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Psychological Disorders and Treatment (Treatment (Cognitive Therapy:…
Psychological Disorders and Treatment
Psychological Disorders
: persistently harmful thoughts, feelings, and action
Psychopathology
: the study of mental disorders
characteristics
Deviance
: does not align with reality/science/etc
Maladaptive
: behaving in a way that doesn't accommodate life
Self-destructive
: causes harm to yourself/others
Causes discomfort/concern to others
general statistics
450 million people
depression and schizophrenia in all cultures
1 in 4 american adults has diagnosable psychological disorder in a given year
nearly 1/2 Americans will have some psychological disorder in their lives
only 7% of US adults severely affected
prevalence measures
Point Prevalence
: the percentage of people in a given population who have a given disorder at any point in time
Lifetime Prevalence
: the percentage of people in a certain situation who have a given disorder at any point in their lives
Etiology
Diathesis-Stress Model
#
#
Genetic Predisposition + Trama --> Diathesis (vulnerability to mental disorder)
minimal stressful circumstances --> low probability of developing disorder
inability to cope with excessive stressful circumstances --> high probability
biological factors
genes, neurotransmitters, fetal exposure, childhood exposure, childhood malnutrition
environmental factors
family systems model
: problems that arise in individual are manifestations of problems within family --> should develop family profile in assessment
#
#
sociocultural model
: psychopathology is result of interactions between individuals and their cultures (ex schizophrenia more common in lower classes).
NOTE: eccentric behavior among wealthy elite less likely to be pathologized, pathology may lead to trouble finding work and thus low SES
cognitive behavioral factors
thoughts can become distorted and produce maladaptive behaviors, can be retaught. Believe thoughts are available to conscious mind
sex and culture
some disorders more common in men (alcoholism) or women (anorexia). Both biological and environmental reasons. some conditions more common in different cultures
Assessment
Self Report
Beck Depression Inventory
Structured Interview
SCID (structured clinical interview for DSM)
Observations
Neuropsychological testing
make patient do tasks like identify shapes blindfolded, tap fingers, etc
tasks performed poorly show problems with particular brain regions
follow up with MRI or PET
psychological testing
assessment continues throughout treatment to evaluate progress
Diagnosis
Diagnostic Statistical Manual for Mental Disorders (DSM)
describes disorders
indicates prevalence of disorders
provide reliable diagnoses
problems
categorical v dimensional approach (diagnosis is not all or nothing, people may fall on the edge and not receive treatment)
comorbidity: many psychological disorders occur together even though DSM-5 treats them as separate disorders (anxiety, depression, substance abuse, panic).
may be due to same underlying factor
p
(like g for intelligence). High p score = impairment, suicide attempts, hospitalization, criminal behavior, worsening impairment over time
"putting any kind of behavior within the compass of psychiatry
labels can cause stigma
instructions for future research
complicated by comorbidity. Many disorders don't exist completely independent of each other
Cultural Syndromes
: disorders that only exist in particular cultures
#
"Insanity"
Rosenham
got healthy people admitted for saying they heard a voice saying "thud", acted completely normally
doctors pathologized normal behavior
only way to get out was to agree they were insane
challenged by hospitals, agreed to send more fakes. Hospital announced it had caught 41 fakes, Rosenhan revealed he had sent no one
Research Domain Criteria (RDoC)
based off
domains of functioning
(vs DSM observable symptoms)
designed to guide new research in domains across multiple levels
guide processes that lead to symptoms to give insight into treating them
examines psychopathology without regard to DSM diagnosis b/c people with same diagnosis may have very different behaviors/responses
Mood Disorders
Major Depressive Disorder
Treatment
Pharmacology
SSRIs
: do not affect histamine or acetylcholine --> fewer side effects
antidepressants treat symptoms, not cause
only drug trials involving individuals with severe depression show clear benefits of drugs over placebos
MOA inhibitors
: block serotonin breakdown in synapse. TOXIC side effects with many foods, last resort medication
tricyclic
antidepressants, block neurotransmitter reuptake, many side effects
USE IN ADOLESCENTS CONTROVERSIAL b/c may cause suicidal thoughts.
