Introduction to Psychopathology PDF 2024

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit...

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of U.C. Regulations and the DMCA and Is Expressly Prohibited.  Notice All Course materials (class lectures and discussions, handouts, examinations, Web materials) and the intellectual content of the Course itself are protected by United States Federal Copyright Law, and the California Civil Code. UC Policy 102.23 expressly prohibits students (and all other persons) from recording lectures or discussions and from distributing or selling lectures notes and all other course materials without the prior written permission of the Instructor (See http://policy.ucop.edu/doc/2710530/PACAOS-100). Students are permitted to make notes solely for their own private educational use. Exceptions to accommodate students with disabilities may be granted with appropriate documentation. To be clear, in this class students are forbidden from completing study guides and selling them to any person or organization. The text has been approved by UC General Counsel. You are granted permission in Psych 183 to download and retain personal copies of these slides solely for your own use.  Anxiety Disorders Obsessive-Compulsive & Related Disorders  Common Signs/Symptoms of Anxiety Cognitive ⚫ “Objectless fear” or feeling of apprehensiveness ⚫ Heightened sense of and vulnerability ⚫ Worrying and rumination ⚫ “Going blank” or “spacing out” ⚫ Irritability, impatience, distractibility ⚫ Hypervigilance Physiological ⚫ Trembling , twitching, “feeling shaky” ⚫ Fatigue, restlessness ⚫ Muscle tension, jitteriness ⚫ Dizziness, lightheadedness ⚫ Fast heartbeat, breathing rate ⚫ Sweating, cold or clammy hands ⚫ Dry mouth, nausea, diarrhea ⚫ Altered appetite and sleep Note: Anxiety can be chronic or acute. Acute intense anxiety is called a “panic attack.” Panic attacks occur in many anxiety disorders.  Signs/Symptoms of Panic Attack (Acute Anxiety Episode) ⚫ palpitations, pounding heart, or accelerated heart rate ⚫ sweating ⚫ trembling or shaking ⚫ sensations of shortness of breath, choking, smothering ⚫ chest pain or discomfort ⚫ nausea or abdominal distress ⚫ feeling dizzy, unsteady, lightheaded, or faint ⚫ Dissociative experiences – derealization (feelings of unreality) – depersonalization (being detached from oneself) ⚫ fear of dying, losing control or going crazy ⚫ paresthesias (numbness or tingling sensations) ⚫ chills or hot flushes Note: Panic attacks are frequently seen when patients go to ER’s thinking they are having a heart attack (it’s important to go anyway!).  Fear, Anxiety, and the Brain ⚫ Amygdala – registers emotional aspects of situations (e.g., threat) ⚫ Locus Coeruleus – controls arousal of Amygdala neocortex, and Locus Coeruleus in activates Reticular Formation hypothalamic- pituitary axis and Autonomic NS Autonomic Nervous System (ANS) = Sympathetic + Parasympathetic NS’s Anxiety-Related Actions of the Sympathetic N.S. Pituitary release of ACTH, which triggers release of steroid hormones from adrenal gland, causing increased appetite and anti-inflammatory actions. Adrenal gland secretion of epinephrine and norepinephrine Pupillary dilation Drying of mucosal linings (mouth, stomach, intestines) Increased sweating Heightened heart rate Constriction of blood vessels in skin and gut, and diversion of blood flow to muscles (raises BP) Speeded respiration and airway relaxation Emergency release of glucose into the circulation  GABA and Anxiety ⚫ Sites related to anxiety in animals involve the neurotransmitter GABA (Gamma-Aminobutyric Acid). ⚫ Anxiety-prone people have deficits in GABA. ⚫ Chemically blocking GABA increases anxiety. ⚫ Ethyl alcohol (ETOH, i.e., the psychoactive part of liquor, wine, beer) and common anti-anxiety medications bind to GABA receptor areas and mimic GABA. ⚫ GABA is only one of many neurotransmitters involved in anxiety: – GABA and 5HT (serotonin) both inhibit anxiety. – Epinephrine, norepinephrine, and dopamine increase anxiety.  