abnormal exam 1 (1)
TRANSCRIPT
Chapter 5 Anxiety Disorders
Fear:
- Physical: flight of fight response to perceived danger.
- Present-oriented
- Innate alarm response to a real or perceived current threat
Anxiety:
- Feel threatened about a future event; reaction to a future threat.
Fear & Anxiety: Associated Symptoms
Fear
- Surges of arousal necessary for “fight or flight”
- Thoughts of immediate danger
- Escape behaviours
Anxiety
- Muscle tension
- Vigilance in preparation for future danger
- Cautious/avoidant behaviours
… DSM-5, APA, (2013)
Normal vs. Abnormal Anxiety
- Experiencing anxiety is normal and can be beneficial at certain levels
E.g., Yerkes-Dodson Law
- Anxiety is considered abnormal when it impairs functioning and interferes with well-being
o Unrealistic
o Excessive
o Persistent (typically 6 months or more)
For each anxiety disorder, the main criteria in the DSM to distinguish normal and abnormal anxiety
1. Severe distress
2. Impairs daily life
Components of Anxiety
**Know a few for each category.
Behaviors play a key role in whether or not anxiety persists.
Anxiety Disorders
- Panic Disorder
- Agoraphobia
- Specific Phobia
- Social Phobia
- Generalized Anxiety Disorder
- *Obsessive Compulsive Disorder
- *Post-Traumatic Stress Disorder
*No longer classified under Anxiety Disorders in DSM-5
DSM-V:
- OCD is now in OC & related disorders
- PTSD is in trauma & stressor-related disorders
- Separation anxiety disorder added
- Selective mutism added
To differentiate anxiety disorders, consider:
- The types of situations feared
- Content: thoughts and beliefs associated with anxiety
Panic Attacks
- Abrupt sense of intense fear or discomfort; peaks within minutes
- Must have ≥4 of the following physical/cognitive symptoms
o Racing heart
o Sweating
o Trembling or shaking
o Shortness of breath or smothering sensations
o Feelings of choking
o Chest pain/discomfort
o Nausea or abdominal distress
Types of Panic Attacks
- Expected: obvious cue or trigger
- Unexpected: occurs for no apparent reason, out of the blue. Ex: nocturnal panic
It’s VERY important to know if panic attacks are expected or not for diagnosis.
Panic Disorder - Recurrent (at least two), unexpected panic attacks
- At least one attack followed by ≥1 month of ≥1 of:
o Persistent concern/worry about additional attacks or their consequences
o Significant maladaptive change in behavior related to the attacks (e.g., avoidance of
exercise)
Cognitive Perspectives
- Catastrophic Misinterpretation Theory
o Selective attention bodily sensations
o Misinterpretation of bodily sensations
o Snowballing catastrophic thinking
- Anxiety Sensitivity Theory
o Enduring belief that symptoms of anxiety have harmful consequences. Fear of fear.
Phobias
Effect all sorts of people
- Persistent and excessive fear to certain situations/things
- Symptoms include:
o Feelings of panic, dread, horror, or terror
o Reactions that are automatic and uncontrollable: take over the person’s thoughts
o Physical symptoms in face of feared object/situation
o Avoidance of the feared object or situation: overwhelming desire to flee the situation
Imagined or exaggerated fear.
Fear is a normal response to a genuine danger.
Divided into three categories based on the cause of the fear/avoidance
1. Agoraphobia
2. Specific phobias
3. Social anxiety disorder.
Agoraphobia “Fear of the market place”
- Fear and anxiety about (2 or more) places where it seems escape would be difficult to
escape or get help in case of emergency
o Using public transportation
o Being in open spaces
o Being in enclosed places
o Standing in line or being in a crowd
o Being outside of the home alone
- Situations are avoided, require companion, or endured with distress
DSM-V separated agoraphobia and panic disorder, but they often appear together.
Most people get agoraphobia after first experiencing panic attacks (but not everyone).
Specific Phobias
- Fear/anxiety about or avoidance of specific objects or situations (or places)
- Categories o Animal type: specific animals or insects o Natural environment type: events or situations in the natural environment (e.g.,
storms, heights) o Situational type: public transportation, bridges, flying, elevators, etc. o Blood-injection-injury type: blood, injuries, injections o Other: ex: situations that lead to vomiting
Avoidance is key. Symptoms must interfere with everyday life.
It’s common for people to have multiple specific phobias (for individuals who have any, the average
is 3). You are very likely to develop a phobia of something else in the same category that you already
have one in.
Anxiety is immediate and intense when they encounter their phobia. Anxious at the thought of an
encounter with the phobia, they go to great lengths to avoid an encounter.
Must be persistent for six months.
Social Anxiety Disorder (Social Phobia)
- Fear/anxiety about or avoidance of social interactions and situations that involve the possibility
of being scrutinized
o Social interactions
o Being observed
o Performing in front of others
- Specify if: Performance only
More likely to disrupt the individual’s life.
Performance only impacts the individual’s professional life more than their personal life
(usually)
- Being negatively evaluated by others
- Being embarrassed, humiliated or rejected
- Offending others
Look beyond the feared situation and at the NATURE of that fear to distinguish agoraphobia vs.
social anxiety.
Social Anxiety Disorder
Rapee & Spence (2004)
The DSM uses a categorical approach, but mild social anxiety is not really different than severe anxiety,
just less intense. The main difference is in the individual’s perception of how much it impairs their
quality of life.
During diagnosis, consider the combined effect of level of social anxiety as well as the extent to which he
or she believes it causes distress and impairments.
Life Interference: Social Anxiety Disorder usually becomes apparent during adolescence because there’s
a shift from spending all time with family and increased social interactions.
Generalized Anxiety Disorder (GAD)
- Persistent and excessive anxiety and worry about various domains (e.g., work/school
performance) that the individual finds difficult to control
- ≥3 physical symptoms:
o Restlessness
o Easily fatigued
o Difficulty concentrating
o Irritability
o Muscle tension
o Sleep disturbance
Anxious almost all of the time, in almost every situation. Worry about many different things.
Experience these symptoms most days for at least six months.
*Obsessive Compulsive Disorder (now in obsessive compulsive and related disorders)
Presence of obsessions, compulsions, or both
Obsessions:
- Recurrent unwanted intrusive thoughts, urges, or images
- Attempts at suppression or neutralization
Compulsions:
- Repetitive behaviors or mental acts
- Aimed at preventing anxiety or a dreaded event
OCD Cycle
*Posttraumatic Stress Disorder - Exposure to traumatic event
- Intrusion symptoms
- Avoidance of associated stimuli
- Negative changes in thought and mood
- Changes in arousal and reactivity
- > 1 month duration of symptoms
No longer an anxiety disorder. Now trauma & stressor-related disorders.
Traumatic event:
- Exposure to actual or threatened death, serious injury, or sexual violence in one of the
following ways:
o Directly experiencing
o Witnessing it occur to others
o Finding out it happened to a family member or close friend
o Repeated exposure to aversive details of traumatic event (police officer with child
abuse cases)
Intrusion:
- Recurrent memories, dreams, feeling disconnected from oneself (flashbacks)
Different from anxiety disorders because there’s anxiety/distress AFTER the event.
PTSD
- Understanding risk/resilience to PTSD after traumatic events will help inform treatment and
prevention
http://www.youtube.com/watch?v=zKBO2aqVy3c
Presentation of Anxiety Disorders
- Lifetime prevalence rate for any anxiety disorder is ~31%
- More common in females than males (2:1)
- Tend to be chronic and recurrent without treatment
- Significant social and occupational impairment
Comorbidity
- High among anxiety disorders
- Other disorders
- Depression
- Substance use disorders
- Eating disorders
- Personality disorders
Etiology: Vulnerability-Stress Model
- Vulnerabilities are underlying factors
- Factors work together to develop anxiety disorders
- There’s no single-factor cause.
- It’s an integrated model because it’s complex
- 23-40% genetics (depending on the disorder)
Biological Factors
- Neuroanatomy
- Neural fear circuit
*Amygdala
- Sensory information comes into the thalamus, detecting threat, mobilizing
defensive actions
- Higher brain functioning isn’t related to the fear response, fear arises out of hyper
excitability of fear circuits in brain
- Neurotransmitters
- E.g., GABA
- Transfer information between brain structures involved in anxiety
- Benzos lower anxiety by acting on GABA receptors
- Genetic heritability
Psychological Factors
- Behavioral factors
o Learning theories
o Classical and operant conditioning: anxiety is the product of learned maladaptive
responses
- Cognitive factors (Aaron Beck)
o Biased perceptions about the world, the future, and the self
o Avoidance/ escape behavior maintains anxiety: short term relief, causes an
overestimation on the amount of danger, underestimate of coping ability.
o Emotions are influenced by the way people think about or appraise themselves in
the world.
