Sleep - Week 5, Lecture 7 PDF

Week 5, Lecture 7: Sleep Sleep myths busted: - You need 8 hours of sleep to function properly - Those who dream are heavier sleepers - Waking up 2-3 times a night is normal - Large Individual variability in how much sleep is needed Effects of sleep deprivation or oversleeping...

Week 5, Lecture 7: Sleep Sleep myths busted: - You need 8 hours of sleep to function properly - Those who dream are heavier sleepers - Waking up 2-3 times a night is normal - Large Individual variability in how much sleep is needed Effects of sleep deprivation or oversleeping - Cognitive dysfunctions - Increased heart rate variability, heart attack risk - Impaired immune system Why do we sleep? - Energy conservation, better for survival - Immune function and hormonal restoration (melatonin) - Memory consolidation 1. Need sleep before learning. Without sleep memory circuits are not effective 2. Need sleep after learning to consolidate new memories and cement memory: a. File transfer process: hippocampus cortex b. Replay studies with rats show memories are replayed and scored into new circuits c. Integration & association Interconnect new memories together Studies on sleep VR exposure treatment for spider phobia, significant improvement in condition with 90 mins of sleep following the treatment. (Kleim et al 2014) Sleep mechanisms 1. Sleep debt (homeostasis): longer you are awake the greater the sleep pressure 2. Biological clock controlled by suprachiasmatic nucleus (above optic nerves) a. Circadian rhythm: sunlight inhibits the melatonin system while nighttime stimulates production of the hormone. 28  Two-process model of sleep: The two-process model of sleep regulation, proposed by Alexander Borbély in the 1980s, explains how sleep and wakefulness are regulated by the interplay of two distinct processes: Process S (sleep pressure) and Process C (circadian rhythm). These processes work together to determine when we feel sleepy and when we wake up. 1. Process S: Sleep Pressure Definition: Process S refers to the homeostatic drive for sleep, which builds up during wakefulness and dissipates during sleep. Mechanism: ○ Adenosine is a byproduct of energy consumption in the brain, its buildup signals the need for rest. High buildup of adenosine results in a high sleep pressure. ○ During sleep, particularly during slow-wave (deep) sleep, adenosine and other metabolites are cleared, reducing sleep pressure. 2. Process C: Circadian Rhythm Definition: Process C represents the circadian (24-hour) biological rhythm governed by the body’s internal clock, primarily located in the suprachiasmatic nucleus (SCN) of the hypothalamus. Mechanism: ○ The circadian rhythm is influenced by external cues, such as light and darkness (zeitgebers), but it persists even without them. ○ It regulates the timing of various physiological processes, including alertness, body temperature, hormone secretion (e.g., melatonin), and sleep propensity. Interaction Between Process S and Process C The two processes interact to regulate sleep and wakefulness: 29  1. Sleep Onset: Sleep occurs when sleep pressure (Process S) is high, and the circadian rhythm (Process C) aligns with a low point in alertness. 2. Wakefulness: Wakefulness is maintained when circadian signals promote alertness, even if sleep pressure is increasing. 3. Misalignment: Disruptions, such as jet lag or shift work, can cause misalignment between the two processes, leading to sleep difficulties. REM Sleep: Muscles from neck down are shut off - cannot enact dreams Can only think of one thing at a time - elements are integrated together Visual system is working Core sleep ○ First 3 sleep cycles (+/- 5 hours) most important ○ Almost all deep sleep ○ Main part of the dream sleep Residual sleep ○ Later hours of the night ○ Not as important ○ Contain a lot of dream sleep Quality over quantity Treatments: - Light therapies - Melatonin (except for insomniacs) - Chronotherapy (a behavioural treatment that attempts to move bedtime and rising time later and later each day, around the clock, until a person is sleeping on a normal schedule) 30 Night terror vs Nightmare Night terror disorder is mostly prevalent in children, affecting around 3% of adults. Individuals with this disorder awake with an intense sense of panic but no memory of nighttime images, disoriented upon waking. Sometimes it helps to wake children up an hour before it typically occurs, but a child should not be awoken during a night terror, instead reassure them and lead them back to bed. Nightmares happen usually in the second half of the night (REM sleep). Individuals are oriented when waking, aware that the nightmare occurred and able to recall narrative/image. Affects 2-5% of the population. > Across all disorders, 30% also have nightmares. > Nightmares is one of the unique predictors of suicide risk. > Comorbidity of nightmares and other psychopathologies where individuals with nightmares experience symptoms of other disorders more intensely than those without nightmares. Nightmares can persist after PTSD treatment, and can increase risk of PTSD relapse. Treatment: - Imaginary rehearsal therapy: