Abnormal Psychology Notes PDF

MODULE 1 Abnormal psychology is concerned with understanding the nature, causes, and treatment of mental disorders. A major problem is that there is no one behaviour that makes someone abnormal. However, there are some clear elements or indicators of abnormality but no single indicator is sufficien...

MODULE 1 Abnormal psychology is concerned with understanding the nature, causes, and treatment of mental disorders. A major problem is that there is no one behaviour that makes someone abnormal. However, there are some clear elements or indicators of abnormality but no single indicator is sufficient in and of itself to define or determine abnormality. Nonetheless, the more that someone has difficulties in the following areas, the more likely he or she is to have some form of mental disorder: 1. Suffering: If people suffer or experience psychological pain, we are inclined to consider this as indicative of abnormality. For example, depressed people clearly suffer, as do people with anxiety disorders. Although suffering is an element of abnormality in many cases, it is neither a sufficient condition nor even a necessary condition to consider something as abnormal. For example, you may have a test tomorrow and be suffering with worry but the suffering would hardly be labelled as abnormal. 2. Maladaptiveness: Maladaptive behaviour is often an indicator of abnormality. Maladaptive behaviour interferes with our well-being and with our ability to enjoy our work and our relationships. For example, - person with anorexia may restrict her intake of food to the point where she becomes so emaciated that she needs to be hospitalized - person with depression may withdraw from friends and family and may be unable to work for weeks or months. However, not all disorders involve maladaptive behaviour. 3. Statistical Deviancy: The word abnormal literally means “away from the normal” but simply considering statistically rare behaviour to be abnormal does not provide us with a solution to our problem of defining abnormality. Also, just because something is statistically common doesn’t make it normal. The common cold is certainly very common, but it is regarded as an illness nonetheless. For example, genius is statistically rare, as is perfect pitch. However, we do not consider people with such uncommon talents to be abnormal in any way. On the other hand, intellectual disability (which is statistically rare and represents a deviation from normal) is considered to reflect abnormality. In defining abnormality, we make value judgements i.e., - something that is statistically rare and undesirable such as severely diminished intellectual functioning is more likely to be considered abnormal than - something that is statistically rare and highly desirable such as genius or - something that is statistically common but undesirable such as rudeness 4. Violation of the Standards of Society: When people fail to follow the conventional social and moral rules of their cultural group, we may consider their behaviour abnormal. For example, driving a car or watching television would be considered highly abnormal for the Amish of Pennsylvania. However, both of these activities reflect normal everyday behaviour for most other Pennsylvania residents. Another example is people do not believe that it is acceptable to murder a woman who has a premarital or an extramarital relationship in the US. However in Pakistan, karo-kari (a form of honour killing where a woman is murdered by a male relative because she is considered to have brought disgrace onto her family) is considered justifiable by many people. A behaviour is most likely to be viewed as abnormal when it violates the standards of society and is statistically deviant or rare. For example, parking illegally, which is a violation, is so  statistically common that we don’t consider it as abnormal behaviour but if a mother drowns her children there is instant recognition that this is abnormal behaviour. 5. Social Discomfort: When someone violates a social rule, those around him or her may experience a sense of discomfort or unease. For example, if someone you met only 4 minutes ago begins to chat about her suicide attempt, unless you are a therapist working in a crisis intervention centre, this would probably be considered as an example of abnormal behaviour. 6. Irrationality and Unpredictability: There is a point at which a given unorthodox behaviour is likely to be considered abnormal. For example, if a person sitting next to you suddenly began to scream and yell obscenities at nothing, you would probably regard that behaviour as abnormal. It would be unpredictable, and it would make no sense to you. But disordered speech and the disorganized behaviour of patients with schizophrenia are often irrational and such behaviours are also a hallmark of the manic phases of bipolar disorder. 7. Dangerousness: Someone who is a danger to himself or herself or to another person must be psychologically abnormal. Therapists are required to hospitalize suicidal clients or contact the police (as well as the person who is the target of the threat) if they have a client who makes an explicit threat to harm another person. But, as with all of the other elements of abnormality, we cannot rely only on dangerousness as our sole feature of abnormality. For example, a person who is into race car driving or keeping poisonous snakes as pets is dangerous to themselves and others but it doesn’t mean they are mentally ill. Conversely, we cannot assume that someone diagnosed with a mental disorder must be dangerous. For example, although mentally ill people do commit serious crimes, serious crimes are also committed every day by people who have no signs of mental disorder. In addition, because society is constantly shifting and becoming more or less tolerant of certain behaviours, what is considered abnormal or deviant in one decade may not be considered abnormal or deviant a decade or two later. For example, - homosexuality was classified as a mental disorder at one point but this is no longer the case. - pierced noses and navels were regarded as highly deviant and prompted questions about a person’s mental health a generation ago but now such adornments are common and is considered fashion by many. The DSM-5 and the Definition of Mental Disorder The accepted standard for defining various types of mental disorders is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders commonly referred to as the DSM and the current version is DSM-5. According to DSM-5, - a mental disorder is defined as a syndrome that is present in an individual and that involves clinically significant disturbance in behaviour, emotion regulation, or cognitive functioning. These disturbances are thought to reflect a dysfunction in biological, psychological, or developmental processes that are necessary for mental functioning. - mental disorders are usually associated with significant distress or disability in key areas of functioning such as social, occupational or other activities. Predictable or culturally approved responses to common stressors or losses (death of a loved one) are excluded. The DSM provides all the information necessary (descriptions, lists of symptoms) to diagnose mental disorders and it provides clinicians with specific diagnostic criteria for each disorder. Formal Diagnostic Classification of Mental Disorders (DSM AND ICD) There are two major diagnostical manuals of clinical psychology and psychiatry that list investigated disorders. These are the DSM and the ICD (International Classification of Disease). Both are extremely comprehensive classifications. They cover all areas of mental health such as neurodevelopmental and dissociative disorders, somatic symptom disorders, sexual dysfunctions, paraphilic disorders, and personality disorders. Certain differences in the way symptoms are grouped in these two systems can sometimes result in a different classification on the DSM than on the ICD. For example, when a professional psychologist diagnoses depression, the definition in these two manuals reports a series of symptoms that the patient exhibits or is likely to exhibit. In this particular condition, the definition includes feelings of apathy, crying, and suicidal thoughts. Symptoms generally refers to the patient’s subjective description, clinical assessment and diagnosis the complaints she or he presents about what is wrong. Signs are objective observations that the diagnostician may make either directly (such as the patient’s inability to look another person in the eye) or indirectly (such as the results of relevant tests administered by a psychological examiner). To make any given diagnosis, the diagnostician must observe the particular criteria—the symptoms and signs that the DSM indicates must be met. The Evolution of the DSM The DSM is currently in its fifth edition (DSM-5), published in 2013 after considerable debate and controversy. This system is the product of more than a six-decade evolution involving increasing refinement and precision in the identification and description of mental disorders.  The first edition of the manual (DSM-I) appeared in 1952 and was largely an outgrowth of attempts to standardize diagnostic practices in use among military personnel in World War II.  The 1968 DSM-II reflected the additional knowledge gained from an increased post-war mental health research effort supported by the federal government. Over time, practitioners recognized a defect in both these early efforts: The various types of disorders identified were described in narrative and jargonladen terms that proved too vague for mental health professionals to agree on their meaning.  DSM-III (1980) and DSM-IV-TR (2000) provided further modification and elaboration of disorders with efforts to make the diagnostic classification clearer.  DSM-5, published in 2013, incorporated more theoretical shifts in diagnostic thinking for many years and has been the most controversial alteration to diagnostic thinking to date.  MODULE 2 Anxiety disorders are  a group of disorders that share obvious symptoms of clinically significant fear or anxiety.  have unrealistic, irrational fears or anxieties of disabling intensity as their principal and most obvious manifestation.  create enormous personal, economic, and health care problems for those affected.  also associated with an increased occurrence of a number of medical conditions including asthma, chronic pain, hypertension, arthritis, cardiovascular disease, and irritable bowel syndrome  people with anxiety disorders are very high users of medical services.  