Anxiety Disorders ⚫ Most frequently occurring psychiatric problems in the general population, and are showing recent increases in adolescent and young adults, especially during and after Covid. ⚫ Overall, anxiety disorders run strongly in families, and are often co-morbid with Major Depression and Stress disorders. 50-70% of people with lifetime Major Depression also have lifetime anxiety disorders. This suggests a common “distress” inheritance. ⚫ Anxiety disorders carry increased risk of alcoholism / drug abuse and “self-medication”  DSM-5-TR Nosology of Anxiety and Obsessive-Compulsive Disorders (Major) Anxiety Disorders: ⚫ Panic disorder ⚫ Agoraphobia ⚫ Generalized Anxiety Disorder ⚫ Separation Anxiety Disorder ⚫ Social Anxiety Disorder (Social Phobia) ⚫ Specific Phobias (Major) Obsessive-Compulsive and Related Disorders (Now a separate-but-related disorder category in DSM-5-TR): ⚫ Obsessive-Compulsive Disorder ⚫ Body Dysmorphic Disorder ⚫ Hoarding Disorder ⚫ Trichotillomania ⚫ Excoriation (Skin-Picking) Disorder Some Common Physical Disorders That Can Mask As “Anxiety Disorders” ⚫ Hyperthyroidism ⚫ Pheochromocytomas (adrenal tumors that over- secrete adrenalin) ⚫ Inner ear disease (causes balance problems which make people anxious, and which people sometimes confuse with anxiety) ⚫ Angina pectoris (chest pain from reduced blood flow to heart) ⚫ Hypoglycemia (low blood sugar) ⚫ Mitral valve prolapse (floppy mitral valve, causes weak oxygenation of brain & body) ⚫ Cardiac arrhythmias ⚫ Drug effects (from, e.g. caffeinism, nicotine addiction, nasal decongestants, psychostimulants, asthma inhalers) Panic Disorder  Panic Disorder ⚫ Occurrence of panic attacks without warning. One month or more of: ⚫ Apprehensiveness about further attacks and their consequences (losing control, having a heart attack, “going crazy”). ⚫ Pattern of avoidance and disability as a result.  Facts About Panic Disorder ⚫ One-year and lifetime prevalences ~ 2 - 3% ⚫ Female : Male ratio ~ 2:1 ⚫ Develops mostly during young adulthood (ages 20-24), rarely seen in children. ⚫ Increased risk with background of child abuse/neglect, and with mitral valve prolapse. ⚫ Course is typically chronic but waxing and waning , and is associated with other anxiety disorders, and with Substance Use Disorders. Rates of co-morbidity with Major Depression are as high as 60%. ⚫ Most people with Panic Disorder can identify major stressors in the months preceding their first panic attack (e.g., conflicts, losses, health scares). ⚫ Panic attacks can be triggered in susceptible people by various stimulants, including caffeine, nicotine, marijuana (depending on the strain and the person). ⚫ People who suffer from Panic Disorder may be more “interoceptive” than others, i.e., they seem to be more attuned to internal sensations than non-sufferers, and anxiety about these sensations escalates by a feedback loop. ⚫ 25% of people with Panic Disorder have suicidal ideation. 