Dysfunctional beliefs about the threat/danger; search for information that
supports the maladaptive belief; jump to conclusions
Social/Interpersonal Factors
- Insecure attachment: esp. anxious-ambivalent style. Learn to fear being abandoned by
loved ones. Develop through parents who are inconsistent in their emotional caregiving.
- Parenting practices
o Rejection, over-control, over-protection, modeling anxious behaviors: foster beliefs
of helplessness in children; general psychological vulnerability.
- Family functioning
o Prolonged exposure to family dysfunction
o Associated with the most extreme trajectories of anxious behaviors.
Vulnerability-Stress Model (diathesis-stress model)
http://education-portal.com/academy/lesson/assessing-the-diathesis-stress-model-strengths-and-
weaknesses.html#lesson
People are born with a vulnerability to a certain mental illness and life stressors influence whether
they will end up getting that disease or not.
Pros: recognizes the nature AND nurture; explains twin studies
Cons: simplistic; we don’t know the exact interaction.
Psychological Treatment
Cognitive Behavioural Therapy: asking people to confront situations/thoughts that make them
anxious.
- Cognitive Restructuring: irrational, anxiety-provoking thoughts are challenged and changed
- Exposure Techniques: systematic, repeated, and prolonged exposure to anxiety-provoking
stimuli (that they avoided because of anxiety-provoking properties).
Cognitive Restructuring
Anxiety is caused by unhealthy, maladaptive, unhelpful thinking patterns.
The way we feel results from our beliefs about situations.
Overestimate the probability and severity of various threats and also underestimate their own
ability to cope with such threats.
Collaborative empiricism: process where the client and therapist work together to assess every
aspect of a situation to find the most plausible interpretation. The therapist does not argue or
confront.
- Steps:
o Identifying maladaptive thoughts
o Challenging these thoughts
o Developing more balanced, realistic thoughts
- Thought Record
Exposure Techniques
- Graduated exposure: exposed to the actual situation; in-vivo exposure (may be internal
[worries] or external situations).
o By facing anxiety-provoking stimuli or situations, fears become extinguished.
o Learn to cope or deal with the anxiety
o New evidence is gathered that goes against previous maladaptive beliefs
- Exposure hierarchy
Begin at the bottom and increase to situations.
Systematic desentization: relax response paired with the stimulus
Exposure Therapy for Anxiety Disorders
http://abcnews.go.com/Health/video/exposure-therapy-anxiety-disorders-4658885
Chapter 6 Dissociative & Somatoform Disorders The Health Anxiety Inventory (HAI)
- Assesses clinical state health anxiety
- Used to conceptualize a disorder as a continuum/dimension
- Low scores indicating minimal or very mild health anxiety to extreme scores that
represent clinical disorders like somatic symptom disorders (SSD) or
hypochondriasis
- Differentiates people suffering from health anxiety from those who have actual physical
illness but who are not excessively concerned about their health.
- Three dimensions are important on the HAI:
- reassurance seeking
- avoidance
- perceived negative consequences of being ill
Somatoform Disorders (DSM-IV)
Soma – body
In somatoform disorders, psychological problems take a physical form. The following
characteristics define somatization:
a) physical symptoms have no known physiological or organic basis
b) the symptoms are not under voluntary control; no intentional faking
c) the symptoms are assumed to be psychologically caused by anxiety
d) individuals typically preoccupied with their health and the physical symptoms,
convinced something is terribly wrong with their bodies
Explanation for Somatization
DSM-5 has dramatically changed how it diagnoses somatic disorders
- It no longer uses the term somatoform but instead calls these disorders somatic
symptom and related disorders.
- DSM-5 has broaden the inclusion criteria quite considerably, which has been very
controversial
- Hypochondriasis is a fear or conviction that one suffers from a serious, undiagnosed
disease (e.g., cancer). This fear is based on the misinterpretation of benign physical
sensations (e.g., headache) and persists despite appropriate medical evaluation.
- Most often people with high health anxiety have hypochondriasis, although
illness phobia and other clinical conditions may be present in health anxiety. So
health anxiety is the broader term that psychologists prefer because it is linked
to normal health concerns in the general population.
DSM-5 Somatic Symptom & Related Disorders
- There are 5 types of disorders under somatic symptoms and related disorders in DSM-5
- Body dysmorphic disorder (BDD), which appears in DSM-IV under somatoform
disorders, has been moved to obsessive-compulsive and related disorders in DSM-5.
- Hypochondriasis now becomes SSD or illness anxiety disorder.
1. Somatic symptom disorder (SDD):
- multiple current somatic symptoms that are distressing or disrupt daily life (could be
only pain if severe)
2. Illness anxiety disorder: preoccupation with having or acquiring a serious, undiagnosed
medical illness; somatic symptoms absent or only mild
- The anxiety and preoccupation with illness are present but there are no somatic
symptoms, or if present, they are of mild intensity. The anxiety here is focused not
on having a physical complaint but rather on the meaning, significance or cause of
the complaint.
3. Conversion disorder: one or more symptoms of altered voluntary motor or sensory function
that are not due to neurological or medical conditions.
- Physically normal people experience sensory or motor symptoms, such as sudden loss of
vision, paralysis or difficulty swallowing that suggests some neurological damage but
body organs and the nervous system are fine.
- Functional neurological symptom disorder because this term emphasizes that the
condition is a “disorder of function” and not of structure.
- DSM-5 emphasizes that to make this diagnosis, there must be clear evidence that the
symptoms are incompatible with neurological diseases (e.g., the symptoms are present
with one type of neurological examination but then absent with a different test of the
same neurological disease)
- Usually develops in adolescence or early adulthood, prevalence is less than 1%, seen in
more women than men, and an episode can end abruptly only to return again later in
the same or different form.
- In early publications, CD was grouped under hysteria, and psychoanalytic theory thought
CD was caused by the energy of a repressed instinct being diverted into sensory-motor
channels and thus blocking physical functioning. Thus anxiety and psychological conflict
were believed to be converted into physical symptoms
- Cognitive and behavioral explanations emphasize the importance of reinforcement for
enacting a disability role, a tendency to discount the importance of psychological
factors contributing to the present complaints, illness beliefs, denial of external
stressors, suppression of distress expression, and avoidance behaviors.
4. Psychological factors affecting other medical conditions: presence of one or more clinically
significant psychological or behavioral factors that adversely affect a medical condition by
increasing the risk for suffering, death or disability.
- This diagnosis is made when the person exhibits psychological or behavioral factors that
adversely affect the treatment or course of a medical condition. These behaviors
include:
- psychological distress
- patterns of interpersonal interaction
- maladaptive coping styles
- maladaptive health behaviors
- denial of symptoms
- poor adherence to medical recommendations
- So a person with diabetes could be diagnosed with this condition if s/he refused to
adhere to dietary restraints or check his/her blood sugar levels, or the person with acute
chest pain who denies the need for treatment
5. Factitious disorder: the falsification of medical or psychological signs and symptoms in oneself
or others that are associated with the identified deception.
- intentionally produces the physical or psychological signs of illness in what appears to
be a desire to assume a sick role
- In DSM-5 FD is ruled out if the person fabricates symptoms for some external reward or
gain such as avoid military service or obtain financial compensation. In those cases, we
refer to this simply as malingering (i.e., lying).
- People with FD will engage in deceptive practices to produce signs of illness such as fake
an elevated body temperature, put blood in their urine to simulate kidney/urinary tract
infections, or take blood-thinning medication to produce symptoms of hemophilia.
DSM-IV vs. DSM-V
DSM-IV: Somatization Disorder
A. History of many physical complaints beginning before age 30, persistent & impairing
B. Has 4 pain, 2 GI, 1 sexual and 1 pseudoneurological symptoms
C. Above symptoms not due to a medical condition or are excessive
DSM-5: Somatic Symptom Disorder
A. One or more somatic symptoms that are distressing or disruptive
B. Excessive thoughts, feelings, or behavior related to somatic symptoms or health
C. State of being symptomatic is persistent for at least 6 months
Changes:
1. DSM-IV required multiple somatic complaints so you get this very confusing list of
somatic symptoms in Criterion B that must be met. These symptoms could be present at
any time during the course of the disorder. However Criterion B was a confusing array
of symptoms for clinicians to assess, it probably set the threshold for diagnosis too
high, and it depend a lot on historical recollection of the patient.
