Abnormal Psychology Exam 1 ReviewChapter 4: Anxiety DisordersAnxiety, Fear, Panic – Some Definitions

- Anxietyo Mood state characterized by marked negative affect and bodily symptoms of

tension in which a person apprehensively anticipates future danger or misfortune.

o The future-oriented mood stateo Anxiety may involve feelings, behaviors, and physiological responses.

- You are thinking about the test you have next week, and you are really concerned because you have not done well on past tests. You notice that your heart is beating a little faster than usual. You are most likely experiencing anxiety.

- Fearo Emotion of an immediate alarm reaction to present danger or life threatening

emergencies.o The present-oriented mood stateo Involves abrupt activation of the sympathetic nervous system

“Fight or Flight”o Strong avoidance/ escapist tendencieso Marked negative affect

- Imagine that you are driving your car when someone in another car suddenly pulls out in front of you. It seems that you are going to crash into the other car, but you are able to brake and prevent an accident. As you continue driving, you notice that your heart is racing, your breathing is more rapid than usual, and you feel a little dizzy. What is the name of this experience? – Fight or Flight

- Panico Sudden, overwhelming fright or terroro Panic attack – Abrupt experience of intense fear or discomfort accompanied

by several physical symptoms, such as dizziness or heart palpitations.o Three basic types of panic as described in DSM-IV-TR:

Situationally bound (cued) Unexpected (uncued) Situationally predisposed Unexpected and Situationally predisposed attacks are important in

panic disorders. Situationally bound attacks are more common in specific phobias or social phobias.

- Mark always has panic attacks when he is in elevators but never in other circumstances. His panic attacks are known as Situationally bound.

- Characteristics of Anxiety Disorderso Pervasive and persistent symptoms of anxiety and/or fear

o Involves excessive avoidance and escapeo Cause clinically significant distress and impairment

- Biological Contributions to Anxiety and Panico Genetic vulnerability

Contributions from collections of genes in several areas on chromosomes make us vulnerable when the right psychological and social factors are in place.

o Anxiety and Brain circuits Depleted levels of gamma-aminobutyric acid (GABA)

o Limbic (amygdala) and the septal-hippocampal systems – area in the brain most often associated with anxiety

o Behavioral Inhibition System (BIS) When activated by signals from the brain stem of unexpected events,

our tendency is to inhibit activity, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present

- What biological system connects the septal and hippocampal area of the limbic system to the cortex, and when activated, causes a person to feel anxious and to apprehensively evaluate a situation to determine whether danger is present? – Behavioral Inhibition System

o Fight/Flight System (FF) Immediate alarm-and-escape response to fear resembling human panic

- Psychological Contributions to Anxiety and Fearo Integrated Model

Early childhood – experiences with uncontrollability and unpredictability A sense of control (or lack of it) that develops from these early

experiences is the psychological factor that makes us more or less vulnerable to anxiety in later life.

o Social Contributions Stressful life events in later life trigger vulnerabilities

- An Integrated Modelo Integrative view – triple vulnerability model

Generalized biological vulnerability Generalized psychological vulnerability Specific psychological vulnerability

Figure 4.2 The Three Vulnerabilities that Contribute to the Development of Anxiety Disorders. If Individuals possess all Three, the Odds are Greatly Increased that they will develop an Anxiety Disorder after Experiencing a Stressful Situation.

- Common processes: the problem of comorbidityo Comorbidity is common across the anxiety disorderso Major depression is the most common secondary diagnosiso About half the patients have two or more secondary diagnoseso Comorbidity suggests:

Common Factors A relation between anxiety and depression

The Anxiety Disorders: An Overviewo Generalized anxiety disorder (GAD)o Panic disorder with and without agoraphobiao Specific Phobiaso Social Phobia (SAD)o Posttraumatic Stress Disorder (PTSD)o Obsessive-compulsive Disorder (OCD)

- Generalized Anxiety Disorder (GAD)o Anxiety disorder characterized by intense, uncontrollable, unfocused, chronic,

and continuous worry that is distressing and unproductive, accompanied by physical symptoms of tenseness, irritability, and restlessness.

o Excessive uncontrollable anxious apprehension and worry – makes one irritableo Coupled with strong, persistent anxietyo Persists for six months of moreo Somatic symptoms differ from panic (e.g., muscle tension)o Epidemiology

Affects about 3.1% of the general population Onset is often insidious, beginning in the early adulthood Very prevalent among the elderly Tends to run in families

o Female/Male Ratio Females outnumber males approximately 2:1

Differences between disorders where gender makes a difference and those in which it doesn’t make any difference

People KNOW they are worrying too much about inconsequential stuff Sometimes people worry about things that don’t matter to keep

from worrying about things that do matter In mild or moderate disorder, people go crazy in socially acceptable ways Women in our culture have more permission to be immobilized by

fear, to not do things because they are afraid Guys have more permission to drink intoxicants. So, guys drink too much and women worry too much. Usually, when there is a sex difference if

1. Disorder is mild or moderate so people have some maneuvering room

Usually , when there is NO sex difference if 1. Disorder is more severe: people have no room to bargain

Again: Specific phobias and panic disorders vs. OCD

- A man reports difficulty sleeping, distractibility, and stomachaches for the past six months. During this time, he has been worrying a lot about his mother's health, his daughter's difficulties in school, and his performance at work; he spends a lot of time worrying, and feels that he can't stop himself. What is the most likely diagnosis? – General Anxiety Disorder

o Generalized Anxiety Disorder: Associated Features Associated Features:

People with GAD have been called “autonomic restrictors” when compared to those with other anxiety disorders.

Only difference of those with GAD from normal controls is muscle tension under specific measurement conditions.

Fail to process emotional components of thoughts and images MAYBE

- What kind of cognitive bias do people with GAD have, compared to people who do not have GAD? – They automatically and quickly focus their attention on potential threats.

o Major Problem with the Field: Correlation Does Not Mean Causation! We can’t do experiments: that would require us giving some people GAD

and not giving it to others. So: people who do or do not fit the stereotype for GAD or whatever

disorder are being compared. People, who differ in two ways, differ in 3 ways, 5 ways, in fact millions

of ways! Any one of those unmeasured ways can cause the relationship you are

looking at.

Science searches for answers (at least in part) by eliminating competing hypotheses.

But it is impossible to eliminate the hypothesis that some other unmeasured variables caused the two variables to a correlational study to have a relationship with each other.

We can’t make causal inferences based on correlation because we can’t eliminate the hypothesis that one of these other (unstudied, and often not feasible to study) factors is the causal agent.

o We must know what will directly cause changeo Treatment of GAD: Generally weak

Benzodiazepines – often prescribed Antidepressants Psychological interventions – cognitive-behavioral therapy Meditation therapy Combined treatments – acute vs. long-term outcomes

- According to the text, benzodiazepines are the most frequently prescribed drugs for GAD.

Figure 4.3 An Integrative Model of GAD

- Panic Disorder With and Without Agoraphobiao Overview and defining features

Panic Disorder with Agoraphobia (PDA) – Fear and avoidance of situations the person believes might induce a dreaded panic attack.

Agoraphobia – Anxiety about being in places or situations from which escape might be difficult.

Panic Disorder without Agoraphobia (PD) – Panic attacks experienced without development of agoraphobia.

Experiences of unexpected panic attack (i.e., a false alarm) Develop anxiety, worry, or fear about another attack Many develop agoraphobia

- The part of the brain that is believed to be responsible for panic disorder is the amygdala.

o Facts and Statistics Affects about 2.7% of the general population Onset is often acute, mean onset between 20 and 24 years of age 66% of individuals with agoraphobia are female

o Cultural Influences Panic disorders exist worldwide, although its expression may vary from

place to place. It is more accepted for women to report fear and to avoid

numerous situations

- Why are the majority of people who suffer from agoraphobia women? -- It is more accepted for women to report fear and to avoid numerous situations

o Causes Triple Vulnerability Model We all inherit—some more than others—a vulnerability to stress, which is

a tendency to be generally neurobiologically over-reactive to the events of daily life (generalized biological vulnerability).

But some people are also more likely than others to have an emergency alarm reaction (unexpected panic attack) when confronted with stress-producing events.

8% to 12% has occasional attacks vulnerabilityo Associated Features

Nocturnal panic attacks – 60% panic during deep non-REM sleep Interoceptive avoidance – avoidance of internal physical sensations

- Avoidance of internal physical sensations is called Interoceptive avoidance.

o Medication Treatment Target serotonergic, noradrenergic, and GABA systems SSRIs (e.g., Prozac and Paxil) are preferred drugs Relapse rates are high following medication discontinuation

o Psychological and Combined Treatments

Cognitive-behavioral therapies are highly effective No evidence that combined treatments produces better outcome Best long-term outcome is with cognitive-behavioral therapy alone Panic Control Treatment (PCT) – Cognitive-behavioral treatment for

panic attacks, involving gradual exposure to feared somatic sensations and modification of perceptions and attitudes about them.

Combined psychological and drug treatments Innovative approaches

Psychological (CBT) treatment followed by drug treatments D-cycloserine (DCS)

- A major study sponsored by the National Institutes of Mental Health examined various treatments for panic disorder. Which of the following was found to be most effective long term (six months after treatment ended)? – Cognitive-Behavioral Treatment alone

Figure 4.6 Responders Based on the Panic Disorder Severity Scale Average Item Score after Acute and After Maintenance Conditions

- Specific Phobias: An Overviewo Overview and Defining Features

Specific Phobia: Unreasonable fear of a specific object or situation that markedly interferes with daily life functioning.

