PSY 183 Fall 2024 Midterm Study Guide PDF

PSY183 Fall 2024 Midterm Exam Fair-Game Sheet * will NOT need to know numerical percentages or prevalences Leading risk factors for suicide Stressful events and situations: combat stress, immediate and major stressors, long term stressors ○ Social isolation, serious illness,...

PSY183 Fall 2024 Midterm Exam Fair-Game Sheet * will NOT need to know numerical percentages or prevalences Leading risk factors for suicide Stressful events and situations: combat stress, immediate and major stressors, long term stressors ○ Social isolation, serious illness, abusive or repressive environments, occupational stress, etc. Mood and thought changes: ○ Psychache: a feeling of psychological pain that seems intolerable to the person ○ A sense of hopelessness, dichotomous thinking (keyword ONLY) Alcohol and drug use ○ Alcohol lowers inhibitions, reduces fear, impairs judgment and thinking ○ More intoxicated = more lethal method used Mental disorders: severe depression, chronic alcoholism, schizophrenia ○ Depressed + substance-dependent → particularly prone to suicidal impulses ○ Risk of suicide actually increases when mood improves in major depressive disorder patients, since they have more energy to act on their ideations Interpersonal beliefs of perceived burdensomeness and thwarted belongingness + the psychological capability for suicidal acts ⇒ suicide Strongest suicide predictor = biological abnormalities + key psychosocial factors (i.e. childhood traumas) Protective factors in suicide More thorough belonging in family, religious institutions, and community → lower risk of suicide Stable structures in surrounding social environment Regular serotonin levels and normal functioning brain circuitry Basic interventions to prevent suicide and treat high-risk people Treatment after attempt: ○ Medical care for injuries, brain damage, etc. ○ Psychotherapy or drug therapy follows Systematic follow-up care is crucial in preventing future attempts ○ Dialectical behavior therapy (DBT): assess, challenge, and change negative attitudes, teach better coping and problem solving skills Helps to accept and build tolerance of psychological distress/thoughts, rather than eliminate them Suicide prevention: ○ Suicide prevention programs and crisis intervention: identify and respond to individuals who are at risk of killing themselves ○ In therapy:  Establish positive relationship Understand and clarify the problem Assess suicide potential on lethality scale Assess and mobilize their resources Formulate a plan to make changes and establish no-suicide contract Reduce the public’s access to lethal and common means of suicide General evidence for “contagiousness” of suicide Modeling, in which suicidal acts serve as a model for another Social contagion effect: trauma and a sense of loss increases the risk of suicide among relative and friends of the victim Bizarre cases that are highly publicized have lead to similar suicidal acts ○ Ex: politically motivated self-burning suicide media report → 82 people followed without political motivation Other possible models include celebrities or coworkers Anxiety Disorders Nature of clinical “anxiety”: signs and symptoms Anxiety: the central nervous system’s physiological and emotional response to a vague sense of threat or danger Anxiety disorder: suffering from such disabling fear and anxiety that one cannot lead a normal life Generalized anxiety disorder (GAD): marked by persistent and excessive feelings of anxiety and worry about numerous events and activities ○ Described as free-floating anxiety: anxiety about practically anything ○ Experiencing disproportionate, uncontrollable, and ongoing anxiety and worry about multiple matters → reduced quality of life Cognitive signs and symptoms: ○ Objectless fear or feeling of apprehensiveness; a generalized fear, feeling weary ○ Heightened sense of and vulnerability ○ Worrying and rumination ○ Going blank or spacing out ○ Irritability, impatience, distractibility ○ Hypervigilance Physiological signs and symptoms: ○ 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 Anxiety can be chronic or acute ○ Chronic: likely that anxiety runs in the family ○ Acute intense anxiety: panic attack Same anxiety symptoms Dissociative experiences (derealization, depersonalization) Fear of dying, losing control or going crazy Paresthesias: numbness or tingling sensations Chills or hot flashes Sociocultural characteristics that affect anxiety GAD is most likely to develop in people who are faced with dangerous ongoing societal conditions ○ Highly threatening environments develop feelings of tension, anxiety, fatigue, sleep disturbances ○ Poverty: high crime rates, poor opportunities, health problem risks Rates of GAD are ~ 2 times higher among low income people vs. high income Wage decreases → GAD rate increases ○ Nervios or ataques de nervios in Hispanic individuals GAD is also more common among members of high-income societies than those from low-income societies ○ Low-income: mind is preoccupied with survival ○ High-income: less demands → mind is free to wander and worry Separation anxiety is a common psychological disorder among kids ○ Trouble being separated from their family for fear of losing them to some circumstance ○ Otherwise, normal functioning when near their parents Can even develop in adulthood, after experiencing trauma with losing someone ○ Become consumed with the concern about another important person in their life → severe distress Brain areas, neurotransmitters and ANS involvement in anxiety Amygdala: registers emotional aspects of situations, hooking up what we are experiencing with the emotional significance of it Locus coeruleus: controls arousal of neocortex, and activated hypothalamic-pituitary axis and autonomic NS Fear circuit in the brain is excessively active, hyperactive, in people with GAD ○ Regions include: prefrontal cortex, anterior cingulate cortex, insula, amygdala ○ Low levels of GABA → hyperactive circuit functioning → GAD ○ Improper functioning of structures and neurons in the fear circuit → GAD  ○ We still need a better understanding: Possibility of 2 separate circuits, one producing physical/behavioral reactions, the other producing cognitive processes GABA (gamma-aminobutyric acid): anxiety-prone people have deficits in GABA ○ Chemically blocking GABA increases anxiety ○ Common anti-anxiety medications bind to GABA receptor areas and mimic GABA GABA and serotonin inhibit anxiety Epinephrine, norepinephrine, and dopamine increase anxiety Anxiety-related actions of the sympathetic NS (fight or flight): ○ Pituitary release of ACTH → 