2. Another significant change was the deletion of the DSM-IV requirement that the
symptoms cannot be explained by a medical condition or the symptoms are in excess
of what you would expect with the medical condition. This criteria is gone in DSM-5
and so the concern is now we’ll be overdiagnosing SSD; that anyone with health
worries about their diabetes, heart condition or cancer will be diagnosed as having
SSD and then given psychotropic medications for their anxiety
3. DSM-5 puts a lot more emphasis on the psychological or emotional characteristics of
somatization. So under excessive thoughts, feelings or behavior (Criterion B) at least
one of the following must be met:
a) Disproportionate & excessive thoughts about seriousness of the symptoms
b) Persistently high anxiety about health or symptoms
c) Excessive time & energy devoted to symptoms & health concerns
CBT Model for Somatic Disorder (Hypochondriasis)
1. Misinterpretation of bodily sensations
2. Pre-existing dysfunctional beliefs about symptoms and disease; self-schemas of being
weak & unable to cope
3. Excessive attentional focus on bodily sensations
4. Attentional bias for illness-related information; beliefs about disease “trump” beliefs
about being healthy
5. False belief that healthy means “symptom-free”
6. Futile search for safety (“guaranteed health”)
7. Secondary reinforcements for sick role
CBT Model of SSD (Hypochondriasis)
The following are the various elements of CBT for SSD:
1. Misintepretation of bodily sensations
- The central assumption of the CBT model is that individuals with SSD
misinterpret specific physical complaints or symptoms as possibly indicating the
presence of a serious illness or medical condition
2. Pre-existing dysfunctional beliefs about symptoms and disease; beliefs that you are
weak, vulnerable & unable to cope
- Past personal experiences, family history of concern about illness or death, even
media exposure to disease can instill maladaptive beliefs about the threat of
illness and need to certain about the safety of health
3. Excessive attentional focus on bodily sensations
- Given the presence of these maladaptive illness beliefs, the SSD person becomes
hypervigilant for unusual physical sensations
4. Attentional bias for illness-related information; schema-congruent (having disease)
“trumps” schema-incongruent (being healthy)
- People with SSD tend to give information processing priority to health
information that confirms their illness-beliefs that symptoms are dangerous; that
certain diseases are highly like and more dangerous than they actually are; also
they tend to discount evidence they are in good heath
5. False belief that healthy means “symptom-free”
- People with SSD often hold unrealistic beliefs about good health
6. Futile search for safety (“guaranteed healthy”; search for certainty)
- Based on false beliefs of health, individuals with SSD embark on a quest to obtain
medical reassurance of “guaranteed” prevention of the dreaded illness
- Problem is all of this is based on feeling free of anxiety. As long as they feel
anxious, they doubt that the symptom is benign
7. Secondary reinforcements for sick role
- With hypochondriacial or SSD, individuals might receive some secondary gain
from their health complaints; the might receive attention, sympathy or comfort
from others
- Individuals who actually receive something tangible, like a long-term disability
payment, will actually do worse in treatment.
Attentional Bias in Health Anxiety
• 242 undergraduates classified as high, medium or low health anxiety (HA) based on
questionnaire; screened out medical illness
• 10 illness threat words, 10 negative, 10 positive & 10 neutral words
• words presented in modified Stroop colour-naming task
• high HA group were significant slower to colour-name illness words only
If the CBT model of health anxiety is correct, we would expect that people with hypochondriasis
or high health anxiety would exhibit a selective information processing bias for threatening
illness information. This Canadian study conducted at the University of Regina found
experimental evidence that high health anxiety people do selectively process or attend to
negative illness information.
1. They divided a student, nonclinical sample in low, medium and high health anxiety
based on their scores on the Illness Attitudes Scale.
2. Then they ran all participants through a modified Stroop colour naming experiment. In
this experiment, participants are presented words printed in various colours. The task is
to name the colour of the printed word. If you take longer to name the colour, it means
the word has interfered in your colour naming- you must have been paying some
attention to the word. So if the word CANCER appears in red on the screen and you take
longer to say “red”, then your attention must have been drawn to the word itself.
3. The high HA group took longer to colour name the threatening illness words but not
any of the other types of words. Therefore, they must have been more strongly drawn
to the meaning of the illness words. We interpret this to indicate that high HA is
characterized by a selective attentional bias for illness threat, which is consistent with
the CBT model previously in the last slide. However a more recent 2013 study run on
clinical patients revealed that hypochondriacal individuals have an attentional bias for
illness threat and panic-related threat characterized by autonomic arousal (Gropolis et
al., 2013, Journal of Consulting & Clinical Psychology).
Treatment of Somatic Disorder (Hypochondriasis)
• Rule out physical cause to symptom
• Differentiate from panic disorder
• Take into account patient’s cultural context
• Cognitive-behavior therapy (75% improvement rate)
– Modify dysfunctional illness beliefs & misinterpretations of bodily sensations
– Intentional exposure to feared bodily sensations & avoided health information
– Response prevent reassurance-seeking & safety seeking behavior
- SSDs are difficult to treat. There is some evidence that fluoxetine (Prozac) may be
promising and in mild cases, psychoeducation can be effective.
- CBT produces the best outcome in more severe and chronic cases.
1. Rule out physical cause to symptom before mental health referral
- Physicians need to take physical complaints seriously and rule out a physical or medical
cause for the complaint
- Only after all tests come back negative can we entertain the possibility of panic disorder
or SSD. In this sense SSD becomes a residual diagnostic category.
2. Make differential diagnosis (i.e. panic disorder)
- Must differentiate SSD from other mental disorders, especially panic disorder, which
also involves the misinterpretation of more specific physical symptoms.
- Also the major difference is that panic involves the fear of a specific physical calamity at
a particular moment in time such as having a heart attack, fear of suffocation or of
having a panic attack
- In SSD the fear of serious illness or disease; a more generalized, longer-term fear of
death & dying from disease.
3. Take into account patient’s cultural context
- Certain ethnic groups often have higher rates of somatic symptoms when depressed,
anxious, etc.
4. Cognitive-behavior therapy (75% improvement rate)
a) Modify dysfunctional illness beliefs & misinterpretations of bodily sensations
b) Intentional exposure to feared bodily sensations & avoided health information
learn to deal with illness-related information in a more benign manner
learn to tolerate the uncertainty of life and well-being
c) Response prevent reassurance-seeking.
The patient is encouraged not to seek reassurance from family or friends that
s/he is okay, is not ill
The therapist discourages repeated trips to the family doctor, or the demand to
run endless medical tests; we also discourage surfing the Internet for
information every time the individual has an unexpected or inexplicable physical
sensation or complaint.
Chapter 8 Depression & Suicide Very often depression is linked to triggers: things about our environment. Feelings: negative affect
dominates. Stuck in negative outlook on life (about their life: negative self-referent). [Loss failure,
disappointment.]
- It’s normal to feel sad.
- “Empty” feeling
- Thoughts: the way we think influences the way we feel
- Depression distortions & rumination
- Negative focus on self, memories become biased
- Anxiety, anger and irritability increase
- Sad: ponder life
- Depression: no motivation, isolate, avoidance (conserving energy)
Depression: A Case Example
Jan Turns 20
• Periods of sadness, feeling blue that can last several days but sporadic throughout the week
• Feels unmotivated, uninterested in school but likes to party
• Sleep is chaotic; goes to bed late and often sleeps in missing class
• Tends to “graze” rather than eat meals; often not hungry
• Has to really push herself to get to class or study
• Tends to be negative, a pessimist
• Is easily distracted; had to hold her attention on important tasks
• Has slashed at her wrists when feeling frustrated, angry at herself: coping mechanism.
She doesn’t meet the DSM-5 criteria for Major Depression.
Normal vs. Clinical Depression
Continuum of severity?
Normal Depressed Mood:
- No motivation, fatigue
- Not enjoyable, but probably wouldn’t kill themselves.
- Still important because they MIGHT have MDD.
Clinically Depressed Mood:
- Loss of interest & appetite loss, usually occur together
- Suicide: feels like you’ll never get better
- Leave from work/school. Stress leave.
DSM-V: MDD is a disease, not related to normal depressed mood.
DSM-5 Criteria for Major Depressive Episode
Exactly like DSM-IV criteria except…
THIS WAS REMOVED:
Criterion E was if the symptoms are not better accounted for by bereavement (grief) and persist for two
months.
DSM-IV: grief (death within the past two months) cannot be MDD unless the symptoms are exaggerated
(suicidal ideation).
DSM-V eliminates the grief component, but there’s a huge footnote.
TEXTBOOK PAGE 177.