TADS (Treatment for Adolescents with Depression Study)
proved they are as effective in teens as in adults, especially with cognitive behavioral therapy. NOTE: suicide rates have dropped since use of SSRIs became widespread
Cognitive-Behavioral Treatment
just as effective as antidepressants
often used in conjunction with meds
other methods
Electroconvulsive Therapy (ECT)
uses electric shock to produce a seizure (given muscle relaxants)
Transcranial Magnetic Stimulation (TMS)
uses magnetic field to temporarily turn of brain in stimulated area
Deep Brain Stimulation (DMS)
phototherapy for seasonal affective disorder
aerobic exercise
Environmental Influences
social isolation. Also, people may avoid depressed friends which can cause downward spiral
life crises --> depression under right conditions
culture and sex
#
Externalizing
(male stress response)
--> alcohol/substance use, conduct disorder, antisocial personality
Internalizing
(female stress response)
fear --> agoraphobia, social anxiety, phobias
distress --> depression, anxiety
highest rates of depression in women in developing countries
women's risk for depression nearly double that of men, possibly from overwork and lack of support. May also be because of male reluctance to admit to depression or seek treatment
cognitive influences
learned helplessness
: seeing yourself as unable to have effect on events in life
overgeneralize negative events, think in extremes
Cognitive Triad
: negative thoughts about self, situation, future
Explanatory Style
: explaining bad things as result of internal, global, and stable factors --> inc risk of depression
Genetic Influences
circadian rhythms
left prefrontal cortex
damage --> depression
major depression involves deficiency of one or more monoamines (ie serotonin)
run in families
concordance between identical twins 2-3x higher than between fraternal twins, not as strong influence as others (schizophrenia)
different from
Persistent Depressive Disorder
which is mild/moderate and
Depressive Personality
which is mild
Lieberman: "apathy, incompetence, irritability, anxiety, zero energy, zero motivation to do anything, sleep disturbances)
Anxiety Disorders
#
mood disorders causing fear of negative evaluation (judgement, embarrassment, rejection). Especially in performances and social interactions
Diagnostics
DSM 5
marked fear or anxiety about social situations that could lead to scrutiny
fear of acting in a way that will be negatively evaluated
avoidance of social situations
anxiety out of proportion to actual threat
persistent (>6 months)
difference from shyness: disorder requires
clinically significant impairment and distress
HOW it is diagnosed
clinical interviews
only a disorder if fear negatively affects life
Epidemiology
3-7% prevalence in 1 year
5-12% in lifetime
more common in females
typical onset in adolescence (when people form schemas about themselves and others)
comorbidity with other anxiety disorders, depression, alcohol and substance disorders
Risk Factors
Biological
HPA axis
reactivity (cortisol and stress pathways)
Amygdala
hypersensitivity
Psychological
Temperament
Attachment Sype
Rejection sensitivity
Environmental
early maternal stress
social rejection
Etiology
Classical Conditioning
: initial exposure to social situation + negative experience --> conditioned fear of that social situation
Operant Conditioning
: conditioned fear --> anxiety to future social situation --> avoidance of future social situations --> acute alleviation of anxiety --> avoidance behavior reinforced --> maladaptive cognitions about self and other social situations --> positive feedback to more anxiety
Avoidance Behaviors
become self-perpetuating through reinforcement in positive feedback loop. Safety behaviors help "tolerate" acute anxiety but make it worse in long run by not teaching coping. Avoidance can also lead to future social rejection
biased thinking
biology
inhibited child --> anxiety as adult, esp. social
greater amygdala activation when viewing novel faces
Treatment
Medications
Anxiolytics
taking medication before situations of acute anxiety is functionally analogous to safety behaviors (if you ever forget valium you will panic)
Beta Blockers
slightly better than anxiolytics b/c only reduce physical symptoms not anxiety
SSRIs
(except buproprion)
only work for severe cases and mood/self image regulation, does not address learning experience
tranquilizers
for immediate phobia response
Cognitive Behavioral Therapy
Exposure
to hierarchies of fearful situations to extinguish learned fear response
Behavioral Experiments
: test maladaptive cognitions for their basis in reality
Reduction of safety behaviors
Social Skills Training
Fear Hierarchy
for specific phobias
reciprocal inhibition
: when two responses are incompatible, only one may exist in memory
relaxation training
types: specific phobia, generalized anxiety, social anxiety, panic disorder