cognitive-behavioral technique. Creating a new and positive ending which is repeated in the imagination throughout the day. - Prazosin can block CNS. recently downgraded this recommendation REM sleep behavior disorder: motor neurons remain active, movement during sleep. - Clonazepam for relaxing muscles - Can be a early sign of neurodegenerative disorders (ie: parkinson's disorder) Sleep paralysis is not in the DSM-5 - Hypnagogic or hypnopompic hallucinations Insomnia disorder Insomnia disorder as a chronic condition is frequent (up to 10% of the adult population, with a preponderance of women especially vulnerable during menopause), and signifies an important and independent risk factor for physical and, especially, mental health. DSM5: Difficulty falling asleep, maintaining sleep or early morning waking Must occur 3x a week for 3 months Should cause significant distress or dysfunctioning Not explained by other disorders (ie sleep apnea, ptsd) 31 Treatment Cognitive-behavioural models of insomnia led to the conceptualization of cognitive-behavioural therapy for insomnia, which is now considered as first-line treatment for insomnia worldwide. 50-70% are treated with medication (benzodiazepine), however, CBTI is recognised as the optimal route as medication is not considered long-term solution due to addictiveness, drowsiness Special attention to dysfunctional sleep related thoughts ○ Other cognitive strategies include, thought-blocking, paradoxical intention “stay awake as long as you can” ○ Behavioral: stimulus control (conditioning research, bed is only for sleep) keep consistent sleep and wake times, reduce time spent in bed ○ Sleep restriction to increase sleep pressure, improve sleep efficiency. (Time asleep becomes the new total time in bed) ○ Future research strategies will include the combination of experimental paradigms with neuroimaging and may benefit from more attention to dysfunctional overnight alleviation of distress in insomnia. ○ Still however, a significant proportion of patients responding insufficiently to cognitive-behavioral therapy for insomnia ○ 64% ( ) of patients improve following CBTI Incorrect timing of melatonin can worsen sleep issues Nosology: Insomnia probably more frequently occurs as a comorbid condition together with somatic and mental disorders, than it does in its isolated form. DSM-5, ICSD-3 and ICD-11 pay respect to this by explicitly allowing co-morbidity. 60-80% of those with depression also have sleep difficulty. 3x more likely to develop depression if you also have insomnia. Combination makes depression treatment more difficult, bidirectionally influencing each other Predisposition: genetic contribution, 30-60% genetic influence Personality: associated with high neuroticism and perfectionism. General sensitivity to stress Trigger and perpetuating: stressful life event, safety behaviors or substance use reinforcing insomnia 32 ACT: acceptance, psychological flexibility skills Hyperarousal in the day and in the night is a hallmark of insomnia Attention- Intention - effort pathway. Sleep is automatic, attention to sleep can increase arousal and actually hinder sleep entry. Patients are asked about sleep during clinical interviews. If insomnia is expected, ask the patient to fill in sleep diaries. Measuring sleep objectively Polysomnography - measure heart rate while sleeping Wristband actigraphy Lecture 8: Social Media - Technology can enhance well-being, (DBCI) - Technology can create a digital divide Problematic smartphone use Lower sleep quality Depressive symptoms Perceived stress Poor educational attainment ○ Can be a cyclic etiology 33 Operationalization and Assessment Need more information than just frequencies, ○ frequency of screen use is well researched ○ Correlational, cross-sectional ○ Mixed in terms of directionality ○ Cause and effect Problematic use vs addiction ○ We should avoid the use of the term addiction … Behavioral addiction tendencies, not a substance addiction ○ Some argue that there is not enough evidence, as we cannot assess smartphone use Kormendi et al 2016; by using DSM-5 criteria we may overestimate smartphone addiction prevalence ○ Olsen et al 2022 estimated 28% of participants surveyed Craving, salience and preoccupation Loss of control, tolerance and withdrawal like symptoms Beyond traditional addiction criteria Smartphone itself or the application on it? Habitual use Disruptive distractions from daily life Vital role of smartphone in daily life The anxious generation: Jonathan Haidt Causal link between social media use and mental illness in youth ○ Limitation (Candice Odgers): Interpretation of research data generational specificity of mental health crisis in youth Odgers argues against Haidt’s thesis; claims it is a nuanced relationship (consider; war, climate crisis, pandemic etc to explain rise in mental illness symptoms in youth) We need an experimental manipulation to assess a correlational relationship (direction of effect: is it more social media use = more anxiety, or is it more anxiety = more social media use?) Association between social media use frequency and substance use frequency ○ Predictive