Major Depressive Episode vs. Grief
MDE
- Predominant feeling is depression (an inability to anticipate happiness)
- Persistent depressed mood
- Thinking is focused on self-criticism and rumination
- Thoughts of worthlessness and self-loathing
Grief
- Predominant feeling is emptiness or lost
- Dysphoria (sadness) comes in waves (pangs of grief)
- Focused thinking on missing loved one
- Self-esteem is persevered
- Difference in the quality of feelings. Assess quality of depression
- Abnormal grief: prolonged grief reaction where the person sinks into grief and doesn’t come
out. Persistent, does not occur in waves
Annual Prevalence of Mood Disorders in Canada Diagnosed by Health Professional
Based on: rate of people diagnosed by health professionals. Young people tend not to get treatment
for depression.
Community samples: depression rates may be higher for younger people.
MDD includes bipolar, dysthymia. 6% of women, 3% of men (women 2x more mood disorders than
men).
Anxiety is the first most common disorder, then substance use and depression.
Annual Prevalence of Mood Disorders by Province
Canadian Community Health Survey (2003).
Biggest mental health survey in Canada.
20,382 people in NB meet MDD criteria, 3.4% annual rate.
Family; collectivist; society = kind of protective. More close.
Mood Disorders
Global perspective: big difference between countries. World Mental Health Survey (2007); 17
countries, 85,052 people. Face to face interviews.
- U.S. has the highest lifetime prevalence (31.4%)
- China = 7.3%
- France = 30.5%
- Nigeria = 8.9%
- Japan = 14.1%
MDD rates are different between cultures because of the difference in the expression of
psychological symptoms.
Other DSM-5 Depression Disorders
Disruptive mood dysregulation disorder: chronic, severe & persistent irritability (mainly children)
- Last 15 years: 5000% increase in childhood diagnosis of bipolar disorder. Hopefully the
DMDD will fix this.
- DMDD: severe, recurring tempter outbursts. Anger & irritability. At least 3 temper tantrums
a week.
Persistent Depressive Disorder: depressed mood more days than not for at least 2 years
- Dysthymia: chronic, low-grade depression. At least two symptoms of regular depression
(major depression). Changed to Persistent Depressive Disorder.
Premenstrual Dysphoric Disorder: mood liability, irritability, dysphoria & anxiety that occurs
repeatedly during the premenstrual phase (luteal phase)
- 5+ symptoms one week before period (luteal phase). Depression follows the menstrual
cycle.
- VERY distressing
- Chart mood changes for two cycles
- 1.8 – 5.8% of menstruating women would meet diagnostic criteria for PDD.
- Bloating, joint pain, breast tenderness.
- Have mood swings, irritability, anxiety, loss of interest, poor concentration, low energy
Substance/Medication-Induced Depressive Disorder: MDE symptoms due to ingestion, injection or
inhalation of substance
- Symptoms during or soon after drug exposure
- Temporal pattern of depression after drug exposure
Depressive Disorder due to another Medical Condition: prominent & persistent depressed mood
that related to direct physiological effects of medical condition (e.g., hypothyroidism, stroke,
Parkinson’s disease, etc)
- Illnesses that can directly cause depression
Other Specified Depressive Disorder: depressive symptoms but less than 5; person has significant
distress or impairment (e.g., recurrent brief depression, short-duration depressive episodes, etc);
clinician specifies why full criteria not met (not 2 weeks, too few symptoms, etc)
Unspecified Depressive Disorder: same as above except clinician does not specify why person failed
to meet full criteria
- Categories when it should probably be dimensional
Depression: DSM-5 Specifiers - With anxious mood
- With mixed features: 3 or more hypo/manic features
- With melancholic features: lack of reaction; loss of pleasure
- With atypical features: laughing a lot; mood reactivity; sleep more; weight gain; heavy limbs.
- With psychotic features: ECT candidate: delusion of badness.
- With catatonia: stopping and starting paralysis in posture
- With peripartum onset (postpartum depression)
o 3-6% of women are depressed during pregnancy and for the weeks following birth.
Often experience severe anxiety and panic attacks.
- With seasonal pattern (seasonal affective disorder- SADS): regular, temporal onset of
depression. Sunlight.
o Northern hemisphere more SADS, not as many in the Southern hemisphere.
o Become depressed in the fall, and then less in the spring.
o Wake in the early morning and can’t sleep
o Psychomotor agitation
“Going, Going, Gone”: The Strange Case of Depressive Personality Disorder
A. Pervasive pattern of depressive cognitions and behaviors that begins by early adulthood,
present in a variety of contexts, as indicated by 5+ of the following:
- usual mood that is dejection, gloominess, unhappy
- self-concept beliefs of inadequate & low self-esteem
- high self-criticalness & blame
- brooding & worrisome
- negative, critical & judgmental toward others
- pessimistic
- tendency to feel guilt or remorse
B. Doesn’t occur just during MDE or is better accounted for by dysthymic disorder
Significant impairment in functioning and distress.
DPD Dysthymia
- Chronic negativity & lack of interest/pleasure (anhedonia)
- Neuro-vegetative symptoms absent - Criticalness towards others is stronger
- Persistent sadness - Neuro-vegetative symptoms are
present
Reasons why not in the DSM-V dropped DPD:
- Very high comorbidity
- DSM-V working group decided DPD is better seen as traits than a type
- It’s as stable as other PDs but does not meet the threshold.
- Not all depression is episodic - ICD-10 does not have DPD - DSM-IV had DPD in provisional category, DSM-V eliminated it completely - 2% of general population have DPD - It’s hard to treat - Second most common personality disorder seen by clinicians
Self-Reported Depressive Symptoms
Illustrates the dimensional nature of depression (not categories) because of the overlap in the
curves.
Major depression mean: 22.9 symptoms
Non-clinical mean: 13.31 symptoms
No such thing as indigenous (?) vs. reactive depression.
- Dependent: you contribute to the event (stress). (Stressful environment at work)
- Chronic stressors: single parent, drug-addicted father. (Single parent, drug addicted partner)
- Episodic: you did nothing to contribute to this event. It happened out of the blue. (Severe
car accident, severe head trauma etc.) Major contributor to depression
Stress generation:
- Depression can effect life events
- Depression itself can generate stress
Depression Trigger: Negative Life Events.
Events influence the onset and intensity.
- Severe major life events cause depression onset, especially loss or exit events. The more severe
the life event, the harder it is to treat the depression (ex: motorcycle accident)
- Depression more severe when associated with life events
- Daily stress + disadvantaged economic status predict depression
- Mixed evidence about the role of minor life events or daily hassles
- Having life stressors while in treatment reduces treatment effectiveness
- Life events after recovery increase the risk of relapse
Freud: A depression-prone individual becomes fixated at the oral stage and becomes excessively
dependent on others for self-esteem. Depression happens when:
- Excessively dependent
- Experience a loss
o 80% of depression had experienced a major life event in the 6 months to 1 year
prior. Life events cause 29-69% of depression
Most toxic events: Loss or threatened loss (exit events)
Stress-generation: life event and depression cause each other. Not one way.
Not the Whole Story
INTERACTION between the negative life event and diathesis.
Diathesis-stress: pre-existing, enduring disposition that increases the probability of onset of a
depression episode when there’s a negative life event.
We need to take into account more variables to see who becomes depressed.
Factors:
- Neuroticism
- Social dependency
- Low self-esteem
- Negative attribution style
- Trait rumination
Beck’s Cognitive Theory of Depression: a diathesis-stress model
- An underlying cognitive vulnerability
In depression, the self-schema is very important. It influences how we see ourselves, others, and the
world.
Schema: internal representation. Enduring mental framework of knowledge and experience.
We develop schemas through experience.
Cognitive errors: we tend to see things black and white, personalize, and overgeneralize.
Cognitive errors + negative automatic thoughts are biased information processing (contribute to
depressive symptoms & makes them worse by cycling).
Cognitive Vulnerability
Example of exaggerated core belief: I need the love, approval, acceptance, and admiration of EVERY
person I come into contact with.
The Depression Gene
Genetics accounts for 30-40% of depression.
Caspi et al. (2003) discovered the depression gene through a longitudinal study from age 3-26.
Genetic analysis. Divided into three groups:
Group A: 2 copies of short allele 5-HTTLP (which regulates/transports serotonin). BAD.
Group B: 1 copy of the short allele. BAD.
Group C: 1 copy of long allele. BEST.
The short allele is associated with low serotonin transcription (which is bad), but kids with
depression also needed a negative life event (interaction).
Clarke et al. (2010) serotonin transporter gene (5-HTTPLR) may interact with neuroticism, not
negative life events, to increase depression.
EXAM: Describe the depression gene. Is it “dead”? - Many researchers think 5-HTTPLR is still the best candidate to influence depression.
- 1 or 2 copies of the short allele 5-HTTLP (which regulates/transports serotonin) are
BAD
- Having 1 long copy of the allele is best because the short allele is associated with low
serotonin transcription (which is bad), but kids with depression also needed a
negative life event (interaction).
