mania. (requires specifying whether a predominantly manic or predominantly depressive episode is present). - Dysphoric (anxious or depressive) features are found more commonly in mania than thought, and it can be severe. - It's important to determine the course or temporal patterning of the depressive or manic episodes. (do they tend to recur, if they do, do they recover fully for at least 2 months between episodes ("full remission") or only partially recover retaining some depressive symptoms (partial remission." **Mood Disorder Includes:** **DEPRESSIVE DISORDERS** - Major depressive disorder - Persistent depressive disorder - Double depression - Peripartum depression - Seasonal affective disorder - Premenstrual Dysphoric Disorder - Disruptive Mood Disregulation Disorder **BIPOLAR DISORDERS** - Bipolar I - Bipolar II - Cyclothymia **Depressive Disorders** - These disorders differ from one another in the frequency and severity with which depressive symptoms occur and the course of the symptom (chronic or non-chronic). - The two most important factors describing mood disorders are severity and chronicity. **Major Depressive Disorder** - Most easily recognized mood disorder. - Absence of manic or hypomanic episodes before or during the disorder. - Recurrent- occurrence of 2 or more major depressive episodes which were separated by at least 2 months which during the individual was not depressed. Recurrence is important in predicting the future course of the disorder as well as in choosing appropriate treatments. - The median lifetime number of major depressive episodes is 4-7 - Median duration of recurrent major depressive episodes is 4-5 months, shorter than the average length of the first episode. Additional Criteria for Depressive Disorders In addition to rating severity (mild, moderate, or severe), clinicians use eight basic specifiers to describe Depressive disorder. 1\. **Psychotic Features Specifier.** - -some individuals may experience Hallucinations (seeing or hearing things that aren't there) and Delusions (strongly held but inaccurate beliefs). May also have Somatic (physical) delusions or Auditory hallucinations which are Mood congruent or which are directly related to the depression. - On rare occasions, individuals may have other types of hallucinations or delusions such as delusions of grandeur (believing, for example, they are supernatural, or supremely gifted) not consistent with their depressed mood. Such then is called a Mood Incongruent hallucination or delusion. Although quite rare, it signifies a serious depressive episode which may progress to schizophrenia (or it may have been a symptom of schizophrenia from the start) 2\. **Anxious Distress Specifier.** - \- presence and severity of accompanying anxiety, whether in the form of comorbid anxiety disorders, or anxiety symptom that do not meet all the criteria for disorders. For all depressive and bipolar disorders, the presence of anxiety indicates a more severe condition, it makes suicidal thoughts and completed suicide more likely, and predicts poorer outcome for treatment. 3\. **Mixed Features Specifier.** - \- Predominantly depressive episodes that have several (at least 3) symptoms of mania would meet this specifier. Applies to both within MDD and Dysthymia. 4\. **Melancholic Features Specifier.** - \- applies only if the full criteria for a major depressive episode have been met, whether in the context of dysthymia or not. Includes severe somatic (physical) symptoms (early awakenings, weight loss, loss of libido, excessive or inappropriate guilt and anhedonia (diminished interest in pleasure in activities) 5\. **Catatonic Features Specifier.** - \- absence of movement (a stuporous state) or catalepsy, in which the muscles are waxy and semirigid, so a patients arms or legs remain in any position in which they are placed. May also involve excessive but random or purposeless movement. Was thought to be more commonly associated with schizophrenia. "end state" reaction to feelings of imminent doom. 6\. **Atypical Features Specifier.** - \- Most people suffer from less sleep and lose appetites, but with this specifier they consistently oversleep and overeat during depression and therefore gain weight, leading to higher incidences of Diabetes, they can react with interest or pleasure to some things unlike most depressed individuals. 7\. **Peripartum onset Specifier.** - \- Peri means "surrounding, in this case, the period of time just before and just after birth. Can apply to both depressive and Manic Episodes. 13-19% of women meet criteria for diagnosis of depression, referred to as Peripartum Depression. Higher incidence is found postpartum (after birth) than the period of pregnancy. Fathers may experience increase in depressive symptoms. "Baby Blues" or minor reactions in adjustment to childbirth typically last a few days in some women between 1-5 days of delivery, normal responses to the stresses of childbirth and disappear quickly and the peripartum onset specifier does not apply to them. 8\. **Seasonal Pattern Specifier.** - **Persistent Depressive Disorder (Dysthymia)** - Shares many symptoms with MDD but differs in its course. - May have fewer symptoms but depression remains relatively unchanged over long periods, sometimes 20-30 years or more. - Defined as depressed mood that continues and last 2 years during which the patient cannot be symptom free for more than 2 months at a given time even tough they may not experience all of the symptoms of a major depressive episode. - Considered more severe because it presents higher rates of comorbidity with other mental disorders, are less responsive to treatment, and show a slower rate of improvement over time. - Chronicity (versus nonchronicity) is the most important distinction in diagnosing depression independent of whether the symptom presentation meets criteria for a major depressive disorder, these 2 groups (chronic and nonchronic) seem different not only in course over time but also in family history and cognitive style. - Further specified depending on whether a major depressive episode is part of the picture or not. **Double Depression** - 22% of people suffering from Dysthymia eventually experienced a major depressive episode. - Individuals who suffer both from MDD and Dysthymia are said to have Double Depression. **Onset and duration** - Risk is fairly low (major depression) in early teens, when it begins to rise in a steady (linear) fashion. - Mean age of onset for MDD is 30 years. - Typical age of onset for PDD is early 20's, onset before 21 years are associated with 3 characteristics: (1) greater chronicity (it lasts longer), (2) relatively poor prognosis (response to treatment), (3) stronger likelihood of the disorder running in the family of affected individual. These indicate the insidiousness of the psychopathology in early onset of persistent depressive disorder. May last 20-30 years or more, median duration of 5 years in adults. **From Grief to Depression** - Sometimes individuals experience very severe symptoms requiring immediate treatment, such as full major depressive episode, perhaps with psychotic features, suicidal ideation, or severe weight loss, and so little energy that the individual cannot function. - Usually the natural grieving process has peaked within the first 6 months, some people grieve for a year or longer. The acute grief most of us would feel eventually evolves into Integrated grief in which the finality of death and its consequences are acknowledged and the individual adjusts to the loss. - When grief lasts beyond typical time, 6 months to a year or so, the chance of recovering from severe grief w/out treatment is significantly reduced, a normal process becomes a disorder, suicidal thoughts increase and mostly on joining the beloved disease. Ability to imagine events in the future is generally impaired. Difficulty regulating their own emotions, which becomes rigid and inflexible. Complicated grief may arise. **Acute Grief** - Recurrent strong feelings of yearning, wanting to be reunited with the dead person, possible with to die to be with the deceased loved one. - Pangs of deep sadness, remorse, episodes of crying, interspersed with periods of respite and even positive emotions. - Stream of thoughts or images of diseased, may be vivid or hallucinatory experience of seeing or hearing the deceased. - Struggle to