model, not a causal relationship cannot conclude - need more assessment over time / experimental study 34 Affective: SMU impacting well-being, especially among girls explained through Social comparison theory; Upward comparison Downward comparison Excessive or unfavorable social comparison Reward: Reward sensitivity / reward learning Social media = intermittent reinforcements ○ Unpredictable rewards (novelty) Liking of posts ○ FMRI while their photos are liked, the reward system When are we with our own thoughts Is less external input important Excessive smartphone use and addiction: When harms start outweighing benefits lack of longitudinal studies and examination of between-participant correlations with static assumptions that do not take context and within-participant dynamics of use into account A great challenge lies in the complexity, contextuality and dynamical balance between positive and negative aspects of smartphone use. benchmark for developing a proper definition of excessive smartphone use within or outside the addiction framework. Social media use and its impact on adolescent mental health: An umbrella review of the evidence Mixed Evidence on Mental Health Impacts: Associations between social media use (SMU) and adolescent mental health outcomes are generally weak and inconsistent. Meta-analyses showed small correlations with both positive (e.g., well-being) and negative (e.g., depressive symptoms) outcomes, often within the range of r=0.05 to 0.17) Adolescents are particularly vulnerable due to developmental challenges, including identity exploration, peer influence, and fluctuating well-being. Types of Associations: General SMU is weakly linked to both higher levels of well-being (e.g., happiness) and ill-being (e.g., depressive symptoms). 35  Specific activities, such as browsing or engaging on particular platforms, can have differing impacts, with content quality and interaction nature being critical. Variability in Effects: Substantial variability in individual responses to SMU, with some adolescents experiencing negative effects, others positive, and most negligible impacts. ○ Adolescents’ responses to SMU are moderated by individual differences (e.g., personality, emotional state), social contexts, and situational factors. ○ Positive and negative outcomes coexist, reflecting a need for person-specific analysis. Problematic SMU: Characterized by preoccupation, neglect of important life areas, and inability to stop using SM, but only weakly linked to time spent on SM (explaining about 6% of problematic use). Tutorial 4: Cognition Cognitive distortion is an irrational or biased way of thinking that causes individuals to perceive situations or themselves in a negative and often inaccurate way. Involves faulty or exaggerated thought patterns Occur automatically and reinforce negative beliefs or assumptions Emotional reasoning within phobias is the most common cognitive distortion Function analysis- determine the motivation behind a certain behavior / cognitive distortion Consider current stimulus and response behavior. Evaluate the positive and negative consequences of the protective behavior For the patient, distortion is considered as a positive protective thought pattern, providing comfort Strategy in CBT For which disorders is CBT most effective? - Anxiety disorder - General stress - Bulimia - Anger control What are some potential limitations of CBT based on the findings in the article - Lack of studies for minority groups - Doesn’t always work for elderly patients nor children 36 The Psychology of Suicidal Behavior suicide is perhaps the cause of death most directly affected by psychological factors Prevalence estimates vary widely by country; however, once present, the characteristics of suicidal behaviour are quite consistent across different countries. Most people want to change their life, they don’t really want to die 1. Suicide as a taboo topic Testing guidelines: Difficult to do randomized control trials to test for the effectiveness of intervention treatment Talking about suicide will lead to more suicides: common myth, held even by clinical psychologists Most people die by suicide during the xmas holiday - untrue, most people kill themselves in March.. ‘broken promise effect’. Monday most common day Suicidal ideation Understanding of the psychological processes that underpin both suicidal ideation and the decision to act on suicidal thoughts is particularly important, because interventions should be targeted at addressing suicidal ideation when it first emerges, before it progresses to a suicide attempt How to operationalize suicidal thoughts; have you ever felt so depressed that you thought about committing suicide for a period of over two weeks 26% of people with depression had suicidal thoughts, 8.4% attempt suicide the onset of suicide ideation increases strikingly during adolescence in every country studied cross-nationally, about a third of people who think about suicide will go on to make a suicide attempt ○ more than 60% of these occur during the first year after initial onset of suicide ideation Language matters - Suicide vs ‘self-murder’ - zelfmoord