Extreme irrational fear of a specific object or situation Person will go to great lengths to avoid phobic objects Most recognize that the fear and avoidance are unreasonable Markedly interferes with one’s ability to function

o Facts and Statistics Females are again over-represented.

Consistent around the world Affects about 12.5% of the population

Phobias tend to run a chronic course

Figure 4.7 A Model of the Various Ways a Specific Phobia may Develop

o Subtypes of Specific Phobia Blood-injury-injection phobia – unusual vasovagal response Situational phobia – trains, planes, automobiles, closed spaces Natural environmental phobia – natural events (e.g., heights, storms) Animal phobia – animals and insects Separation anxiety – seen in children – Excessive, enduring fear in some

children that harm will come to them or their parents while they are apart.

- When exposed to the object of their phobia, most people with specific phobia show an increase in heart rate and blood pressure. In contrast, which subtype involves decreased heart rate and blood pressure, and possible fainting? – Blood-Injection -Injury

- A child with separation anxiety disorder has the fear that something bad will happen to him or his parents.

o Causes of Phobias Direct experience Biological and evolutionary vulnerability Traumatic conditioning, prepared tendency, event will happen again

o Psychological Treatments of Specific Phobias Cognitive-behavioral therapies are highly effective – exposure

Require structured and consistent exposure-based exercise under therapeutic supervision

- Which technique appears to be the most effective treatment for phobias? – structured and consistent exposure to the feared stimulus under therapeutic supervision

o Cultural Factors The prevalence of specific phobias varies from one culture to another.

- A woman has always disliked clowns. However, she has very few encounters with them. When she does, she feels uncomfortable. She makes no effort to approach them, but she also makes no effort to avoid them. Which of the following best applies to this woman?

- Social Phobia: An Overviewo Overview and Defining Features

Social Phobia – Extreme, enduring, irrational fear and avoidance of social or performance situations.

Also known as Social Anxiety Disorder (SAD) Extreme and irrational fear in social/performance situations Markedly interferes with one’s ability to function Often avoid social situations or endure them with great distress Generalized subtype – affects many social situations

o Facts and Statistics Affects about 12.1% of the general population, 6.8% in 1-year period Prevalence is slightly greater in females than males Second only to specific phobia in the anxiety disorders Onset is usually during adolescence Peak age of onset at about 13 years

Figure 4.8 A Model of the Various Ways a Social Phobia May Develop

o Causes Biological and evolutionary vulnerability Similar learning pathways as specific phobias Three pathways to social phobias:

Generalized biological vulnerability to develop anxiety Biological tendency to be socially inhibited Both

The existence of a generalized psychological vulnerability would increase an individual's vulnerability.

o Psychological Treatment Cognitive-behavioral treatment (CBT) Cognitive-behavioral group treatment (CBGT) Cognitive-behavioral therapies are highly effective

o Medication Treatment Tricyclic antidepressants and monoamine oxidase inhibitors more

effective than placebo in the treatment of severe social anxiety. SSRIs Paxil, Zoloft, and Effexer – are FDA approved Relapse rates are high following medication discontinuation

- A man who persistently worries about being humiliated or embarrassed when talking to women is showing signs of social phobia.

- According to the text, three pathways to social phobia are possible. Which of the following is NOT one of these? – generalized psychological vulnerability to believing that stressful events are potentially uncontrollable.

- Which of the following drugs has NOT been shown to be effective (compared to placebo) in the treatment of social phobia? – beta-blockers.

- Posttraumatic Stress Disorder (PTSD): An Overviewo Overview and Defining Features

Posttraumatic Stress Disorder – Enduring, distressing emotional disorder that follows exposure to a severe helplessness- or fear inducing threat.

The victim re-experiences the trauma, avoids stimuli associated with it, and develops a numbing of responsiveness and an increased vigilance and arousal.

Main etiologic characteristics – trauma exposure and response Re-experiencing (e.g., memories, nightmares, flashbacks) Avoidance Emotional numbing and interpersonal problems Markedly interferes with one’s ability to function PTSD diagnosis – only after one month post-trauma

- Which of the following must occur in order for a person to develop posttraumatic stress disorder? – experiencing a traumatic event

o Statistics Combat and sexual assault are the most common traumas.

Soldiers face combat again and again Rape victims think about what happened to them. Relive it again

and again PTSD is basically a disorder based on adrenalin. General rule: Too much adrenalin for too long a period and you wind up

with PTSDo Subtypes and Associated Features of PTSD

Acute – may be diagnosed one-three months post trauma Chronic – diagnosed after three months post trauma Delayed onset – onset six months or more post trauma Acute Stress Disorder – PTSD immediately post trauma

- How is acute stress disorder (ASD) different from posttraumatic stress disorder (PTSD)? – ASD occurs right after a traumatic event, and PTSD occurs one month to many years later.

o Causes of PTSD Intensity of the trauma and one’s reaction to it (i.e., true alarm)

Learn alarms – direct conditioning and observational learning Biological vulnerability Uncontrollability and unpredictability

Figure 4.10 A Model of the Causes of PTSD

o Treatment Psychological Treatments

Catharsis – reliving emotional trauma to relieve emotional suffering

Cognitive-behavioral therapies (CBT) are highly effective CBT may include graduate or massed (e.g., flooding) imaginal

exposureo Content of the trauma and the emotions associated with it

are worked through systematically Aim of CBT for PTSD

o Work with the victim to develop a narrative of the traumatic experience that is then reviewed extensively in therapy.

o Cognitive therapy to correct negative assumptions about the trauma, such as blaming oneself in some ways, feeling guilty, or both, is often part of treatment

Any exposure technique will do: EMDR – Eye Movement Desensitization Reprocessing

o Psychological method that helps people to quickly process and heal from the emotional distress that lodges in their minds following traumatic incidents

o EMDR to be highly effective in treating the incapacitating memories and intense emotions associated with psychological trauma

- Researchers have identified protective factors that help prevent the development of PTSD after a person experiences a traumatic event. All of the following are protective factors EXCEPT becoming angry and placing blame on others.

- According to the text, psychological treatment of PTSD typically involves imaginal exposure to the trauma.

- Obsessive-Compulsive Disorder (OCD): An Overviewo Overview and Defining Features

Obsessive-Compulsive Disorder (OCD) – Anxiety disorder involving unwanted, persistent, intrusive thoughts and impulses, as well as repetitive actions intended to suppress them.

Vicious cycle of obsessions and compulsions Cleaning and washing or checking rituals are common. Tic disorder and OCD

Characterized by involuntary movement (sudden jerking of limbs, for example)

Hoarding Strong anxiety and distress about throwing anything away because

everything has either some potential use or sentimental value in their minds

o Statistics Affects about 1.6% of the general population Most with OCD are female Onset is typically in early adolescents or young adulthood OCD tends to be chronic

o Causes of OCD Parallels the other anxiety disorders Early life experiences Learning that some thoughts are dangerous/unacceptable Thought-action fusion – the thought is similar to the action Both generalized biological and psychological vulnerabilities must be

present to develop OCD

Figure 4.11 A Model of the Causes of Obsessive-Compulsive Disorder

o OCD: Treatment Medication treatment

Most effective seem to be those that specifically inhibit the reuptake of serotonin

Clomipramine and other SSRIs – benefits up to 60% of patients Relapse is common with medication discontinuation Psychosurgery (cingulotomy) is used in extreme cases

Psychological treatment Cognitive-behavioral therapy is most effective CBT involves exposure and response prevention Combining CBT with medication – no better than CBT alone Exposure and ritual prevention (ERP) – more effective than drugs

o A process whereby the rituals are actively prevented and the patient is systematically and gradually exposed to the feared thoughts or situations.

- Julie constantly worries that her house will burn down if she does not unplug and check all of her electrical appliances before she leaves the house. She has developed a routine of unplugging and checking that takes her about 1 hour to complete before she can leave home. After performing this routine, she feels a little less anxious, although her anxiety quickly returns after she leaves. Even though Julie recognizes that her actions are

excessive, she feels like she has no control over these behaviors. Based on these symptoms, what problem does Julie seem to have? – obsessive-compulsive disorder

- Connor believes that he must pray every time he thinks a bad thought about his mother or father. This is known as thought-action fusion.

- Which of the following is NOT true about treatment for OCD? -- The type of medication typically used to treat OCD is a psychostimulant.

- Summary of the Anxiety Disorderso Most common forms of psychopathologyo From a normal to a disordered experience of anxiety and fear

Triple vulnerabilities – bio-psycho-social Fear and anxiety – non-dangerous bodily or environmental cues Symptoms and avoidance – significant distress and impairment

o Psychological treatments are generally superior in the long-term outcome if they work beyond placebo effects

Similar treatments for some anxiety disorders Specific & agoraphobia, OCD, PTSD Does that mean that some anxiety-related disorders share common

processes? Differences in Gender Ratios

Chapter 5: Somatoform and Dissociative Disorders

Somatoform Disorders- Somatoform disorder – Pathological concern of individuals with the appearance or

functioning of their bodies, usually in the absence of any identifiable medical condition.- Dissociative disorder – Disorder in which individuals feel detached from themselves

or their surroundings and feel reality, experience, and identity may disintegrate.o Soma – meaning “body”

Preoccupation with health and/or body appearance and functioning Aside from hypochondriasis, no identifiable medical condition causing the

physical complaints. Hypochondriasis – Somatoform disorder involving severe anxiety

over belief in having a disease process without any evident physical cause.