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 Physical conditions that can masquerade as anxiety disorders These physical symptoms can all be confused with anxiety disorder Hyperthyroidism: metabolism, heart rate, and blood pressure all increase dramatically Pheochromocytomas: adrenal tumors are over-secreting adrenaline → constant feelings of sympathetic fight or flight Inner ear disease: balance problems → feeling anxious and dizzy Angina pectoris: reduced blood flow to heart → chest pain, harder breathing Hypoglycemia: low blood sugar → feeling weak, dizzy, shaky Mitral valve prolapse: chronic weak oxygenation of brain and body → constant state of panic Cardiac arrhythmias: irregular heartbeats → interfering with heart’s ability to function Drug effects: caffeinism, nic addiction, nasal decongestants, psychostimulants, asthma inhalers Types of symptomatic treatments for anxiety, including classes of anxiolytic medications: differences, precautions, side effects, and general classes of drugs Psychotherapy: ○ Cognitive therapy: normalization, de-catastrophizing, paced metronomic breathing ○ Supportive therapy  ○ Muscle relaxation training ○ Meditation techniques ○ Stress management training ○ Biofeedback: technological meditation, patients are given feedback about physiological activity Anxiolytic: lysing, or cutting off, the anxiety ○ For acute use: benzodiazepines or beta-blockers (rarely, used for stage fright) ○ For chronic use: SSRIs or atypical antidepressants Anticonvulsant (gabapentin): walking around in a fog Atypical anxiolytics Antipsychotics (worth the side effects for very severe anxiety) Drug therapies: ○ Sedative-hypnotic drugs: low doses are calming in effect, high doses help people fall asleep Benzodiazepines: provides relief from anxiety by mimicking GABA at receptors GABA is inhibitory, it stops neurons from firing → excitability stops, fear and anxiety subsides Short-lived effects: when stopped, anxiety returns just as strong Produces undesirable side effects: drowsiness, lack of coordination, memory loss, depression, aggression → one can become physically dependent Mixes badly with other drugs/substances Barbiturates: more addictive ○ Antidepressant medications: increase serotonin and norepinephrine → improved functioning in the fear circuit Able to bring some relief to GAD patients (60%) ○ Antipsychotic medications: altering dopamine activity in the fear circuit → relieve anxiety Can produce serious side effects Major etiological aspects and diagnostic features of, and treatments for: Generalized anxiety disorder (GAD) Generalized anxiety disorder (GAD): a disorder marked by persistent and excessive feelings of anxiety and worry about numerous events and activities 2:1 F:M ratio Etiology (psychodynamic, humanistic, cognitive, biological perspectives): ○ Unresolved childhood anxiety: Freund argued that early developmental experiences produce an unusually high level of anxiety in some  People who suffered extreme punishments or overprotectiveness as children have higher levels of anxiety later Extreme punishment → belief that one’s Id impulses are dangerous → feeling anxiety whenever they experience impulses Overprotected children → Ego defense mechanism may be too weak to cope with anxiety of life stressors ○ GAD arises when people stop looking at themselves honestly and acceptingly, building self-judgment Denying/distorting true thoughts, emotions, and behaviors → anxious, unable to fulfill potential as human beings Carl Rogers’ explanation: too much unconditional positive regard from others → overly critical and harsh self-standards, or conditions of worth ○ Maladaptive assumptions: more and more assumptions → develop GAD Albert Ellis holds that people are guided by basic irrational assumptions Basic irrational assumptions: inaccurate/irrational beliefs held by people with various psychological problems that lead them to act and react inappropriately Facing stressful events + making assumptions = interpreting as dangerous, overreacting, feeling fear Aaron Beck argued that people with GAD constantly hold silent assumptions that imply they are in imminent danger ○ Metacognitive theory: people with GAD implicitly hold both positive and negative beliefs about worrying Positive: worrying is a useful way of appraising and coping with threats → they look for and examine all signs Negative: worrying is a bad thing, and that repeated worrying is harmful → meta-worries: worrying about worrying Concerned that they are going crazy or losing out because they keep worrying → GAD ○ Intolerance of uncertainty theory: individuals cannot tolerate the knowledge that negative events may occur, even small possibilities Worry constantly + unbearable uncertainty over the possibility of an unacceptable negative outcome + uncertain attempts to find “correct” solution → vulnerability to developing GAD People with GAD display higher levels of intolerance of uncertainty than people with normal degree of anxiety Develops in early childhood; can be passed on from parents to children ○ Avoidance theory: individuals worry repeatedly in order to reduce or avoid uncomfortable states of bodily arousal  People with GAD have greater bodily arousal, and worrying serves to reduce this arousal People with GAD experience fast and intense body reactions, find these overwhelming, worry more when aroused, and can reduce arousal by worrying ○ GAD patients have deficient GABA production levels or few/broken receptors ○ Abnormally functioning fear circuit in the brain; excessively active, hyperactive ○ Biological relatives of a person with GAD are more likely than nonrelatives to also have GAD 15% of relatives have GAD Diagnostic features: ○ Debilitating worry, fretfulness on most days over at least 6 months ○ Worry is excessive, hard to control or put aside; sometimes justified/maintained by the worrier ○ Varied anxiety symptoms, including: Restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, insomnia Sometimes: nausea, diarrhea and irritable bowel hyperstartle, headaches ○ May emerge at any age ○ Non-Hispanic white Americans are more likely than members of minority groups to develop GAD Treatments: ○ Habit control ○ Anxiolytic (anti-anxiety) medications ○ Psychodynamic therapies: Utilize techniques of free association, resistance, and dreams to help GAD patients becomes less afraid of id impulses and control them Object relations therapists use methods to help patients identify and settle childhood relationship problems ○ Client-centered therapy: show unconditional positive regard for clients and empathize with them Acceptance and caring → allow clients to recognize their true needs, thoughts, emotions → anxiety and symptoms will subside Usually more helpful to anxious clients than no treatment But only sometimes better than placebo therapy ○ Cognitive-behavioral therapies: Rational-emotive therapy: focus on changing maladaptive assumptions Point out irrational assumptions, suggest more appropriate ones, and assign homework to practice this process Brings at least modest relief  Acceptance and commitment therapy (mindfulness-based therapy): “new-wave” cognitive-behavioral therapists aim to guide clients to recognize and change their dysfunctional use of worrying Educate them on the role of worrying in their disorder, have them observe their arousal and responses Learn to appreciate the triggers, misconceptions, and their misguided efforts to control worrying Accept their worries, rather than eliminate → less upset and less influenced by them ○ For mild to moderate anxiety: exercise, support groups Panic Disorder, incl. heightened interoception and “anxiety sensitivity” Panic disorder: occurrence of panic attacks without warning ○ Panic attacks: periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass 5:2 F:M ratio Etiology: ○ Panic attacks are believed to be more prevalent among people who have lots of stressors in their lives → constantly on the edge of breaking down ○ Panic attacks can be triggered in susceptible people by various stimulants, Ex: caffeine, nicotine, marijuana ○ People who suffer from Panic Disorder may be more “interoceptive” than others: more attuned to internal sensations than non-sufferers Feeling the flow of blood through their body, feeling how deeply they’re breathing ○ People who suffer from panic disorder have a hyperactive panic circuit Panic circuit: amygdala, hippocampus, ventromedial nucleus of hypothalamus, central gray matter, locus coeruleus Inherited development of abnormalities in this circuit Close relatives share rates of panic disorder more than distant relatives ○ Locus Coeruleus: panic reactions related to irregularities in norepinephrine activity in the locus coeruleus ○ Panic-prone individuals may experience more frequent or intense bodily sensations ○ Panic-prone individuals have had more trauma-filled events → greater expectations of catastrophe ○ Panic-prone individuals have a high degree of anxiety sensitivity: a tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful Diagnostic features:  ○ 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 ○ Course is typically chronic but waxing and waning ○ Associated with other anxiety disorders, and with Substance Use Disorders ○ Rates of co-morbidity with Major Depression are as high as 60% ○ 25% of people with Panic Disorder have suicidal ideation ○ Typically sets the stage for development of agoraphobia Treatments: ○ Dietary/medication control, such as restrictions on caffeine, nicotine, marijuana ○ Anxiolytic medications ○ Antidepressant medication Mainly SSRIs as a chronic preventative Antidepressants that increase norepinephrine in the brain seemed to alleviate symptoms Antidepressant drugs bring improvement to more than ⅔ of panic disorder patients Improvement lasts as long as the drugs are continued ○ Psychotherapy ○ Cognitive-behavioral therapy: aims to correct misinterpreted bodily sensations Educate clients about the general nature of panic attacks, causes of sensations, and tendency to misinterpret Teach clients to apply more accurate interpretations and ways to cope better with anxiety Biological challenge tests are used to induce panic and provide them with opportunities to apply their skills ⅔ of participants become free of panic through cognitive-behavioral therapy ○ Cognitive-behavioral therapy, drug therapy, or a combination of these approaches, are helpful to those displaying both panic disorder and agoraphobia Derealization / depersonalization Derealization: feelings of unreality Depersonalization: being detached from oneself; observing their own bodies from a different perspective Agoraphobia Agoraphobia: a fear of venturing into public places or situations where escape might be difficult or help may be unavailable if one were to become panicked or incapacitated 2:1 F:M ratio Etiology:  ○ 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” ○ Peak ages are in late adolescence and young adulthood More independence, more responsibilities, leaving the safety of the home ○ Cognitive-behavioral models: idea that fears are conditioned and reinforced by processes of classical conditioning and modeling Diagnostic features: ○ Marked fear or anxiety triggered by real or imagined exposure to a range of situations ○ Fear is that escape is impossible or help will be unavailable, especially if a panic attack occurs Self-fulfilling prophecy: begin to avoid more and more places, more and more people ○ The intensity of agoraphobia fluctuates Severe: limited and imprisoned in their homes → social life dwindles, can’t hold a job, become depressed ○ Many experience panic attacks when they enter public places → receive 2 diagnoses of agoraphobia and panic disorder ○ Twice as common among poor people compared to wealthy people Agoraphobia is chronic and persistent without treatment Treatments: ○ Antidepressant medication, typically an SSRI ○ Utilize exposure approaches, offering considerable relief to many people In vivo (in real life) desensitization: exposing them to what they are most anxious about Help clients venture farther and farther from their homes to gradually enter outside places Use support, reasoning, and coaxing to get them to confront the world ○ Support groups: small number of patients go out together for exposure sessions that last several hours, encouraging one another to eventually do tasks on their own ○ Home-based self-help programs: give clients and their families detailed instructions to carry out exposure treatments themselves ○ 70% of agoraphobic clients who receive exposure treatment find it easier to enter public places ○ Improvement persists for years; however, are often partial rather than complete → about half have relapses  Agoraphobia + panic disorder seem to benefit less from exposure therapy alone Social anxiety disorder (social phobia) Social anxiety disorder: severe, persistent, irrational anxiety about social or performance situation in which they may face scrutiny or embarrassment from others 3:2 F:M ratio Etiology: ○ Develops in late adolescence or young adulthood; beginning to think and care about how others perceive you ○ Dysfunctional beliefs and expectations regarding the social realm: Unrealistically high social standards, believing they must be perfect in social situations Believing they are unattractive social