or zelfdoding died by suicide instead of committed suicide Women have higher rates of non-lethal suicidal behaviour than do men ○ gender paradox, women use more discrete methods (ie pills), men use more aggressive means men are more likely to die by suicide 37 Terror management theory: Existential anxiety: Humans have a unique awareness of our mortality, leading to a deep seated fear of death. —> adherence to their cultural norms bolsters sense of self-fulfillment, stigmatize those who die by suicide, as it contradicts the life-saving drive embedded in cultural worldviews. Alberto Camus - Myth Of Sisyphus WHO: Global policy on suicide prevention - the act of deliberately killing oneself - requires an autopsy - defined by the intent to die; this is differently conceptualized in different regions. In the UK, self-harm of any kind is considered suicidal behavior, thus death by self injury even if one didn’t intend to die is still considered suicide. This is not the case in the Netherlands World statistics: 700,000 people die a year from suicide 1/10 of those who attempt die In the United States, more soldiers die by suicide then by gun fire/ active duty Theories on Suicide Psycheache Pain, stress, agitation Arrested flight: Mark Williams (2001) Defeat & Entrapment crucial in this model internal vs external entrapment entrapment builds on defeat 1. Diathesis–stress models posit that the negative results of pre-existing vulnerability factors are especially pronounced when activated by stress. a. Emotional dysregulation b. Appraisal system i. Limitation: does not account for why most people who have thoughts of suicide do not attempt suicide (focus on the last two) 2. Joiner’s interpersonal theory of suicide a. Suicidal desire is a necessary though not sufficient cause for a suicide attempt b. difference between suicidal thoughts and behavior c. if a person with high suicidal desire acquires the capability to attempt suicide, then the risk of a serious suicide attempt is increased i. reduced fear of death and increased tolerance for physical pain ii. exposure to and encounter with previous painful experiences increase an 38  individual’s tolerance for the physical-pain aspects of self-harm through habituation process 1. the integrated motivational-volitional model of suicidal behaviour d. belongingness and burdensomeness i. As well as feelings of defeat (ie, feeling defeated after triggering circumstances) and entrapment (ie, unable to escape from stressful, humiliating, or defeating circumstances) are posited to be of most importance within the integrated motivational-volitional model. e. When an individual feels both defeated and trapped, the likelihood that suicidal ideation will emerge increases when motivational moderators (eg, low levels of social support) are present. f. exposure to the suicidal behaviour of others, impulsivity, and having access to the means of suicide 3. Rory O’Connor Pre-motivational, motivational and volitional phase - includes Joiner’s capability, Entrapment & defeat Risks 1. personality and individual differences 2. cognitive factors 3. social factors 4. negative life events 39  Personality In general terms, high levels of neuroticism and low levels of extroversion are associated with suicidal ideation, attempts, and completions - Hopelessness - In a classic study, Beck and colleagues were able to predict 91% of all suicides from hopelessness scores in a 10-year prospective study of patients admitted to hospital with suicidal ideation - Important factor but hopelessness alone does not predict - Impulsivity - Associated with suicide risk - Impulsivity can be useful to predict repeated suicide attempts in individuals with personality disorder - Impulsive aggression is associated with suicide attempts, - Negative urgency, defined as the degree to which a person acts rashly when distressed, also needs further research - Perfectionism - Recent research suggests that the social dimensions of perfectionism increase suicide risk by promoting a sense of social disconnection, which is consistent with the integrated motivational-volitional model and interpersonal theory of suicide. - Optimism and resilience - Low levels of optimism are associated with self-harm in adolescent girls - Optimism has also been shown to buff er the association between hopelessness and suicidal ideation Cognitive factors Cognitive rigidity Rumination Thought suppression Autobiographical memory biases Belongingness and burdensomeness Fearlessness about injury and death Pain insensitivity Problem solving and coping 40  Agitation Implicit associations Attentional biases Future thinking Goal adjustment Reasons for living Defeat and entrapment Life events & risk 20% of adolescents reported that the internet or social networking sites influenced their decision to self-harm. Sexual and physical abuse during childhood are especially strong risk factors for both the onset and persistence of suicidal behaviour, and the risk of suicidal behaviour is particularly high during childhood and adolescence Biological precursors for risk abnormal concentrations of cortisol or a maladaptive cortisol response to stress > Directions for research Psychological autopsy studies, in which information is collected about the deceased person from several informants, have played a key part in under standing the risk factors for suicide Prevention Individuals are most likely to re-attempt within one year after their first attempt, significant for follow up care Assess the capability of an individual for suicide Lecture 10: depression & evolution Annemie Ploeger - developmental psychology Evolutionary perspective on depression CBEN cognition behavior and evolution network in NL DSM criteria for depression diagnosis 1. Feeling of sadness 41  2. No interest or no pleasure in activities 3. Weight changes 4. Insomnia or hypersomnia 5. Agitation or retardation 6. Fatigue loss of energy feeling of worthlessness 7. Poor concentration 8. Recurrent thoughts of death Lifetime prevalence of depression in the United States is 19.2% University students: 33.6% High heritability of mental disorders (30-50%, based on concordance rates of twin studies), however, people with mental disorders have less children ○ Thus we have a paradox: why did natural selection not eliminate mental disorders from the population? ○ The missing heritability. We know it is high, but we cannot explain in genetic terms. Genetics of depression: polygenic disorder What is the function of depression? Is depression an adaptation? Functioning similar to pain? Facilitator of social outreach? Hagen, 2011 overview of theories on why humans get depressed ○ Andrew’s and Thompson; depression as an adaptation for analyzing complex problems ○ Postpartum depression, functions as a signalling for help ○ The social competition hypothesis of depression: argues that depression arises as a result of losing social competition. This is also seen in animals ○ Seasonal - less activity in the winter ○ Ancestral neutrality: depression once had a function, but now does not and is a dormant psychological feature leftover ○ Association with infection / inflammation Brain will easily interpret illness as something wrong Bodies reaction to stress and to infection parallel each other People with depression have a high inflammatory response ○ Mismatch theory Environment of evolutionary adaptedness (EEA): which environments did our ancestors evolve in? Primates; adapted to living in forest What is the evolutionary mismatch hypothesis of depression? ○ Nutrition mismatch: evolutionarily predisposed to seek sugar and fatty foods ○ Physical activity ○ Child Rearing ○ Sunlight ○ Sleep ○ Social interactions 42 Testing the mismatch hypothesis: Modern Hunter-gatherer societies (ie Hadza) live in a less mismatched world, therefore, less depression prevalence in these societies is hypothesized Depression and modernization (Colla 1995) ○ Carlsson et al 2013: compared rural with urban sweden Found a strong association between urbanization and depression Hu et al: depressive symptoms decrease as physical activity increases > many confounding mismatches. Best predictors of depression in high mismatch societies Deviant sleep rhythm Lack of exercise Processed food vs high fibre food Lack of daylight Lack of contact with family or friends Materialism Perfectionism / focus on achievement Worrying (climate change, deadlines) Lack of autonomy Lack of joy Social media addiction Deviant youth Unhealthy habits (smoking, coffee, drugs) Do modern humans behave like captive animals > When studying non weird societies, to what extent should researchers consider linguistic relativity when assessing levels of depression Limitations of the mismatch hypothesis: how accurate is our understanding of our evolutionary past? Article 1: The Evolutionary Mismatch Hypothesis: Implications for Psychological Science Evolutionary psychology considers human cognition, emotion, and behavior to be products of psychological mechanisms that evolved to solve recurrent survival and reproduction challenges in ancestral environments (Buss, 1995; Tooby & Cosmides, 1992) Evolutionary mismatch refers to the adaptive lag that occurs if the environment that existed when a mechanism evolved changes more rapidly than the time needed for the mechanism to adapt to the change Mismatch can arise through natural sources or, commonly in modern societies, human-induced 43 changes. Two types of mismatch are “forced”—when a new environment is imposed on an organism—and “hijacked”—when novel stimuli are favored by a mechanism over stimuli that the mechanism evolved to process. Article 2: An evolutionary mismatch narrative to improve lifestyle medicine: a patient education hypothesis we lay the groundwork for research on how educating patients with an evolutionary mismatch narrative could impact health behaviors and improve outcomes Clinicians can use EM (evolutionary medicine) principles in their patient education to increase health literacy Diseases of civilization: obesity, cardio-vascular diseases, diabetes - Konner and Eaton applied the mismatch framework to humans and developed the ‘evolutionary discordance hypothesis’, - which states that the prevalence of chronic disease has increased due to a departure from the hunter-gatherer lifestyles