This means you make the diagnosis of somatoform disorder by excluding all possible medical conditions.

Since we don’t know everything that can happen, can only exclude disorders you thought of

o Types of DSM-IV-TR Somatoform Disorders Hypochondriasis – Somatoform disorder involving severe anxiety over

belief in having a disease process without any evident physical evidence. Preoccupation with fears of having a serious disease despite

appropriate medical evaluation

Not a delusionary intensity and is not restricted to concern over physical appearance.

Clinically significant distress or impairment because of preoccupation

Duration of 6 months Somatization disorder ; old diagnosis = hysteria

Somatoform disorder involving extreme and long-lasting focus on multiple physical symptoms for which no medical cause is evident.

Conversion disorder ; old diagnosis = hysteria Physical malfunctioning, such as blindness or paralysis, suggesting

neurological impairment but with no organic pathology to account for it.

Pain disorder; old diagnosis = hysteria. Somatoform disorder featuring true pain but for which

psychological factors play an important role in onset, severity, or maintenance.

Pain disorder is unfortunately common Body dysmorphic disorder ; something different

Somatoform disorder featuring a disruptive preoccupation with some imagined defect in appearance (“imagined ugliness”).

o Hypochondriasis DB view is that they are taking minor meaningless sensations too seriously – Again

- Freud believed that unconscious emotional could be manifested in unexplained physical symptoms. This is known as conversion hysteria.

- Which of the following symptoms is most likely to occur in someone with hypochondriasis? – interpreting momentary flutters in the stomach as a sign of illness

- Experts agree that hypochondriasis is basically a disorder of cognition.

- The effectiveness of reassurance and education for treating hypochondriasis is surprising because people with hypochondriasis are not supposed to benefit from reassurance about their health.

o Clinical Description Physical complaints without a clear cause Severe anxiety about the possibility of having a serious disease – Doesn’t

this look like an anxiety disorder Strong disease conviction Medical reassurance does not seem to help

Patients with hypochondriasis are not supposed to benefit from reassurance about their health

Reassurances from numerous MDs that all is well and the individual is healthy have, at best, only a short term effect.

MD shopping; boutique medical practice

It isn’t long before patients are back in the office of another doctor on assumption that the previous doctor missed something.

o Compared with GAD Hypochondriasis looks like an anxiety disorder. Tough to distinguish

o Statistics Good prevalence data are lacking Unique to women, however, the Sex Ratio is actually closer to 50:50 Onset at any age Runs a chronic course

o Causes Cognitive perceptual distortions

Basically a disorder of cognition or perception with strong emotional contributions

Enhanced perceptual sensitivity to illness cues Also tend to interpret ambiguous stimuli as threatening

Familial history of illness Most similar disorder = GAD, more anxiety disorder than like other

somatoform disorder Three other factors:

Develop in the context of a stressful life event (e.g., death or illness)

Disproportionate incidence of disease in their family when they were children

o Carry strong memories of illness that could easily become the focus of anxiety

An important social and interpersonal influence may be operatingo “sick role” – benefits of being sick; receives increased

attention for being illo Treatment

We all know these don’t work well – at least add gatekeeper physician Gatekeeper Physician: A general term that refers to health plans

that attempt to control the cost and quality of care by coordinating medical and other health-related services.

Cognitive Behavioral Treatment (CBT) – Identify and Challenge illness-related misinterpretations

Provide more substantial and sensitive reassurance Mental health professionals devote more time to all concerns the

patient might have and attend more time to the “meaning” of the symptoms

Stress management and coping strategies Same type of drugs (antidepressants) are useful for anxiety and depression

- Somatization Disordero Clinical Description

Extended history of physical complaints before age 30

Substantial impairment in social or occupational functioning Concern about the symptoms, not what they might mean Symptoms become the patient’s identity No physical reason for the symptoms – this one is so obvious, people

miss it. People with only a few medically unexplained physical symptoms may

experience sufficient distress and impairment of functioning to be considered undifferentiating somatoform disorder.

Just a somatoform disorder with fewer than eight symptoms.

o Statistics Rare condition Onset usually in adolescence Mostly affects unmarried, low socioeconomic single (SES) women Runs a chronic course The rates are relatively uniform around the world for medically

unexplained physical symptoms, as is the sex ratio. When the problem is severe enough to meet criteria for disorder,

the sex ratio is approximately 2:1 female to male.

o Causes Familial history of illness Relation with antisocial personality disorder Weak behavioral inhibition system MISSED DIAGNOSIS OR MISDIAGNOSIS OF A

PHYSIOLOGICALLY BASED DISORDER

- Somatization disorder is strongly linked, through family and genetic studies, to antisocial personality disorder.

o Treatment Rob Woolfolk and Dr. Leslie Allen have pioneered the use of a form of

CBT with a little Gestalt and Mindfulness – modest, but positive, results Reduce the tendency to visit numerous medical specialists Assign “gatekeeper physician” Reduce supportive consequences of talk about physical symptoms

- Pain Disorderso Psychological factors play an important role in maintaining pain, particularly

anxiety focused on the experience of pain Judged to play primary role in the onset, severity, exacerbation, or

maintenance of the paino Comes in two types: Acute and Chronico Acute pain occurs when there is damage to the body that will either heal or kill

you. i.e., Bruising a limb and the pain of surgery are examples

Most important enemy is anxiety – treat anxiety with hypnosis, distraction & relaxation.

o An important feature of pain disorder is that pain is REAL and it HURTS, regardless of the cause.

o One reason that it is difficult to diagnose pain disorder is that the experience of pain usually involves some level of both physical and psychological factors.

- Pain disorder is characterized by anxiety focused on the experience of pain.

o Studies using hypnosis in hospitals for post-surgical pain and burns High efficacy for some patients against acute pain Reduced needs for analgesics (e.g., morphine) Get out of hospital faster Generally do better For surgery, hypnosis can be before, during or after surgery

Pain control usually after.o Outpatient care: Chronic Pain

Except for those who practice as part of a surgical staff or in the ER, psychologists usually see patients with chronic pain.

Pain disorder, by definition, involves chronic pain…pain with no end in sight

Sometimes there is a physical lesion that won’t heal causing the pain Often not.

o Pain: An unpleasant sensation strong enough to demand attention We are great at screening out sensations Notice the feeling of shoes on your feet, pants or skirt on your leg Where were they a minute ago?

You were hallucinating their absence. We are very good at screening out sensation

o We only pay attention to salient signals Strong signals demand attention For some chronic pain patients, the signal comes from a lesion that won’t

heal (e.g., bone disorder). For many, however, an initial painful stimulus has faded, but relatively

minor uncomfortable sensations are amplified in the brain into bad pain, sometimes even into agony.

o If you are in pain, chronically, it doesn’t matter where the pain comes from Pain amplified in the brain is no different, as best we know, from chronic

peripherally based pain. Can’t stop either one. Treatment involves getting people active again, distractions from the pain,

self-hypnosis and (often unsuccessful) medical procedureso Mindfulness Helps

To get past the amplifier and back to the original sensation, you have to pay attention to the part that hurts – much focused attention.

With chronic pain, you would have learned not to pay attention to that area, to keep your attention away from the pain.

Mindfulness trains your attention A central mindfulness meditation technique is to carefully watch

your breathingo Don’t change or control it, just watch it

We pay attention to what is important and screen out the rest.o Since you were a baby, you have learned to ignore your

breathing, it goes on by itself. If you can focus on the actual sensation, not the hurting, you can

get past the pain I can go away and leave you free of pain That’s a radical and serious departure from what the rest of the

field thinks

- Conversion Disorder: THE Classic Freudian Disordero Several of Freud’s best known case studies (e.g., Anna O., Dora) were studies of

conversion disordero Freud suggested that in a condition called conversion hysteria unexplained

physical symptoms indicated the conversion of unconscious emotional conflicts into a more acceptable form

o Freud believed the anxiety resulting from unconscious conflicts somehow was “converted” into physical symptoms to find expression.

o He saw intrapsychic conflicts redirecting energy into alternative channels and thus resulting in hysterical symptoms

For example, he had Anna O. desiring older men and unable to face her desires

Dora had a cough. Lengthy complex analysis later, cough got better.o Scientism and Freud

The theory was far more supported by Freud’s theories than the actual case history.

He framed his metaphors (often verified by both him and his students) in terms of 19th century hydraulics, commonly the way neurologists thought about nerves.

o 19th Century Physics and the Mind The hydraulic model gave his theories the patina of science.

But Freud was no scientist – he ignored objections and simply made his theories grander and more all encompassing

Science is a dialogue, the center of which is data and the responses of colleagues

Freud grew disciples, not colleagues. Saw all negative responses as hiding the truth.

o Clinical Description Physical malfunctioning, such as paralysis, blindness, or difficulty

speaking suggesting neurological impairment but with no organic pathology to account for it.