common anxiety disorders in DSM-5 are: - specific phobia - social anxiety disorder (social phobia) - panic disorder - agoraphobia - generalized anxiety disorder In Freud’s formulation, anxiety was a sign of an inner battle or conflict between some primitive desire (from the id) and prohibitions against its expression (from the ego and superego). Sometimes this anxiety was overtly expressed (as in those disorders known today as the anxiety disorders). Historically, anxiety and obsessive-compulsive disorders were considered to be classic neurotic disorders. Although individuals with neurotic disorders show maladaptive and self-defeating behaviours, they are not incoherent, dangerous, or out of touch with reality. To Freud, these neurotic disorders developed when intrapsychic conflict produced significant anxiety. Fear and Anxiety Fear Anxiety an alarm reaction that occurs in response anxiety response pattern is a complex blend of to immediate danger such as a dangerous unpleasant emotions and cognitions that is both predator or someone pointing a loaded more oriented to the future and much more diffuse gun. than fear. involves activation of the “fight-or-flight” involves a general feeling of apprehension about response of the autonomic nervous possible future danger. system. When the source of danger is obvious, the With anxiety, however, we frequently cannot experienced emotion has been called fear. specify clearly what the danger is. For example, “I’m For example, “I’m afraid of snakes”. anxious about my parents’ health”. Its adaptive value is that it allows us to Its adaptive value may be that it helps us plan and escape. prepare for possible threat. In mild to moderate degrees, anxiety actually enhances learning and performance. For example, a mild amount of anxiety about how you are going to do on your next exam, or in your next tennis match, can actually be helpful It is maladaptive when it becomes chronic and severe, as we see in people diagnosed with anxiety disorders.  Three components: Three components: 1. cognitive/subjective components such as 1. cognitive/subjective components such as “I feel afraid/terrified”; “I’m going to die” negative mood, worry about possible future threats 2. physiological components such as or danger, self-preoccupation, and a sense of being increased heart rate and heavy breathing unable to predict the future threat or to control it if 3. behavioural components such as a it occurs. strong urge to escape or flee 2. physiological components such as a state of These components are only “loosely tension and chronic overarousal which may reflect coupled” that is, someone might show risk assessment and readiness for dealing with physiological and behavioural indications danger should it occur. of fear or panic without much of the 3. behavioural components such as a strong subjective component, or vice versa. tendency to avoid situations where danger might be encountered, but there is not the immediate behavioural urge to flee with anxiety as there is with fear. When the fear response occurs in the absence of any obvious external danger, we say the person has had a spontaneous or uncued panic attack. The symptoms of a panic attack are nearly identical to those experienced during a state of fear except that panic attacks are often accompanied by a subjective sense of impending doom, including fears of dying, going crazy, or losing control. These latter cognitive symptoms do not generally occur during fear states. Social Anxiety Disorder/Social Phobia Social phobia or social anxiety disorder is characterized by disabling fears of one or more specific social situations such as public speaking, urinating in a public bathroom, or eating or writing in public. In these situations, a person fears that she or he may be exposed to the scrutiny and potential negative evaluation of others or that she or he may act in an embarrassing or humiliating manner. Because of their fears, people with social phobias either avoid these situations or endure them with great distress. Intense fear of public speaking is the single most common type of social phobia. Causes Environmental Factors:  People with generalized social phobia also may be especially likely to have grown up with parents who were emotionally cold, socially isolated, and avoidant. Such parents devalued sociability and did not encourage their children to go to social events.  many people with social phobia reported that the onset of their social phobia had occurred during a time when they were having problems with their peers such as not fitting in.  Being exposed to uncontrollable and unpredictable stressful events (such as parental separation and divorce, family conflict, or sexual abuse) may play an important role in the development of social phobia. Biological Factors:  Behaviourally inhibited infants, those that share characteristics with both neuroticism and introversion, who are easily distressed by unfamiliar stimuli and who are shy and avoidant are more likely to become fearful during childhood and, by adolescence, to show increased risk of developing social phobia.  Results from several studies of twins have also shown that there is a modest genetic contribution to social phobia Panic Disorder Panic disorder is defined and characterized by the occurrence of panic attacks that often seem to come “out of the blue”. According to the DSM-5 criteria for panic disorder, the person must have experienced recurrent, unexpected attacks that is, panic attacks, and must have been persistently concerned about having another attack or worried about the consequences of having an attack for at least a month (often referred to as anticipatory anxiety). Panic attacks are often “unexpected” or “uncued” in the sense that they do not appear to be provoked by identifiable aspects of the immediate situation. They are fairly brief but intense, with symptoms developing abruptly and usually reaching peak intensity within 10 minutes; the attacks usually subside in 20 to 30 minutes and rarely last more than an hour. In situations in which they might occur during relaxation or during sleep it is known as nocturnal panic. However, if a person experiences panic attacks and becomes very concerned about having additional attacks or worries about the possible consequences of the attack (e.g., having a heart attack or going crazy), a diagnosis of panic disorder will eventually be given. Causes Biological Factors:  panic disorder has a moderate heritable component  people with a history of social or specific phobia are at heightened risk for developing panic disorder  Earlier, the neurobiology of panic attacks involved the locus coeruleus in the brain stem and a particular neurotransmitter, norepinephrine, that is centrally involved in brain activity in this area. However, today it is recognized that increased activity in the amygdala plays a more central role in panic attacks than does activity in the locus coeruleus since amygdala is critically involved in the emotion of fear.  the cognitive symptoms that occur during panic attacks (such as depersonalization, derealization or fears of dying or of losing control) are likely to be mediated by higher cortical centers  people with panic disorder are much more likely to experience panic attacks caused by biochemical dysfunctions (such as inhaling air with altered amounts of carbon dioxide or ingesting large amounts of caffeine)  two primary neurotransmitter systems that are most implicated in panic attacks are the noradrenergic and the serotonergic systems. Noradrenergic activity in certain brain areas can stimulate cardiovascular symptoms associated with panic. Increased serotonergic activity decreases noradrenergic activity which in turn decreases many of the cardiovascular symptoms associated with panic.  inhibitory neurotransmitter GABA has also been implicated in the anticipatory anxiety that many people with panic disorder have about experiencing another attack. GABA is known to prevent anxiety and has been shown to be abnormally low in certain parts of the cortex in people with panic disorder.   people who have high levels of anxiety sensitivity are more prone to developing panic attacks and perhaps panic disorder. Anxiety sensitivity is a trait-like belief that certain bodily symptoms may have harmful consequences. Such a person would endorse statements such as, “When I notice that my heart is beating rapidly, I worry that I might have a heart attack.” Environmental Factors:  People with panic disorder also seem to have their attention automatically drawn to threatening information in their environment such as words that represent things they fear, such as palpitations, numbness, or faint that is, having one’s attention automatically drawn to threatening cues in the environment is likely to provoke more attacks. In short: [Three components of panic disorder: 1. Anticipatory anxiety 2. Agoraphobia 3. Panic attacks] Agoraphobia Agoraphobia involves the fear of public places of assembly. The most commonly feared and avoided situations include streets and crowded places such as shopping malls, movie theatres, and stores. Sometimes, agoraphobia develops as a complication of having panic attacks in one or more such situations. Concerned that they may have a panic attack or get sick, people with agoraphobia are anxious about being in places or situations from which escape would be physically difficult or psychologically embarrassing, or in which immediate help would be unavailable if something bad happened. People with agoraphobia are also frightened by their own bodily sensations, so they also avoid activities that will create arousal such as exercising, watching scary movies, drinking caffeine, and even engaging in sexual activity. As agoraphobia first develops, people tend to avoid situations in which attacks have occurred, but usually the avoidance gradually spreads to other situations where attacks might occur. In moderately severe cases, people with agoraphobia may be anxious even when venturing outside their homes alone. In very severe cases, agoraphobia is an utterly disabling disorder in which a person cannot go beyond the narrow confines of home—or even particular parts of the home. Agoraphobia is a frequent complication of panic disorder. However, many patients with agoraphobia do not experience panic. Recognizing this, in DSM-5 agoraphobia is now listed as a distinct disorder. The exact cause of agoraphobia isn’t known. However, there are several factors that are known to increase your risk of developing agoraphobia. These include having depression, other phobias such as claustrophobia and social phobia, another type of anxiety disorder such as generalized anxiety disorder or obsessive-compulsive disorder, a history of physical or sexual abuse, a substance abuse problem, a family history of agoraphobia. [not from TB] Generalized Anxiety Disorder (GAD) (more than 6 months) Generalized anxiety disorder (formerly known as free-floating anxiety) involves anxiety and worry about many different aspects of life (including minor events) which becomes chronic, excessive, and unreasonable. It is important that the worry - must occur for at least 6 months and must be experienced as difficult to control - cannot be exclusively related to the worry associated with another concurrent disorder, such as the possibility of having a panic attack. - must also be accompanied by at least three of six other symptoms, as listed in the table, such as muscle tension or being easily fatigued. The general picture of people suffering from generalized anxiety disorder is that they live in a relatively constant future-oriented mood state of anxious apprehension, chronic tension, worry, and diffuse uneasiness that they cannot control. They also show marked vigilance for possible signs of threat in the environment and frequently engage in subtle avoidance activities such as procrastination, checking, or calling a loved one frequently to see if he or she is safe. This apprehension is the essence of GAD, leading Barlow and others to refer to GAD as the “basic” anxiety disorder. The nearly constant worries of people with generalized anxiety disorder leave them continually upset and discouraged. Not only do they have difficulty making decisions, but after they have managed to make a decision they worry endlessly, even after going to bed, over possible errors and unforeseen circumstances that may prove the decision wrong and lead to disaster. Causes Environmental Factors  people with GAD may be more likely to have had a history of trauma in childhood than individuals with several other anxiety disorders.  