beings, social unskilled and inadequate, and always in danger of behaving incompetently in social situations Believing that inept behaviors in social situations will inevitably lead to terrible consequences Believe they have no control over their feelings of anxiety ○ Constant anticipation of social disasters, overestimating how poor their social interactions are ○ Performing avoidance and safety behaviors to prevent or reduce disasters Avoidance: avoiding interactions and events with new people Safety behaviors: wearing makeup to cover up embarrassment or gloves to hide shaking hands ○ Tied to genetic predispositions, trait tendencies, biological abnormalities, traumatic childhood experiences, overprotective parents Diagnostic features: ○ Grossly under-diagnosed in managed care population Don’t like being/feeling embarrassed + embarrassment of having social anxiety = no report, not getting diagnosed ○ Pronounced, disproportionate, repeated anxiety about social situations in which the individual could be exposed to possible scrutiny by others ○ Can be generalized or occur in specific situations (non-generalized) ○ Fear of being negatively evaluated by or offensive to others ○ Exposure to the social situation almost always produces anxiety ○ Avoidance of feared situation ○ ⅓ of sufferers are severely disabled: depressed, divorced, unemployed Treatments: ○ Reduce their social fears Medication: taking benzodiazepines or antidepressants reduces fear in 55% of patients, improving functioning in the brain’s fear circuit  Cognitive-behavioral therapy: less likely to relapse than using medications alone Should always be used in treating social fears Exposure therapy: encouraging clients to expose themselves to social situations and remain in them Systematic therapy discussions: clients are guided to re-examine and challenge their maladaptive beliefs and expectations ○ Improve their social skills Social skills training: modeling appropriate behaviors and encouraging them to try, role-playing, and rehearsing new behaviors Therapists provide frank feedback and reinforce clients for performances Social skills training groups and assertiveness training groups are effective by providing reinforcement for one another ○ Proactive psychotherapy: motivate them to take risks, get over embarrassment Specific phobias (types); also, behavioral account of etiology of specific phobias and its validity; idea of phobia “preparedness” 2:1 F:M ratio Types: ○ Animal type Sometimes caused by previous traumatic experiences or exposure to animals; PTSD Sometimes caused vicariously: others’ reactions towards seeing animals act as models ○ Natural environment type: storms, heights, water ○ Situation type: claustrophobia, tunnels, bridges, flying, driving ○ Bodily reactions: vomiting, headache, fever Emetophobia: a fear of vomiting keeps some females from attempting pregnancy ○ Blood-injury-injection type: vasovagal reaction through the vagus nerve Feeling the blood leaving, feeling faint, woozy, and like falling to the floor Etiology: ○ Cognitive-behavioral models focus on the idea that fears are conditioned and reinforced Classical conditioning: 2 events occur close together in time, becoming strongly associated → person reacts similarly to both of them Learn to fear certain objects, situations, or events through conditioning Individuals avoid what they are dreading, permitting fears to become more entrenched Modeling: acquiring a fear through observation and imitation  Observing others expressing intense fear of certain objects or events may lead to an individual also developing fears of the same things ○ Although a phobia can be acquired by classical conditioning, a disorder is not ordinarily acquired this way ○ Once fears are acquired, people tend to avoid what they fear → prevents them from realizing that they are harmless ○ Behavioral-evolutionary explanation proposes that human beings have a predisposition to developing certain fears Preparedness: “prepared” to acquire form phobias and not others Predispositions are transmitted genetically through evolutionary processes: more likely to survive with fears, pass down fear inclinations Diagnostic features: ○ Persistent fears or panic attacks out of proportion to situation, lasting at least 6 months ○ Exposure to the object produces immediate fear ○ Compelling desire to avoid phobic stimulus ○ Insight that fear is excessive ○ Symptoms are unrelated to another disorder Ex: delusional disorder ○ Most specific phobia sufferers have multiple phobias Treatments: ○ People tend to get over their intense phobias throughout their lifetime ○ All treatments are complicated by avoidance behavior: people will not seek treatment for their phobia because it involves dealing with it Easier to just avoid where their phobias will emerge ○ Anxiolytic or antidepressant medication (SSRI) Usually meds are not sufficient; need to deal with the stimuli ○ Systematic desensitization: in the therapy office Relaxation training + construct a fear hierarchy of their phobias Going from 1 (related situations that invoke the least fear) to 10 (situations that invoke the most fear) Relax themselves as they think about the higher levels of their fear ○ In vivo desensitization: in person, in real life Going through the steps in person, exposure to the phobia Calming with repetition ○ Flooding, or implosion therapy: clients are exposed repeatedly and intensively to a feared objects Early evidence for effectiveness, but low treatment acceptance, high therapy dropout rates  Possibility of retraumatization: making them more afraid of their phobia and the therapist ○ Applied tension for blood-injection phobias ○ Experimental: VR therapy for flying and height phobias ○ Self-help groups 70% of patients show significant improvement with exposure treatment → key is actual contact with the feared object or situation Obsessive-compulsive disorder: Obsessive-compulsive disorder: when obsessions or compulsions feel excessive or unreasonable, cause great distress, take up time, and interfere with daily functioning ○ Obsessions: persistent thoughts, ideas, impulses, or images that invade a person’s consciousness Themes include: dirt/contamination, violence/aggression, orderliness, religion, sexuality Themes can vary from culture to culture ○ Compulsions: repetitive, rigid behaviors or mental acts that people feel they must perform to prevent or reduce anxiety Performing compulsions reduces anxiety for a short period of time Forms: cleaning, checking, seeking order or balance, touching, counting, verbal compulsions ○ Obsessive thoughts act as a trigger → compulsive acts are the response Compulsions may