Lack physical or organic pathology Malfunctioning often involves sensory-motor areas Persons show “la belle indifference” (Freud’s classic formulation, but

must have been a style used by the Viennese upper middle and upper class women)

“La Belle Indifference” has not been seen since about 1940.o Statistics

Rare condition, with a chronic intermittent course Seen primarily in females Onset usually in adolescence Common in some cultural and/or religious groups

o Causes Freudian psychodynamic view is still popular Four basic processes in the development of conversion disorder

First, individual experiences a traumatic event – in Freud’s view, an unacceptable, unconscious conflict

Second, because the conflict and the resulting anxiety are unacceptable, the person represses the conflict, making it unconscious.

Third, the anxiety continues to increase and threatens to emerge into consciousness, and the person “converts” it into physical symptoms, thereby relieving the pressure of having to deal directly with the conflict

o This reduction of anxiety is considered to be the primary gain or reinforcing event that maintains the conversion symptom.

Fourth, the individual receives greatly increased attention and sympathy from loved ones and may also be allowed to avoid such attention or avoidance to the secondary gain, the secondarily reinforcing set of events.

Major mood disorders and severe environmental stress, especially sexual abuse, are common among children and adolescents with the conversion disorder of pseudo-seizures

No difference in distress over symptoms among patients with conversion disorder compared to patients with organic disease

o Munchausen Syndrome Munchausen Syndrome by proxy – deliberate actions directed towards

making a child sick Co-workers who create problems just so they can solve them later and take

credit for it. Malingering – Deliberate faking of a physical or psychological

disorder motivated by gain. Factitious disorders – Nonexistent physical or psychological disorder

deliberately faked for no apparent gain except, possibly, sympathy and attention.

- Mrs. Thompson brought her 4-year-old daughter, Carmen, to the emergency room stating that the child had been vomiting nonstop throughout the morning. Carmen's condition improved over the course of several days. On the day of her discharge from the hospital, a nurse walked in as Mrs. Thompson was giving Carmen a drink of floor cleaner. Mrs. Thompson's behavior is consistent with Munchausen syndrome by proxy.

o Treatment Similar to somatization disorder Core strategy is attending to the trauma Remove sources of secondary gain Reduce supportive consequences of talk about symptoms About 50% missed diagnoses

Hypnotherapists with doctoral degree get sent these patients Lengthy discussions with fellow hypnotherapists strongly suggest

that we refer many patients to more competent facilities and about 50% of those referred to us wind up being diagnosed with a physical disorder which, when fixed, gets rid of the problem.

It could be worse, and may have been. A study in the early 1960s in Ireland followed 20 patients formally

diagnosed with “hysteria”, that is, with having symptoms for which there was no physical basis.

Within two years, all but 2 of them were diagnosed with a physical disorder that accounted for the symptoms

Either the mind has yet undiscovered effect on the body, or we had 18 misdiagnoses.

- The symptoms of conversion disorder mimic neurological disorders.

- During the development of conversion disorder, the reduction in anxiety that occurs after the anxiety has been converted into physical symptoms is known as primary gain.

- Body Dysmorphic Disordero Clinical Description

Previously known as dysmorphophobia Preoccupation with imagined defect in appearance Often display ideas of reference for imagined defect Suicidal ideation and behavior are common

o Statistics More common than previously thought Seen equally in males and females Onset usually in early 20s Most remain single, and seek out plastic surgeons Usually runs a lifelong chronic course

o Causes Little is known – disorder tends to run in families

BDD is a somatoform disorder because its central feature is a psychological preoccupation with somatic (physical) issues.

Shares similarities with obsessive-compulsive disorder. People with BDD complain of persistent, intrusive, and horrible

thoughts about their appearance, and they engage in such compulsive behaviors as repeatedly looking in mirrors to check their physical features.

BDD and OCD also have approximately the same age of onset and run the same course

o Treatment Treatment parallels that for obsessive compulsive disorder Medications (i.e., SSRIs) that work for OCD provide some relief Exposure and response prevention is also helpful Plastic surgery is often unhelpful

- Why is body dysmorphic disorder (BDD) classified as a somatoform disorder? – Its central feature is a preoccupation with somatic issues.

- Second BIG Problem: Diagnosis By Exclusiono Diagnosis By Exclusion – A disease or clinical nosology that is rare or

unexpected based on the patient’s details and often unresponsive to therapy, the diagnosis of which is seriously considered only when all other possible — potentially treatable condition — have been completely excluded

o Diagnosis of “hysterical” disorders, conversions, somatization and pain disorder requires physicians to conclude there is no physical basis for problems

o This means the MDs have excluded all other possible diagnoseso But there is no “Dr. House” in most real medical practices.

- Jason believes that his nose is unusually large, ugly, and out of proportion to his face (objective observers would say that his nose is average). When he sees or talks to someone, Jason believes that the other person is looking only at his nose, thinking about how huge and ugly it is. When he is in any public setting, Jason is constantly worrying about others looking at his nose. He does not have any other social concerns. Nonetheless, Jason avoids social situations as much as possible. These problems cause significant impairment in Jason's life. Which of the following best describes Jason's symptoms? – body dysmorphic disorder

- Dissociative Disorders: An Overviewo Overview

Involve severe alterations or detachments Affect identity, memory, or consciousness More serious one = lesion in memory

o 5 types of DSM-IV-TR dissociative disorders Depersonalization Disorder Dissociative Amnesia

Dissociative Fugue Dissociative Trance Disorder Dissociative Identity Disorder

o Depersonalization and Derealization: Meditation, religious rituals, a little dope, unlike the others, no memory lesion

Depersonalization – distortion in perception of reality Derealization – losing a sense of the external world Not abnormal for people in their teens or those experimenting with drugs

or altered states of consciousness Normal consequence of meditation for many Happens during religious ceremonies globally fairly routinely, with or

without the effects of drugs/hallucinogens

- Losing your sense of the reality of the external world is called derealization.

o Depersonalization Disorder Overview and Defining Features

Dissociative disorder in which feelings of depersonalization are so severe they dominate the individual's life and prevent normal functioning.

Severe and frightening feelings of unreality and detachment Feeling dominate and interfere with life functioning

o Primary problem involves depersonalization and derealization

The diagnosis of depersonalization disorder is quite rare and only applied when the experience of depersonalization interferes with normal functioning

Facts and Statistics High comorbidity with anxiety and mood disorders Onset is typically around age 16 Usually runs a lifelong chronic course – if taken seriously

Causes Is it just taking relatively normal experiences too seriously?

o Alternatively, as in panic disorder, are the experiences of those whose lives are adversely affected more serious/frightening and so on.

o Cognitive deficits in attention, short-term memory, spatial reasoning

o Deficits related to tunnel vision and mind emptinesso Such people are easily distracted

Treatment Little is known, but extinction might work here You could create the experiences with hypnosis or use other

methods

o Experience it, then live through it, thus demonstrating that there is nothing to be afraid of

Remember treatment for panic attacks: the stubbed toe approach + panic control treatment

- Studies have shown that individuals with depersonalization disorder have cognitive deficits in all of the following areas EXCEPT general intelligence.

o Dissociative Amnesia Most psychopathology can be understood as a response to stress combined

with social norms and biological vulnerability Name = “dissociative” disorders partially a matter of history and politics Problem not necessarily involved with splitting of consciousness

When real, such problems are really rare Dissociative amnesia – Dissociative disorder featuring the inability to

recall personal information; usually of a stressful or traumatic nature. Includes several forms of psychogenic memory loss Generalized vs. localized or selective type

o Generalized amnesia – Loss of memory of all personal information, including identity.

o Localized or Selective amnesia – Memory loss limited to specific times and events, particularly traumatic events.

o Dissociative Fugue: An Overview Overview

Dissociative disorder featuring sudden, unexpected travel away from home, along with an inability to recall the past, sometimes with assumption of a new identity.

Related to Dissociative Amnesia Take off and find themselves in a new place Leaving the “old place” usually a good idea as there are often

severe penalties involved in not leaving Unable to remember past Unable to remember how they arrived at new location Often assume a new identity

Statistics Usually begin in adulthood Show rapid onset and dissipation Occurs most often in females An apparent distinct dissociative disorder not found in Western

cultures is called amok. Causes

Little is known, but usually good idea to get lost for awhile Trauma and stress can serve as triggers

Treatment Most get better without treatment

Most remember what they have forgotten

- The disorder called amok illustrates the fact that mental illnesses are culturally defined.

o Dissociative Trance Disorder: An Overview Altered state of consciousness in which people firmly believe they are

possessed by spirits; considered a disorder only where there is distress and dysfunction.

Clinical Description Symptoms resemble other dissociative disorders Dissociative symptoms and sudden changes in personality Changes often attributed to possession by a spirit Presentation varies across cultures

Facts and Statistics More common in females than males

Causes Often attributable to a life stressor or trauma

Treatment Little is known Usually acceptable part of culture or specific subculture

o If it ain’t broke, don’t fix it

o Dissociative Identity Disorder (DID): An Overview Disorder in which as many as 100 personalities or fragments of

personalities coexist within one body and mind. Clinical Description

Formally known as multiple personality disorder Defining feature is dissociation of personality Adoption of several new identities (as many as 100) Identities display unique behaviors, voice, and posture Unique aspects of DID

o Alters – different identities or personalitieso Host – the identity that keeps other identities togethero Switch – quick, often instantaneous transition from one

personality to another One aspect for diagnosis of DID is amnesia, as in dissociative

amnesia and dissociative fugue Researchers have demonstrated that college students can simulate

an alter if it was suggested that faking was plausible. “Sociocognitive model” – the possibility of identity fragments and

early trauma is socially reinforced by a therapist

- Another word for separate identities found in dissociative disorders is alters.