Post Traumatic Stress Disorder
(PTSD)
related to tension, anxiety, chronic health problems, memory and attention problems, attention bias toward stimuli associated with trauma
Etiology
trauma
serotonin function
frequent and recurring unwanted thoughts related to trauma
Obsessive Compulsive Disorder (OCD)
treatment
deep brain stimulation of caudate
anti-anxiety meds INEFFECTIVE
SSRIs (except bupropion)
cognitive behavioral therapy, exposure and response prevention therapy
Etiology
caudate
(suppresses impulses) smaller, structural abnormalities, lower functioning
autoimmune response may cause caudate damage
genetic (twin studies)
anxiety that cannot be reduced by normal anxiety reducing behavior
know that obsessions are irrational but cannot stop them
frequent intrusive thoughts and compulsive actions, such as fear of contamination, accidents, aggression
Bipolar Disorder
types
Biopolar II
: less extreme mood elevations (
hypomania
) and major depression
Bipolar I
: more manic episodes than depression
bouts of mania and depression
iritability
mania: elation, euphoria, desire for action, hyperactive, multiple idease
depression: gloomy, withdrawn, inability to make decisions, tired, slowness of thought
can be treated with antipsychotics, lithium or anticonvulsants, and antidepressants (but these can trigger manic episodes)
compliance with drug therapies is a big issue
Common Childhood Disorders
Autism Spectrum Disorder (ASD)
Categories
asperger syndrome
Pervasive developmental disorder not otherwise specified
*childhood disintegrative disorder (CDD)
autistic disorder
Diagnostics
DSM-5 criteria
social communication deficits
delayed language acquisition
odd vocal patterns (robotic, sing-songy)
Echolia (echoing exactly what adult says)
Pronoun Reversal (you wanna get picked up? --> you wanna get picked up! vs
I
)
hyper-literal sense of language
social interaction deficits
deficits in eye contact, attention to name, facial expression, turn-taking, imitation, chit-chat,
lack of theory of mind
interactions focused on meeting needs
bonds
are
formed with caregivers
Restricted, Repetitive Behaviors, Interests, and Activities
stereotypy (repetitive movement)
compulsive behaviors
sameness (resistance to change)
ritualistic behaviors
restricted interests
self-injurious behavior
HOW it is diagnosed
behavioral observation from experienced clinician
medical and developmental history
in-person eval with gold-standard tests
corroborating evidence from multiple reporters
"M-CHAT" is quick screen for red flags
Osterling and Dawson
can diagnose kids by videos of first birthdays
based on social, affective, attention, communication
Biology and Etiology
onset in early childhood
high heritability
sibs 25x more likely to have it
5 males : 1 female
boys: more repetitive behaviors, more restricted or overly focused interests, tend to have trouble with vocab and word knowledge
girls: fewer behaviors, restricted interests more socially acceptable, better vocab and word knowledge
Teratogenic Etiology
"environmental hits" during pregnancy
heavy metals, drugs/alcohol, valproic acid, thalidomide, misoprostal
can trace exact impacts based off of time of hit during pregnancy
antibodies in the womb
Biological Etiology
specific genes associated, may be same as with schizophrenia (also similar symptoms, RDoc says may be related)
70-90% concordance in twins
impaired mirror neuron system --> trouble understanding
why
of actions but not
what
Prevalence
large increase since 2000 (as many as 1 in 68 in '10)
controlling for as many variables as possible, no clear change in prevalence. Increase due to broadened diagnostic criteria, increased availability of diagnostic tools, growing awareness, federal laws (
IDEA
) --> impetus for diagnosis
MMR vaccine
Wakefield
: British gastroenterologist, claimed link between MMR and ASD
Proof he was wrong
not equal rate across sexes
unvaccinated children wouldn't have ASD
symptoms would develop after shot, regardless of age
no replication
unqualified, n=12 with no control, biased sample, parent report, sketchy statistics, money from lobbyists suing MMR manufacturer, patent pending on new MMR schedule
Types
Syndromic
: "essential" (20%). Strongly suspected origin (genetic disorder, environmental "hit") but not
necessarily
causal
Idiopathic
: "essential" (80%). Unknown origin, diagnosis of exclusion
Treatment
Applied Behavioral Therapy
: operant conditioning of good behaviors and generalization of skills. Increases IQ by 20 points
ABA even better if in conjunction with
joint attention
(having parent or teacher mimic actions and maintain eye contact), symbolic play
SSRIs: reduce compulsions and reduce abnormal serotonin functioning
antipsychotics to reduce repetitive behavior
oxytocin injections to improve social functioning
Attention Deficit/ Hyperactive Disorder