- 5-HTTPLR might interact with trait neuroticism, not negative life events
The Depressed Brain
Documented brain changes with antidepressants and CBT Talking changes our brain! It’s unclear
how the brain of a clinically depressed individual differs from a sadness-induced brain.
ACC is LESS activated: important in effortful (conscious) emotion fixing (to feel better)
Amygdala (midbrain) is MORE activated: critical for processing emotion/memories
The dorsolateral prefrontal cortex is LESS activated when depressed (deals with regulations of
emotion, reasoning, thinking, judgment).
Cognitive Endophenotype for Depression
We have 25,000 genes.
Genetic basis to depression is a polymorphism (combination of many genes)
Strongest polymorphism: serotonin transporter gene
Other candidates include:
- Catechol-o-methyl-transferase (COMT/dopamine)
- Dopamine receptor D4
Gene environment interaction activates a negative information processing bias.
Three way interaction between gene, environment, and cognition (Gibb et al., 2013).
Psychological process is in the endophenotype. Stress reactivity activates the
endophenotype.
An endophenotype is “intermediate” between the microscopic world of genes/nerve cells and the experiential and psychological world of symptoms
1. The endophenotype is associated with illness in the population. 2. The endophenotype is heritable. 3. The endophenotype is primarily state-independent (manifests in an individual
whether or not illness is active). 4. Within families, endophenotype and illness co-segregate
Percent of Untreated Depression
(Australia, Canada & USA): Almost half of depressed people don’t get treatment. Maybe because of
stigmatization?
Cognitive Intervention: Depression
Elements of CBT:
1. Psycho-education
2. Problem-solving approach: generate problem list
3. Identify and evaluate negative thinking
4. Generate alternate thinking
5. Behavioral experiments (conversation with husband, exercise)
6. Evaluate outcome
7. Master & pleasure activities
You would be depressed because of the way you think after losing your job, not because you
lost the job. It is the negative thinking that matters.
Defining Suicide
Starts off as intentional.
Women are 3x more likely to attempt suicide
Men are 4x more likely to commit suicide.
Different methods.
Gender differences exist across all age groups.
15% of people with MDE commit suicide
90% of people who have completed suicide have a mental disorder
89% of people attempted suicide had MDE in last 12 months
Suicide: a deliberate act of self-harm taken with the expectation that it will be fatal
A behavior; not a mental illness.
Types of Suicide:
- Death seekers--- clearly and explicitly seek to end their lives
- Death initiators--- believe they are hastening an inevitable death: terminal illness
Suicide is the fourth leading cause of death for individuals between the ages of 15 and 44.
In 2009 there were 3890 suicides in Canada, second leading cause of death between the ages of 15-
24.
Suicide is the leading cause of death for First Nations individuals between the ages of 10 and 44.
(Rates of suicide are 2-4x greater for First Nations individuals: isolation, lack of hope)
Country Differences in Completed Suicides by Gender: Sociological aspect of suicide.
Threshold model for suicidal behaviour
The threshold model of suicidal behavior is an integrative model that seeks to explain how different
types of risk and protective factors interact to produce a threshold for suicidal behaviour. The
different types of factors are:
Long term predisposing risk factors that can be present at birth or soon after birth
- these identify people who are in risk groups: genetic vulnerability, serotonin transporter
gene (5-HTT); also impulsivity, pathological aggression, perfectionism, (personality
traits), problem-solving deficits
Short term risk factors that can develop later in life
- these may predict when someone is most likely to commit suicide (e.g., presence of
depression, schizophrenia, bipolar disorder, suicidal ideation, hopelessness, social
disconnection,, loss experiences,
Protective factors that may be long or short term
- These can offset risk factors
Precipitating risk factors
- occur due to a recent life event or access to a method of committing suicide
- These are events that may tip the balance when a person is at risk.
Joiner’s Interpersonal Theory of Suicide
A proclivity to commit suicide is the product of two interpersonal constructs. These are:
(a) Thwarted need to belong: increased risk when people feel excluded and alienated from
others (“I’m all alone”).
(b) Perceived burdensome: increased risk when people perceive they are burden to others
and so family/loved ones would be better off without them. There does seem to be a
link between perceived burden and other indices of suicidality.
(c) Capability: suicide occurs when people have both the desire and the ways to commit
suicide (i.e., high tolerance for physical pain through nonsuicidal self-injury; high distress
tolerance). Capability differentiates between the suicide ideators and those who
actually attempt or commit suicide. Question: Does this model explain the high suicide
rate among Canadian soldiers and veterans?
(d) Also the interpersonal model suggests a way towards prevention; that in schools and
elsewhere focus on “need to belong” (i.e., social support).
Myths about Suicide
- People who discuss suicide won’t commit the act: At least ¾ of those who take their own
lives have communicated their intention beforehand, perhaps as a cry for help.
- Suicide is committed without warning: The person usually gives many warnings, such as
saying that the world would be better off without him or her, or making unexpected and
inexplicable gifts to others.
- Suicidal people clearly want to die: Most people who contemplate suicide appear to be
ambivalent about their own deaths. For many people, the suicidal crisis passes, and they
are grateful for having been prevented from self-destruction
- The motives for suicide are easily established: The truth is that we do not fully understand
why people commit suicide. For example, just because a severe financial loss precedes a
suicide does not mean that it adequately explains the suicide.
- All who commit suicide are depressed: This misperception may be due to not seeing the
signs of impending suicide. Many people who take their lives are not depressed; some even
appear calm and at peace with themselves.
- Improvement in emotional state means lessened risk of suicide: Those who commit
suicide, especially those who are depressed, often do so after their spirits and energy begin
to rise.
Chapter 9 Schizophrenia Spectrum & Other Psychotic Disorders Psychosis: lack of contact with reality. A mental state characterized by severe impairment or distortion
of reality.
Schizophrenia impacts ALL areas of functioning.
Key Features of Psychotic Disorders
Schizophrenia: can be defined by abnormality in 5 domains. Complex disorder and varies by individual.
Delusions
- Fixed implausible beliefs: individuals adapt their thinking to fit the belief.
- Themes o Persecutory: belief that they will be harmed/harassed by organizations, individuals, or
groups. o Referential: ordinary events have personal meaning. Ex: Comments are directed at you. o Grandiose: belief of exceptional abilities, fame. Ex: Ability to talk to God, control others,
believe that they are God or Jesus.
- Bizarre delusions: to be considered “bizarre” they must not make sense to an individual of the
same culture, clearly implausible, not from ordinary life experiences. o Thought withdrawal o Thought insertion o Behaviors controlled by external force
Even if they’re proven wrong they don’t change their mind.
Preoccupied with the thinking
The “Truman Show” Delusion Gold & Gold, 2012 Cognitive Neuropsychiatry
- Five people have similar delusions of thinking they are on a TV broadcast.
- Taped continuously as a national broadcast.
- Delusion themes remain constant across cultures over time. The form remains constant but the
content changes.
Hallucinations Disturbances of perception occurring without an external stimulus.
15% of mentally healthy college students have had them (but don’t have a psychotic disorder)
- Auditory: most common in schizophrenia (voices).
- Visual
- Tactile: feeling something on your body (outside your body)
- Somatic: inside your body, worms are eating your organs.
Vivid & clear. Hard to differentiate from reality.
Types remain the same across cultures but content varies.
Disorganized Thinking (Speech) Disturbance of thought form, inferred from speech
- Derailment/Loose associations: switch topics quickly/easily
- Incoherence or “word salad”: words very disorganized, gibberish
- Neologisms: words made up that don’t mean anything to anyone else.
Grossly Disorganized or Abnormal Motor Behaviour Disturbed psychomotor behavior: a range of deficits in motor skills
- E.g., agitation, “silliness” Ex: pacing, shouting, swearing
- Difficulty with goal-directed behavior
Catatonic behavior: marked decrease in reactivity to the environment: absence of behaviors. Extreme
form is paralysis (but rare).
Negative Symptoms More impact on daily functioning, harder to treat
Impacts emotion, motivation and pleasure. Deficits/losses in normal functioning
- Affective flattening: severe reduction or complete absence of emotional response, monotone
voice, no eye contact. Doesn’t mean they’re not experiencing emotion.
- Avolition: inability to complete tasks. Disorganized, careless.
- Alogia: reduction in speaking. One or two word answers, no initiation.
- Anhedonia: decrease in pleasure of life
- Asociality: lack of interest in or lack of opportunities for social interactions.
Degenerative disorder: brain based.