- Another word for separate identities found in dissociative disorders is host identities.

- Dr. Jones tells his class that therapists are in a position to suggest the existence of alters, which then can lead to a diagnosis of DID. Dr. Jones is explaining the sociocognitive model.

- What research evidence suggests that at least some people with dissociative identity disorder are not consciously and voluntarily simulating alters? –

Statistics Pre-Sybil, average number of identities was about 2 to start, with a

3rd resolving the problemo Since Sybil, average number of identities recently is close

to 15 – about as many as Sybil Ratio of females to male is very high (9:1)

o This is unusual – Gender ratios seldom much above 2:1 Onset is almost always in childhood (but DID in kids is rarely

reported. And kids are under fairly constant view of some adult.) High comorbidity rates & lifelong, chronic course

Is this the same disorder? Does not look the same With 2 or 3 alters and a host and simple relationships (usually

don’t know each other until therapy), possible to envision relationships

With 15-115, including the dog, the weeping little girl or boy, the protector, the one with a high sex drive, the suicidal one, the non-suicidal self-destructive one, etc.

Dissociative Amnesia rare; Fugue are hen’s teeth, DID? DID consists of a series of complex psychogenic fugues A knows only B. B knows A, C and D. D pets the dog and is

actively self-destructive and suicidal. D has heard of the crying child, but does not know her. E, the crying child, seems to know about A, B, C and F, but not about D or the dog.

Each of these relationships necessitates a fugue state more complex than any seen before

This is not how the organism works. o It is like getting reports of the racing team at Swarthmore

routinely running 3 minute miles.o Since people cannot run a mile 3 minutes, the report has to

be wrong Almost all women; 9:1 Ratio

Lots of DID patients co-morbid Borderline Personality Disorder (BPD)

BDP patients want anything that is distracting or offers rescue/attention/drama

DID is a perfect diagnosis for BDP patientso DID dramatic, absolves them of responsibility for anti-

social behavior and is someone else’s fault How can they pay for intense therapy?

o The borderlines not infrequently turn to prostitution for a while

Is this a higher proportion than usual among borderlines?

o Like most borderline coping things, it doesn’t last longo However, can invoke a new set of rescuers

No one can find the childhood caseso MPD/DID starts by age 9 – possible undeveloped reality

testingo Kids from age 4 – 9 are under pretty frequent adult

supervision, including at schoolo Why don’t we have many cases of childhood MPD

reported? Possibly a disorder of self-presentation in

adulthood, not dissociation in response to incestuous child abuse

Causes Histories of horrible, unspeakable, child abuse Based on accumulated clinical wisdom

o Closely related to PTSD Mechanism to escape from the impact of trauma Fundamental goal is to identify cues or triggers that provoke

memories of trauma, dissociation, or both and to neutralize them

o More important, the patient must confront and relive the early trauma and gain control over the horrible events, at least as they recur in the patient’s mind

Suggestibility is a personality trait Hypnotizability – ability to be hypnotized; vulnerable to

suggestions by the hypnotist Autohypnotic model – when trauma becomes unbearable, the

person’s very identity splits into multiple dissociated identitieso As many as 50% of DID patients clearly remember

imaginary playmates in childhood

- Research has shown that a large percentage of individuals with DID may have concurrent diagnoses of all of the following EXCEPT eating disorders.

- There is a growing body of opinion that DID is an extreme subtype of posttraumatic stress disorder.

- The autohypnotic model suggests that individuals who are hypnotizable may be able to use dissociation as a response to severe trauma.

Recovered Memory Therapy, MPD and Satanic Ritual Abuse From 1980-95 or so, MPD usually involved SRA An individual, more frequently a woman, comes to a therapist with

a relatively common complaint, such as depression and low self-esteem

Associating the presenting symptoms with a possible history of childhood sexual abuse, the therapists seeks to explore whether forgotten sexual abuse is a causative factor

The exploration often involves hypnotic age regression and what has been called “disguised hypnosis” in the form of relaxation instructions combined with guided imagery and “regression work”

The “Courage to Heal” Patients are encouraged to go through pictures of their childhood

and read the book, The Courage to Heal (Bass & Davis, 1988) or another like it is as bibliotherapy

These forms of exploration constitute a strongly suggestive environment in which the patient’s recovery is seen as dependent on her remembering childhood sexual abuse, usually at the hands of her father.

Remembering/fantasizing about “Forgotten Abuse” When images or memories start to emerge, as they often may with

vulnerable patients, they are hailed as confirmation of the therapist’s hypotheses and the beginning of the patient’s recovery

Giving this reinforcement, more memories soon emerge and the patient becomes convinced she is an incest survivor

The therapists may then suggest a meeting at which the angry patient denounces her parents

o At such meeting, it is usual for parents to be forbidden to respond to their daughter’s accusations.

At this point, the patient’s memory has been altered.o The new “memories” are about as real as and, for many

patients, more vivid than other remote memorieso Further, having alienated herself from her family, the

patient is increasingly dependent on support from the therapist and self-help or therapy groups with people who have also learned they are incest survivors.

Cult-like Effectso Both the therapist and the fellow survivors will treat any

remaining doubts about the historical reality of the memories as a pathological retreat into “denial”

o The combination of isolation from previous support, editing the meaning of one’s past life, and participation in a belief system that many people view skeptically and that alienates participants from their families is reminiscent of cult indoctrination

DID and SARo By this time the therapists and patient may have discovered

the patient has multiple personality disordero Depending in part on the therapist’s views, additional

searching may take place that leads to the discovery of satanic ritual abuse

Patients with BPD are more likely to realize they have been ritually abused

What could be worse?o Pretty much all learned that they were victims of terrible

abuse and bore no responsibility for the terrible things that had happened

o Unsurprisingly, in the course of this “treatment”, many patients got worse

Treatment Hypnosis is used to access unconscious memories that cause

different alters to develop. Many individuals with dissociative amnesia get better without

treatment. The process of integrating different alters in DID can cause further

dissociation. Classic Treatment

o Focus is on reintegration of identitieso Identify and neutralize cues/triggers that provoke memories

of trauma/dissociation Alternative Treatment

o Personality is multifaceted, not the unitary constructions of MPD

Therefore, one may well have a number of thought and desires that are unpleasant and scary

Dealing with them is part of what therapy is abouto Insist that the “host” identity is responsible for everything

she doeso Show her that she can insist on being present for moods

and thought that would ordinarily be unacceptableo Note the Reconstructive Power of Memory

Whether things happened historically doesn’t change much of the way we deal with memory

We create narratives in which we are heroes or victimso Victim isn’t working – try for hero status

Whether things happened historically does change how we deal with others

o Your relationship with family should not be destroyed at this time

o You may want a little distance, but accusations of Independent Component Analysis should probably be put on hold for the time being

- What group is particularly unreliable in reporting accurate details of events? – young children

- Individuals with dissociative disorders are treated by therapy, medication, hypnosis.

o Diagnostic Consideration in Somatoform and Dissociative Disorders Separating real problems from faking

Malingering – deliberately faking symptoms False memories and recovered memory syndrome Related Conditions – Factitious Disorder

Factitious disorder by proxyo Summary of Somatoform and Dissociative Disorder

Feature of somatoform disorders Physical problems without an organic cause

Features of dissociative disorders Extreme distortions in perception and memory

Well established treatments are generally lacking

Chapter 6: Mood Disorders and Suicide

Overview of Mood Disorders Normal: mood is responsive to the environment

o Good things happen, you feel good for awhile. o Bad things happen you feel bad for awhile.

o Things stay in some sort of proportion most of the time.o As you get older, it takes even more to throw you off stride.

To understand mood disorders:o You have to understand their phenomenology -- You have to know what it feels

like to be depressed or manic.o Additionally, much of what is different about people with affective disorders

involves physically feeling bad. Depression is not severe sadness

o People with a clinical depression are sometimes sad and sometimes not sad at all.o Depression is a constellation of psychological and physiological states o There are a variety of physical signs, most obviously disruption of circadian

rhythms, that are part of the picture Symptoms of Depression

o Depressed or irritable moodo Diminished interest/pleasure daily activityo Weight loss or gain w/o tryingo Early morning awakening or hypersomnia o Psychomotor agitation or retardationo Fatigue/no energyo Feeling worthless/overwhelmed by guildo Can’t seem to think or concentrateo Recurrent thoughts of suicide, a suicide plan or suicide attempto Life is getting more and more of a messo All for at least 2 solid months

Age and Gendero Disorders with earlier onset tend to be more biologically driven and more severe.o Unipolar depression = twice as many women as men.o Bipolar disorder = just as many women as meno More severe disorders leave you less choice about how to be crazy so tend toward

less gender distinction. o Remember the parallel case in anxiety disorders: lots more females with a specific

phobia, but no gender difference in OCD, a more severe disorder. Key Point

o Major disorders lie to you. o You crave the things that are worst for you.o Depression says “Just relax for a little.” means sit quietly alone in the dark for

awhile and you will feel better.o Exactly the wrong prescription for depression.o Do just the opposite.