restlessness, lack of attention, impulsiveness, miss subtle social cues and make social mistakes
must have 6+ symptoms for 6+ months
11% of boys and 5% of girls
etiology
disturbed families, poor parenting, social disadvantage
genetic: 55% in identical and 32% in nonidentical twins
reduced metabolism in areas of self regulation, motor function. Reduced connection between
frontal lobes
and
limbic system
abnormal activation of
prefrontal cortex
changes in
basal ganglia
which regulate motor behavior and impulse control
underactive brains (hyperactivity raises arousal levels)
diagnosed after entering school (5-7). Do not outgrow by adulthood but may learn to cope with it
treatment
stimulants
to reduce need for hyperactivity, may cause lack of responsibility for behaviors, reduced efficacy over time
behavioral therapy
slight advantage of both together
Thought Disturbance Disorders
Schizophrenia
Diagnosis
Positive Symptoms
Hallucinations
Disorganized speech or behavior
Delusions
Identity
: think you are Jesus, etc
Persecutory
: belief that others are persecuting, spying on, or trying to harm you
Referential
: belief that objects, events, or other people have particular significance to yourself
Guilt
: belief that you have committed a terrible sin
Control
: belief that your thoughts/behaviors are being controlled by an external force
Grandiose
: belief that you have great power, knowledge, talent
Negative Symptoms
Apathy
Lack of emotion
Slowed Speech/Movement
usually diagnosed in early adulthood but signs of unusual social behaviors, severe negative emotions, motor disturbances, problem behavior as kids
risk factors
family history
social impairment
substance abuse
unusual thoughts
suspicion/paranoia
Etiology
Genetic
monozygotic twins --> one has 50% likelihood of developing if other has it
fraternal twins --> 15%
siblings --> 10%
Environmental
child with genetic risk in dysfunctional family --> inc risk (vs healthy family --> low risk)
urban environmental stress (overcrowding --> "
behavioral Sink
: aggression, submissiveness, sexual deviance, reproductive abnormalities)
"schizovirus" hypothesis (may spread in urban areas more quickly)
Biological
dopamine
overactivity: 4x higher D4 receptors --> intensifies brain signals --> positive symptoms
frontal cortex
reduction
thalamus
amygdala
abnormal brain waves
abnormal brain morphology
(enlarged fluid ventricles and increased tissue loss)
temporal lobe
reduction
abnormal glial cells in myelin sheaths
Maternal Effects
conceived during famine --> inc risk
flu during fetal development --> inc risk
Treatment
Classical Antipsychotics
remove a number of positive symptoms but cause unpleasant side effects and don't treat negative symptoms
Newer Antipsychotics
greater reduction of positive symptoms block receptors for dopamine and serotonin to remove negative symptoms, less severe side effects --> greater compliance
prognosis: medication only --> 40% relapse, medication + social skills training --> 20%, medication + family therapy --> 20%, all three --> almost 0%
sometimes improves with age. the later the first symptoms the better the prognosis. women have better prognosis than men (also appears later in women). Better prognosis in developing countries b/c more extensive family networks --> support
Dissociative Disorders
splitting off of some parts of memory from conscious awareness, believed to be caused by trauma
Dissociative Amnesia
forgets that an event happened or loses awareness for substantial block of time
suddenly forget facts including identity
Dissociative Fugue
loss of identity
travel to new location and sometimes assumption of new identity
may end suddenly and person will not remember events during fugue state
Dissociative Identity Disorder
occurrence of two or more identities in the same individual
memory gaps in which person does not recall everyday events
etiology
women who were severely abused as children and coped by pretending it was happening to someone else
identities can differ on age, language, sexual orientation, gender, handwriting, etc
diagnosis often occurs when someone is accused of committing a crime
Personality Disorders
Antisocial Personality Disorder
Symptoms
lack of empathy or remorse
lack of fear and anxiety
often charming and intelligent
Epidemiology
usually in men
1-4% of pop
most apparent in late adolescence and early adulthood
generally improves by age 40
perhaps as much as 50% of prison pop
Ronson
: symptoms common among highly successful businessmen --> antisocial personality disorder can be valuable in some social settings
Etiology
slower alpha wave activity signifies lower overall arousal
relationships to socioeconomic status, child abuse, etc
smaller amygdala --> less responsive to negative stimuli
genetic
malnutrition in childhood
Treatment
very difficult to treat bc psychotropic medications ineffective
behavioral and cognitive approaches have had somewhat more success