accept reality of death, wishing to protest against it, feelings of bitterness or anger about death. - Somatic distress. - Disconnection from the world or other people, indifferent, not interested, or irritable with others. **Integrated grief** - Sense of having adjusted to the loss. - Interest and sense of purpose, ability to function, capacity for joy and satisfaction are restored. - Feelings of emotional loneliness may persist. - Feelings of sadness and longing tend to be back in the background but still present. - Thoughts and memories of the diseased person accessible and bittersweet but no longer dominate the mind. - Occasional hallucinatory experiences of the deceased may occur. - Surges of grief in response to calendar days or other periodic reminders of the loss may occur. **Complicated Grief** - Persistent symptoms of acute grief - Presence of thoughts, feelings, or behaviors reflecting excessive or distracting concerns about the circumstances or consequences of death. **PMDD or Premenstrual Dysphoric Disorder** - Some women experience PMS that, nevertheless, are not associated with impairment of functioning, whereas in PMDD, one can see a combination of physical symptoms, severe mood swings, and anxiety associated with incapacitation during this period of time, all of such evidences indicates that PMDD is a disorder of mood and not just a physical disorder. **DMDD or Disruptive Mood Dysregulation disorder** - The core feature of disruptive mood dysregulation disorder is chronic, severe persistent irritabihty. - This severe irritability has two prominent clinical manifestations, the first of - which is frequent temper outbursts. These outbursts typically occur in response to frustration and can be verbal or behavioral (the latter in the form of aggression against property, self, or others). They must occur frequently (i.e., on average, three or more times per week) over at least 1 year in at least two settings such as in the home and at school, and they must be developmentally inappropriate. - The second manifestation of severe irritability consists of chronic, persistently irritable or angry mood that is present between the severe temper outbursts. - This irritable or angry mood must be characteristic of the child, being present most of the day, nearly every day, and noticeable by others in the child\'s environment **Bipolar Disorders** - The key identifying feature for bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes in an unending roller coaster ride from the peaks of elation to the depths of despair. - The old term for bipolar is manic depressive. - Bipolar II disorder- major depressive episodes alternate with hypomanic episodes rather than full manic episodes. - Bipolar I disorder- same criteria, but the individual experiences a full manic episode. - Cyclothymic Disorder- similar in ways to dysthymia, like it, cyclothymic disorder is a chronic alternation of mood elevation and depression and does not reach the severity of manic or major depressive episodes. Individuals with such tend to be in one mood state or the other for years with relatively few periods of neutral (Euthymic) mood. **Bipolar I** - **Criteria have been met for at least one manic episode** - **The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.** - **Major Dep**ressive episodes alternate with full manic episode. - As in the criteria set for major depressive disorder, for the manic episodes to be considered separate, there must be a symptom-free period of at least 2 months between them, **Bipolar II** A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode. Criteria for a hypomanic episode are identical to those for a manic episode (see DSM-5 Table 7.2), with the following distinctions: 1\) Minimum duration is 4 days; 2\) Although the episode represents a definite change in functioning, it is not severe enough to cause marked social or occupational impairment or hospitalization; 3\) There are no psychotic features. B. There has never been a manic episode. C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychoticdisorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify current or most recent episode: Hypomanic: If currently (or most recently) in a hypomanic Episode Depressed: If currently (or most recently) in a major depressive episode **Cyclothymic Disorder** - The key identifying feature for bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes in an unending roller coaster ride from the peaks of elation to the depths of despair. - The old term for bipolar is manic depressive. - Bipolar II disorder- major depressive episodes alternate with hypomanic episodes rather than full manic episodes. - Bipolar I disorder- same criteria, but the individual experiences a full manic episode. - **Cyclothymic Disorde**r- similar in ways to dysthymia, like it, cyclothymic disorder is a chronic alternation of mood elevation and depression and does not reach the severity of manic or major depressive episodes. Individuals with such tend to be in one mood state or the other for years with relatively few periods of neutral (Euthymic) mood. A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met D. The symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreni- form disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With anxious distress - **Catatonic features specifier** - - **Rapid-cycling Specifier** - Unique specifier to Bipolar I and II disorders. - Some people move quickly in and out of depressive or manic episodes. - An individual w/ bipolar disorder who experiences at least four manic or depressive episodes within a year is considered to have a rapid-cycling pattern. - Appears to be a severe variety of bipolar disorder that does not respond well to standard treatments. - Higher possibilities of suicide attempts and severe episodes of depression compared to non-cycling groups. - Rapid cycling tends to increase in frequency over time and can reach severe states in which patients cycle between mania and depression w/out any break. When this happens, it is referred to as rapid switching or rapid mood switching, and it is particularly treatment-resistant form of the disorder. - Fortunately, rapid cycling does not seem to be permanent. **Psychological Dimensions** **Learned Helplessness** **Martin Seligman** - People become anxious and depressed when they decide that they have no control over the stress in their lives, these findings evolved into an important model called the learned helplessness theory of depression. - Depressive attributional style is (1) internal, in that the individual attributes negative events into personal failings ("it\'s all my fault"): (2) stable, inthat, even after a particular negative event passes, the attribution that "additional bad thigs will always be my fault" remains, and (3) global, in that the attributions extend across a variety of issues. **Negative Cognitive styles** - Aaron T. Beck (father of both cognitive therapy and cognitive behavioral therapy) suggested that depression may result from a tendency ton interpret everyday events in a negative way. - People with depression make the worst out of everything. - Beck classified the types of "Cognitive errors" that characterized all of the way of thinking of his depressed patients, from the long list he compiled, two representative examples namely arbitrary infence and overgeneralization. - Arbitrary inference is evident when a depressed individual emphasizes the negative rather than the positive aspects of a situation. - According to beck, people who are depressed think like this all the time. - They make cognitive errors in thinking negatively about themselves, their immediate world, and their future. all three areas together are called the Depressive Cognitive Triad. - In addition, he theorizzed, after a series of negative events in childhood, individuals may develop a deep seated negative schema. **Suicide** - More men commit suicide during old age - More women commit suicide during middle age. **Three important indices of Suicidal Behavior** - **Suicidal Ideation** - Seriously thinking about suicide. - **Suicidal Plans** - Formulation of a specific methods for killing oneself. - **Suicidal attempts** - The person survives. - Distinguish "attempters" (self-injurers with intent to die) from "gesturers" (self-injurers who intend not to die but to influence of manipulate somebody or