1st Line Panic Disorder Treatments ⚫ Dietary / medication control (e.g., caffeine, nicotine, marijuana) ⚫ Anxiolytic medications (mostly benzodiazepines, mainly Xanax) - for acute use only; note: Xanax often causes rebound anxiety, longer-lasting benzos (e.g., Ativan, Valium, Klonopin) indicated. Benzodiazepines are “alcohol in a pill” – they are synergistic, and cross-tolerant with ETOH (i.e., they are mutually addictive) ⚫ Antidepressant medication (mainly, SSRI’s like Zoloft, Prozac, Paxil, Celexa, Lexapro, etc.), chronically as preventative ⚫ Psychotherapy: – Cognitive therapy: normalization, de-catastrophizing, paced metronomic breathing) – Supportive therapy  Agoraphobia (“Fear of the Marketplace”) ⚫ Marked fear or anxiety triggered by real or imagined exposure to a range of situations, most often public ones. Fear is that escape is impossible or help will be unavailable, especially if a panic attack occurs. ⚫ Prevalence ~1.5 %, 2:1 Female : Male ratio. ⚫ Peak ages are in late adolescence and young adulthood. ⚫ Often develops (30-50% of cases) with prior panic attacks, as ritualized avoidance of situations that might trigger panic attacks, and is then co-diagnosed with Panic Disorder. – home, or room within the home, becomes “safety zone” – reluctance to venture outside safety zone without “escape route” ⚫ Treatment: – Antidepressant medication (typically, an SSRI) – In vivo desensitization ⚫ Disorder is chronic and persistent without treatment. Generalized Anxiety Disorder (GAD) General Diagnostic Criteria for Generalized Anxiety Disorder (GAD) ⚫ Debilitating worry, fretfulness on most days over at least 6 months. ⚫ Worry is excessive, hard to control or put aside and is sometimes justified by the worrier. ⚫ Varied anxiety symptoms, including: – restlessness – fatigue – difficulty concentrating or mind going blank – irritability – muscle tension – insomnia or fitful sleep – Sometimes: nausea, diarrhea and irritable bowel, hyperstartle, headaches Facts About Generalized Anxiety Disorder ⚫ 1-year prevalence ~ 3%. ⚫ Mean age of onset is age 35, but sometimes emerges during adolescence. Many GAD sufferers report lifelong excessive worrying. ⚫ Females > Males: 2:1 ratio. ⚫ More common among members o high-income societies than those from low-income societies. ⚫ 75% of GAD sufferers have another mental disorder, usually Major Depression. ⚫ Affects 10-20% of the elderly, who are beset with frailty, medical illness, and losses – which lead to vulnerability and fear. ⚫ 36 % of GAD sufferers self-medicate w/ ETOH and other drugs (e.g., marijuana, anti-anxiety meds) (J.Nerv.Ment.Dis., 2006). ⚫ Substance abuse and dependence often develops with GAD, and so causality may be bi-directional.  Symptomatic Treatments for Anxiety ⚫ Habit control (e.g.,coffee, cigarettes, stimulant medications) ⚫ Anxiolytic (anti-anxiety) medications – For acute use: ⚫ Benzodiazepines, e.g., Xanax, Ativan, Klonopin, Valium ⚫ Mostly for stage fright: Beta-blockers, e.g., Inderal (propanolol) – For chronic use: ⚫ Most often: SSRI’s (Prozac, Lexapro, Celexa, Zoloft, etc.) or atypical antidepressants (e.g., Cymbalta, Effexor) ⚫ Anti-convulsant Neurontin (gabapentin) ⚫ Occasionally: – Atypical anxiolytics, e.g., Buspar (buspirone) – For severe anxiety untreated by usual medications, antipsychotics like Seroquel, Risperdal, Zyprexa, Latuda ⚫ Psychotherapy – Supportive, cathartic – Muscle relaxation training – Meditation techniques – Stress management training – Biofeedback ⚫ For mild to moderate anxiety: – Exercise – Support groups  Social Anxiety Disorder (formerly, Social Phobia)  Social Anxiety Disorder (Social Phobia) ⚫ Most common anxiety disorder – 1-yr prevalence of ~8 %, lifetime prevalence up to 15% – More common in females: ratio of 1.5 to 1 – Develops in late adolescence or young adulthood – Grossly under-diagnosed in managed care population ⚫ Occurs when people become disabled by: – Intense, persistent, and chronic fears