most effective therapy is residential treatment center or correctional facility
stimulants to increase arousal only work short term
prevention: therapy for child with
conduct disorder
(persistent patterns of inappropriate behavior) to prevent development of APD
difference from psychopathy: no glibness, inflated self worth, shallow emotion, manipulativeness. Psychopaths kill with intention (want something), APDs kill impusively
inflexible and enduring behavior patterns that impair social functioning
3 clusters: odd/eccentric, dramatic/emotional/erratic, anxious/fearful
10% of pop total
Clusters
A
: odd or eccentric
B
: dramatic, emotional, erratic
C
: anxious or fearful
controversial because just extreme versions of normal personality traits
Borderline Personality Disorder
disturbances in identity, emotion, and impulse control (on the border between normal and psychotic). Lack strong sense of self, fear of abandonment, can't be alone --> manipulative behavior. Sleep disturbances
1-2% of adults, twice as common in men as women, high rate in prisoners
etiology
frontal lobes
: diminished function --> lack of impulse control
low
serotonin levels
trauma/abuse
unreliable/unavailable caretakers or rejection from caretakers
caretakers who encouraged dependence too much
treatment
traditional psychotherapy unsuccessful b/c impulsivity, emotional disturbances, identity disturbances
Dialectical Behavior Therapy (DBT)
"radical acceptance"
target extreme dysfunctional behaviors and replace with more appropriate ones
explore past trauma that might be root of emotional problems
develop self respect and independent problem solving
Treatment
Psychotherapy
: formal psychological therapy aimed at changing patterns of thought, emotion, or behavior
Biological Therapies
: based on notion that psychological disorders result from neural and bodily abnormalities
psychopharmacology
long-term success requires continued treatment, not necessarily effective over long periods of time
Psychodynamic Therapy (Freud)
: increase self-awareness of unconscious psychological processes (
insight
)
focus on relationships, fantasies, childhood, dreams
expensive, time consuming, minimal empirical evidence for Freud's theories
new approach focuses more on current relationships than childhood
Humanistic Therapy
: emphasizes personal experience and individual's belief system, treat patient as a whole
client-centered therapy
: encourages individual growth through greater self-understanding. create safe and comforting setting to access true feelings, unconditional positive regard. "
reflective listening
" = repeating concerns to help person clarify feelings
motivational interviewing
: client-centered approach over very short period to address ambivalence about problematic behaviors. Helps identify discrepancies between current state and ideal state. Good for drug/alcohol abuse
Behavior Therapy:
behavior is learned and can therefore be unlearned through classical and operant conditioning. Often includes exposure
Cognitive Therapy
: distorted thoughts can produce maladaptive behaviors and emotions. treatment modify these thoughts, changes the way brain functions!!!
cognitive restructuring
: recognize maladaptive thought patterns and replace them with ways of viewing the world that are more in tune with reality
rational emotive therapy
: therapist teaches client errors in thinking and demonstrates more adaptive thoughts
interpersonal therapy
: integrates cognitive and psychodynamic therapies to help understand social relationships and express emotions
mindfulness based cognitive therapy
: help awareness of negative thoughts and feelings and help learn to disengage through meditation
cognitive behavioral therapy
: correct faulty cognitions and train new behaviors
Group Therapy
: less expensive, learn from others' experiences, build social support. 8 people is ideal size, often augments individual therapy
Family Therapy
: focuses on family context (systems approach). Helps with family attitudes/ relationships/ expressed emotions, which are crucial to longterm prognosis. Expressed emotions do not always predict relapse if in culture where family intervention is accepted
cultural beliefs affect treatment efficacy
psychotropic medications
: affect mental processes by changing neurochemistry
antidepressants
MAO inhibitors (blocks serotonin breakdown in synapse)
tricyclic antidepressants, block neurotransmitter reuptake
SSRIs block serotonin reuptake
antipsychotics
traditional: bind to dopamine receptors, cause muscle twitching, do not treat negative symptoms
atypical antipsychotics block dopamine, serotonin, norepinephrine, acetylcholine, histamine
anti-anxiety
: increase GABA (inhibitory neurotransmitter). Cause drowsiness and addiction
Psychological Treatments
: evidence based psychotherapy
smith and glass
: no one type of psychotherapy necessarily superior