The Major Depressive Disorders are in three categories:o Major Depressive Disorder

Major period of time where you're sad, where things are going wrong Single episode – highly unusual

Recurrent episodes – more common Single manic episode or only manic episodes is very, very rare Cognitive symptoms - feelings of worthless, indecisiveness Anhedonia - Loss of pleasure/interactions of usual activites

o Dysthymic Disorder Lower grade of depression but more chronic Overview and defining features

Symptoms are milder than major depression Persists for at least 2 years No more than 2 weeks symptom free Symptoms can persist unchanged over long periods (≥ 20 years)

o Double Depression Basically both a major depressive disorder and dysthymic disorder where

you have someone who basically throughout his or her life has been sad, has had this kind of overlying depression, and then has episodes of major depressive episodes

Major depressive episodes and dysthymic disorder Dysthymic disorder often develops first Facts and statistics

Associated with severe psychopathology Associated with a problematic future course

Bipolar Disorderso Common name -- Manic Depressiveo Bipolar I Disorder: where you have very distinct major depressive periods of

time and very distinct manic depressive, manic periods of time.  It is as if you have to go 130 mph. Everything going very fast. Pretty self-

destructive. Alternations between full manic episodes and depressive episodes Facts and statistics

Average age of onset is 18 years Can begin in childhood Tends to be chronic Suicide is a common consequence

o Bipolar II Disorder: you would have mania that wouldn't be as high, so you'd have depressive periods and then kind of little blips of feeling manic, but not the very high highs that you would see in bipolar one

Alternations between major depressive and hypomanic episodes Facts and statistics

Average age of onset is 22 years Can begin in childhood 10% to 13% of cases progress to full bipolar I disorder Tends to be chronic

o Cyclothymic Disorder: kind of like dysthymic disorder where you're kind of getting ups and downs, but not high peaks that you would in bipolar disorder where you have people being sad and then people up and then people being sad

Chronic version of bipolar disorder

Manic and major depressive episodes are less severe Manic or depressive mood states persist for long periods Must last for at least 2 years (1 year for children and adolescents) Facts and statistics

Average age of onset is 12 to 14 years Most are female Cyclothymia tends to be chronic and lifelong High risk for developing bipolar I or II disorder

o Typical pattern: Mania, depression, normal moodo Atypical: Depression, mania normal moodo Rapid cycling: Depression, mania, depression, mania At least 4 times a year.

Little or no normal mood. Really hard to successfully treat Differences in the Course of Mood Disorders

o Course specifiers Longitudinal course

Past history of mood disturbance History of recovery from depression and/or mania

Rapid cycling pattern Applies to bipolar I and II disorder only

Seasonal pattern Episodes covary with changes in the season Many view seasonal affective disorder as a mild form of bipolar

disorder Mood Disorders: Additional Facts and Statistics

o Worldwide lifetime prevalence 16% for major depression

o Sex differences Females are twice as likely to have major depression Gender imbalance disappears after age 65

Why? Possibly because guys often have highly structured environments, women less so?

Differential reward systems? Hormonal variation? Post partum depression

Bipolar disorders equally affect males and femaleso Book: Fundamentally similar in children and adults (Karlin has reservations)o Prevalence of depression seems to be similar across subcultures (Although some

differences. African-americans slightly less. American Indians moreo Relation between anxiety and depression – negative affect

Most depressed persons are anxious Not all anxious persons are depressed

Mood Disorders: Familial and Genetic Influenceso Family Studies

Rate is high in relatives of probands Relatives of bipolar probands tend to have unipolar depression

o Adoption studies – data are mixed o Twin studies

Concordance rates are high in identical twins Severe mood disorders have a strong genetic contribution Heritability rates are higher for females compared to males Vulnerability for unipolar or bipolar disorder

Appears to be inherited separately. Karlin Question: Does that make them separate disorders? What

does that mean for the spectrum view? KQ: Relatives of bipolar probands tend to have unipolar

depression. If really different disorders, how come? Neurological Influences

o Neurotransmitter systems Serotonin and its relation to other neurotransmitters Mood disorders are related to low levels of serotonin Karlin: It ain’t that simple. When SSRIs such as prosac and zoloft are

given, levels of serotonin go up. By the time SSRIs are effective, however, serotonin levels back down to level at which you started. Like diuretics for blood pressure

o Permissive hypothesis: Serotonin (5HT) regulates norepinephrine (NE). NE gets dysregulated with less 5HT.

o Simple notion: low NE + 5HT = Depressiono High DA adds psychotic symptomso The endocrine system

Elevated cortisol Karlin: Current medical thinking: Depression is an inflammatory disease. Whichever: Nerve cell death and disturbance of neurogenesis, especially

in the hypocampus o Sleep disturbance

Hallmark of most mood disorders Relation between depression and sleep and circadian rhythms in general

Psychological Dimensions (Stress)o Stressful life events

Stress is strongly related to mood disorders Poorer response to treatment Longer time before remission

o The relation between context of life events and mood What’s good for you may not be good for others Karlin: Remember the humiliation research. Social rejection related to

depression. E.g. bad marriages go hand in hand w depression. Remember imagainings: Bad marriages cause depression or depression causes bad marriages or both caused by common factor????

At beginning, Stress triggers depression: Think back to imaginings: depression triggers stress?

Reciprocal-gene environment model Psychological Dimensions (Learned Helplessness)

o The learned helplessness theory of depression Lack of perceived control over life events

Karlin: Lousy theory of depression. You have to know it, but I don’t have to teach it.

Martin Seligman's theory that people become anxious and depressed when they make an attribution that they have no control over the stress in their lives (whether or not they actually have control)

o Karlin; Theories authors both at Penn. Are theories related? Beck is better.o Learned helplessness and a depressive attributional style

Internal attributions Negative outcomes are one’s own fault

Stable attributions Believing future negative outcomes will be one’s fault

Global attribution Believing negative events will disrupt many life activities

All three domains contribute to a sense of hopelessness Psychological Dimensions (Cognitive Theory)

o Negative coping styles Depressed persons engage in cognitive errors Tendency to interpret life events negatively

o Types of cognitive errors Arbitrary inference – overemphasize the negative Overgeneralization – negatives apply to all situations

o Cognitive errors and the depressive cognitive triad Think negatively about oneself Think negatively about the world Think negatively about the future In bipolar depression add: Ambitious striving for goals, perfectionism,

self-criticism and often other criticism Social and Cultural Dimensions

o Marital relations Marital dissatisfaction is strongly related to depression This relation is particularly strong in males

o Mood disorders in women Females over males Except bipolar disorders Gender imbalance likely due to socialization Karlin: Read the section on cognitive disorders among women. I think it is

one of the best sections in the book o Social support

Extent of social support is related to depression Lack of social support predicts late onset depression Substantial social support predicts recovery from depression

An Integrated Theoryo Shared biological vulnerability

Overactive neurobiological response to stresso Exposure to stress

Activates hormones that affect neurotransmitter systems

Turns on certain genes Affects circadian rhythms Activates dormant psychological vulnerabilities Contributes to sense of uncontrollability Fosters a sense of helplessness and hopelessness

o Social and interpersonal relationships/support are moderators Treatment of Mood Disorders: Trycyclic Medications

o Widely used (e.g., Tofranil, Elavil)o Block reuptake

Norepinephrine and other neurotransmitterso Therapeutic effects

Can takes 2 to 8 weeks o Negative side effects are common: Constipation; dry eyes; rapid heartbeato May be lethal in excessive doses Scares MDs for good reason. So, usually,

only psychiatrists prescribe Monoamine Oxidase (MAO) Inhibitors

o Monoamine oxidase (MAO) Block monoamine oxidase This enzyme breaks down serotonin/norepinephrine Slightly more effective than tricyclics Good drugs for smart and compliant patients

o Must avoid foods containing tyramine Examples include beer, red wine, cheese Many patients don’t like the dietary restrictions Karlin: MDs afraid of lawsuits. Think patients are stupid or won’t listen.

Do not know of anyone who even knows anyone who has actually seen a hypertensive (high BP) crisis.

Selective Serotonergic Reuptake Inhibitors (SSRIs)o Specifically block reuptake of serotonin

Fluoxetine (Prozac) is the most popular SSRIo SSRIs pose no unique risk of suicide or violenceo Negative side effects are common

Lithiumo Lithium is a common salt

Primary drug of choice for bipolar disorders Can be toxic

o Side effects may be severe Dosage must be carefully monitored

o Why lithium works remains unclearo Karlin: All drugs are, in sufficient quantity toxic. Usually toxic level is well above

effective level. With lithium, the toxic and effective doses overlap Electroconvulsive Therapy (ECT)

o ECT is often effective for cases of severe depression and when nothing else works Karlin: Once upon a time, ECT caused permanent damage, mostly due to

oxygen deprivation during procedure.

Quite violent seizures in old days Result: Bad rep for ECT Brilliant answer: AN ANAESTHESIOLOGIST Lots of oxygen, no moving around on the table, undetectable side effects

o Now, side effects are few and include short-term memory losso 8-10 sessions administered as oupatient o Karlin: there are advantages and disadvantages to shocking only the nondominant

hemisphere. o You want quick onset and quick offset of seizure. Solution: have another ECT

guy look over the EEG. Then the first doc gets very carefulo Uncertain why ECT workso Relapse is common

Psychosocial Treatmentso Cognitive therapy

Addresses cognitive errors in thinking Also includes behavioral components

o Interpersonal psychotherapy Focuses on problematic interpersonal relationships

o Outcomes with psychological treatments Comparable to medications Research does not suggest advantage for combined treatment Karlin: Better for selected cases, worse for others. Remember

antidepressants can make things worse for people with bipolar aspects. Otherwise, meds can make people able to do psychological treatments.