for which we are well adapted. Narrative vs statistical evidence to improve health literacy A meta-analysis comparing the effectiveness of these two educational strategies revealed that narrative evidence produces greater intentions for behavioral change among patients Sherry (2018) found that explaining nutrition in an evolutionary context was necessary to change students’ perceptions of healthy eating An evolutionary narrative may impact several stages of behavior change: a patient’s attitude, perception of specific behaviors, and increase self-efficacy, all of which are the precursors to lifestyle modification Personality Disorders and Stalking The personality disorders are grouped into three clusters based on descriptive similarities: Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often appear odd or eccentric Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Individuals with these disorders often appear anxious or fearful 44 Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders. Stalking and psychopathy A study of 137 inmates in New York convicted of stalking, 25% did not have clinical or psychiatric disorders 75% had either anxiety disorders, personality disorders, substance abuse, psychotic and mood disorders - Stalking of practitioners by clients occurs twice as often as it does in the general population Lecture 11: BDP BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both Borderline Personality Disorder (BPD) is often described as being "on the borderline" between psychosis and neurosis due to its historical conceptualization and the nature of its symptoms. Early used the term "borderline" to describe individuals whose symptoms didn't fit neatly into the categories of psychosis (a severe loss of reality) or neurosis (milder emotional disturbances like anxiety or depression). ○ The term "borderline" was introduced to capture the unique and overlapping characteristics of BPD, reflecting the complexity of the disorder. Features Resembling Psychosis Transient Psychotic Episodes: Under severe stress, individuals with BPD may experience brief episodes of paranoia or dissociation, which resemble psychotic symptoms. Distorted Perceptions: These can include extreme shifts in perception of relationships (idealizing or devaluing others) and intense emotional reactions that feel overwhelming. Features Resembling Neurosis Emotional Dysregulation: Intense mood swings and chronic feelings of emptiness or fear of abandonment. Interpersonal Conflicts: Difficulty in maintaining stable relationships due to impulsivity, dependency, or fear of rejection. Self-awareness: Unlike individuals with psychosis, people with BPD usually retain insight into their thoughts and behaviors, which aligns more closely with neurotic disorders. 45 Personality dysfunction captured on five dimensional domains (negative affectivity, detachment, dissociality, disinhibition, anankastia) Typical manifestations of the borderline pattern: Negative self-image: view of the self as inadequate, bad, guilty, disgusting, and contemptible an experience of the self as profoundly different and isolated from other people a painful sense of alienation and pervasive loneliness proneness to rejection hypersensitivity, often leading to problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships frequent misinterpretation of social signals Biological Although the precise neurobiological underpinnings remain elusive, disturbances in a corticolimbic circuitry involving the amygdala, hippocampus, insula, anterior cingulate, orbitofrontal cortex, and medial prefrontal cortex seem to contribute to problems in emotion regulation, interpersonal disturbances, and inconsistent identity. ( ERIDII ) > Amygdala hyper-reactivity to threat-related stimuli has been linked to increased emotional responsiveness across several different diagnoses > vulnerability factors such as sleep problems, alcohol or drug misuse, or serious social problems While there is no medication specifically approved for BPD, certain drugs are used to manage symptoms: Mood stabilizers (e.g., lamotrigine): For emotional dysregulation and impulsivity. Antidepressants (e.g., SSRIs): For co-occurring depression and anxiety. Antipsychotics (e.g., aripiprazole): For severe symptoms like impulsivity or transient psychosis. Medications are typically used as adjuncts to psychotherapy and not as primary treatment Psychotherapeutic Approaches Dialectical Behavior Therapy (DBT): ○ The most studied and widely used therapy for BPD, DBT focuses on mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance. It has been shown to reduce self-harm, suicidality, and emotional dysregulation. Mentalization-Based Therapy (MBT): ○ Aims to improve individuals' ability to understand their own and others' mental states, which helps in managing interpersonal relationships and emotional responses. 