communicate a cry for help. - Males commit suicide more often than females in most of the world, but female attempts at suicide is at least 3 times as often. **Causes** - Emile Durkheim defined a number of suicide types based on the social or cultural conditions in which they occured namely: - **Depending on how integrated we are to society:** - **Altruistic Suicide** - a "formalized" suicide that was approved of, such as the ancient custom of hara-kiri in Japan; the individual who brought dishonor to himself or his family was expected to impale himself on a sword. When social group involvement is too high, expecation from a grou\[p is being met at a very high level such as a sacrifice for a cult or religion (marta or a suicide bomber) - **Egoistic Suicide** - Loss of social supports as an important provocation for suicide. (older people who lose touch with their friends and family. Relates to the person being alone or an outsider and subsequently, they see themselves alone in the world. Low social interaction with others. - **How society is organized around you** - **Anomic Suicides** - result of marked disruption, such as the sudden loss of a high-prestige job. (Anomie is feeling lost and confused). Low degree of regulation, carried out during periods of considerable stress and frustration. - **Fatalistic Suicides** - results from a loss of control over one\'s own destiny. When people are kept under tight regulation such as in north korea. Where there is extreme rule in order or high expectations set upon a person or people in which leads them to a sense of a sense of no self or individuality. **Is Suicide Contagious?** Short answer is yes Suicides are often romanticized in media **Somatic Symptom and Related Disorder** **Five basic somatic symptom and related disorders:** 1. **Somatic symptom disorder** 2. **Illness anxiety disorder** 3. **Psychological factors affecting medical condition** 4. **Conversion disorder** 5. **Factitious disorder** **The first three (somatic symptom disorder, illness anxiety disorder, and psychological factors affecting medical condition) overlap considerably since each focuses on a specific somatic symptom, or set of symptoms, about which the patient is so excessively anxious or distressed and it interferes with functioning.** 1. **Somatic Symptom Disorder** - Formerly Briquet's syndrome. - Somatic symptom is characterized by an extreme focus on physical symptoms (pain or fatigue) which causes major distress and problems in functioning. - Problems preoccupying people seem initially, to be physical disorders. - Individuals with somatic symptom disorder have multiple, current, somatic symptoms that are distressing or result in significant disruption of daily life. Symptoms may be specific (localized pain) or relatively nonspecific (fatigue). - People with this do not usually feel the urgency to take action but continually feel weak and ill, and they avoid exercising, thinking it will make them worse. - A common example would be the experience of severe pain in which psychological factor plays a role in maintaining or exacerbating the pain whether there is a clear physical reason for the pain or not. - In some cases, the important factor is not whether the physical symptom has a clear medical cause or not, but rather that psychological behavioral factors, particularly anxiety and distress, are making up the severity and impairment associated with the physical symptoms - An important featuer of these physical symptoms is that it is real and it hurts whethere there are clear physical reasons or not 2. **Illness Anxiety Disorder** - Formerly known as "hypochondriasis" - Physical symptoms are either not experienced at the present time or are very mild, but severe anxiety is focused on the possibility of having or developing a serious disorder. - The concern is primarily with the idea of being sick instead of the physical symptom itself. - The threat seems so real that reassurance from physicians does not seem to help. - Research suggests that Somatic symptom disorder and illness anxiety disorder share many features with the anxiety and mood disorders particularly the panic disorder. - Somatic symptom disorder and illness anxiety disorder are characterized by anxiety or fear that one has a serious disease. The essential problem is anxiety, but its expression is different from that of anxiety disorders. - Reassurance from doctors only have short-term effects because many of such individuals mistakenly believe they have a disease, a difficult-to shake belief sometimes referred to as "disease conviction" **Panic Disorder vs Somatic Symptom Disorder** Somatic Symptom Disorder -focus on long term process of illness and disease (Cancer or AIDS) \- Most don't stop seeing doctors even if reassured Panic attack -fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack -panic patients continue to believe that their panics might kill them, but most learn rather quickly to stop going to doctors and emergency rooms. -focuses on the specific set of 10-15 sympathetic nervous symptoms associated with panic attacks 3. **Psychological Factors Affecting Medical Condition** - The presence of a diagnosed medical condition (Asthma, diabetes, cancer) is adversely affected (increased severity or frequency) by one or more psychological or behavioral factors. - Example: Anxiety severe enough to clearly worsen an asthmatic condition. 4. **Conversion Disorder (Functional Neurological Symptom Disorder)** - Anxiety resulting from unconscious conflicts somehow was "converted" into physical symptoms to find expressions, according to freud. - Freud used the term conversion hysteria for these disorders (which were fairly common in his practice) because he believed that the symptoms were an expression of repressed sexual energy---that is, the unconscious conflict that a person felt about his or her repressed sexual desires. However, in Freud's view, the repressed anxiety threatens to become conscious, so it is unconsciously converted into a bodily disturbance, thereby allowing the person to avoid having to deal with the conflict. not done unconsciously. - Freud also thought that the reduction in anxiety and intrapsychic conflict was the "primary gain" that maintained the condition, but he noted that patients often had many sources of "secondary gain" as well, such as receiving sympathy and attention from loved ones. - the primary gain for conversion symptoms is continued escape or avoidance of a stressful situation. Because this is all unconscious (i.e., the person sees no relation between the symptoms and the stressful situation), the symptoms go away only if the stressful situation has been removed or resolved. Relatedly, the term secondary gain, which originally referred to advantages that the symptom(s) bestow beyond the "primary gain" of neutralizing intrapsychic conflict, has also been retained. Generally, it is used to refer to any "external" circumstance, such as attention from loved ones or financial compensation, that would tend to reinforce the maintenance of disability. - "Functional" refers to a symptom without an organic cause. Freud identified four basic processes: 1. The individual experiences a traumatic event (Freud defines it as an unacceptable, unconscious conflict.) 2. Because the conflict and the resulting anxiety are unacceptable, the person represses the conflict making it unconscious 3. The anxiety continues to increase and threatens to emerge into consciousness. The person "converts" it into physical symptoms. The reduction of anxiety is called primary gain or the reinforcing event that maintains the symptom 4. 