Meds can add “bounce” to the system The Nature of Suicide

o Facts and Statistics Eighth leading cause of death in the United States. Leading cause of death among young people Overwhelmingly a white and Native American phenomenon Suicide rates are increasing, particularly in the young

o Gender differences Males are more successful at committing suicide than females Females attempt suicide more often than males

o Risk Factors Family History

Suicide in the family Neurobiology

Low serotonin levels Preexisting psychological disorder Alcohol use and abuse Past suicidal behavior Experience of a shameful/humiliating stressor Publicity about suicide and media coverage

Psychache --Karlin

o Suicide is a response to unbearable pain. The pain is not physical, but psychological.

o The source of the pain can be and not infrequently is anticipated embarrassment, rejection, social opprobrium and/or humiliation.

o The highest suicide rate is for white males over 50. (Note, not suicide attempt, completed suicide)

o Men who are occupationally successful, but whose status is threatened or lost, are the most likely to commit suicide

Social Rejection -- Karlino Notice that it is not the guys who never made it, who are born losers or at least not

winners.o Rather, it is the seemingly successful who kill themselves.o The humiliation/rejection thing works for kids too, to some degree.o They “can’t face” parents or peers for some failure or betrayal.o Leaving to avoid consequences such as prison

Lethality -- Karlino You must assess how lethal are possible ways to kill a patiento A patient with guns needs to be hospitalized. Someone with pills is a little less

dangerous.o Religious beliefs prevent suicide.o Family obligations prevent suicide.o Youth and being female predict suicide attempts, but not completed suicide.o Many people die seemingly unintentionally. For example, someone is supposed to

come home and gets seriously delayed. Treatment for Suicide

o No-suicide Contract: a promise not to do anything remotely connected with suicide without contacting the mental health professional first

If refuses contract and the suicidal risk is high, immediate hospitalization is indicated, even against the will of the patient

o Suicide Prevention Programso Cognitive-behavioral problem-solving approach

Summary of Mood Disorderso All mood disorders share

Gross deviations in mood Common biological and psychological vulnerability

o Occur in children, adults, and the elderlyo Onset, maintenance, and treatment are affected by

Stress Social support

o Suicide is an increasing problem Not unique to mood disorders

o Medications and psychotherapy produce comparable resultso High rates of relapse

Chapter 8 -- Eating and Sleep Disorders

Eating Disorders: An Overview Two major types of DSM-IV-TR eating disorders

o Anorexia nervosa and Bulimia nervosao Severe disruptions in eating behavioro Extreme fear and apprehension about gaining weighto Strong sociocultural origins – Westernized views

Other Subtypes of DSM-IV-TR eating disorderso Binge Eating Disordero Obesity – A growing epidemic

Bulimia Nervosa: Overview and Defining Features Binge eating – hallmark of bulimia

o Binge Eating excess amounts of food

o Eating is perceived as uncontrollable Compensatory Behaviors

o Purging Self-induced vomiting, diuretics, laxatives

o Some exercise excessively, whereas others fast DSM-IV-TR subtypes of bulimia

o Purging subtype – most common subtypeo Nonpurging subtype – about one-third of bulimics

Bulimia Nervosa: Associated Features Associated medical features

o Most are within 10% of target body weighto Purging methods can result in severe medical problems

Erosion of dental enamel, electrolyte imbalance Kidney failure, cardiac arrhythmia, seizures, intestinal problems,

permanent colon damage Associated psychological features

o Most are overly concerned with body shapeo Fear of gaining weighto Most have comorbid psychological disorders

Medical consequences: o Salivary gland enlargement causes by repeated vomiting. The result is a chubby

facial appearance.o Erosion of dental enamel on the inner surface of the front teeth.o May produce an electrolyte imbalance (i.e., disruption of sodium and potassium

levels) which, in turn, can lead to potentially fatal cardiac arrhythmia and renal failure.

o Intestinal problems resulting from laxative abuse are also potentially serious.

Some individuals with bulimia also develop marked calluses on the fingers and backs of hands resulting from efforts to vomit by stimulating the gag reflex.

Anorexia Nervosa: Overview and Defining Features Successful weight loss – hallmark of anorexia

o Defined as 15% below expected weighto Intense fear of obesity and losing control over eatingo Anorexics show a relentless pursuit of thinnesso Often begins with dieting

DSM-IV-TR subtypes of Anorexiao Restricting subtype – limit caloric intake via diet and fastingo Binge-eating-purging subtype

Associated featureso Most showed marked disturbance in body imageo Most are comorbid for other psychological disorderso Method of weight loss have life threatening consequences

Binge-Eating Disorder: Overview and Defining Features Binge-eating disorder – appendix B of DSM-IV-TR

o Experimental diagnostic categoryo Engage in food binges without compensatory behaviors

Associated Featureso Many persons with binge-eating disorder are obeseo Concerns about shape and weighto Often older than bulimics and anorexicso More psychopathology vs. non-binging obese people

Bulimia and Anorexia: Facts and Statistics Bulimia

o Majority are female – 90%+o Onset around 16 to 19 years of ageo Lifetime prevalence is about 1.1% for females, 0.1% for maleso 6-7% of college women suffer from bulimiao Tends to be chronic if left untreated

Anorexiao Majority are female and whiteo From middle- to upper-middle-class familieso Usually develops around age 13 or early adolescenceo More chronic and resistant to treatment than bulimia

Cross-cultural considerations Developmental considerations

Causes of Bulimia and Anorexia: Toward an Integrative Model Media and cultural considerations

o Being thin = success, happiness…really?

o Cultural imperative for thinness Translates into dieting

o Standards of ideal body size Change as much as fashion

o Media standards of the ideal Are difficult to achieve

Biological Considerationso Can lead to neurobiological abnormalities

Psychological and behavioral considerationso Low sense of personal control and self-confidenceo Perfectionistic attitudeso Distorted body image Preoccupation with foodo Mood intolerance

Dietary restraint Family influences Biological dimensions Psychological dimensions An integrative model

Medical and Psychological Treatment of Bulimia Nervosa Psychosocial treatments

o Cognitive-behavioral Therapy (CBT) Is the treatment of choice Basic components of CBT

Medical and Drug Treatmentso Antidepressants

Can help reduce binging and purging behavior Are not efficacious in the long-term Tricyclics and SSRI (Prozac) help reduce frequency of binging and

purging Medical Treatment

o Sibutramine (Meridia)o Psychological Treatment

CBT Similar to that used for bulimia Appears efficacious

Interpersonal psychotherapy Equally as effective as CBT

Self-help techniques Also appear effective

Goals of Psychological Treatment of Anorexia Nervosa General goals and strategies

o Weight Restorations First and easiest goal to achieve

o Psychoeducationo Behavioral and cognitive interventions

Target food, weight, body image, thought and emotiono Treatment often involves the familyo Long-term prognosis for anorexia is poorer than bulimiao Preventing eating disorders

Obesity: Background and Overview Not a formal DSM disorder Statistics

o In 2000, 30.5% of adults in the United States were obese; 33.8% in 2008o Mortality Rates

Are close to those associated with smokingo Increasing more rapidly

For teens and young childreno Obesity

Is rapidly growing in developing nations

Obesity and Disordered Eating Patterns Obesity and night eating syndrome

o Occurs in 7-19% of treatment seekerso Occurs in 42% of individuals seeking bariatric surgeryo Patients are wide awake and do not binge eat

Causeso Obesity is related to technological advancemento Genetics account for about 30% of obesity caseso Biological and psychosocial factors contribute as well

Obesity Treatment Treatment

o Moderate success with adultso Greater success with children and adolescents

Treatment progression – from least to most intrusive options First Step

o Self-directed weight loss programs Second Step

o Commercial self-help programs Third Step

o Behavior modifications programs Last Step

o Bariatric surgery

Sleep Disorders: An Overview Two major types of DSM-IV-TR sleep disorders

o Dyssomnias

Difficulties in amount, quality, or timing of sleepo Parasomnias

Abnormal behavioral and physiological events during sleep Assessment of disordered sleep:

o Polysomnographic (PSG) evaluation Electroencephalograph (EEG) – brain wave activity Electrooculograph (EOG) – eye movements Electromyography (EMG) – muscle movements Detailed history, assessment of sleep hygiene and sleep efficiency

o Actigraph -- This instrument records the number of arm movements, and the data can be downloaded into a computer to determine the length and quality of sleep

o Sleep Efficiency (SE)

The Dyssomnias: Overview and Defining Features of Insomnia Insomnia and primary insomnia

o One of the most common sleep disorderso Microsleepso Problems initiating/maintaining sleep, and/or nonrestorative sleepo Primary insomnia – unrelated to any other conditiono 35% of adults report daytime sleepiness

Facts and Statisticso Often associated with medical and/or psychological conditionso Affects females twice as often as males

Associated Featureso Unrealistic expectations about sleepo Believe lack of sleep will be more disruptive than it usually is

An integrated model

The Dyssomnias: Overview and Defining Features of Hypersomnia Hypersomnia and primary hypersomnia

o Sleeping too much or excessive sleepo Experience excessive sleepiness as a problemo Primary hypersomnia – unrelated to any other condition

Facts and Statisticso Often associated with medical and/or psychological conditions

Associated Featureso Complain of sleepiness throughout the dayo Able to sleep throughout the night