of being watched and judged by others, and of doing things that will be humiliating or embarrassing. – Can be generalized or occur in specific situations (non-generalized) – One-third are sufferers are very disabled, and are more likely to be depressed, divorced, unemployed or under-employed. ⚫ Awareness that fears are excessive ⚫ Common “performance situations”: – Public speaking (Toastmasters) – Public restroom use – Going to parties – Eating in front of others – Bedroom (some cases of erectile dysfunction, orgasmic dysfunction) ⚫ Most commonly treated with medications (benzodiazepines and/or SSRI’s) plus supportive and proactive psychotherapy. Mostly for males, erectile dysfunction is often treated with meds like Viagra or Cialis. Specific Phobia  Specific Phobias ⚫ Persistent fears or panic attacks out of proportion to situation ⚫ Compelling desire to avoid phobic stimulus ⚫ Insight that fear is excessive ⚫ Symptoms are unrelated to another disorder.  Facts About Specific Phobias ⚫ Have a one-year prevalence of ~7%, and a lifetime prevalence of ~9% in the U.S. ⚫ Mean duration of a specific phobia is about 20 yrs. ⚫ Females > Males: 2:1 to 3:1 ratio ⚫ Most specific phobia sufferers have multiple phobias  Types of Specific Phobias ⚫ Animal type ⚫ Natural environment type (i.e. storms, heights, water) ⚫ Situation type (i.e. claustrophobia, tunnels, bridges, flying, driving) ⚫ Bodily reactions (vomiting, headache, fever). A phobia about vomiting (emetophobia) keeps some females from attempting pregnancy ⚫ Blood-injury-injection type (vasovagal reaction) ⚫ Range of most common phobic stimuli undercuts a straightforward Pavlovian conditioning view of specific phobia (i.e. people develop phobias to snakes more than automobiles or bathtubs)  Treatments for Specific Phobias ⚫ All treatments are complicated by avoidance behavior. ⚫ Anxiolytic or antidepressant medication (preferably, an SSRI) ⚫ Systematic desensitization (in the therapy office) or in vivo (“in real life”) desensitization. ⚫ Flooding – presenting the most intense version of phobic stimulus first. Rarely used due to high therapy dropout rates, and possibility of retraumatization. ⚫ Applied tension for blood-injection phobias. ⚫ Experimental: VR therapy for flying and height phobias. ⚫ Self-help groups. Obsessive-Compulsive and Related Disorders (OCD) Obsessive-Compulsive Disorder (OCD) ⚫ Debilitating, unwanted (ego-dystonic): – obsessions (intrusive thoughts, impulses, images) – compulsions (repetitive behavior to ward off anxiety or an unwanted impulse). Compulsions are usually external behaviors, but may also be compulsory sequences of thoughts. ⚫ Recognition that one’s obsessions and compulsions are excessive or unreasonable ⚫ Significant distress or impairment for over one hour per day.  Facts About OCD ⚫ One-year prevalence ~ 2% ⚫ About 80% of OCD sufferers have coexisting Major Depression. ⚫ ½ of OCD cases begin in childhood, and these childhood cases are mostly males and are more severe. ⚫ OCD cases beginning in adolescence or adulthood are less severe, and females = males in prevalence. ⚫ 20% of OCD cases have 1st-degree relatives with OCD. Severe OCD Basal Ganglia  Basal Ganglia and Frontal Cortex Basal Ganglia Frontal Cortex Thalamus Overactivity in the basal ganglia and the orbito-frontal cortex is seen in OCD. Frontal Cortex and OCD  Common Obsessions and Compulsions in OCD Obsessions % Compulsions % Multiple obsessions 60 Checking 63 Contamination 45 Washing 50 Excessive doubt 42 Counting 36 Somatic 36 Need to ask or confess 31 Need for symmetry or Arranging/organizing 28 exactness 31 Collecting/Hoarding 18 Fear of causing harm to 28 self or others Multiple compulsions 48 Fear of being sexually inappropriate 26 Other (praying, repeating words) 13 98% of OCD sufferers have both obsessions and compulsions.  