lack of safety signals in the environment. If a person mostly experiences predictable stressors, he or she cannot only predict when something bad is likely to happen but can also feel safe when that signal is missing. But if another person has experienced many unpredictable or unsignaled stressors he or she will not have developed safety signals for when it is appropriate to relax and feel safe, and this uncertainty may lead to chronic anxiety.  parents of anxious children often have an intrusive, overcontrolling parenting style, which may serve only to promote their children’s anxious behaviours by making them think of the world as an unsafe place in which they require protection and have little control themselves.  Experience with unpredictable and/or uncontrollable life events may create a vulnerability to anxiety and promote current anxiety. For example, having a boss or spouse who has unpredictable bad moods or outbursts of temper for seemingly trivial reasons might keep a person in a chronic state of anxiety. Biological Factors  Although evidence for genetic factors in GAD is mixed, there does seem to be a modest heritability.  highly anxious people have a kind of functional deficiency in GABA, which ordinarily plays an important role in the way our brain inhibits anxiety in stressful situations.  Serotonin is also involved in modulating generalized anxiety   An anxiety-producing hormone called corticotropinreleasing hormone (CRH) has also been strongly implicated as playing an important role in generalized anxiety. Obsessive-compulsive and related disorders are  disorders that include obsessions and compulsions. Obsessions are persistent and highly recurrent intrusive thoughts or images that are experienced as disturbing and inappropriate. Compulsions are repetitive behaviours (such as handwashing or checking) that the person feels must be performed in response to the obsession.  These behaviours have the goal of preventing or reducing distress or preventing some dreaded outcome from occurring.  includes disorders like - Obsessive Compulsive Disorder (OCD) - hoarding disorder - excoriation (skin picking) disorder - body dysmorphic disorder (BDD) - trichotillomania (compulsive hair-pulling). Obsessive-compulsive disorder is no longer classified as an anxiety disorder. Obsessive Compulsive Disorder (OCD) (obsessions and compulsions must take at least 1 hour a day) Obsessive-compulsive disorder (OCD) is defined by the occurrence of unwanted and intrusive obsessive thoughts or distressing images accompanied by compulsive behaviours performed to undo or neutralize the obsessive thoughts or images or as a way of preventing some dreaded event or situation. According to DSM-5, obsessions involve persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing, inappropriate, and uncontrollable. People who have such obsessions actively try to resist or suppress them or to neutralize them with some other thought or action. Compulsions can involve either overt repetitive behaviour that are performed as lengthy rituals (such as hand washing, checking, putting things in order over and over again) or covert mental rituals (such as counting, praying, or saying certain words silently over and over again). The compulsive behaviours are performed with the goal of preventing or reducing distress or preventing some dreaded event or situation. A person with OCD usually feels driven to perform this compulsive, ritualistic behaviour in response to an obsession, and there are often very rigid rules regarding exactly how the compulsive behaviour should be performed. A person with OCD must recognize that the obsession is the product of his or her own mind rather than being imposed from without (as might occur in schizophrenia). However, most people with OCD have “insight” about exactly how senseless and excessive their obsessions and compulsions are. Most of us have experienced minor obsessive thoughts, such as whether we remembered to lock the door or turn the stove off and occasionally engage in repetitive or stereotyped behaviour, such as checking the lock on the door or checking the stove. With OCD, however, the thoughts are excessive and much more persistent and distressing, and the associated compulsive acts interfere considerably with everyday activities. The diagnosis requires that obsessions and compulsions must take at least 1 hour in a day, and in severe cases they may take most of the person’s waking hours. Many obsessive thoughts involve  contamination fears  fears of harming oneself or others  pathological doubt  need for symmetry (e.g., having magazines on a table arranged in a way that is “exactly right”)  sexual obsessions  obsessions concerning religion or aggression Obsessive thoughts involving themes of violence or aggression might include a wife being obsessed with the idea that she might poison her husband or child, or a daughter constantly imagining pushing her mother down a flight of stairs. Even though such obsessive thoughts are only very rarely acted on, they remain a source of often excruciating torment to a person plagued with them. There are five primary types of compulsive rituals:  cleaning (handwashing and showering)  repeated checking  repeating  ordering or arranging  counting For a smaller number of people, the compulsions are to perform various everyday acts (such as eating or dressing) extremely slowly (primary obsessional slowness), and for others the compulsions are to have things exactly symmetrical or “evened up” Causes: Biological Factors:  There is a moderate genetic heritability for OCD. Evidence also shows that early-onset OCD has a higher genetic loading than later-onset OCD.  people with OCD have abnormally high levels of activity in two parts of the frontal cortex, which are also linked to the limbic area.  overactivation of the orbital frontal cortex, which stimulates “the stuff of obsessions,” combined with a dysfunctional interaction among the orbital frontal cortex, the corpus striatum or caudate nucleus, and the thalamus may be the central component of the brain dysfunction in OCD.  the neurotransmitter serotonin strongly implicates OCD. increased serotonin activity and increased sensitivity of some brain structures to serotonin are involved in OCD symptoms  People with OCD also have low confidence in their memory ability which may contribute to their repeating their ritualistic/compulsive behaviours over and over again  people with OCD have deficits in their ability to inhibit both motor responses and irrelevant information which also leads to repetitive, compulsive behaviours. Body Dysmorphic Disorder (BDD) Body dysmorphic disorder is when an individual is obsessed with some perceived or imagined flaw or flaws in their appearance to the point where they firmly believe they are disfigured or ugly. This preoccupation is so intense that it causes clinically significant distress and impairment in social or occupational functioning. Although it is not considered necessary for the diagnosis, most people with BDD have compulsive checking behaviours (such as checking their appearance in the mirror excessively or hiding or repairing a perceived flaw). Another very common symptom is avoidance of usual activities because of fear that other people will see the imaginary defect and be repulsed. In severe cases, they may become so isolated that they lock themselves up in their houses and never go out, even to work People with BDD may focus on almost any body part such as - their skin has blemishes - their breasts are too small - their face is too thin (or too fat) - their face is disfigured by visible blood vessels that others find repulsive, and so on. Men are more likely to obsess about their genitals, body build, and balding, whereas women tend to obsess more about their skin, stomach, breasts, buttocks, hips, and leg. Some researchers estimate that about half the people with BDD have concerns about their appearance that are of delusional intensity. People with BDD frequently seek reassurance from friends and family about their defects, but the reassurances almost never provide more than very temporary relief. They also frequently seek reassurance for themselves by checking their appearance in the mirror countless times in a day (although some avoid mirrors completely). They are usually driven by the hope that they will look different, and may think their perceived defect does not look as bad as it has at other times. However, much more commonly they feel worse after mirror gazing. They frequently engage in excessive grooming behaviour, often trying to camouflage their perceived defect through their hairstyle, clothing, or makeup. Body dysmorphic disorder was classified as a somatoform disorder in DSM-IV-TR because it involves preoccupation with certain aspects of the body. However, because of its very strong similarities with OCD, it was moved out of the somatoform category and into the OCD and related disorders category in DSM-5. Causes: Biological Factors:  the neurotransmitter serotonin also implicates BDD. increased serotonin activity and increased sensitivity of some brain structures to serotonin are involved in BDD.  over-concern with a perceived or slight defect in physical appearance is a moderately heritable trait  patients with BDD demonstrate performance deficits on tasks that measure executive functioning (e.g., manipulating information, planning, and organization), which is thought to be guided by prefrontal brain regions Environmental Factors:  people who develop BDD often hold attractiveness as their primary value since in today’s world there is a great value on attractiveness and beauty (“If my appearance is defective, then I am worthless”).  