DSM-5 Criteria for Schizophrenia
A. ≥ 2 symptoms
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. Functional impairment
C. Disturbance persists for ≥ 6 months
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features ruled out
E. Not due to substance or medical condition
F. If history of ASD or communication disorder, diagnosis made only if prominent delusions or
hallucinations present for ≥ 1 month
**Must have either disorganized speech, delusions or hallucinations for a significant period of time over
one month.
Schizophrenia subtypes were eliminated in the DSM-V (they had little use and might change over time,
didn’t help treatment or prognosis).
Other DSM-5 Psychotic Disorders Psychotic disorders differ in symptom presentation, severity, and duration. SPECTRUM.
Schizotypal personality disorder: symptoms below threshold for diagnosis of a psychotic disorder.
- Below the threshold for psychosis. Seem odd, eccentric, cognitive/perceptual distortions. Odd
beliefs/magical thinking. Persistent over time. Lack of close friends.
Delusional disorder: at least 1 month of delusions but no other psychotic symptoms
- At least one month of delusions, but no other symptoms. Regular delusion types but also
erotomanic (belief of someone of higher status is in love with them stalking behavior), and
jealous (delusions about partner being unfaithful).
Brief psychotic disorder: lasts more than 1 day and remits by 1 month
- Occurs suddenly, unexpected.
Schizophreniform disorder: duration <6 months and no requirement for decline in functioning
Spectrum:
Brief psychotic disorder Schizophreniform Schizophrenia.
Schizoaffective disorder: mood episode and active-phase symptoms of schizophrenia occur together;
preceded or are followed by ≥2 weeks of delusions or hallucinations without prominent mood
symptoms
- Psychotic and mood symptoms together. But before the episode, two weeks of delusions or
hallucinations alone (make them the primary symptoms).
Substance/medication-induced psychotic disorder: psychotic symptoms due to drug of abuse,
medication, or toxin exposure
- No symptoms after the removal of the medication.
Psychotic disorder due to another medical condition: psychotic symptoms consequence of medical
condition
- Ex: Epilepsy.
DDX: differential diagnosis diagnoses to rule out.
Assessment of Severity
Impaired cognition related to functional impairment.
Depression & mania: mood symptoms don’t only appear in schizoaffective disorder.
Schizophrenia:
- 20% attempt suicide
- 5-6% complete suicide
- Often due to comorbid depression & substance use command hallucinations
Course of Schizophrenia
- Phases: cycle through multiple times. o Prodromal: the beginning
Slow and gradual development. Fewer social interactions, lack of hygiene,
inappropriate displays of emotion, cognitive impairments. Tend not to make
diagnosis until active phase because prodromal symptoms could be for a variety
of reasons. o Active: psychotic symptoms
Delusions, hallucination, etc. Positive symptoms. Some people cycle through phases, others mostly remain in the active phase.
o Residual Similar to prodromal, don’t appear psychotic. Maybe below threshold positive
behaviors. Suicide attempts higher in the residual phase.
- Gender o Age of onset earlier for men
Early to mid-20’s for men Late 20’s for women
o Different presentation of symptoms
Women show more positive symptoms, less socially impaired, better adjusted,
because less negative symptoms and maybe already married (have support),
stable, lifestyle (because of age of onset).
20% live a normal life. Only a small number recover completely.
Diathesis-Stress Model Walker et al., 2004
Not just biological factors, there are social & psychological factors too.
Stress is a trigger. These individuals do not necessarily experience more stress, but are more sensitive to
stress.
Adolescent neuro-maturation is a large genetic component to schizophrenia.
The biological vulnerability at birth influences the brain structure and function. Inherited & acquired
factors (flu during pregnancy, brain trauma).
Biological vulnerability interacts with changes in brain (adolescents) and environmental stressors.
Together they push individuals into the development of psychosis. LATENT vulnerability/diathesis (not
yet expressed or observed).
There is no specific pathway to schizophrenia.
Social Factors Expressed emotion (EE) & relapse/rehospitalization
Family characteristics like high expressed emotion can have a negative impact on schizophrenia.
EE: when family members act a certain way to their schizophrenic person (too much emotional
involvement): stressful for schizophrenian). Critical/Hostile.
Antipsychotic Medications Reduce symptoms, do not cure. Work more on positive symptoms than the negative symptoms.
- First-generation (Typical): 1950s
o Chlorpromazine
o Extra-pyramidal side effects: muscle spasms/shaking (similar to seen in Parkinson’s)
(e.g., tardive dyskinesia): involuntary facial movements, irreversible when used long
term.
- Second-generation (Atypical): 1980s
o Clozapine, risperidone, olanzapine
o Risk for agranulocytosis: reduction in white blood cells, bad to fight off infections, need
regular blood tests.
Side effects:
- First generation: uncontrollable body movements. Motor, Parkinson’s-like symptoms. Lack of
dopamine.
- Second generation: less risk for motor impairments… but cardio/metabolic side effects, weight
gain.
Both generations reduce dopamine’s action on the brain. Second generation meds also target other
receptors (serotonin)
Cognitive Deficits in Schizophrenia Not targeted by antipsychotic medication. Not even a criteria for schizophrenia…
Tells you what tests to use with someone with schizophrenia.
Goal of research: to create medications effective in treating cognitive impairments.
Many stakeholders: pharmaceutical companies, food…
Psychosocial Interventions Drugs cannot restore the life of a person with schizophrenia, they don’t target negative symptoms.
A combination of medication and psychosocial interventions is important in order to target as many
symptoms as possible.
- Social skills training
o Focus on developing practical social & living skills to increase independence and
decrease stressors: adapt to life.
o Conversations, coping with stress, household tasks, developing employment-related
skills
- Family therapy
o Psycho-education
o Coping strategies for family
o Decrease EE.
Chapter 10 Eating Disorders What are Eating Disorders?
In DSM-5, “Feeding and Eating Disorders”
- pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa,
bulimia nervosa, binge-eating disorder
DSM-5 broad definition: Feeding and eating disorders: persistent disturbances of eating or
eating-related behavior, which results in an altered consumption or absorption of food and
significant impairments in physical health or psychosocial functioning.
DSM-IV-TR: Classification & Diagnosis
There’s a relationship among the three diagnoses.
Eating disorders NOS includes the most people.
Bulimics cannot be anorexic.
Diagnosis of NOS doesn’t help people because how can you help a disorder that is not
specified?
Out-patient stats: ½ NOS, 1/3 bulimia, rest anorexia.
Anorexia is generally impatient because of low weight.
Anorexia Nervosa & Bulimia Nervosa Core psychopathology: over-evaluation of shape and weight & ability to control them (key feature;
more than normative discontent)
Different from body shape dissatisfaction, a common occurrence in the population
Anorexia Nervosa (AN): DSM-5 criteria A. Energy intake restriction leading to significantly low body weight (look at BMI)
B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with
weight gain (doesn’t go away with weight loss)
C. Disturbance in self-perceived weight or shape
Self-esteem is REALLY based on weight/appearance.
AN: Subtypes During the last 3 months…
- Restricting type: No episodes of binge eating or purging behavior. Weight loss primarily
through dieting, fasting, and/or excessive exercise: more control
- Binge-eating/purging type: Recurrent episodes of binge eating or purging behavior: higher
impulsivity
Purging includes self-induced vomiting, misuse of laxatives, etc.
AN: Associated Features - Medical conditions
- Excessive exercise levels
- Depressive symptoms
- Obsessive-compulsive features: related and not related to food
- Control, inflexible thinking
Bulimia Nervosa (BN): DSM-5 criteria: you don’t have to be underweight.
A. Recurrent episodes of binge eating
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain: vomiting,
laxatives, diuretics, animas.
C. Self-evaluation is unduly influenced by body shape and weight
At least one per week for three months. Severity is based on the number of compensatory
behaviors/week.
Binge Eating Episode Not continuous snacking.
An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time, an amount of food that is definitely larger than what
most individuals would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode
Triggers: Negative mood, dietary restraints, stressors (ex: beach), boredom.
BN: Associated Features
- Medical conditions: teeth, bathroom problems
- Normal weight – overweight range
- Rituals
- Rigid/absolute thinking
- Guilt, shame, embarrassment
BN vs. AN Binge-Eating/Purging Type
Differentiation
- Weight (AN: underweight)
- Frequency (BN: at least 1x/week; AN: recurrent in past three months)
- Binge-eating/ purging requirements (BN: both binging and purging; AN: one or both)
New Diagnosis in DSM-5:
Binge-eating disorder
Binge-Eating Disorder (B-ED)
A. Recurrent episodes of binge eating B. Binge-eating episodes associate with ≥ 3 of the following:
C. Distress regarding binge eating
D. Binge occurs on average at least 1x/week for 3months
E. No compensatory behaviors (no purging; different from BN)
Severity is based on the number of binge episodes per week.