represent a yielding to obsessions Compulsions can also serve to control obsessions Risk factors ○ Equally common in men and women and among different racial/ethnic groups 1:1 F:M ratio ○ Family pedigree studies show biological factors play a role: Identical twins: one twin with OCD, 53% of cases the other does too Fraternal twins: 23% of cases 20% of OCD cases have 1st-degree relatives with OCD → abnormalities in the cortico-striato-thalamo-cortical circuit are partly the result of genetic inheritance ○ Overactivity in the basal ganglia and the orbito-frontal cortex is seen in OCD OCD arises from rigidity in communication between the 2 structures Malfunctioning can produce brain-lock: locked onto a specific thought, not being able to move on to the next one ○ Tendency to blame oneself and to try and neutralize their obsessions/compulsions They often expect something bad to happen to them Neutralizing brings temporary relief from discomfort → it becomes reinforced and will likely be repeated  ○ Hold exceptionally high standards of conduct and morality Thought-action fusion view: believe that intrusive negative thoughts are equivalent to actions and capable of causing harm Signs/symptoms ○ Symptoms and severity may fluctuate over time ○ Occurrence of repeated obsessions, compulsions, or both ○ Obsessions or compulsions take up considerable time: significant distress or impairment for over 1 hour per day ○ Recognition that one’s obsessions and compulsions are excessive or unreasonable Course ○ Tends to develop childhood or young adulthood and typically persists for many years ½ of OCD cases begin in childhood → these are more severe ○ Males: tend to get OCD in childhood (5-6 years old), prognosis tends to be worse ○ Females tend to get OCD in adolescence and adulthood, milder form Prognosis (outcome) ○ 40% seek treatment, many for an extended time ○ Combination of cognitive-behavioral and drug therapies = BEST Yield higher levels of symptom reduction and bring more relief than alone Improvements may also continue for years ○ In some cases, major depression follows OCD Feeling invaded by these thoughts, out of control of their own behavior → learned helplessness No more control over their own life, overrun by obsessions and compulsions → depression Treatments ○ Psychodynamic therapies try to help uncover and overcome underlying conflicts and defenses through free association and therapist interpretation Short-term psychodynamic therapies are used now: more direct and action-oriented ○ Cognitive-behavioral treatment methods include educating clients about their disorder, guiding them to identify and challenge their cognitions, and come to accept their thoughts as inaccurate and their actions as unnecessary Exposure and response prevention (exposure and ritual prevention): Clients are repeatedly exposed to objects or situations that produce anxiety, obsessive fears, and compulsions to practice resisting behaviors Compose exercises that clients must do as homework to reduce the number and impact of obsessions and compulsions  50-70% have been found to improve with cognitive-behavioral therapy; improve indefinitely ○ Antidepressant drugs: increasing serotonin in high doses Improvement in between 50-60% of OCD patients Obsessions and compulsions are not totally gone, but cut almost in half Must be continued indefinitely to prevent relapse ○ Neurosurgery for complex cases: involving pathways to/from frontal lobes Invasive: Deep Brain Stimulation (DBS) using implanted electrodes Cutting of pathways Non-invasive destruction of pathways by heating: Targeted radiation using gamma knife Focused ultrasound Brain areas involved in OCD ○ Basal ganglia and orbito-frontal cortex Basal ganglia: involved in smooth transition of thoughts Orbito-frontal cortex: smooth selection of thoughts, choosing what to shift thoughts to ○ Cortico-striato-thalamo-cortical circuit: orbitofrontal cortex, cingulate cortex, striatum, thalamus, amygdala In charge of regulating primitive impulses and leading us to act on or disregard them Hyperactive in OCD; symptoms arise/subside after structures in this circuit are damaged Increasing serotonin within the cortico-striato-thalamo-cortical circuit helps correct hyperactivity levels OCD-spectrum disorders: OCD related disorders: disorders in which obsessive-like concerns drive people to repeatedly and excessively perform certain abnormal patterns of behavior Hoarding Disorder: individuals feel compelled to save items; become very distressed if they try to discard them ○ ~ 1:1 F:M ratio ○ → excessive accumulation of items presents danger and hazards ○ Impairs personal, social, and occupational functioning Body-Focused Repetitive Behaviors: ○ 3:1 to 10:1 F:M ratio ○ People often try to stop or reduce these harmful behaviors ○ Triggered/accompanied by stress or anxiety ○ Trichotillomania (hair-pulling disorder): repeatedly pulling out hair from scalp, eyebrows, eyelashes, etc.  ○ Excoriation (skin-picking) disorder: repeatedly picking at the skin, resulting in significant sores or wounds Body Dysmorphic Disorder: individuals become preoccupied with the belief that they have certain defects or flaws in their physical appearance ○ 1:1 F:M ratio ○ Obsessive concern about appearance and body parts + compulsive acts Mirror checking, camouflaging, excessive grooming, skin picking, etc. ○ Anxious avoidance of others and going great lengths to cover up with defects ○ Half of BDD individuals have delusions of reference Body Integrity Dysphoria (formerly known as BIID): discontent with one’s anatomy and desire for amputation ○ Belief that one’s limbs do not “belong” to one’s body and it must be amputated for them to feel “whole” ○ Rehearsal activity: pretending/imitating the amputated state in private and in public ○ Very certain in which limbs and level of amputation desired Pursuit of elective amputation or attempts at self-amputation ○ Can include non-amputation bodily changes: to be deaf, blind, paralyzed, or disfigured ○ Amputation or other surgery is the only known treatment “Unofficial members”: Tourette’s Syndrome: characterized by anxiety, involuntary tics/spasms, and coprolalia (uttering curse words) Delusional Disorder (erotomanic type): fantasized love and stalking, often exacerbated by social media Homosexual OCD: fear of / aversion to being gay/lesbian ○ Obsessive self-questioning about one’s responses to same vs. opposite sex ○ Not officially recognized or in DSM-5-TR PANDAS ○ Streptococcus + OCD = 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 Commonly hand-washing and preoccupation with germs ○ Rapid remission of symptoms usually occurs with