4\. The individual receives greatly increased attention and sympathy from loved ones and may avoid responsibilities. Secondary gain. Freud was basically correct on at least the first three but not the fourth. - Most often the individuals have experienced a traumatic event that must be escaped at all cost. - Adolescents with conversion disorder were more likely to have experienced significant stress and adjustment difficulties, such as school or the loss of a significant figure. - They rated their mother as overinvolved and overprotective (pwede sa etiology) - Tends to occur in less educated, lower socioeconomic groups. - Generally have to do with physical malfunctioning, such as paralysis, blindness, or aphonia (difficulty speaking) without any physical or organic pathology accounting for the malfunction. Additional effects may be total mutism and the loss of the sense of touch. - Develops in adolescence or early adulthood typically after a life stressor Four categories of symptoms: \(1) sensory - Today the sensory symptoms or deficits are most often in the visual system (especially blindness and - tunnel vision), in the auditory system (especially deafness), or in the sensitivity to feeling (especially the anesthesias). In the anesthesias, the person loses her or his sense of feeling in a part of the body. One of the most common is glove anesthesia, in which the person cannot feel anything on the hand in the area where gloves are worn \(2) motor - The most common speech-related conversion disturbance is aphonia, in which a person is able to talk only in a whisper although he or she can usually cough in a normal manner. (In true, organic laryngeal paralysis, both the cough and the voice are affected.) Another common motor symptom, called globus hystericus, is difficulty swallowing or the sensation of a lump in the throat \(3) seizures - involve pseudoseizures, which resemble epileptic seizures in some ways but can usually be fairly well differentiated via modern medical technologyMoreover, patients with conver\_x0002\_sion seizures often show excessive thrashing about and writhing not seen with true seizures, and they rarely injure themselves in falls or lose control over their bowels or bladder, as patients with true seizures frequently do. \(4) a mixed presentation of the first three categories. - Early observations dating back to Freud suggested that most people with conversion disorder showed very little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight. This seeming lack of concern (known as la belle indifférence---French for "the beautiful indifference") in the way the patient describes what is wrong was thought for a long time to be an important diagnostic criterion for conversion disorder. However, more careful research later showed that la belle indifférence actually occurs in only about 20 percent of patients with conversion disorder, so it was dropped as a criterion - Dating back since the greeks (Hysteria); the Conversion disorder was one of the several disorders grouped together under the term hysteria. 5. **Malingering and Factitious Disorders** **Malingering (faking)** - In malingering, a person intentionally fakes a symptom to avoid a responsibility, such as work or military duty, or to achieve some goal, such as being awarded an insurance settlement. Often, malingering has a clear potential for reward; this is in contrast to factitious disorder, where the sole goal often seems to be to adopt the patient role. - To distinguish between malingering and functional neurological disorder, clinicians try to determine whether the symptoms have been consciously or unconsciously adopted; in malingering, the symptoms are under voluntary control, which is not thought to be the case in functional neurological disorder. **Factitious disorders**- - falls somewhere between malingering and conversion disorders. Symptoms are under voluntary control but have no obvious reason for voluntarily producing the symptoms except for possibly assuming a sick role and receive increased attention. - \- In factitious disorder, people intentionally produce physical symptoms (or sometimes psychological ones) to assume the role of a patient. They may make up symptoms---for example, reporting acute pain. Some will take extraordinary measures to make themselves ill. They may injure themselves, take damaging medications, or inject themselves with toxins. - Factitious disorders may extend to other members of the family. Example: a mother may purposely make her child sick, evidently for the attention and pity given to her as the mother of the sick child. - When an individual deliberately makes someone else sick, the condition is called "factitious disorder imposed on another" or Munchausen syndrome by proxy - Factitious disorder may also be diagnosed in a parent who creates physical illnesses in a child; in this case it is called factitious disorder imposed on another or Munchausen syndrome by proxy **Dissociative disorders** **Depersonalization-derealization disorder** **Dissociative amnesia** **Localized** **Generalized** **Dissociative fugue** **Dissociative identity disorder** - the mild sensations that most people experience occasionaly are slight alterations, or detachments in consciousness or identity are called dissociation or dissociative experiences. They are considered normal, but some people experience them so intensely that they lose thier identity entirely and assume a new one, or they lose their memory or sense of reality and are unable to function. - Dissociative disorders are a group of conditions involving disruptions in a person's normally integrated functions of consciousness, memory, identity, or perception (APA, 2013; Spiegel et al., 2013). Included here are some of the more dramatic phenomena in the entire domain of psychopathology: people who cannot recall who they are or where they may have come from, and people who have two or more distinct identities or personality states that alternately take control of the individual's behavior. - The term dissociation refers to the human mind's capacity to engage in complex mental activity in channels split off from, or independent of, conscious awareness. - Dissociation only becomes pathological when the dissociative symptoms are "perceived as disruptive, invoking a loss of needed information, as producing discontinuity of experience"or as "recurrent, jarring involuntary intrusions into executive functioning and sense of self" - The concept of dissociation was first promoted over a century ago by the French neurologist Pierre Janet - automatic nonconscious processes that are to a large extent autonomous with respect to deliberate, self-aware direction and monitoring. Such unaware processing extends to the areas of implicit memory and implicit perception, where it can be demonstrated that all persons routinely show indirect evidence of remembering things they cannot consciously recall (implicit memory- an experiential or functional form of memory that cannot be consciously recalled) and respond to sights or sounds as if they had perzceived them (as in conversion blindness or deafness) even though they cannot report that they have seen or heard them (implicit perception) - Like somatic symptom disorders, dissociative disorders appear mainly to be ways of avoiding anxiety and stress and of managing life problems that threaten to overwhelm the person's usual coping resources. Both types of disorders also enable the individual to deny personal responsibility for his or her "unacceptable" wishes or behavior. In the case of DSM-defined dissociative disorders, the person avoids the stress by pathologically dissociating---in essence, by escaping from his or her own autobiographical memory or personal identity. - When individuals feel detached from themselves or their surroundings, almost as if they are dreaming or living in slow motion, they are having dissociative experiences. - Most likely to happen after an extremely stressful event, when tired or sleep deprived. 1. **Depersonalization-Derealization Disorder** - **Depersonalization** - Your perception alters so that you temporarily lose the sense of your own reality, as if you were in a dream and you were watching yourself. - **Derealization** - Your sense of reality of the external world is lost - e.g. things may seem to chnge shape or size These sensations of unreality are characteristics of the dissociative disorders because, in a sense, they are a psychological mechanism where one "dissociates" from reality. 