Another factor could be that as children, people were reinforced for their overall appearance more than for their behaviour and this could also lead to BDD.  Another possibility is that they were teased or criticized for their appearance, which caused conditioning of disgust, shame, or anxiety to their own image of some part of their body. (Anxiety Spectrum Disorders – PTSD, ASD) Posttraumatic Stress Disorder (PTSD) (at least 1 month) Posttraumatic stress disorder occurs after an extreme traumatic event, in which a person reexperiences the event, avoids reminders of the trauma, and exhibits persistent increased arousal. Traumatic stressors include combat, rape, being confined in a concentration camp, and experiencing a natural disaster such as a tsunami, earthquake, or tornado. PTSD was classified as an anxiety disorder in DSM-IV. In DSM-5 post-traumatic stress disorder is now grouped with other disorders in a new diagnostic category called trauma- and stress or related disorders. In DSM-5, the clinical symptoms of PTSD are grouped into four main areas:  Intrusion: Recurrent reexperiencing of the traumatic event through nightmares, intrusive images, and physiological reactivity to reminders of the trauma.  Avoidance: Avoidance of thoughts, feelings or reminders of the trauma.  Negative cognitions and mood: This includes symptoms such as feelings of detachment as well as negative emotional states such as shame or anger, or distorted blame of oneself or others.  Arousal and reactivity: Hypervigilance, excessive response when startled, aggression, and reckless behaviour. Causes The study of causal risk factors that might be involved in the development of PTSD has been a controversial area because of two major reasons: 1. First, the very notion of PTSD makes it explicit that PTSD is caused by experiencing trauma. So why should we look any further if we wish to know what causes PTSD? 2. The second concern is that, if some people are more likely to develop PTSD in the face of severe stress than other people are, might this not lead to double victimization, with victims of trauma also being stigmatized and being blamed for the troubles that they have? On the other side of the issue, we know that not everyone who is exposed to a traumatic event will develop PTSD. In order to prevent and better treat this disorder, we therefore need to understand more about the factors that are involved in its development.  nature of the traumatic stressor and how directly it was experienced  If the level of stress is high enough, then, the average person can be expected to develop some psychological difficulties (which may be either short-lived or long term) following a traumatic event. Acute Stress Disorder (ASD) (at least 2 days) Acute stress disorder is a disorder that occurs within 4 weeks after a traumatic event and lasts for a minimum of 2 days and a maximum of 4 weeks. This is a diagnostic category that can be used when symptoms develop shortly after experiencing a traumatic event and last for at least 2 days. The existence of this diagnosis means that people with symptoms do not have to wait a whole month to be diagnosed with PTSD. Moreover, if symptoms persist beyond 4 weeks, the diagnosis can be changed from ASD to PTSD.  MODULE 3 Personality disorders (formerly known as a character disorder) are a result of gradual development of inflexible and distorted personality and behavioural patterns that result in persistently maladaptive ways of perceiving, thinking about, and relating to the world. In many cases, major stressful life events early in life help set the stage for the development of these inflexible and distorted personality patterns. Two of the general features that characterize most personality disorders are - chronic interpersonal difficulties and - problems with one’s identity or sense of self According to general DSM-5 criteria for diagnosing a personality disorder, the person’s enduring pattern of behaviour must be pervasive and inflexible, as well as stable and of long duration. It must also cause either clinically significant distress or impairment in functioning and be manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control. People with personality disorders often cause at least as much difficulty in the lives of others as they do in their own lives. Other people tend to find the behaviour of individuals with personality disorders confusing, exasperating, unpredictable, and, to varying degrees, unacceptable. Personality disorders are often associated with (or comorbid with) anxiety disorders, mood disorders, substance use problems and sexual deviations. One summary of evidence estimated that about three-quarters of people diagnosed with a personality disorder also have another disorder as well. The DSM-5 personality disorders are grouped into three clusters. These were derived on the basis of what were originally thought to be important similarities of features among the disorders within a given cluster.  Cluster A: People with these disorders often seem odd or eccentric, with unusual behaviour ranging from distrust and suspiciousness to social detachment. It includes - Paranoid personality disorder - Schizoid personality disorder - Schizotypal personality disorder  Cluster B: Individuals with these disorders share a tendency to be dramatic, emotional, and erratic. It includes - Histrionic personality disorder - Narcissistic personality disorder - Antisocial personality disorder - Borderline personality disorder  Cluster C: People with these disorders often show anxiety and fearfulness. It includes - Avoidant personality disorder - Dependent personality disorder - Obsessive-compulsive personality disorder Paranoid Personality Disorder Individuals with paranoid personality disorder have a pervasive suspiciousness and distrust of others, leading to numerous interpersonal difficulties. - They tend to see themselves as blameless, instead blaming others for their own mistakes and failures—even to the point of ascribing evil motives to others. - Such people are chronically tense and “on guard,” constantly expecting trickery and looking for clues to validate their expectations while disregarding all evidence to the contrary. - They are often preoccupied with doubts about the loyalty of friends and hence are reluctant to confide in others. - They commonly bear grudges, refuse to forgive perceived insults and slights, and are quick to react with anger and sometimes violent behaviour. People with paranoid personalities are not usually psychotic; that is, most of the time they are in clear contact with reality, although they may experience transient psychotic symptoms during periods of stress. People with paranoid schizophrenia share some symptoms found in paranoid personality, but they have many additional problems including more persistent loss of contact with reality, delusions, and hallucinations. Nevertheless, individuals with paranoid personality disorder do appear to be at elevated liability for schizophrenia. Causes Little is known about important causal factors for paranoid personality disorder  Some have argued for partial genetic transmission that may link the disorder to schizophrenia but it is not a strong one.  There is a modest genetic liability to paranoid personality disorder itself that may occur through the heritability of low agreeableness (high levels of antagonism) and high levels of neuroticism (angry-hostility), which are among the primary traits in paranoid personality disorder. (biological factor)  Environmental/psychosocial causal factors that are suspected to play a role include parental neglect or abuse and exposure to violent adults. Schizoid Personality Disorder Individuals with schizoid personality disorder are usually unable to form social relationships and usually lack much interest in doing so. - They tend not to have good friends, with the possible exception of a close relative. - Such people are unable to express their feelings and are seen by others as cold and distant. - They often lack social skills and can be classified as loners or introverts, with solitary interests and occupations, although not all loners or introverts have schizoid personality disorder. - People with this disorder tend not to take pleasure in many activities, including sexual activity, and rarely marry. - They are not very emotionally reactive, rarely experiencing strong positive or negative emotions, but rather show a generally apathetic mood making them appear as cold and aloof. In terms of the five-factor model, they show extremely high levels of introversion (especially low on warmth, gregariousness, and positive emotions). They are also low on openness to feelings (one facet of openness to experience) and on achievement striving. Causes  any genetic link that may exist is very modest. Even schizoid personality traits have also been shown to have only a modest heritability. (biological factor)  severe disruption in sociability seen in schizoid personality disorder may be due to severe impairment in an underlying affiliative system  individuals with schizoid personality disorder exhibit cool and aloof behaviour because of maladaptive underlying schemas that lead them to view themselves as self-sufficient loners and to view others as intrusive. Their core dysfunctional belief might be, “I am basically alone” or “Relationships are messy [and] undesirable” Schizotypal Personality Disorder Individuals with schizotypal personality disorder are also excessively introverted and have pervasive social and interpersonal deficits (like those that occur in schizoid personality disorder), but in addition they have cognitive and perceptual distortions, as well as oddities and eccentricities in their communication and behaviour.  - While they do maintain contact with reality, highly personalized and superstitious thinking is characteristic of people with schizotypal personality - Under extreme stress they may experience transient psychotic symptoms - They often believe that they have magical powers and may engage in magical rituals. Other cognitive–perceptual problems include ideas of reference (the belief that conversations or gestures of others have special meaning or personal significance), odd speech, and paranoid beliefs. Oddities in thinking, speech, and other behaviours are the most stable characteristics of schizotypal personality disorder and are similar to those often seen in patients with schizophrenia. In fact, many researchers conceptualize schizotypal personality disorder as a weakened form of schizophrenia. Although some aspects of schizotypy appear related to the five=factor model of personality (specifically facets of introversion and neuroticism), the other aspects related to cognitive and perceptual distortions are not adequately explained by the model. In fact, the core symptoms of schizotypy form the basis of the only proposed trait that does not map neatly unto the five factors of normal personality, psychoticism, and it consists of three facets: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation. Causes  The heritability of schizotypal personality disorder is moderate. (biological factor)  There are also biological associations of schizotypal personality disorder with schizophrenia since same deficits can be seen such as ability to track a moving target visually, ability to sustain attention, and deficits in working memory (e.g., being able to remember a span of digits).  