antibiotic therapy ○ Accounts for only a small % of childhood OCD Why hypochondriasis is often considered an OCD-Spectrum Disorder Hypochondriasis (DSM-5-TR Illness Anxiety Disorder) ○ Obsession with disease and feeling as if there is something wrong with them  ○ Often considered an OCD-spectrum disorder because of shared features: Both involve persistent, intrusive thoughts and a need for reassurance to alleviate distress Obsessions center on health-related fears and beliefs about having or developing a serious illness, despite medical evaluations indicating otherwise Engage in “safety behavior” similar to compulsions From Canvas Assigned Readings and Text Addenda: Student Mental Health Is in Crisis: Nature of stressors on college students and consequences Stressors can vary: coursework, relationships, adjustment to campus life, economic strain, social injustice, mass violent, COVID losses Consequences: a variety of solutions are required ○ Struggling with academics → workshops to focus on stress, sleep, time management, goal setting ○ Mourning loss, facing loneliness, low self-esteem, interpersonal conflict → peer counseling ○ Acute, severe, personal concerns → professional counselors Need opportunities to increase resilience, build new skills, connect with one another Psychotherapy and the Pursuit of Happiness: National Mental Health Act (NMHA): led to establishment of National Institute of Mental Health and the provision of funding towards training psychotherapists ○ Post WWII had led to an increase in mental health problems ○ Not enough trained mental health personnel Emergence of clinical psychology ○ Clinical psychologists were the ones actually working with patients ○ They wanted to practice psychotherapy on their own without restrictions of physician supervision ○ NMHA brought psychiatrists and clinical psychologists into conflict → an increasing demand of mental health clinicians motivating clinical psychologists to practice on their own ○ Clinical psychologists began to popularize psychotherapy among the public → great public demand for therapists ○ Clinical psychologists were seen as a reasonable alternative to psychiatrists ○ Public opinion of clinical psychology and psychotherapists formed a love-hate relationship Rise of short-term psychotherapy and community psychology  ○ Kennedy sought to deinstitutionalize mental health care and discharge patients back into their homes → community psychology Community mental health centers quickly became the go-to, exposing Americans to psychotherapy ○ Clinicians realized that their clients wanted a professional to solve their problems (not just explain them) quickly Millions of Americans generated lots of pressure to treat everyone They began to modify their therapy with no guidance, treating patients with a time limit → Short-term psychotherapy: therapy lasting 20 sessions or less ○ Short-term therapy is extremely criticized and seen as unhelpful Acting as a friend is not a legitimate goal of therapy Long-term therapists believe that no real change can occur on this level, by simply behaving or thinking differently Evolution of “caring” ethos ○ Social networks collapsing, loneliness rising, many unhappy people ○ The use and prescription of psychoactive drugs (Valium) led psychiatrists to believe that this was the end of psychotherapy ○ Clinical psychologists relied exclusively on the talking cure and viewed drug therapy as a threat They realized the need to reconnect with people in their own way They wanted to relieve people’s anxieties towards psychotherapy being “brain shrinking” and reiterate the need for therapeutic conversation ○ Developed non-university-based psychology degree programs that are more people oriented than research ○ Clinical psychologists, counselors, and social workers began to change their image to a warm, caring professional Presented themselves as caregivers who want to talk to them, vs. doctors who just want to drug them ○ Began building a simpler vocabulary to connect with everyone Self-esteem Stress ○ → shift in society towards a “caring” ideology Caring professional is someone you can confide in of your troubles, someone who wanted to understand and help you Evolution of managed care ○ Managed care: a system in which healthcare costs are reduced by bringing together panels/networks of providers ○ Psychiatry began to diminish, and psychiatrists held relatively minor roles under emergence of managed care  Medication managers ○ Rise of managed care changed the nature of mental health care, rather than access Fewer psychotherapy sessions, as well as reduced time per session ○ Effectiveness of therapies were judged based on whether they made clients feel better → managed care refused to pay for psychoanalysis ○ Downgraded the importance of scientific expertise when deciding which professionals to fire in healthcare panels Mental Disorders: Infectious Diseases? (Text pp. 4-1 – 4-12): Problems w/ neurotransmitter account of antidepressant medication action ○ SSRIs increase serotonin in areas of the brain and they improve depression and anxiety, but this connection isn’t direct ○ Counterexample: tianeptine (Coaxil, Stablon, Tatinol) Tianeptine is an antidepressant just as effective as SSRIs, but it is a selective serotonin reuptake enhancer Reduces serotonin transmission in the brain ○ Changes in neurotransmitters are just spinoff/side effects? ○ Antidepressant medications promoting the release of neuronal growth factors, Brain-Derived Neurotrophic Growth Factor (BDNF) Depression results in the loss of major connections and reduced levels of BDNF BDNF triggers the growth of connections among neurons in the brain Treatment restores BDNF ○ Neurotrophic hypothesis of depression: BDNF is deficient in depression and vital for its remediation Malarial cure of neurosyphilis ○ Syphilis symptoms develop 15-20 years after initial infection → believed to be a mental disorder, called it general paresis ○ Richard von Krafft-Ebing discovered that general paresis patients had already been infected with syphilis Introducing syphilis to general paresis patients resulted in no new syphilis infections ○ Wagner Jauregg discovered that introducing malaria into general paresis patients would induce a high fever, baking and killing syphilis inside the brains General paresis/neurosyphilis cure through pyrotherapy Evidence suggesting possible infectious etiologies for: ○ OCD Malfunctioning basal ganglia → tendency to go into brain-lock  Brain-lock: stuck on thoughts or impulses, can’t let go of them, may have to exercise some compulsions to achieve temporary relief Compulsions can be short (tics, spasms) or long (counting, hand-washing, putting things in balance, etc.) For up to ⅓ of cases, onset of OCD is abrupt, following some infection from GABHS (group A beta-hemolytic streptococcal) bacteria PANDAS: Pediatric Autoimmune Neuropsychiatric Disease Associated with Streptococcal infection Found in children that recovering from infection → OCD signs and symptoms gradually recede A single course of antibiotics usually resolves both the infection and the OCD manifestations Auto-immune response: immune system attempting to kill bacteria, but it ends up damaging the basal ganglia cells instead ○ Major Depression Borna disease virus (BDV), a small virus related to rabies Immunological markers of BDV were more common in patients with affective disorders than controls Levels of these markers tended to track the course of the depressive or manic episodes The virus itself could be isolated from patients with current affective disorder Swedish children were followed from birth over 40 years: Kids of mothers who had any kind of infection during pregnancy showed elevated risks of depression and autism spectrum disorder Risk of depression was 24% higher Subtle fetal brain injuries associated with infection → changes that were sufficient to result in later disability and diagnosis ○ Schizophrenia Seasonality of schizophrenia births, with most cases occurring among those born in winter months Fingerprint irregularities Geographical regions patterns of higher-than-normal prevalence of schizophrenia consistent with disease spread Maternal exposure to the influenza virus, especially during 6th month of gestation; accounts for 6% of schizophrenia cases Higher among individuals born to mothers who were pregnant during flu epidemic 1957  20% higher risk among individuals whose mothers were exposed to Rubella virus during pregnancy Brain wiring is scrambled in utero Pathogens can act as neuro teratogens (fetal brain deformers), resulting in bad fetal wiring Toxoplasma parasite in house cats (discovered by E. Fuller Torrey) causes toxoplasmosis Other concerns include influenza viruses, cytomegalovirus (CMV), and Zika virus associated with small heads and numerous fetal brain abnormalities Ketamine and Other Medication Treatments for Depression (Text pp. 8-1 – 8-6): Procedure and evidence on ketamine therapy ○ Observed in 7 patients: intravenous treatments of ketamine on 2 successive days → dramatic recovery from depressions, but no improvement with just saline treatments ○ Ketamine is used as an anesthetic for pain control with critical injuries and for children and veterinary anesthetic Usually injected into muscle or infused into a vein Feeling disconnected, immobilized, no pain, having vivid hallucinations and “out of body” experiences ○ Works by acting as antagonist (blocker) at NMDA receptor sites within the glutamate neurotransmitter system ○ Depression studies have been done testing K, using low doses that keep patients in dissociative trance state for 45 mins-1 hour Sufficient to trigger the antidepressant effect ○ Randomized, placebo-controlled, couple-blind crossover study to test the effect of ketamine infusion on TRD Those who received ketamine showed significant improvements that persisted through the next week Improvements began within 2 hours of infusion ○ Suicide ideation study compared effect of ketamine vs. minor tranquilizer Suicide ideation marked lower in the ketamine group, with such advantage persisting about one week Potential advantages of ketamine treatment for Major Depression ○ Low doses ○ Infusions are safe and well-tolerated (other than psychosis-like after-effects in small percentages of patients) ○ Rapid improvements beginning immediately after infusions ○ Improvements in depression persisted through the next week ○ Decreases suicidal ideation  TRD and general alternatives for TRD management ○ Not everyone responds to antidepressant medications 10-15% not at all 30-40% respond partially and remain somewhat disabled by their condition ○ Alternative recovery methods: Switching antidepressants: usually after 6-12 weeks has passed; response rates increase from 7% → 70% Adding a second antidepressant: don’t have to endure a washout period where there is no medication in their system Lithium or thyroid hormone Adding lithium carbonate (which is usually given to Bipolar I disorder patients) enhances serotonin neurotransmission along a different path ○ Added concern of having to monitor blood-level to avoid toxicity and kidney damage Thyroid hormone may help partly reverse a metabolic slowdown that is seen in depression patients Improvements made by administering these are more modest and less predictable when paired with SSRIs or newer antidepressants Dramatic improvements with paired with older tricyclic antidepressants Atypical antipsychotic: supplement existing antidepressant (either tricyclics or SSRIs) with atypical antipsychotic Non-medication approaches: Transcranial magnetic stimulation (TMS) Vagal nerve stimulation (VNS) Direct brain stimulation (DBS) Electroconvulsive therapy (ECT) Combinatorial pharmacogenomics: refers to the interactions of people’s genetic makeup with the pharmacologies of the medications they take ○ Is the pharmacology behind an antidepressant compatible with a patient’s genotype? ○ Identify the brain circuits involved in depression and the mechanisms of gene expression associated with these ○ Identify the molecular basis for depression and ways to address its treatment at the molecular level ○ GeneSight© test purpose: uses data regarding 12 genes and 56 relevant medications  36 hours → receive color-coded chart listing gene-medication interactions and which are optimal Patients taking medications prescribed with GeneSight information improved significantly compared to those without Body Integrity Identity Disorder (Text pp. 5-1 – 5-5): Parallels w/transgenderism ○ Neurological variations Transgenderism: between one’s physical sex and gender identity BIID: between one’s physical body parts and their body image ○ Both have little desire to change the way they identify or view themselves/their body ○ Psychotherapy and psychotropic medication are useless in changing the body image → only recourse is to change the body Transgenderism: hormone/gender confirmation therapy BIID: amputation ○ After physical variation, very high satisfaction rates, few people feel post-surgical regret, state better quality of life Etiology ○ Early experiences witnessing amputations ○ Finding this prospect exciting or sexually arousing Apotemnophilia: a love for amputation; assumes BIID to be a kind of fetish Only a minority find BIID sexual ○ BIID considered an inborn neurological