DSM-5-TR Obsessive-Compulsive Related Disorders (“OCD-Spectrum Disorders”) ⚫ Hoarding Disorder (2-5 % of population, ~1:1 F:M) – excessive shopping and collecting of possessions (sometimes, animals) – anxiety about discarding possessions – possessions crowd out living space – embarrassment about showing living space to others – Often related to deficient self-care ⚫ Body-Focused Repetitive Behaviors (2-5% of population, 3:1 to 10:1 F:M diagnostic ratios): – Trichotillomania (hair-pulling, from scalp, eyelashes, eyebrows) – Excoriation (Skin-Picking) Disorder (skin-, nail- and cuticle- picking) ⚫ Body Dysmorphic Disorder (2.5% of population, 1:1 F:M) – obsessive concern about appearance and body parts (usually skin, hair, nose) and compulsive acts (mirror checking, camouflaging, excessive grooming, and skin picking) – can become compulsive consumers of plastic surgery – pattern of anxious avoidance of others – half of BDD individuals have delusions of reference – Body Integrity Dysphoria subtype – discontent with one’s anatomy and desire for amputation Unofficial Members of OCD-Related Disorders ⚫ Gilles de la Tourette Syndrome (“Tourette’s”) – Anxiety – Tics – Coprolalia ⚫ Hypochondriasis (DSM-5-TR: Illness Anxiety Disorder) ⚫ Delusional Disorder (Erotomanic Type) – Fantasized love and stalking (often exacerbated by social media) ⚫ “Homosexual OCD” (HOCD) – not officially recognized or in DSM-5-TR – Fear of / aversion to being gay/lesbian – Obsessive self-questioning about one’s erotic responses to same vs. opposite sex ⚫ Bulimia nervosa, Anorexia Nervosa  Body Integrity Dysphoria*: ⚫ A belief, usually from early childhood, that one or more limbs (usually the legs) do not “belong” to one’s body, and that amputation of the limb(s) will achieve "wholeness." ⚫ Certainly regarding the limb(s) involved and the level of amputation desired. ⚫ Rehearsal activity (pretending) during which they imitate the amputated state in private and in public. ⚫ Pursuit of elective amputation or attempts at self- amputation. ⚫ BIID can include non-amputation bodily changes, such as beliefs that one “should” be deaf, blind, paralyzed, or disfigured. ⚫ Amputation or other surgery is the only known treatment. *formerly Body Identity Disorder (BIID) and see Text Addendum Body Integrity Dysphoria (from Whole, 2003)  Streptococcus and OCD: PANDAS Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections ⚫ Seen in school-age children who develop strep throat or strep rash, usually with fever and urinary incontinence. ⚫ Sudden onset of tic disorder, or OCD signs/symptoms, most commonly hand-washing and preoccupation with germs. ⚫ Rapid remission of symptoms usually occurs with antibiotic therapy. ⚫ PANDAS accounts for only a small % of childhood OCD, but may point to possible mechanisms involved in OCD (auto- immunity, neurotoxicity?).  1st Line OCD Treatments ⚫ Antidepressant therapy with serotonin-boosting medications (usually requires high doses): – SSRIs, e.g., Prozac, Luvox, Celexa, Lexapro – Tricyclics, esp., clomipramine (Anafranil) ⚫ Behavior Therapy: – Thought stopping – Response prevention ⚫ Neurosurgery for otherwise intractable cases (involves pathways to/from frontal lobes): Invasive: – Deep Brain Stimulation (DBS) using implanted electrodes – Cutting of pathways Non-invasive destruction of pathways by heating: – Targeted, triangulated radiation using gamma knife – Newest: Focused ultrasound OCD Treatment by Focused Ultrasound End