2. **Dissociative Amnesia** - Amnesic episodes usually last between a few days and a few years. Although many people experience only one such episode, some people have multiple episodes in their lifetimes. - In typical dissociative amnesic reactions, individuals cannot remember certain aspects of their personal life history or important facts about their identity. Yet their basic habit patterns---such as their abilities to read, talk, perform skilled work, and so on---remain intact, and they seem normal aside from the memory deficit. - Thus the only type of memory that is affected is episodic (pertaining to events experienced) or autobiographical memory (pertaining to personal events experienced). The other recognized forms of memory---semantic (pertaining to language and concepts), procedural (how to do things), and short-term storage---seem usually to remain intact, although there is very little research on this topic. - Easiest to understand of sever dissociative disorder - The holes in memory are too extensive to be explained by ordinary forgetfulness. The information is not permanently lost, but it cannot be retrieved during the episode of amnesia, which may last for as short a period as several hours or as long as several years. The amnesia usually disappears as suddenly as it began, with complete recovery and only a small chance of recurrence. **\ Generalized Amnesia** \- People who are unable to remember anything, including who they are. May be lifelong or may extend from a period in the more recent past such as 6 months or a year previously. **Localized Amnesia** \- Failure to recall specific events, usually traumatic, that occur during a specific period. **Dissociative Fugue** - Fugue literally means "flight" - Memory loss revolves around a specific incident- an unexpected. - Most individuals just take off and later find themselves in a new place, unable to remember how they got there. - During these trips, a person sometimes assumes a new identity or at least becomes confused about the old identity - Usually ends abruptly, and the individual returns home, recalling most, if not all, of what happened. - It is more than memory loss since it involves at least some disintegration of identity, if not, an adoption of a new one. - In rare cases a person may retreat still further from real-life problems by going into an amnesic state called a dissociative fugue, which, as the term implies (the French word fugue means "flight"), is a defense by actual flight---a person is not only amnesic for some or all aspects of his or her past but also departs from home surroundings. - This is accompanied by confusion about personal identity or even the assumption of a new identity (although the identities do not alternate as they do in dissociative identity disorder). During the fugue, such individuals are unaware of memory loss for prior stages of their life, but their memory for what happens during the fugue state itself is intact. - Fugue states usually rather end abruptly, and the individual returns home, recalling most, if not all, of what happened. - Quite common during war. - In most cases of dissociative amnesia, forgetting is selective for traumatic events or memories rather than generalized. - Seldom appears before adolescence. - More common in women and is often associated with stress or trauma. - A distinctive dissosiative state found not only in western cultures is called amok (as in "running amok"). Individuals in this trancelike state often brutally assault and sometimes kill people or animals. if the person is not killed himself, he will probably not remember the episode. it is only one of a number of "Running syndromes" (prevalence of running disorders is somewhat greatr in women as with most dissociative disorders.) - Among native peoples of the artic, running disorder is termed pivloktoq. Among the Navajo tribe, it is called frenzy witchcraft. **Diagnosing** In diagnosing dissociative amnesia, it is important to rule out other common causes of memory loss, such as dementia and substance abuse. Dementia can be fairly easily distinguished from dissociative amnesia. In dementia, memory fails slowly over time, is not linked to stress, and is accompanied by other cognitive deficits, such as an inability to learn new information. Memory loss after a brain injury or substance abuse can be linked to the time of the injury or substance use. **Onset** Seldom appears bere adolescence and usually occurs in adulthood. rare to appear for the first time after an individual reaches the age of 50. 3. **Dissociative Identity Disorder** - People may adopt as many as 100 new identities. Average is closer to 15. - It is not true that there are "multiple" complete personalities so the name of the disordr was changed from multiple personality disorders to DID. - **Alters**- shorthand term for the different identities in DID - Diagnostic criteria includes amnesia, as in dissociative amnesia. - The person who becomes the patient and asks for treatment is usually a "host" identity. - The first personality to seek treatment is seldom the original personality of the person - **Switch**- the transition of one personality to another - A college student could simulate an alter if it was suggested that faking was plausible. - Patients with DID acted more like simulators concerning other identities, about which they profess no memory (interidentity amnesia), suggests the possibility of faking. **Causes** - Almost every patient reports being horribly, often unspeakably, abused as a child. - One thing a child could do in such situations is to escape into a fantasy world; they can be somebody else. - Not all trauma is caused by abuse. - DID is rooted in a natural tendency to escape or "dissociate" from the unremitting negative affect associated with abuse. Lack of social support seems to be implicated. - DID seems similar in its etiology to post traumatic stress disorder, but remember that not everyone experience PTSD after severe trauma. - One perspective suggests that DID is an extreme subtype of PTSD. Emphasis is on the process of dissociation than on symptoms of anxiety. - Etiology of DID Almost all patients with DID report severe childhood abuse. There is also evidence that children who are abused are at risk for developing dissociative symptoms, although whether these symptoms reach diagnosable levels is not clear (Chu, 2000). - There are two major theories of DID: the posttraumatic model and the sociocognitive model. Despite their confusing names, both theories actually suggest that severe physical or sexual abuse during childhood sets the stage for DID. - The posttraumatic model proposes that some people are particularly likely to use dissociation to cope with trauma, and this is seen as a key factor in causing people to develop alters after trauma. - The other theory, the sociocognitive model, considers DID to be the result of learning to enact social roles. According to this model, alters appear in response to suggestions by therapists, exposure to media reports of DID, or other cultural influences. **Autohypnotic model** - people who are suggestible may be able to use dissociation as a defense against extreme trauma **An Overview of Personality Disorders** - When personality characteristics interfere with relationship with others, cause the person distress, or in general disrupt activities of daily living, we consider these to be "personality disorders." - Unlike many of the disorders, personality disorders are chronic; they do not come and go but originate in childhood and continue throughout childhood. - A personality disorder is a persistent pattern of emotions, cognitions, and behavior that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships. - Having a personality disorder may distress the affected person, however, individuals with personality disorders may not feel any subjective distress, in fact, it may be others who acutely feel distressed because of the actions of the person with the disorder which is particularly common with antisocial personality disorder - One factor important to the success of treatment is how the therapist feels about the client. The emotions of therapist brought about by clients (countertransference) tend to be negative for those diagnosed with personality disorders, especially those in Cluster A (odd or eccentric cluster) and Cluster B (the dramatic, emotional, or erratic cluster) - Prior to DSM-5, The personality disorders were included in Axis II. **Categorical and Dimensional Models** - The problems with personality disorder lies in the degree rather than the kind of qualities the people posses. The problems of people with personality disorders may just be extreme versions of the problems many of us experience temporarily such as being shy or suspicious. - The issue that continues to be debated in the field is whether personality disorders are extreme versions of otherwise normal personality variations (Dimensions) or ways of relating that are different from psychologically healthy behavior (Categories) **Personality Disorder Clusters** **Cluster A - The odd or eccentric cluster** - **Paranoid personality disorder** - **Schizoid** - **Schizotypal** **Cluster B -The dramatic, emotional, or erratic clusters.