B-ED: Associated Features
- Occurs in normal-weight/overweight and obese individuals
- Distinct from obesity (most people with obesity do not have B-ED; comorbid conditions
though, more stress? greater distress?)
DSM-5 “Other” Categories
- Other Specified Feeding or Eating Disorder: specifies why they did not meet criteria.
- Unspecified Feeding or Eating Disorder
Etiology: causes of EDs
Biological
- Genetics (~50% heritability estimates)
- Neurotransmitters (serotonin)
Psychological
- Personality traits & individual differences
o AN & BM: Perfectionism, obsessiveness, lack of awareness of internal feelings,
negative self-view, low self-esteem, identity problems, poor body image, depressive
moods.
o For BN in particular: impulsivity
Social/cultural
- Social expectations of beauty & thinness: attempt to feel good
- Family factors: parents can pass on pathological values/beliefs
Three P’s:
- Predisposing: biological, psychological & social/cultural factors all interact to form the core
psychopathology. Ex: core dissatisfaction with shape and weight
- Precipitating: triggers/events. Ex: puberty, death of a loved one
- Perpetuating: physical and psychological symptoms that serve to maintain the disorder. Ex:
starvation symptoms, isolation.
Transdiagnostic Cognitive-Behavioural Formulation: maintains ANY ED.
The core psychopathology is what needs to be changed.
You can shift between EDs, not exactly separate disorders.
Cognitive Behavioural Therapy: treatment for EDs
CBT initially developed for BN but not also used for AN.
50% of individuals recover fully after completion of CBT.
- Establish control over eating
- Modify beliefs about body shape and weight
- Additional targets:
o Perfectionism
o Low self-esteem
o Mood-intolerance
o Interpersonal difficulties
Break the continuing cycle.
1. Psycho-education. Restricting = more likely to binge.
2. Identify beliefs and start to modify them. Challenge beliefs.
Chapter 11 Substance-Related and Addictive Disorders -Substance: any natural or made substance? With psychoactive affects
-Directly activates the brain reward system; reinforcement of behaviors and production of memories.
- They produce pleasure-high feelings.
-Social context is very important to look at even though the biological effects are the same.
Frequency of Substance Use
2011 Canadian Alcohol and Drug Use Monitoring Survey (N=10,076; 12 month prevalence)
- Alcohol: 78%
- Cannabis: 9.1% (lifetime = 39.4%)
- Other illicit drug use (cocaine/crack, speed, hallucinogens, ecstasy, salvia,
methamphetamine/crystal meth): 9.4%
You can’t just look at the percentages to determine what is normal or abnormal.
Consider the impact on functioning, not just the prevalence.
Binge Drinking
Binge: four or more drinks for women, five or more drinks for men, in one occasion.
Canadian Campus Survey (2004)
6,282 university undergraduate students from 40 universities completed questionnaires
Binge-drinking is associated with the social context:
- Living arrangements: more often drink more if not living with parents
- Parties/bars
- The larger the group of people, the more you drink
- People drink two times as much when also drinking energy drinks.
Consequences of binge drinking:
- Accidents/falls
- Mood, memory problems
- Permanent brain damage
- Violent/aggressive behavior
- Poor judgment
- Impulsive behavior
- Stop breathing
- Cardiac arrest
- Choke on vomit
- Death: Overdose.
DSM-5: Substance-Related Disorders
The DSM-IV has substance use (milder) and substance dependence (severe/addiction) as separate
categories. The DSM-V combined them.
There is no caffeine use disorder.
Substance Use Disorders
- Classes: alcohol, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotic/anxiolytics,
stimulants, tobacco, other
Substance-Induced Disorders (these are states, not chronic conditions)
- Intoxication: can be diagnosed with or without substance use disorder.
Unwanted/problematic behavior or psychological changes due to psychological effects of a
substance.
- Withdrawal: clinically significant distress due to the cessation (stopping) substance use. It
must cause significant distress or impairment.
- Other substance/medication-induced mental disorders: (psychotic disorders)
Substance Use Disorders (SUDs) o Pathological pattern of behavior related to use of a substance.
o Cognitive, behavioral, and physiological symptoms indicating that the individual continues
using the substance despite significant substance-related problems
Four general categories of symptoms:
- Impaired control
- Social impairment
- Risky use
- Pharmacological criteria: (psychological)
o Severity rating
- Based on number of symptoms. (Mild, moderate or severe) Mild = 2-3 symptoms Moderate = 4-5 symptoms Severe = 6+ symptoms
- In DSM-IV, substance use was moderate, substance dependence was severe.
Alcohol Use Disorder
A problematic pattern of alcohol use leading to clinically significant impairment or distress, as
manifested by at least two of the following, within a 12-month period:
ANY of the 2 of the 11 symptoms.
Impaired control:
- Out of control about alcohol use
- Daily activities revolve around getting or drinking alcohol
- Urges
Social impairment:
- Alcohol impairs daily functioning.
- Not showing up to class/work
- Drinking in non-socially acceptable places
- Impacts relationships.
Risky use:
- Using alcohol when risky to do so.
- Drinking and driving
- Extreme sports
- Continued use when it’s known it’s dangerous
Pharmacological criteria:
- Tolerance: requiring larger doses to get the preferred effect; threshold increase.
- Withdrawal: clinically significant distress due to the cessation (stopping) substance use. It must
cause significant distress or impairment. Or drinking to avoid withdrawal (hangover).
Prevalence of Alcohol Use Disorder
- Onset: late adolescence – early adulthood. Peaks then gradually decrease (linear) with age
- Men 2x more than women
- Developmentally limited condition that tends to remit with age
o Generation differences?
o Sensation-seeking/impulsivity when younger?
o Developmental maturational processes: “maturing out” process.
Non-Substance-Related Disorders: Gambling Disorder
New addition to DSM-V.
- Need 4 of 8 symptoms over a 12 month period
A. Persistent and recurrent problematic gambling behavior leading to clinically significant
impairment or distress, as indicated by the individual exhibiting 4 or more symptoms in a 12-
month period
B. The gambling behavior is not better explained by a manic episode
Increasing amounts of money gambled to achieve excitement, restless and irritable when stopping.
Pre-occupied with gambling, gamble when feeling down, and lie to cover up.
Purely behavioral. The activity is reinforcing rather than having addicting psychological responses.
Does this disorder fit with substance use disorders? Is it similar? Should it be a disorder?
Cognitive-Behavioral Theory: Not all substance use becomes a disorder.
- Maladaptive patterns of substance use learned from parents: role models, learning, starts at
an early age.
- Positive expectations about substance effects: beliefs about the appropriateness of drugs
are developed
- Reinforcing effects of substance use: makes you cooler, happier; believe alcohol with lower
anxiety; minimize negative effects; improve mood; decrease self-consciousness.
- Environmental support for use of the substance: people around you influence your attitudes
about drugs and alcohol; hanging out at bars.
Causes:
- Genetics explain 40-60% of variance (not everything, just an underlying biological
vulnerability).
- Learning
Beliefs and behavior influence one another.
Assessment
- Substance use (SCID-IV): semi-structured interview
o Quantity, frequency/duration, severity
- Other problems: Comorbidity. Mental health, health, family, legal problems.
- Motivation: How motivated is the individual to change? This says a lot about how treatment is
going to go.
- CBT functional analysis: Substance use patterns. Antecedents, triggers, associations,
consequences.
- Partner/family: roles in substance use. Do they use with them? Are they supportive?
Treatment Components
- Motivational Interviewing o Goal: to get clients to recognize they want to change instead of telling them they need
to. Help the client identify values and see that the substance won’t or doesn’t with the
values. o Technique: decisional balance. Identify pros + cons of drinking. Addressing the patient’s
ambivalence about changing.
- Cognitive-Behavioral strategies: o Skills training to change the individual’s environment to avoid high risk situations (going
to a bar). o Learning how to manage situations o Modifying unrealistic expectations of drug (only way to be happy) o Learning how to cope with cravings o Developing other ways to obtain positive reinforcers (other stress managers) o Learning how to refuse: assertive communication.
- Partner/family involvement: individuals are more likely to succeed when there’s involvement of
a social support system
- Self-help groups (e.g., AA): Large role for substance-use problems o Assess if a good candidate or not
Affiliative, problem solving with others, own support system isn’t there or not
enough of one.
- Relapse Prevention: o A lot of people do relapse o Identify and manage stressors that could lead to relapse o Individual taught to anticipate and deal with relapses o Deal with catastrophization – if you have one drink you don’t need to have eight. o Moderation is okay for individuals with mild to moderate alcohol problems. Reducing
the harm is sufficient, it’s not necessary to completely cut it out.