teenagers who have schizotypal personality disorder have been shown to be at increased risk for developing schizophrenia and schizophrenia-spectrum disorders in adulthood  it has also been proposed that there is a second subtype of schizotypal personality disorder that is not genetically linked to schizophrenia. This subtype is characterized by cognitive and perceptual deficits and is instead linked to a history of childhood abuse and early trauma.  Schizotypal personality disorder in adolescence has been associated with elevated exposure to stressful life events and low family socioeconomic status. (environmental factor) Histrionic Personality Disorder Excessive attention-seeking behaviour and emotionality are the key characteristics of individuals with histrionic personality disorder. - these individuals tend to feel unappreciated if they are not the center of attention - their lively, dramatic, and excessively extraverted styles often ensure that they can charm others into attending to them. But these qualities do not lead to stable and satisfying relationships because others tire of providing this level of attention. - In craving stimulation and attention, their appearance and behaviour are often quite theatrical and emotional as well as sexually provocative and seductive - They may attempt to control their partners through seductive behaviour and emotional manipulation - They also show a good deal of dependence - Their speech is often vague and impressionistic - They are usually considered self-centered, vain, and excessively concerned about the approval of others, who see them as overly reactive, shallow, and insincere. Histrionic personality disorder is highly comorbid with borderline, antisocial, narcissistic, and dependent personality disorder diagnoses. In terms of the five-factor model, histrionic personality disorder involves very high levels of extraversion which include high levels of gregariousness, excitement seeking, and positive emotions and high levels of neuroticism particularly involving the depression and self-consciousness facets. They are also high on openness to fantasies Causes  There is some evidence for a genetic link with antisocial personality disorder. (biological factor)  Presence of maladaptive schemas revolving around the need for attention to validate self- worth. Core dysfunctional beliefs might include, “Unless I captivate people, I am nothing” and “If I can’t entertain people, they will abandon me”. Narcissistic Personality Disorder Individuals with narcissistic personality disorder show an exaggerated sense of self-importance, a preoccupation with being admired, and a lack of empathy for the feelings of others. There are two subtypes of narcissism: grandiose and vulnerable narcissism The grandiose presentation of narcissistic patients is manifested by traits related to grandiosity, aggression, and dominance. - These are reflected in a strong tendency to overestimate their abilities and accomplishments while underestimating the abilities and accomplishments of others. - Their sense of entitlement is frequently a source of astonishment to others, although they themselves seem to regard their lavish expectations as merely what they deserve. - They behave in stereotypical ways (e.g., with constant self-references and bragging) to gain the acclaim and recognition they crave. - They often think they can be understood only by other high-status people or that they should associate only with such people because they believe they are so special. - Their sense of entitlement is also associated with their unwillingness to forgive others for perceived slights, and they easily take offense. Vulnerable narcissists have a very fragile and unstable sense of self-esteem. - for these individuals, arrogance and condescension is merely a façade for intense shame and hypersensitivity to rejection and criticism. - They may become completely absorbed and preoccupied with fantasies of outstanding achievement but at the same time experience profound shame about their ambitions. - They may avoid interpersonal relationships due to fear of rejection or criticism. Some narcissistic individuals may fluctuate between grandiosity and vulnerability In terms of the five-factor model, both subtypes are associated with high levels of low agreeableness/interpersonal antagonism (which includes traits of low modesty, arrogance, grandiosity, and superiority), low altruism (expecting favourable treatment and exploiting others), and tough-mindedness (lack of empathy). However, a primarily grandiose narcissist is exceptionally low in certain facets of neuroticism and high in extraversion and a vulnerable narcissist has very high levels of neuroticism/negative affectivity. Causes  grandiose narcissism is associated with parental overvaluation  vulnerable narcissism has been associated with emotional, physical, and sexual abuse, as well parenting styles characterized as intrusive, controlling, and cold Antisocial Personality Disorder (ASPD) Individuals with ASPD continually violate and show disregard for the rights of others through deceitful, aggressive, or antisocial behaviour, typically without remorse or loyalty to anyone. The outstanding characteristic of people with ASPD is their tendency to persistently disregard and violate the rights of others. They do this through a combination of deceitful, aggressive, and antisocial behaviours. These people have a lifelong pattern of unsocialized and irresponsible behaviour with little regard for safety—either their own or that of others. They tend to be impulsive, irritable, and aggressive and to show a pattern of generally irresponsible behaviour. This pattern of behaviour must have been occurring since the age of 15, and before age 15 the person must have had symptoms of conduct disorder, a similar disorder occurring in children and young adolescents who show persistent patterns of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules at home or in school. Causes Biological Factors  moderate heritability for antisocial or criminal behaviour and for ASPD  ASPD and other externalizing disorders like alcohol and drug dependence and conduct disorder all share a strong common genetic vulnerability Environmental Factors  adopted-away children of biological parents with ASPD were more likely to develop antisocial personalities if their adoptive parents exposed them to an adverse environment such as marital conflict or divorce, legal problems, and parental psychopathology than if their adoptive parents exposed them to a more normal environment. Borderline Personality Disorder (BPD) People with BPD show a pattern of behaviour characterized by impulsivity and instability in interpersonal relationships, self-image, and moods. - The central characteristic of BPD is affective instability, manifested by unusually intense emotional responses to environmental triggers, with delayed recovery to a baseline  emotional state. Affective instability is also characterized by drastic and rapid shifts from one emotion to another. - people with BPD have a highly unstable self-image or sense of self, which is sometimes described as “impoverished and/or fragmented”. - Another very important feature of BPD is impulsivity characterized by rapid responding to environmental triggers without thinking (or caring) about long-term consequences. - Self-mutilation (such as repetitive cutting behaviour) is another characteristic feature of BPD Given their affective instability combined with unstable self-image, it is not surprising that these people have highly unstable interpersonal relationships. These relationships tend to be intense but stormy, typically involving overidealizations of friends or lovers that later end in bitter disillusionment, disappointment, and anger. These individuals’ high levels of impulsivity combined with their extreme affective instability often lead to erratic, self-destructive behaviours such as gambling sprees or reckless driving. Suicide attempts, sometimes flagrantly manipulative, can be part of the clinical picture. Most people with BPD also have cognitive symptoms which includes relatively short or transient episodes in which they appear to be out of contact with reality and experience delusions or other psychotic-like symptoms such as hallucinations, paranoid ideas, or severe dissociative symptoms. Causes  genetic factors play a significant role in the development of BPD. Even personality traits of affective instability and impulsivity, which are both very prominent in BPD, are themselves partially heritable.  people with BPD often appear to be characterized by lowered functioning of the neurotransmitter serotonin, which is involved in preventing behavioural responses. This may be why they show impulsive-aggressive behaviour, as in acts of self-mutilation.  Patients with BPD may also show disturbances in the regulation of noradrenergic neurotransmitters.  Psychosocial/environmental causal factors such as childhood adversity and maltreatment is linked to adult BPD. People with this disorder usually report a large number of negative— even traumatic—events in childhood such as abuse and neglect, and separation and loss. Although this and many other related studies suggest that BPD is often associated with early childhood trauma, most such studies have many shortcomings and unfortunately cannot tell us that such early childhood trauma plays a causal role. These are: 1. Although prospective research to date supports this idea, the majority of evidence comes from retrospective self-reports of individuals who are known for their exaggerated and distorted views of other people. 2. Childhood abuse is certainly not a specific risk factor for borderline pathology because it is also reported at relatively high rates with some other personality disorders as well as with other disorders such as dissociative identity disorder. 