** - **Antisocial** - **Borderline** - **Histrionic** - **Narcissistic** **Cluster C - Anxious or fearful cluster.** - **Avoidant** - **Dependent** - **Obsessive-compulsive** **Statistics and Development** - Gathering the prevalence of personality disorders is difficult and varies a great deal because many people with these problems do not seek help on their own. - Gender differences in the disorders - More women diagnosed with borderline personality disorder - More men identified with antisocial personality disorder. - Personality disorders were thought to originate in childhood and continue into the adult years. - Analyses suggest that personality disorders could remit over time, however, they may be replaced by other personality disorders. **Gender Differences** - Men diagnosed with a personality disorder tend to display traits characterized as more aggressive, structured, self-assertive, and detached and women tend to present with characteristics that are more submissive, emotional, and insecure. - There exists a gender bias especially when it comes to histrionic personality disorder as the disorder exhibits characteristics such as excessive emotionality and attention seeking which is more common among females. - The "macho" personality in which the individual possesses stereotypically masculine traits, is nowhere to be found in the DSM. **Independent personality disorder** - Puts work above relationships with loved ones. - Reluctant to take account other's needs when making decisions, especially concerning the individual's career or use of leisure time. - Passively allows others to assume responsibility for major areas of social life because of inability to express necessary emotion. **Personality Disorder Under Study** - Other personality disorders have been studied for inclusion in the DSM for example: - The existence of these disorders remain controversial so they were not included in DSM-5 Paranoid - "I cannot trust people" Schizotypal - "it's better to be isolated from others" Schizoid- "relationships are mess, undesirable" Histrionic - "people are there to serve or admire me" Narcissistic - "since I am special, I deserve special rules" Borderline - "I deserve to be punished" Antisocial - "I am entitled to break rules" Avoidant - "if people knew the "real" me, they will reject me" Dependent - "I need people to survive, be happy" Obsessive-Compulsive - "people should do better, try harder" **Cluster A personality Disorder** - Three personality disorders share common features that resemble some of the psychotic symptoms seen in schizophrenia. **Paranoid Personality Disorder** - Being a little wary of other people and their motives can be adaptive, but being too distrustful can interfere with making friends, working with others, and, in general, getting through general interactions in afunctional way. - People with Paranoid personality disorder are excessively mistrustful and suspicious, without any justification. - They assume other people are out to harm or trick them; therefore, they tend not to confide in others. - The defining characteristic is a pervasive unjustified distrust. - Even events that have nothing to do with them are interpreted as personal attacks. - People with this personality disorder may either be argumentative, may complain, or may be quiet. - These individuals are sensitive to criticism and have excessive need for autonomy. - Increases the risk of suicide, and these people tend to have a poor overall quality of life. **Causes of Paranoid Personality Disorder** **Limited biological contributions.** - Strong role for genetics. **Psychological contributions are even less certain.** - Early mistreatment or traumatic childhood experiences may play a role in the development of personality disorder, although caution is warranted when interpreting these results, because there may be strong bias in the recall of these individuals who are already prone to viewing the world as a threat. - Schemas of personality disorder is thought to be able to explain the behavior of people with this disorder. "people are malevolent and deceptive," "they'll attack you if they get the chance," and "you can be okay only if you stay on your toes," these maladaptive way to view the world pervades every aspect of the lives of these individuals. **Cultural Factors** - Certain groups of people, such as prisoners, refugees, people with hearing impairments, and older adults, are thought to be particularly susceptible because of their unique experiences. **Treatment of Paranoid Personality Disorder** - They are unlikely to seek professional help. When they do, the trigger is usually a crisis in their lives, or other problems such as anxiety or depression, not necessarily the personality disorder. - Establishing a meaningful therapeutic alliance between the client and the therapist becomes an important fist step. - The therapist often use cognitive therapy to counter the person's mistaken assumptions bout others, focusing on changing the person's beliefs that all people are malevolent and most people cannot be trusted. - However, there are no confirmed demonstrations that any form of treatment can significantly improve the lives of people with paranoid personality disorder to date. - Only 11% of the therapists who treat them thought these individuals would continue long enough to be helped. **Schizoid Personality Disorder** - Do you know someone who is a loner? Someone who would choose a solitary walk over an invitation to a party? A person who comes to class alone, sits alone, and leaves alone? Now magnify this preference for isolation and you can begin to grasp the impact of Schizoid Personality Disorder. - Shows a pattern of detachment from social relationships and a limited range of emotions in interpersonal situations. - They seem aloof, cold, and indifferent to other people. - Schizoid, a term used by Bleuler, describe people who have a tendency to turn inward and away from the outside world. They lack emotional expressiveness and pursued vague interests. - Seem neither to desire nor to enjoy closeness with others, including romantic or sexual relationships. - They appear cold and detached and do not seem affected by praise or criticism. - One of the changes I the DSM-IV-TR was the recognition that at least some people with schizoid are sensitive to the opinion of others but are unwilling or unable to express this emotion. For them, isolation may be extremely painful. - Homelessness appears to be prevalent among them. - The social deficiencies are similar to those of people with paranoid personality disorder, although they are more extreme. - They "consider themselves to be observers, rather than participants in the world around them." - They do not have unusual thought processes that characterize other disorders in cluster A. For example, people with schizotypal personality disorders often have ideas of reference, mistaken beliefs that meaningless events relate just to them. In contrast, those with schizoid personality disorder share the social isolation, poor rapport, and constricted affect (neither positive or negative emotion) seen in people with paranoid personality disorder. **Causes** - Childhood shyness is reported as a precursor to later adult schizoid personality disorder. - Abuse and neglect in childhood are also reported. - Parents of children with autism are more likely to have schizoid personality disorder. - It is possible that a biological dysfunction found in both autism and schizoid personality disorder combines with early learning or early problems with interpersonal relationships to produce the social deficits that define schizoid personality disorder. **Treatment** - It is rare for people with this disorder to request treatment except in response to a crisis such as extreme depression or losing a job. - Therapists often begin treatment pointing out the value in social relationships. - The person may be taught the emotions felt by others to learn empathy. - Social skills training. - The therapists take the part of a friend or significant other in a technique known as role-playing and helps the patient practice