The Dyssomnias: Overview and Defining Features of Narcolepsy Narcolepsy – daytime sleepiness and cataplexy

o Cataplexic attacks REM sleep, precipitated by strong emotion

o Facts and Statistics – rare condition Affects about 0.3% to .16% of the population

Equally distributed between males and females Onset during adolescence Typically improves over time

o Associated Features Cataplexy, sleep paralysis, and hypnagogic hallucinations Daytime sleepiness does not remit without treatment

The Dyssomnias: Overview of Breathing-Related Sleep Disorders Breathing-related sleep disorders

o Sleepiness during the day and/or disrupted sleep at nighto Sleep Apnea

Restricted air flow and/or brief cessations of breathing Subtypes of Sleep Apnea

o Obstructive sleep apnea (OSA) Airflow stops, but respiratory system works

o Central Sleep Apnea (CSA) Respiratory systems stops for brief periods

o Mixed Sleep Apnea Combination of OSA and CSA

Facts and Statisticso Occurs in 1-2% of populationo More common in maleso Associated with obesity and increasing age

Associated Featureso Persons are usually minimally aware of apnea problemo Often snore, sweat during sleep, wake frequentlyo May have morning headacheso May experience episodes of falling asleep during the day

Circadian Rhythm Sleep Disorders Circadian rhythm disorders

o Disturbed sleep (i.e., either insomnia or excessive sleepiness)o Due to brain’s inability to synchronize day and night

Nature of circadian rhythms and body’s biological clocko Circadian rhythms – do not follow 24hr clocko Suprachiasmatic nucleus

Brain’s biological clock, stimulates melatonino Types of circadian rhythm disorders

Jet lag type Shift work type

Medical Treatments Insomnia

o Benzodiazepines and over-the-counter sleep medicationso Prolonged use

Can cause rebound insomnia, dependenceo Best as short-term solution

Hypersomnia and narcolepsyo Stimulants (i.e., Ritalin)o Cataplexy

Usually treated with antidepressants Breathing-related Sleep Disorders

o May include medications, weight loss, or mechanical devices Circadian Rhythm Sleep Disorders

o Phase delays Moving bedtime later (best approach)

o Phase advances Moving bedtime earlier (more difficult)

o Use of very bright light Trick the brain’s biological clock

Environmental treatments

Psychological Treatments Relaxation and stress reduction

o Reduces stress and assists with sleepo Modify unrealistic expectations about sleep

Stimulus control procedureso Improved sleep hygiene – bedroom is a place for sleepo For children – setting a regular bedtime routine

Combined treatmentso Insomnia – short-term medication plus psychotherapyo Other dyssomnias

Little evidence for the efficacy of combined treatments

The Parasomnias: Nature and General Overview Nature of Parasomnias

o The problem is not with sleep itselfo Problem is abnormal events during sleep, or shortly after waking

Two classes of parasomniaso Those that occur during REM (i.e., dream) sleepo Those that occur during non-REM (i.e., non-dream) sleep

The Parasomnias: Overview of Nightmare Disorder Nightmare disorder

o 10-50% of children and 1% of adults have nightmareso Occurs during REM sleepo Involves distressful and disturbing dreamso Such dream interfere with daily life functioning and interrupt sleep

Features of nightmare disorder include the following:

o Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, generally during the second half of the sleep period

o On awakening from the frightening dreams, the person rapidly becomes oriented and alert

o The dream experience, or the sleep disturbance resulting from the awakening, causes significant distress or impairment in functioning

o Nightmares do not occur exclusively during the course of another mental disorder and are not due to the direct physiological effects of a substance or a general medical condition

Facts and Associated Featureso Dreams often awaken the sleepo Problem is more common in children than adults

Treatmento May involve antidepressants and/or relaxation training

The Parasomnias: Overview of Sleep Terror Disorder- Sleep terror disorder

o 5% of children and <1% of adults have sleep terroro Recurrent episodes of panic-like symptoms during non-REM sleepo Often noted by a piercing scream

- Features of sleep terror disorder include the following:o Recurrent episodes of abrupt awakening from sleep, usually occurring during the

first third of the major sleep episode and beginning with a panicky screamo Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing,

and sweating, during each episodeo Relative unresponsiveness to efforts of others to comfort the person during the

episodeo No detailed dream is recalled, and there is amnesia for the episodeo The episodes cause clinically significant distress or impairment in functioningo The disturbance is not due to the direct physiological effects of a substance or a

general medical condition- Facts and associated features

o More common in children than adultso Child cannot be easily awakened during the episodeo Child has little memory of it the next day

- Treatment – a wait-and-see postureo Scheduled awakenings prior to the sleep terroro Severe caseso Antidepressants (i.e., Imipramine) or benzodiazepines

The Parasomnias: Overview of Sleep Walking Disorder• Sleep walking disorder – somnambulism

– Occurs during non-REM sleep– Usually during first few hours of deep sleep

– Person must leave the bed• Facts and associated features

– Problem is more common in children than adults– Problem usually resolves on its own without treatment– Seems to run in families

- Features of sleepwalking disorder include the following:o Repeated episodes of rising from bed during sleep and walking about, usually

occurring during the first third of the major sleep episodeo While sleepwalking, the person has a blank, staring face; is relatively

unresponsive to the efforts of others to communicate; and can be awakened only with great difficulty

o On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for the episode

o Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation)

o The sleepwalking causes clinically significant distress or impairment in functioning

o The disturbance is not due to the direct physiological effects of a substance or a general medical condition

- Related conditionso Nocturnal eating syndrome – Person eats while asleep

Summary of Eating and Sleeping Disorders- All eating disorders share

o Gross deviations in eating behavioro Fear or concern about weight, body size, appearanceo Heavily influenced by social, cultural, and psychological factors

- Bulimia Nervosa and Anorexia Nervosa - How does binge-eating disorder differ from bulimia?

o There are two prevalent eating disorders. In bulimia nervosa, dieting results in out-of-control binge-eating episodes that are often followed by purging the food through vomiting or other means. Anorexia nervosa, in which food intake is cut dramatically, results in substantial weight loss and sometimes dangerously low body weight

- Binge-eating Disordero In binge-eating disorder, a pattern of binge eating is not followed by purging.

- Statistics And Course For Eating Disorders o Bulimia nervosa and anorexia nervosa are largely con-fined to young, middle- to

upper-class women in Western cultures who are pursuing a thin body shape that is culturally mandated and biologically inappropriate, making it extremely difficult to achieve.

o Without treatment, eating disorders become chronic and can, on occasion, result in death.

- Causes Of Eating Disorders

- What social, psychological, and neurobiological factors might cause eating disorders?o In addition to sociocultural pressures, causal factors include possible biological

and genetic vulnerabilities (the disorders tend to run in families), psychological factors (low self-esteem), social anxiety (fears of rejection), and distorted body image (relatively normal-weight individuals view themselves as fat and ugly).

- Treatment Of Eating Disorders- How does the use of medications compare with psychological therapies for the treatment

of eating disorders?o Several psychosocial treatments are effective, including cognitive-behavioral

approaches combined with family therapy and interpersonal psychotherapy. Drug treatments are less effective at the current time.

- Obesity- What are some possible causes of obesity?

o Obesity is not a disorder in DSM but is one of the more dangerous epidemics confronting the world today. Cultural norms that encourage eating high-fat foods combine with genetic and other factors to cause obesity, which is difficult to treat.

- All sleep disorders shareo Interference with normal process of sleepo Interference results in problems during wakingo Heavily influenced by psychological and behavioral factors

- Incidence of eating and sleep disorders is increasing- More effective treatments for eating and sleep disorders are needed

- Sleep Disorders- What are the critical diagnostic features of the major sleep disorders?

o Sleep disorders are highly prevalent in the general population and are of two types: dyssomnias (disturbances of sleep) and parasomnias (abnormal events such as nightmares and sleepwalking that occur during sleep).

o Of the dyssomnias, the most common disorder, primary insomnia, involves the inability to initiate sleep, problems maintaining sleep, or failure to feel refreshed after a full night's sleep. Other dyssomnias include primary hypersomnia (excessive sleep), narcolepsy (sudden and irresistible sleep attacks), circadian rhythm sleep disorders (sleepiness or insomnia caused by the body's inability to synchronize its sleep patterns with day and night), and breathing-related sleep disorders (disruptions that have a physical origin, such as sleep apnea, that lead to excessive sleepiness or insomnia).

o The formal assessment of sleep disorders, a polysomno-graphic evaluation, is typically done by monitoring the heart, muscles, respiration, brain waves, and other functions of a sleeping client in the lab. In addition to such monitoring, it is helpful to determine the individual's sleep efficiency, a percentage based on the time the individual actually sleeps as opposed to time spent in bed trying to sleep.

- What medical and psychological treatments are used for the treatment of sleep disorders?o Benzodiazepine medications have been helpful for short-term treatment of many

of the dyssomnias, but they must be used carefully or they might cause rebound insomnia, a withdrawal experience that can cause worse sleep problems after the

medication is stopped. Any long-term treatment of sleep problems should include psychological interventions such as stimulus control and sleep hygiene.

- How are rapid eye movement and nonrapid eye movement sleep related to the parasomnias?

o Parasomnias such as nightmares occur during rapid eye movement (or dream) sleep, and sleep terrors and sleepwalking occur during nonrapid eye movement sleep.