3. Childhood abuse nearly always occurs in families with various other pathological dynamics, such as marital discord and family violence. These factors may be more important than the abuse in the development of BPD. Avoidant Personality Disorder Individuals with avoidant personality disorder show extreme social inhibition and introversion, leading to lifelong patterns of limited social relationships and reluctance to enter into social interactions. Feeling inept and socially inadequate are the two most prevalent and stable features of avoidant personality disorder. - They do not seek out other people because of their hypersensitivity to, and fear of, criticism and rebuff, yet they desire affection and are often lonely and bored. - Their inability to relate comfortably to other people causes acute anxiety and is accompanied by low self-esteem and excessive self-consciousness, which in turn are often associated with depression. - individuals with this disorder also show more generalized timidity and avoidance of many novel situations and emotions (including positive emotions), and show deficits in their ability to experience pleasure as well - higher levels of dysfunction and distress are also found in the individuals with avoidant personality disorder, including more consistent feelings of low self-esteem Some investigators conclude that avoidant personality disorder may simply be a somewhat more severe manifestation of generalized social phobia due to a substantial overlap between the two. In avoidant personality, introversion and neuroticism are also both elevated (they too are moderately heritable) Causes  Some research suggests that avoidant personality may have its origins in an innate “inhibited” temperament that leaves the infant and child shy and inhibited in novel and ambiguous situations. (biological factor)  traits prominent in avoidant personality disorder show a modest genetic influence and that the genetic vulnerability for avoidant personality disorder is at least partially shared with that for social phobia. (biological factor)  Moreover, there is also evidence that the fear of being negatively evaluated, which is prominent in avoidant personality disorder, is moderately heritable. (biological factor)  avoidant personality disorder can also be developed in some children who experience emotional abuse, rejection, or humiliation from parents who are not particularly affectionate (environmental factor) Dependent Personality Disorder Individuals with dependent personality disorder show an extreme need to be taken care of, which leads to clinging and submissive behaviour. - They also show acute fear at the possibility of separation or sometimes of simply having to be alone because they see themselves as inept - These individuals usually build their lives around other people and subordinate their own needs and views to keep these people involved with them. Accordingly, they may be indiscriminate in their selection of mates. - They often fail to get appropriately angry with others because of a fear of losing their support, which means that people with dependent personalities may remain in psychologically or physically abusive relationships. - They have great difficulty making even simple, everyday decisions without a great deal of advice and reassurance because they lack self-confidence and feel helpless even when they have actually developed good work skills or other competencies. - They may function well as long as they are not required to be on their own. It is quite common for people with dependent personality disorder to have a comorbid diagnosis of mood and anxiety disorders as well as eating disorders. In terms of the five-factor model, dependent personality disorder is associated with high levels of neuroticism and agreeableness. Causes  modest genetic influence on dependent personality traits such as neuroticism and agreeableness (biological factor)  children grown with parents who are authoritarian and overprotective might lead them to believe that they are reliant on others for their own well-being and are incompetent on their own. (environmental factor)  Cognitive theorists describe the underlying maladaptive schemas for these individuals as involving core beliefs about weakness and competence and needing others to survive such as, “I am completely helpless” and “I can function only if I have access to somebody competent” Obsessive-Compulsive Personality Disorder (OCPD) Perfectionism and an excessive concern with maintaining order and control characterize individuals with OCPD. Their preoccupation with maintaining mental and interpersonal control occurs in part through careful attention to rules, order, and schedules. Rigidity, stubbornness, and perfectionism, as well as reluctance to delegate, are the most prevalent and stable features of OCPD. - They are very careful in what they do so as not to make mistakes, but because the details they are preoccupied with are often trivial they use their time poorly and have a difficult time seeing the larger picture and can result in their never finishing projects. - They also tend to be devoted to work to the exclusion of leisure activities and may have difficulty relaxing or doing anything just for fun. - At an interpersonal level, they have difficulty delegating tasks to others and are quite rigid, stubborn, and cold, which is how others tend to view them. People with OCPD do not have true obsessions or compulsive rituals that are the source of extreme anxiety or distress as seen in people with OCD. Instead, people with OCPD have lifestyles characterized by overconscientiousness, high neuroticism, inflexibility, and perfectionism. People with OCD are more likely to be diagnosed with avoidant or dependent personality disorder than OCPD and there are only three symptoms of OCPD that seem to occur at elevated rates in people with OCD relative to controls: perfectionism, preoccupation with details, and hoarding. According to the five-factor dimensional approach to understand OCPD, the individuals have excessively high levels of conscientiousness which leads to extreme devotion to work, perfectionism, and excessive controlling behaviour. They are also high on assertiveness (a facet of extraversion) and low on compliance (a facet of agreeableness). Another influential biological dimensional approach—that of Cloninger (1987)—posits three primary dimensions of personality: novelty seeking, reward dependence, and harm avoidance. Individuals with obsessive-compulsive personalities have - low levels of novelty seeking (i.e., they avoid change) - low levels of reward dependence (i.e., they work excessively at the expense of pleasurable pursuits) - high levels of harm avoidance (i.e., they respond strongly to aversive stimuli and try to avoid them). Causes  OCPD traits show a modest genetic influence (biological factor) Other factors include a family history of personality disorders, anxiety or depression, childhood trauma, including child abuse that leaves you feeling like being ‘perfect’ is the only way to survive and having a pre-existing mental health condition, especially an anxiety disorder. [not from TB]  MODULE 4 Mood disorders (formerly called affective disorders) are disturbances of mood that are intense and persistent enough to be clearly maladaptive. The two key moods involved in mood disorders are - mania, often characterized by intense and unrealistic feelings of excitement and euphoria - depression, which usually involves feelings of extraordinary sadness and dejection. (hypomania, includes symptoms present in mania but less severe) Some people with mood disorders experience - only time periods or episodes characterized by depressed moods - manic episodes at certain time points and depressive episodes at other time points. - normal mood states between both types of episodes. Although this concept is accurate to a degree, sometimes an individual may have symptoms of mania and depression during the same time period. In these mixed-episode cases, the person experiences rapidly alternating moods such as sadness, euphoria, and irritability, all within the same episode of illness. unipolar depressive disorders - the person experiences only depressive episodes (MDD) bipolar and related disorders - the person experiences both manic and depressive episodes (bipolar I, bipolar II, cyclothymia) The other primary kind of mood episode is a manic episode, in which the person shows a markedly elevated, euphoric, or expansive mood, often interrupted by occasional outbursts of intense irritability or even violence—particularly when others refuse to go along with the manic person’s wishes and schemes. These extreme moods must persist for at least a week for this diagnosis to be made. In addition, three or more additional symptoms must occur in the same time period, ranging from - behavioural symptoms (such as a notable increase in goal-directed activity) - mental symptoms where self-esteem becomes grossly inflated and mental activity may speed up (such as a “flight of ideas” or “racing thoughts”) - physical symptoms (such as a decreased need for sleep or psychomotor agitation). In milder forms, similar kinds of symptoms can lead to a diagnosis of hypomanic episode, in which a person experiences abnormally elevated, expansive, or irritable mood for at least 4 days. In addition, the person must have at least three other symptoms similar to those involved in mania but to a lesser degree (e.g., inflated self-esteem, decreased need for sleep, flights of ideas, pressured speech, etc.). Although the symptoms listed are the same for manic and hypomanic episodes, there is much less impairment in social and occupational functioning in hypomania, and hospitalization is not required. Two types of serious mood disorders:  major depressive disorder (MDD; in which only major depressive episodes occur)  bipolar disorder (in which both manic and depressive episodes occur) Major Depressive Disorder (MDD) MDD is a moderate-to-severe mood disorder in which a person experiences only major depressive episodes but no hypomanic, manic, or mixed episodes. It is also known as unipolar major depression. To receive a diagnosis of major depressive disorder, a person must be in a major depressive episode and never have had a manic, hypomanic, or mixed episode. An affected person must experience either markedly depressed moods or marked loss of interest in pleasurable activities most of every day, nearly every day, for at least two consecutive weeks. When a diagnosis of major depressive disorder is made, it is usually also specified whether this is a first, and therefore single (initial) episode or a recurrent episode (preceded by one or more previous episodes). This reflects the fact that depressive episodes are usually time limited. [Even infants may experience a form of depression (formerly known as anaclitic depression or despair) if they are separated for a prolonged period from their attachment figure (usually their mother) although current thinking suggests this may not happen until at least 18 months of age] Causes Biological Factors  moderate genetic contribution to unipolar depression  the deficiencies of two neurotransmitters, norepinephrine or serotonin, play a role in depression since they are involved in the regulation of behavioural activity, stress, emotional expression, and vegetative functions (involving appetite, sleep, and arousal)—all of which are disturbed in mood disorders.  