establishing and maintaining social relationships. **Schizotypal Personality Disorder** - Typically socially isolated, like those with schizoid, in addition, they also behave in ways that would seem unusual to many of us, and they tend to be suspicious and to have odd beliefs. - Considered by some to be on a continuum (on the same spectrum) with schizophrenia but without the more debilitating symptoms, such as hallucinations and delusions. Because of this close connection, DSM-5 includes this disorder under both the heading of a personality disorder and as well as under the heading of a schizophrenia spectrum disorder. - Have psychotic-like (but not psychotic) symptoms (such as believing everything relates to them personally), social deficits, and sometimes cognitive impairments or paranoia. - These individuals are often considered odd or bizarre because of how they relate to other people, how they think and behave, and how they dress. - They have ideas of reference. People with schizophrenia also have ideas of reference, however, they are usually not able to "test reality" or see the illogic of their ideas. - Odd beliefs or engage in "magical thinking," believing, for example, that they are clairvoyant or telepathic. - Notice the subtle but important difference between feeling as if someone else is in the room and the more extreme perceptual distortion of people with schizophrenia who might report there is someone else in the room when there isn'. - Clinicians must be aware that different cultural beliefs or practices may lead to a mistake in diagnosis of this disorder. **Causes** - Historically, Schizotype was used to describe people who were predisposed to develop schizophrenia. - Some people are thought to have the schizophrenia genes (the genotype), yet because of the relative lack of biological influences (prenatal illnesses) or environmental stresses (e.g., poverty, maltreatment), some will have the less severe schizotypal personality disorder. - Genetic research also seems to support a relationship between schizophrenia and schizotype. - Environment can also strongly influence schizotypal personality disorder. Some research suggests that schizotypal symptoms are strongly associated with childhood maltreatment among men, and this childhood maltreatment seems to result in posttraumatic stress disorder symptoms among women.. - Using magnetic resonance, generalized brain abnormalities can be observed. - Cognitive assessment points to mild to moderate decrement in the ability to perform on tests involving memory and learning, suggesting some damage in the left hemisphere of the brain. **Treatment** - 30-50 percent of those with this disorder met the criteria for major depressive disorder. - A combination of approaches including antipsychotic medication, community treatment (a team of support professionals providing therapeutic services), and social skills training to treat the symptoms experienced by individuals with this disorder. - This combination of approaches either reduced symptoms or postponed the onset of later schizophrenia. **Cluster B Personality Disorder** **Antisocial Personality Disorder** - "social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a trail of broken hearts, shattered expectations and empty wallets. Completely lacking in conscience and empathy, they take what they want and do as they please, violating social norms without the slightest sense of guilt or regret." - Philippe Pinel first identified it as a "medical" problem **Clinical Description** Tend to have long histories of violating the rights of others. - Often described as being aggressive because they take what they want, indifferent to the concerns of other people. - Lying and cheating seem to be second nature to them, and often they appear unable to tell the difference between the truth and the lies they make up to further their own goals. - Substance abuse is common, occurring in 60% of the people with antisocial personality disorder, and appears to be a lifelong pattern among these individuals. - PCP or angel dust was mentioned in the case - Long-term outcome is usually poor regardless of gender. - Philippe Pinel identified what he called manie sans delire (mania without delirium) to describe people with unusual emotional response and impulsive rages but no deficits in reasoning ability. - Moral insanity, egopathy, sociopathy, and psychopathy. - There continues to be a debate if psychopathy and antisocial personality disorder really are two distinct disorders. **Defining Criteria** - **Cleckley Criteria** developed by Hervey Cleckley identifies 16 major characteristics of psychopathic personality. - Robert hare and his colleagues, building on the descriptive works of cleckley researched the nature of psychopathy and developed a 20 item checklist that serves as an assessment tool. Six criteria that hare includes in his Revised **Psychopathy Checklist** (PCL-R) are as follows: 1. Glibness/superficial charm 2. Grandiose sense of self-worth 3. Pathological lying 4. Conning/manipulative 5. Lack of remorse or guilt 6. Callous/lack of empathy. **Antisocial Personality Disorder and Criminality** - Some psychopaths have few or no legal or interpersonal difficulties. In other words, some psychopaths are not criminals and some do not display outward aggressiveness that was included in the DSM-IV-TR criteria for Antisocial personality disorder. - Intelligence Quotient may be the possible cause of the discrepancies. Low IQ means higher risk for getting in trouble, whereas having a higher IQ may help protect some people from developing more serious problems, or may at least prevent them from getting caught. **Conduct Disorder** - Children who engage in behaviors that violate society's norms. - Two subtypes - Childhood-onset type (onset of at least one criterion characteristic of CD prior to the age of 10) - Adolescent-onset type (absence of any criteria characteristic of CD prior to age 10 years) - "with callous-unemotional presentation" an additional subtype. This designation is an indication that the young persons presents in a way that suggests personality characteristics similar to an adult with psychopathy. - Most often diagnosed in boys -- become juvenile offenders and tend to become involved with drugs. - The likelihood of an adult having antisocial personality disorder or psychopathy had conduct disorder as children and increases if, as a child, he or she had both conduct disorder and ADHD. **Genetic Influences** - Family, twin, and adoption studies all suggest a genetic influence on both antisocial personality disorder and criminality. - Gene-Environment Interaction **Neurobiological Influences** - General brain damage does not explain why some people become psychopaths or criminals; these individuals appear to score as well on neuropsychological tests as the rest of us. **Arousal Theories** Emphasized two hypotheses: - **Underarousal hypothesis** - Psychopaths have abnormally low levels of cortical arousal. They seek stimulation to boost their chronically low levels of arousal. - **Fearlessness hypothesis** - Psychopaths possess a higher threshold for experiencing fear than most other individuals. Things that greatly frighten normal people have little effect on the psychopath. - J**effrey Gray's Model of Brain Functioning** - There are three major brain systems that influence learning and emotional behavior: - Behavioral inhibition system - Reward system - Fight/Flight system - The BIS and the Reward system have been used to explain the behavior of people with psychopathy. **Psychological and Social Dimensions** - Once psychopaths set their sights on a reward goal, they are less likely than nonpsychopaths to be deterred than non psychopaths despite the signs the goal is no longer achievable. - Aggression in children with antisocial personality disorder may escalate partly as a result of their interactions with their parents. **Developmental Influences** - as children move into adulthood, the forms of antisocial behaviors chang - from truancy and stealing from friends to extortion, assaults, armed robbery, or other crimes. - The rates of antisocial behavior begins to decline rather markedly around the age of 40 though it remains unanswered why. **An integrative Model** - These people have a genetic vulnerability to antisocial behaviors and personality traits, genetics may lead to