condition: a mismatch between one’s internal body scheme and the physical body ○ Evidence in defective body-image circuitry located in the superior parietal lobule (SPL) in the right parietal lobe of the brain just above and behind right ear Normal functioning of SPL circuitry: intact body image congruent with our actual physical body ○ Structural differences in the premotor cortex of the frontal lobes: involved with the perception of body boundaries and self-awareness Signs/symptoms ○ Many report feeling as if limbs weren’t “right” or “natural” → “foreign limb syndrome” Disturbance in “body ownership” We normally experience out entire body as belonging to us Xenomelia, or foreign limb Course ○ Feeling the desire to amputate  ○ People with BIID have gotten amputations done by surgeons ○ Some have amputated their own limbs using desperate and dangerous methods such as guns and chainsaws ○ Some desire paralysis of their limbs rather than amputation ○ BIID patients experience unrelenting suffering without treatment ○ Better quality of life with treatment Treatment ○ Surgical amputation ○ Self-amputation ○ Paralysis ○ Pretending to be amputees to try and feel more comfortable with their bodies Controversy ○ Medical ethics: removing healthy limbs violates the vow “first, do no harm” National health service banning further surgeries Present, few surgeons in private hospitals will do them on demand, but at great personal expense Insurance doesn’t pay Under the radar Bioethicist Sabine Muller argued that BIID was a neurological disorder, and part of it included the compulsive desire to amputate Desire is part of the pathology → physicians may be ethically bound not to comply ○ Perhaps not doing the amputation is unethical, as it condemns the BIID sufferer to lifelong mental disability ○ Pragmatic: offer amputations, otherwise patients will seek unsafe self-amputations ○ Humanitarian with Hippocratic twist: not amputating does harm since it leaves the patient to certain suffering ○ Libertarian: does the patient own his own limbs, and does he have the right to do with them as he wishes? Clinical Focus: Tourette Syndrome (Text p. 5-6) Tourette's Syndrome ○ Convulsive movements or abnormal tics of the hand and arms and complex movements ○ Sudden cries, other vocalizations, or inexplicably uttering words that do not make sense in context, including coprolalia (uttering vulgar words) Relationship to OCD ○ Tourette movements are involuntary, similar to the way compulsions are No control over tics or vocalizations  No control over performing compulsions Urges are similar to urge-to-action behaviors such as yawning and stretching ○ Both stem from neural causes involving the basal ganglia Basal ganglia: a brain structure that helps regulate smooth movements and smooth transitions into thinking Tourette’s: abnormality of the basal ganglia, right hemisphere Symptoms are controlled with haloperidol, an antipsychotic drug that blocks dopamine synapses in the basal ganglia OCD: malfunctioning basal ganglia → tendency to go into brain-lock Brain-lock: stuck on thoughts or impulses, can’t let go of them, may have to exercise some compulsions to achieve temporary relief Cases practice: Bank: - Major Depressive Disorder - Bipolar Disorder - Generalized Anxiety Disorder - Obsessive-Compulsive Disorder - Panic Disorder - Social Anxiety Disorder - Agoraphobia - Post-Traumatic Stress Disorder (PTSD) - Specific Phobia - Body Dysmorphic Disorder Case 1: Jared has stopped enjoying the things he used to love, like playing guitar and going out with friends. He often feels tired and struggles to get out of bed, no matter how much he sleeps. He’s been experiencing feelings of worthlessness and even finds himself wondering if life is worth living. ⇒ major depressive disorder Case 2: Ella has a constant, nagging worry that something bad will happen to her family. She often thinks about every small detail that could go wrong and feels restless, even though there’s no specific event triggering her worry. She’s always tense, can’t concentrate, and has trouble relaxing. ⇒ GAD Case 3: Max gets intense, unexpected episodes where his heart races, he sweats profusely, and feels like he can’t breathe. He sometimes thinks he’s having a heart attack during these episodes. He’s started to avoid places where these attacks have happened, like crowded stores. ⇒ panic disorder Case 4: Mira has an overwhelming fear of spiders. Even seeing a photo of one makes her feel panicked, and she avoids going into her basement, where she’s seen spiders before. She finds herself doing extra checks around the house to make sure there are no spiders nearby. ⇒ specific phobia Case 5: Olivia has an unshakable feeling that others are judging her harshly whenever she’s in social settings. She’s terrified of speaking up in class or even meeting new people, and she’s missed out on job opportunities because of her fear of social interactions. ⇒ social anxiety disorder Case 6: Dylan has been feeling over-the-top happy and full of energy for the last several days. He’s been sleeping only a few hours a night and still feels full of ideas, making plans to start several new projects. However, last month he felt so low he could barely get out of bed. ⇒ bipolar disorder Case 7: Sophia can’t leave her house without checking multiple times to ensure the door is locked, even if she’s already certain it’s locked. She also feels the need to repeatedly wash her hands for fear of germs, and if she doesn’t follow these routines, she becomes extremely anxious. ⇒ OCD Case 8: After witnessing a traumatic car accident, Ben finds himself reliving the event in nightmares and flashbacks. He avoids driving near the accident location and becomes anxious whenever he hears sounds similar to the crash, like car horns or sirens. ⇒ PTSD Case 9: Sara avoids crowded places like shopping malls or movie theaters because she fears feeling trapped. She’s worried that if she has a panic attack in such places, she won’t be able to get out quickly. Her friends have noticed she rarely leaves her house anymore. ⇒ agoraphobia Case 10: Ryan constantly feels self-conscious about his nose, convinced it’s much larger than anyone else’s. He avoids social events because he believes others are staring at it and judging him, even though his friends and family reassure him that it looks normal. ⇒ body dysmorphic disorder Answers: 1. Major Depressive Disorder 2. Generalized Anxiety Disorder 3. Panic Disorder 4. Specific Phobia 5. Social Anxiety Disorder 6. Bipolar Disorder 7. Obsessive-Compulsive Disorder 8. Post-Traumatic Stress Disorder (PTSD) 9. Agoraphobia 10. Body Dysmorphic Disorder