the neurotransmitter dopamine is so prominently involved in the experience of pleasure and reward. Hence, dopamine dysfunction (especially reduced dopaminergic activity) plays a significant role in at least some forms of depression since the inability to experience pleasure is an important symptom of depression.  Elevated cortisol levels are a causal factor as it is seen in patients with depression  Depression is also accompanied by dysregulation of the immune system and is associated with activation of the inflammatory response system.  damage (for example, from a stroke) to the left, (but not the right), anterior prefrontal cortex often leads to depression. depression in people without brain damage may nonetheless be linked to lowered levels of brain activity in this same region.  Patients who are depressed often show one or more of a variety of sleep problems, ranging from early morning awakening, periodic awakening during the night (poor sleep maintenance), and, for some, difficulty falling asleep.  some kind of circadian rhythm dysfunction may play a causal role in many of the clinical features of depression. Two current theories are (1) that the size or magnitude of the circadian rhythms is blunted, and (2) that the various circadian rhythms that are normally well synchronized with each other become desynchronized or uncoupled  for a small minority of women who are already at high risk (for example, by being at high genetic risk), hormonal fluctuations may trigger depressive episodes, possibly by causing changes in the normal processes that regulate neurotransmitter system. Environmental Factors  Chronic major depression has been associated with serious childhood family problems and an anxious personality in childhood.  Seasons could also be a causal factor since a majority (but not all) become depressed in the fall and winter and normalize in the spring and summer.  severely stressful life events often serve as precipitating factors for unipolar depression. Most of the episodic stressful life events involved in precipitating depression concern loss of a loved one, serious threats to important close relationships or to one’s occupation, or severe economic or serious health problems. people with depression who have experienced a stressful life event tend to show more severe depressive symptoms than those who have not experienced a stressful life event.  people with depression sometimes generate stressful life events through their poor interpersonal problem solving (such as being unable to resolve conflicts with a spouse), which is often associated with depression. Bipolar Disorders (I and II) Bipolar disorder is also known as manic-depressive illness  Bipolar-I Bipolar-II Experiences mixed episodes. A mixed episode Experiences clear-cut hypomanic episodes as is characterized by symptoms of both full- well as major depressive episodes. blown manic and major depressive episodes for at least 1 week, whether the symptoms are intermixed or alternate rapidly every few days. Diagnosis for bipolar-I is given even if the Diagnosis for bipolar-II is given when periods of periods of depression do not reach the depressed mood meet the criteria for major threshold for a major depressive episode. depression. Similarities between bipolar-I and bipolar-II  Both bipolar I and II are typically recurrent disorders, with people experiencing single episodes extremely rarely. The manic episodes either immediately precede or immediately follow a depressive episode; in other cases, the manic and depressive episodes are separated by intervals of relatively normal functioning. The recurrences can be seasonal in nature, in which case bipolar disorder with a seasonal pattern is diagnosed.  The duration of manic and hypomanic episodes tends to be shorter than the duration of depressive episodes. Bipolar II disorder is equally or somewhat more common than bipolar I disorder. Causes Biological Factors  There is a greater genetic contribution to bipolar I disorder than to unipolar disorder.  mania is caused by excesses of the neurotransmitters, norepinephrine or serotonin. However, serotonin activity appears to be low in both depressive and manic phases.  increased dopaminergic activity in several brain areas may be related to manic symptoms of hyperactivity, grandiosity, and euphoria.  use of drugs such as cocaine stimulate dopamine and produce manic-like behaviour while drugs like lithium reduce dopaminergic activity and are antimanic.  Cortisol levels are elevated in bipolar depression, but they are usually not elevated during manic episodes  Variations in brain glucose metabolic rates. Using PET, it can be seen that blood flow to the left prefrontal cortex is reduced during depression and during mania it is increased in certain other parts of the prefrontal cortex.   disturbances in biological rhythms such as circadian rhythms. During manic episodes, patients with bipolar disorder tend to sleep very little (by choice, not insomnia), and this is the most common symptom to occur prior to the onset of a manic episode. During depressive episodes, they tend toward hypersomnia. Even between episodes people with bipolar disorder show substantial sleep difficulties, including high rates of insomnia. Environmental Factors  Stressful life events are a precipitating factor in bipolar depressive and manic episodes. The stressful life events are thought to influence the timing of an episode, perhaps by activating the underlying vulnerability.  Other social environmental variables such as poor social support may also affect the course of bipolar disorder. Cyclothymic Disorder Mild mood disorder characterized by cyclical periods of hypomanic and depressive symptoms. People subject to cyclical mood changes less severe than the mood swings seen in bipolar disorder for at least 2 years, may receive a diagnosis of cyclothymic disorder. In the depressed phase of the disorder, the person’s mood is dejected, and experiences a distinct loss of interest or pleasure in customary activities and pastimes. The person may also show low energy, feelings of inadequacy, social withdrawal, and a pessimistic, brooding attitude. In the hypomanic phase of the disorder, the person may become especially creative and productive because of increased physical and mental energy. Individuals with cyclothymia are at greatly increased risk of later developing full-blown bipolar I or II disorder Psychotic Disorders Schizophrenia It is a severe disorder that is often associated with considerable impairments in functioning. The disorder is characterized by an array of diverse symptoms, including extreme oddities in perception, thinking, action, sense of self, and manner of relating to others. However, the hallmark of schizophrenia is a significant loss of contact with reality, referred to as psychosis. A delusion is essentially a flawed belief that is fixed and firmly held despite clear contradictory evidence. People with delusions believe things that others who share their social, religious, and cultural backgrounds do not believe. A delusion therefore involves a disturbance in the content of thought. Delusions reflect a disorder of thought content. Delusions are common in schizophrenia and certain types of delusions or false beliefs are quite characteristic. Prominent among these are beliefs that - one’s thoughts, feelings, or actions are being controlled by external agents (made feelings or impulses) - one’s private thoughts are being broadcast indiscriminately to others (thought broadcasting) - thoughts are being inserted into one’s brain by some external agency (thought insertion) - some external agency has robbed one of one’s thoughts (thought withdrawal). Also common are  delusions of reference, where some neutral environmental event (such as a television program or a song on the radio) is believed to have special and personal meaning intended only for the person.  delusions of bodily changes (e.g., bowels do not work) or removal of organs, are also not uncommon.  delusions of grandeur - false belief that one is a noted or famous person, such as Napoleon or the Virgin Mary.  delusion of persecution - false belief that one is being mistreated or interfered with by one’s enemies  delusions of control - believe that their feelings, thoughts and actions are controlled by others. A hallucination is a sensory experience that seems real to the person having it, but occurs in the absence of any external perceptual stimulus. Hallucinations can occur in any sensory modality (auditory, visual, olfactory, tactile, or gustatory). However, auditory hallucinations (e.g., hearing voices) are by far the most common. Even deaf people who are diagnosed with schizophrenia sometimes report auditory hallucinations. Hallucinations often have relevance for the patient at some affective, conceptual, or behavioural level. Patients can become emotionally involved in their hallucinations, often incorporating them into their delusions. In some cases, patients may even act on their hallucinations and do what the voices tell them to do. Disorganized speech is the external manifestation of a disorder in thought form. A person affected with disorganized speech fails to make sense, despite seeming to conform to the semantic and syntactic rules governing verbal communication, that is, the words and word combinations sound communicative but the listener is left with little or no understanding of the point the speaker is trying to make. The failure is not attributable to low intelligence, poor education, or cultural deprivation. In some cases, completely new, made-up words known as neologisms appear in the patient’s speech. An example might be the word detone, which looks and sounds like a meaningful word but is a neologism. Formal thought disorder is a term clinicians use to refer to problems in the way that disorganized thought is expressed in disorganized speech. Disorganized behaviour can show itself in a variety of ways. - Goal-directed activity is almost universally disrupted in schizophrenia. - There is impairment in areas of daily routine functioning, such as work, social relations, and self-care, to the extent that the person is not himself or herself anymore. For example, the person may no longer maintain minimal standards of personal hygiene or may exhibit a profound disregard of personal safety and health. - It also appears as silliness or unusual dress (e.g., wearing an overcoat, scarf, and gloves on a hot summer day). Catatonia is an even more striking behavioural disturbance. A patient with catatonia may show a virtual absence of all movement and speech and it is called a catatonic stupor. At other times, the patient may hold an unusual posture for an extended period of time without any seeming discomfort. Positive symptoms are those that reflect an excess or distortion in a normal range of behaviour and experience, such as delusions and hallucinations. Negative symptoms reflect an absence or deficit of behaviours that are normally present. Important negative symptoms in schizophrenia include  flat affect - blunted emotional expressiveness  alogia - which means very little speech  avolition - the inability to initiate or persist in goal-directed activities. For example, the patient may sit for long periods of time staring into space or watching TV with little interest in any outside work or social activities. Although most patients exhibit both positive and negative symptoms during the course of their disorders, a great number of negative symptoms in the clinical picture is not a good sign for the patient’s future outcome. Causes Biological Factors  disorders of the schizophrenia type are “familial” and tend to run in families, that is, there is a moderate genetic heritability. There is a strong association between the closeness of the blood relationship and the risk for developing the disorder. For example, if your first-degree relative has schizophrenia, you are more likely to develop it than if your third-degree relative has schizophrenia.  