46  Schema-Focused Therapy (SFT): ○ Focuses on identifying and changing maladaptive thought patterns and behaviors rooted in early life experiences. Transference-Focused Psychotherapy (TFP): ○ Utilizes the patient-therapist relationship to explore and address distorted interpersonal patterns. General Psychiatric Management (GPM): ○ A simpler, less intensive approach focusing on psychoeducation, case management, and crisis intervention. Integrated care models that combine therapy, medication, and case management are often effective. Programs that involve families and support networks can help improve outcomes by fostering understanding and reducing stress. Lecture 12: Radicalization The wrong dichotomy between mental illness and terrorism > How should we look at a psychiatric problem in real life ? Genetic coded vulnerability and the environment What is the developmental history of individuals who become extremists Radicalization > extremist > terrorist Extremism and terrorism strategies in the Netherlands - Extremism is fairly poorly defined - More attention on people with psychiatric problems, assuming that those with psychiatric disorders are more prone/vulnerable to extremism. Radicalization in essence is a general process, a broad perspective Research: what drives an extremist? Hypothetical model: Narrative serving as explanatory models What narratives can offer as a function? The individual needs (power, status, sense of purpose) can be met by their function within the narrative - Create an ingroup: by paying attention to the ingroup you reinforce the outgroup, create group loyalty - Relative deprivation can create a sense of community - quest for significance, threat of a loss of significance 47 Ordinary values can be modified for economic gain When sacred values are threatened the willingness to fight and die increase > Social exclusion can make people more vulnerable to using violence, they can even feel willingness to fight and die over ordinary values Conspiracy theory is the conviction that a group of actors meets in secret agreement with the purpose of attaining some malevolent goal Role of the internet and truth decay Authentic offense or string emotional attribution to the conspiracy, belief in fighting against evil Shared belief (a delusion is an individually held belief) Apocalyptic In-group in opposition with outgroup (delusion is autonomous mechanism) Ingredients of conspiracy theory: ○ Patterns (interconnectedness) ○ agency (ascribing intentionality to the actions of conspiracy) ○ Coalition (working in conjunction) ○ Threat ○ Secrecy (difficult to invalidate) Motives and functions of conspiracy theory: - Epistemic: building up a stable understanding of the world - existential: causal explanations serves the need to feel safe in their environment - Social: interact with others who share and reinforce conspiracy belief - Even if the content of the narrative is not scientifically sound, the function of the narrative may still be to provide comfort or understanding Sovereign citizens Many sovereign citizens believe that: - The state is a corporate firm and cannot make laws - They deregister as dutch civilian (BSNs) and instead are ‘people of flesh and blood’ What are the risks of conspiracy beliefs? Micro level - Enhance discrimination and discrimination - During covid, negative effect of health - Administrative overload in the case of sovereign citizens - Homelessness - Association with political extremisms Meso level - In family conflict, social isolations - Mobilisation of vulnerable people - Financial problems - Sheriffs - Conspiricists often arm themselves with the belief that the government and police are out to get them, this can lead to violence 48 Stalking Stalking, like radicalization, can be seen as a fixsation belief Out of proportion fixation idea, unmet need which they try to address by seeking contact Stalking could be considered an outcome of radicalisation, if considered by a broad perspective Approx 2-15% of people have been stalked Mental healthcare professionals at highest vulnerability to being stalked (11-21%) Motives The rejected stalker: ○ after the ending of a relationship these individuals stalk their former partner (mostly men) Resentful stalker: ○ fixation on a grievance Intimacy seeker: ○ convinced of mutual affection Incompetent lover: ○ does not know how to initiate a relationship Sexually motivated stalker ○ Predator type Risk taxation instruments: Screening Assessment for stalking and harassment (SASH) Stalking risk profile (SRP) Dylann Roof example - Adopted right wing narrative; “said i'm sorry, i had to do it” felt like he would initiate a civil war - Internet grooming by alt right, he had autistic spectrum condition and was identified by them as vulnerable and easy to carry out extremist behavior Psychiatric assessment: Quiet and withdrawn No sense of cause - result No understanding of social rules Non verbal restrictions, ( grinning or giggling ) Sensory overstimulation Fixated interests (star wars, racism) Verbal age 14, biological age 21, social emotional ag 9 Damon Smith example: - Asperger's syndrome, form of autism - Specific interest in firearms and bombs, without any notion of consequence ‘thought it would be a nice prank to leave the bomb on the tube’ Police thought it was a terrorist attack as he had looked at jihad sites for bomb manuals, Example of unmet needs being tied up with the function of the narrative. 49