- Moderation vs. abstinence?
- Pharmacotherapy: E.g., antibuse: makes you violently ill if you drink. Methadone.
Treatment Success
Chapter 12 Personality Disorders Traits: characteristics of an individual that can be observed or measured, has cross-situational
consistency, and endurance over time. The combined expression of many traits defines one’s
personality.
Traits are maladaptive in PDs.
- Excessive
- Inappropriate
- Cause distress/impairment, especially in relationships.
- PDs are all based on personality types. This is a problem because there’s low reliability in
diagnosis.
- Treatment is difficult because these individuals often have difficulty with relationships.
- A longstanding pattern of behaviors, thoughts, and feelings that is highly maladaptive to the
individual or people around them (narcissistic and antisocial don’t experience much personal
impairment, mostly those around them experience it)
- Culture is important
- No clear beginning or end
DSM-5 Definition of Personality Disorder
An enduring patter of inner experience and behavior that deviates markedly from the expectations of
the individual’s culture,
a. is pervasive and inflexible (seen across many situations),
b. has an onset in adolescence or early adulthood,
c. is stable over time, and
d. leads to distress or impairment
Normal, Healthy Personality
DSM does not define healthy personality.
There is no consensus on an omnibus definition of optimal or even “normal” personality. Many
specific personality traits have been identified that are associated with greater happiness, life
satisfaction, productivity and well-being. A few examples are:
- Sociability or extraversion
- Optimism
- Positive affectivity
- Autonomy, self-control
- Independence
- Learned resourcefulness
- Emotional stability
More components of a healthy personality:
- Sense of playfulness
- Transcendence/spirituality
- Work ethic/desire to pursue meaningful work
- More positive than negative emotion
- A desire to enhance social relationships
DSM-5 General Personality Disorder
A. Enduring pattern of inner experience & behavior that deviates markedly from
expectations of one’s culture, and deviation manifested in 2 or more of the
following areas: 1. Cognition (perceiving & interpreting self, others, events)
2. Affectivity (range, intensity, lability, appropriateness of emotional
response)
3. Interpersonal functioning
4. Impulsive control
B. Enduring pattern is inflexible & pervasive
C. Enduring pattern leads to sign. distress or impairment
D. Pattern is stable and has long duration: traits traced to adolescence/early
adulthood. If client is under 18, symptoms must be present for over a year.
Antisocial must be diagnosed after 18.
E. Pattern not better explained by another disorder or substance
The Problem with PDs - Strong evidence PDs are dimensional, not categorical
- Low temporal stability: test-retest reliability ranges from 0.11-0.57
- High incidence of comorbid PDs
- Culture and gender bias: dependent PD is more common/likely for women; antisocial and
narcissistic PD are more common/likely for men.
- Measurement & assessment problems: PDs tend to be egosytonic: embedded in personality.
Not aware of problem, no personal distress. Individuals often lack insight so their response is
invalid.
- Overuse of “not otherwise specified” criteria: third most common PD.
- Personality structure is not completely different, just more extreme.
DSM-5 Dimensional PDs: Alternative, Provisional Approach
A. Disturbance in self and interpersonal functioning as defined by:
1. Self-identity (clear boundaries, stable self-esteem, accuracy of self-appraisal) & self-
direction (pursuit of coherent & meaningful life goals, self-reflect productively, etc)
2. Empathy (understanding & appreciation of others’ experience, tolerance of differing
perspectives, etc) & intimacy (desire & capacity for closeness, deep & enduring
connections with others, etc.)
B. Presence of pathological personality traits (negative affectivity, detachment, antagonism,
disinhibition & psychoticism)
C. Pervasiveness & stabilty
D. Not better accounted by other conditions
Narcissistic Personality Disorder
Marey & Skodol (2013) used both categorical and dimensional models on 337 people, found
considerable correspondence between the two, arrived at the same PD label.
Theories of Personality Disorders - Genetic Factors- family studies suggest many PDs run in families
- Developmental Factors- traumatic or stressful past events; disruptions; too much or too little
nurturance: negative emotionality and sociability, disruptions/traumas in early life, low
affection, punishment, early abuse
- Cognitive Factors- develop unique set of beliefs about the world, self & others that leads to
dysfunctional compensatory strategies
Adult PDs originate early in life and may be pre-programmed at the genetic level. Roots in infant
temperament.
Cognitive Theory of PDs
Traits have an adaptive, evolutionary value, but in PDs they become excessive, rigid, inappropriate, and
maladaptive.
Young: Schema focused therapy
Masha Lenehan: dialectical behavior therapy.
Basic Elements of PD Treatment
- Biological & psychological factors must be considered
- Determine patient’s treatment readiness
- Individualized treatment approach
- Multiple intervention strategies for less willing
- Goal to shift from maladaptive personality functioning to adaptive personality functioning
- Flexible, rigid treatment is not effective
- Patient’s readiness, willingness and commitment to treatment are very important
- Idiographic approach: individually tailored, case-formulation driven
- Pace of change is slow. Therapy is long because changing a personality takes several months to
many years.
Therapies for Personality Disorders Therapy for the borderline personality: Weak ego, goal of treatment is to strengthen it.
- Object-relations psychotherapy
- Dialectical behaviour therapy (DBT)
o Teach individuals with BPD to modulate and control their extreme emotionality and
behaviours
o Teach them to tolerate feeling distressed
o Help them learn to trust their own thoughts and emotion
- Medication is often prescribed but effectiveness is questionable.
- SSRIs increase suicide risk, esp. for BPD because increased impulsivity
- Antipsychotics and mood stabilizers are sometimes used
Chapter 19 Forensic Psychology (mental disorder and the law) Criminal Offence
Two elements of a crime:
- actus reus (the act; break into a house and steal)
- mens rea (the intention; on purpose)
Mental disorder can “negate” mens rea (doesn’t eliminate the act)
Criminal Responsibility
“insanity defense”
This defense is rarely used and if often unsuccessful.
Not Criminally Responsible on Account of a Mental Disorder (NCRMD)
Criminal Code of Canada (Section 16):
“No person is criminally responsible for an act committed or an omission made while suffering
from a mental disorder that rendered the person incapable of appreciating the nature and
quality of the act or omission or of knowing that it was wrong.”
- NGRI until 1991 (not guilty by reason of insanity), automatically got sent to a psychiatric
facility for an indefinite (open ended) amount of time (PROBLEMS: sometimes longer than a
prison sentence for that crime, sometimes people didn’t get the treatment they needed)
- In 1991: Case of Regina vs. Swain. Supreme court ruled indeterminate detention infringed
on rights.
Introduced
- Introduced NCRMD.
o Replaced term of “insanity” with “mental disorder”
o The defendant now is “not responsible” instead of “not guilty”
o It included persons incapable of knowing their actions are legally or morally wrong
Criteria for Involuntary Commitment (also called Civil Commitment)
-Taking away freedom but they have not committed a crime
-The majority of people in psychiatric hospitals went voluntarily (the individual agrees to be
hospitalized)
The person must:
- be mentally ill (diagnosis)
- be in need of treatment
- pose danger or threat to the safety of himself or herself or others (or unable to care for
himself or herself)
Rationale:
- The government has a humanitarian responsibility to care for its weaker members
- The state (police) has a duty to protect public safety, health & welfare.
Civil commitment is provincial (procedures differ across provinces)
Two types of commitment:
- Emergency: temporal confinement for 2-3 days (usually)
- Formal: involuntary commitment for a longer amount of time. May be court ordered
or from a hearing. There must be convincing evidence and the case must be
reviewed regularly (every 3 months).
Community Mental Health Order: can be given a choice of following a treatment plan and live in
the community or being sent to the hospital. This is good for schizophrenia because they stop
taking their medications because of side effects or because they think they don’t need them.
Confidentiality and Duty to Protect
Tarasoff vs. Regents of the University of California et al. (1976)
1) They should have recognized dangerousness
2) They failed to notify the victim
Not liable of failure to commit Potter (it wasn’t their duty), but liable for not telling Tarasoff.
You are required to violate confidentiality to protect the client or society, if they intend to harm
themselves or others.
Clinician Duties to Clients & Society
Four Primary Principles:
1. Respect for the dignity of the individual
2. Responsible caring: minimize risk
3. Integrity in the relationship
4. Responsibility to society
Reporting Process (in NB)
(Very often they are frivolous allegations)
Psychologists are governed by:
- Criminal & common law
- Canadian Code of Ethics for Psychologists
- By-laws of College of Psychologists of New Brunswick (CPNB)
Greater focus on qualification and competence – broadly defined)