maternal infections such as rubella (German measles) and toxoplasmosis (a parasitic infection) that occur during the development of a foetus has also been linked to increased risk for the later development of schizophrenia.  Early prenatal nutritional deficiency is also a risk factor of later developing schizophrenia  If a mother experiences an extremely stressful event late in her first trimester of pregnancy or early in the second trimester the risk of schizophrenia in her child is increased  abnormalities in the structure and function of the brain is also a cause for schizophrenia.  two of the major neurotransmitters implicated in schizophrenia are dopamine and glutamate (dysfunction in glutamate transmission)  attentional dysfunctions could be indicators of a biological susceptibility to at least some forms of schizophrenia Environmental Factors  disturbances and conflict in families that include an individual with schizophrenia may well be caused by having a person with psychosis in the family. In other words, rather than causing the schizophrenia, family communication problems could be the result of trying to communicate with someone who is severely ill and disorganized  Being raised in an urban environment seems to increase a person’s risk of developing schizophrenia.  research is also showing that recent immigrants have much higher risks of developing schizophrenia than do people who are native to the country of immigration. In other words, there is something about moving to another country that appears to be a risk factor for developing schizophrenia (One possibility is that immigrants are more likely to receive this diagnosis because of cultural misunderstandings)   People with schizophrenia are twice as likely as people in the general population to smoke cannabis. Of course, the vast majority of people who use cannabis do not develop schizophrenia. In short Schizoaffective Disorder It is a form of psychotic disorder in which the symptoms of schizophrenia co-occur with symptoms of a mood disorder. In other words, the person not only has psychotic symptoms that meet criteria for schizophrenia but also has marked changes in mood for a substantial amount of time. Subtypes of schizoaffective disorder can be unipolar or bipolar since mood disorders can be unipolar or bipolar. Schizoaffective disorder's reliability is generally poor, and clinicians often disagree on who meets the criteria for the diagnosis. In an effort to improve this, in DSM-5 it is specified that mood symptoms have to meet criteria for a full major mood episode and also have to be present for more than 50% of the total duration of the illness. This clarification should help improve the reliability of this diagnosis and possibly also decrease the number of people who receive it In general, the diagnosis for patients diagnosed with schizoaffective disorder is somewhere between that of patients with schizophrenia and that of patients with mood disorders. Researchers don't know exactly what causes schizoaffective disorder. But it's likely to be caused by a combination of factors, such as stressful or traumatic life events, childhood trauma, brain chemistry and genetics [not from TB] Schizophreniform Disorder Schizophreniform disorder is a category reserved for schizophrenia-like psychoses that last at least a month but less than 6 months and so do not warrant a diagnosis of schizophrenia. Because of the possibility of an early and lasting decrease after a first psychotic breakdown, the prognosis for schizophreniform disorder is better than that for established forms of schizophrenia. Although researchers haven’t yet identified the exact cause of schizophreniform disorder, they think a combination of genetic, biochemical (imbalance in neurotransmitters) and environmental factors such as poor social interactions or a highly stressful event may be involved. [not from TB] Delusional Disorder Patients with delusional disorder hold beliefs that are considered false and absurd by those around them. Unlike individuals with schizophrenia, people with this disorder may otherwise behave quite normally. Their behaviour does not show the gross disorganization and performance deficiencies characteristic of schizophrenia, and general behavioural deterioration is rarely observed in this disorder, even when it proves chronic. One interesting subtype of delusional disorder is erotomania. Here, the theme of the delusion involves great love for a person, usually of higher status. One study suggests that a significant proportion of women who stalk are diagnosed with erotomania. Researchers don’t yet know the exact cause of delusional disorder but genetic factors, biological factors such as abnormalities in the brain and environmental factors such as social isolation, envy, distrust, suspicion and low self-esteem could contribute to the development of this disorder. [not from TB] OTHER IMPORTANT STUFF Difference between Schizoid Personality Disorder and Avoidant Personality Disorder Schizoid Personality Disorder Avoidant Personality Disorder Individuals with schizoid personality disorder Individuals with avoidant personality disorder are usually unable to form social relationships show extreme social inhibition and and usually lack much interest in doing so introversion, leading to lifelong patterns of limited social relationships and reluctance to enter into social interactions. A loner with schizoid personality disorder is A loner who is avoidant is shy, insecure, and more aloof, cold, and relatively indifferent to hypersensitive to criticism criticism People with schizoid personality disorder do People with avoidant personality disorder do enjoy their aloneness. not enjoy their aloneness Some features of dependent personality disorder overlap with those of borderline, histrionic, and avoidant personality disorders, but there are differences as well. Both borderline personalities and dependent personalities fear abandonment. However, - the borderline personality, who usually has intense and stormy relationships, reacts with feelings of emptiness or rage if abandonment occurs - the dependent personality reacts initially with submissiveness and appeasement and then finally with an urgent seeking of a new relationship. Histrionic and dependent personalities both have strong needs for reassurance and approval, but - the histrionic personality is much more gregarious, flamboyant, and actively demanding of attention - the dependent personality is more docile and self-effacing. It can also be hard to distinguish between dependent and avoidant personalities. - avoidant personalities have trouble initiating relationships because they fear criticism or rejection, which will be humiliating - dependent personalities have great difficulty separating in relationships because they feel incompetent on their own and have a need to be taken care of Some features of OCPD overlap with some features of narcissistic, antisocial, and schizoid personality disorders, although there are also distinguishing features. Individuals with - narcissistic and ASPDs may share the lack of generosity toward others but tend to indulge themselves - OCPD are equally unwilling to be generous with themselves. Both schizoid and OCPD may have a certain amount of formality and social detachment, but - the schizoid personality lacks the capacity for close relationships. - person with OCPD has difficulty in interpersonal relationships because of excessive devotion to work and great difficulty expressing emotions. Difference between OCD and OCPD OCD OCPD occurrence of unwanted and intrusive Perfectionism and an excessive concern with obsessive thoughts or distressing images maintaining order and control accompanied by compulsive behaviours performed to undo or neutralize the obsessive thoughts or images or as a way of preventing some dreaded event or situation. It is an obsessive-compulsive related disorder It is a personality disorder A person with OCD usually feels driven to A person with OCPD do not have true perform this compulsive, ritualistic behaviour in obsessions or compulsive rituals that are the response to an obsession, and there are often source of extreme anxiety or distress. Instead very rigid rules regarding exactly how the have lifestyles characterized by compulsive behaviour should be performed. overconscientiousness, high neuroticism, inflexibility, and perfectionism. Difference between Social Anxiety Disorder and Avoidant Personality Disorder Social Anxiety Disorder Avoidant Personality Disorder disabling fears of one or more specific social extreme social inhibition and introversion, situations such as public speaking, urinating in a leading to lifelong patterns of limited social public bathroom, or eating or writing in public. relationships and reluctance to enter into social interactions It is an anxiety disorder It is a personality disorder People with this disorder usually avoid specific people with this disorder typically avoid all social situations, such as eating around others areas of social interaction. or public speaking Experience high levels of anxiety in any social Completely avoids a social situation. situation a person fears that she or he may be exposed a person fears of criticism and rebuff and thus to the scrutiny and potential negative does not interact with people even when they evaluation of others or that she or he may act desire to do so. They also avoid many novel in an embarrassing or humiliating manner. situations and emotions (including positive emotions) due to the same.