differences in neurotransmitter and neurohormone (dopamine and serotonin) function that influences aggressiveness, as well as differences in neurohormone (cortisol) function that affects the way people deal with sterss; these brain differences may lead to personality traits such as callousness, impulsivity, and aggressiveness that characterize people eiwht psychopathy. - One potential gene-environment interaction may be seen in the role of fear conditioning in children. Genetic influences interact with environmental influences (learning to fear threats) to produce adults who are relatively fearless and therefore engage in behaviors that cause harm to themselves and others. - The importan element is that in this integrative model of antisocial behavior, biological, psychological, and cultural factors combine in intricate ways to create a person with antisocial personality disorder. **Treatment** - One of the major problems with treating people in this group typical of numerous personality disorders is that they rarely identify themselves as needing treatment. - They can be manipulative even with their therapists, most clinicians are pessimistic about the outcome of treatment for adults who have antisocial personality disorder, and there are few documented success stories. - Therapists agree with incarcerating these people to defer future antisocial acts. - Clinicians encourage the identification of high-risk children so that treatment can be attempted before they become adults. - Cognitive behavioral therapy can reduce the likelihood of violence 5 years after treatment. - The most common treatment strategy for children involves parent training. Parents are taught recognize behavior problems early and to use praise and privileges to reduce problem behavior and encourage prosocial behavior. Successful treatment can be hindered because of high degrees of family dysfunction, socioeconomic disadvantage, high family stress, a parent\'s history of antisocial behavior, and severe conduct disorder on part of the child. **Prevention** - Early interventions. **Borderline Personality Disorder** - People often lead tumultuous lives. - Their moods and relationships are unstable, and usually they have a poor self- image. - They often feel empty and are at great risk of dying by their own hands. **Clinical Description** - One of the most common personality disorders observed in clinical settings. Obeserved in every culture and is seen about 1-2% of the general population. - Turbulent relationships, fear of abandonment but lacking control over their emotions. They often engage in suicidal behaviors, self-mutilative, or both, cutting, burning, or punching themselves. - 6% succeed at suicide. - On the positive side, long-term outcome is encouraging, with up to 88% achieving remission more than 10 years after initial treatment. - Often intense, from anger depression in a short time. - The core feature is dysfunction in the area of emotion. - The characteristic instability is seen as a core feature with some describing this group as being "stably" unstable, this instability extends to impulsivity (drug abuse and self-mutilation) - Cutting sometimes are described as tension-reducinb by people who engage in these behaviors. - Chronically bored and have difficulties with own identitiy. - Mood disorders are common with 20% having major depression and 40% having bipolar. - Eating disorders are fairly common, 25% of bulimics have borderline personality disorder. - 6% is diazgnosed with at least once substance use disorder. - Like Antisocial personality disorder, They tend to improve during their 30\'s and 40\'s though they may continue to have difficulties in old age. **Causes** - More prevalent in families with the disorder and somehow linked with mood disorders. - Emotional reactivity may be an inherited influence. - Important genetic studies are investigating genes associated with the neurochemical serotonin because dysfunction n this system has been linked to the emotionalinstability, suicidal behavior, and impulsivity seen in people with this disorder. - Elevated tendency to experience shame was associated with low self-esteem, low quality of life, and high levels of anger and hostility. Shame has also been found to be related to self-inflicted injury. - An important environmental risk factor in gene-environment interaction explanation for the disorder is the possible contribution of early trauma, especially sexual and physical abuse. - Observed in people who have gone through rapid cultural changes. The problems of identity, emptiness, fears of abandonment and low anxiety threshold have been found in children and adult immigrant. - Although sexual and physical abuse seems to play an important role int the etiology of the disorder, neither appears to be necessrayof sufficent to produce the syndrome. **An integrative Model** - There is currently no accetpted integrative model for this disorder. - It is tempting though, to borrow from the work on anxiety disorders to outline a posible view. - The triple vulnerability theory - First vulnerability (or diathesis) is a generalized **biological vulnerability.** - Emotional Reactivity. - Generalized **Psychological vulnerability.** - Tendency to view the world as threatening and react strongly to real and perceived threaths. - **Specific Psychological vulnerability** - Learned from early environmental experiences: where early trauma, abuse, or both may advance this sensitivity to threats. - When a person is stressed, he/she becomes overly reactive (biological tendency) and this interacts with the psychological tendency to feel threatened which may result in outbursts and sucicdal behaviors. **Treatment** - In contrast to those with antisocial personality disorder, who rarely acknowledge requiring help, they appear quite distressed and are more likely to seek treatment even than people with anxiety and mood disorders. - Mood stabilizers can be effective. - Treatment are complicated by problems with drug abuse, compliance with treatment, and suicide attempts, as a result, clinicians are reluctant to work with them. - Dialectical Behavioral Therapy (DBT) (Marsha Linehan) involves helping people cope with the stressors that seem to trigger suicidal behaviors. - DBT may help reduce suicide attempts, dropouts from treatment, and hospitalizations. **Histrionic Personality Disorder** - They tend to be overly dramatic and often seem almost to be acting, which is why they use the term histrionic, which means theatrical in manner. - Inclined to express their emotions in an exaggerated fashion. (hugging someone they have just met or crying uncontrollably during a sad movie. - They tend to be vain, self-centered, and uncomfortable when they are not in the limelight. - Often seductive in their appearance and behavior, and they are typically concerned about their looks. - They seek reassurance and approval constantly and may become upset aor angry when others do not attend to them or praise them. - They also tend to be impulsive and have great difficulty delaying gratification. - Cognitive style is impressionistic, characterized by a tendency to view situations in global, black-and-white terms. - Speech is often vague, lacking in detail, and characterized by exaggeration. **Causes** - Despite its long history, little research has been done on the causes or treatment of histrionic personality Disorder. - One hypothesis involves a possible relationship with antisocial personality disorder, evidence suggests that histrionic and antisocial personality co-occur more often than chance would account for. - 2/3 of people with histrionic personality also met criteria for personality disorder. - The association has led to the suggestion that histrionic and antisocial personality may be sex-typed alternative expressions of the same unidentified underlying condition. Females more on histrionic and males more on antisocial. **Treatment** - Modification of the attention-getting behavior. - Large part of therapy focused on interpersonal problems, people with histrionic personalities ofen manipulte others through emotional crises, using charm, sex, seductiveness, or complaining. - They need to be shown how the short- term gains derived from the interactional style result in long-term costs, and they need to be taught more appropriate ways of negotiating their wants and needs. **Narc