SUSS PSY 203 ABNORMAL PSYCHOLOGY STUDY UNIT 2 (Part 1 of 2) (EATING…
SUSS PSY 203 ABNORMAL PSYCHOLOGY STUDY UNIT 2 (Part 1 of 2)
ANXIETY, TRAUMA-RELATED/ STRESSOR RELATED, AND OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Anxiety, Fear, Panic: Definitions and disorders
A. Anxiety - Anxiety disorder
B. Fear/Panic - Phobia/Panic disorder
It is a
negative, future-oriented mood state
characterised by somatic symptoms of
physical tension and by apprehension about the future
Anxiety may be expressed as subjective unease, worried behaviours, and/or physiological responses
Includes the following:
Post-traumatic stress disorder (PTSD)
Obsessive-compulsive & related disorders.
Generalised anxiety disorder (GAD)
Separation anxiety disorder
3. Generalised anxiety disorder (GAD)
Generalised anxiety disorder (GAD)is often considered the basic anxiety disorder. It is characterised by
intense/ unfocused/ uncontrollable anxiety.
What distinguishes pathological worrying/anxiety from the normal kind we all experience occasionally, is the inability to control anxiety or worry process.
The physical symptoms of GAD differ from panic and include muscle tension, mental agitation, susceptibility to fatigue, irritability, and difficulty sleeping.
GAD may be
caused by several factors, including a genetic contribution
as indicated by twin studies. What is inherited appears to be a tendency to be anxious, not GAD itself.
Treatment of GAD has typically involved benzodiazepine
, although this has not been empirically supported.
focus on the worry process and avoidance
of feelings of anxiety and negative affect and seem to work about as well as drugs.
Exposure to worrisome thoughts and anxious images is utilised with
coping skills training
. Preliminary evidence supports this approach. Recently, a treatment for GAD has been developed that incorporates procedures focusing on acceptance rather than avoidance of distressing thoughts and feelings.
Generalised anxiety disorder (GAD) Model (Pg 133)
4. Separation anxiety disorder
Separation anxiety disorder is characterized by children’s unrealistic and persistent worry that something will happen to their parents or other important people in their life or that something will happen to the children themselves. As a result, the child may refuse to attend school or sleep alone
2. Obsessive-compulsive and related disorder
Obsessive-compulsive disorder (OCD)
A condition characterized by
patterns of Obsession
i.e. persistent, unwanted, irrational thoughts and behaviours.
Leading to compulsion
which repetitive actions to alleviate that compulsion.
Obsessive-compulsive disorder (OCD) is similar in many respects to the other anxiety disorders, but the dangerous event in OCD is not external but internal (i.e., thoughts, images, impulses).
People with OCD equate thoughts with the specific actions or activity represented by the thought, a phenomenon referred to as
Thought-action fusion may, in turn, be
caused by attitudes of excessive responsibility
and resulting guilt developed during childhood, when even a bad
thought is associated with evil intent.
learn this through
process of misinformation
Treatment of OCD includes drug therapy, however, the average treatment gain is moderate, and relapse is common when medications are discontinued.
The most effective psychological treatment is exposure and ritual prevention whereby the rituals are actively prevented and the patient is systematically and gradually exposed to the feared thoughts or situations
OCD Model (Pg 167)
Body Dysmorphic Disorder
an irrational, obsessive preoccupation with one's imagined and fictitious physical defect.
It was previously considered a somatoform disorder because of the focus on a “body” issue, but more recently the emphasis on the anxiety caused by the exaggerated or imagined defect has caused it to be recategorized as an anxiety disorder.
Patients suffering from BDD often turn to plastic surgery or other medical interventions which only increases their preoccupation and distress.
1. Posttraumatic stress disorder (PTSD)
PTSD often arises after a person
experiences a traumatic event and/or personal loss
during which induces fear, helplessness, or horror. The patient then continues to
re-experience the event through memories, re-enactments, nightmares, or flashbacks
In an attempt to avoid anything that reminds them of the trauma, the patient may often display a characteristic
restriction or numbing of emotional responsiveness
, which may be disruptive to interpersonal relationships.
PTSD cannot be diagnosed sooner than one month post-trauma.
The DSM-5 subdivides PTSD into acute and chronic types
Acute PTSD may be diagnosed one to three months after the traumatic event
Chronic PTSD is associated with more long-term avoidance and greater comorbidity than acute PTSD.
In psychoanalytic therapy, relieving emotional trauma to relieve emotional suffering (through imaginal exposure) is called
. The trick is in arranging the re-exposure so that it will be therapeutic rather than traumatic.
Cognitive therapy to correct negative assumptions about the trauma is often part of treatment.
Some SSRIs (e.g., Prozac, Paxil) may be helpful for PTSD because they relieve the severe anxiety and panic attacks that co occur with this disorder.
PTSD Model (Pg 161)
Fear is an immediate alarm reaction to danger (fight or flight response; emergency or defensive reaction fear).
Fear is a
present-oriented mood state characterised by strong avoidance
and activation of the sympathetic nervous system.
It differs psychologically and biologically from anxiety.
anxiety is a future-oriented mood state
, characterized by apprehension. Fear, on the other hand, is an immediate emotional reaction to current danger characterized by strong escapist action tendencies and, often, a surge in the sympathetic branch of the autonomic nervous system:
A panic attack is an
abrupt experience of intense fear
or discomfort accompanied by physical symptoms such as heart palpitations, chest pain, shortness of breath, and dizziness.
Two types of panic attacks are described in the DSM-5:
Expected (Cued) Panic Attack (Associated with specific /social phobia)
Unexpected (Uncued) Panic Attack (Associated with Panic disorder)
Expected (Cued) Panic Attack
i.e. If you know you are afraid of
high places or of driving over long bridges, you might have a panic attack in these situations but not anywhere else
extreme and irrational fear of a specific object
or situation that markedly interferes with one’s ability to function. The four major subtypes of specific phobia are as follows:
Major types of specific phobia
A situational phobia is characterised by fear of public transportation or enclosed places (e.g., Claustrophobia).
Initially taught to be similar to panic disorder but was later found to be different.
The main difference between situational phobia and panic disorder is that people with situational phobia never experience panic attacks outside the context of their phobic object or situation People with panic disorder, in contrast, might experience unexpected, uncued panic attacks at any time
Natural Environment Phobia
Natural environment phobia concerns
extreme fears of situations or events occurring in nature,
such as heights, storms, or water.
Note that they are
not phobias if they are only passing fears
. They have to be persistent (lasting at least six months) and to interfere substantially with the person’s functioning, leading to avoidance.
Persons suffering from blood-injury-injection phobia differ from all the other phobias because they experience drops in heart rate and blood pressure and increased urges to faint, as opposed to other phobias which trigger increase heart rates and blood pressure.
Also, this type of phobia runs in families more strongly than any phobic disorder we know
Animal phobia refers to
fears of animals and insects
Yes, I know, some fears are common but it becomes phobic if the fear severely interferes with normal functioning.
i.e people with mice phobias are unable to read magazines for fear of unexpectedly coming across a picture
of one of these animals
Causes of phobia
experiencing a false alarm (panic attack) in a specific situation
i.e. in regard to situational phobia, some people fear driving because they experienced an unexpected panic attack during which they
felt they were going to lose control of the car and cause a major accident. Their driving was not impaired, and their catastrophic thoughts were simply part of the panic attack.
Seeing someone else have a traumatic experience
may be enough to instil a phobia in the watcher.
Phobias acquired by direct experience, involve
experiencing real danger
or pain which results in an alarm response (a
being repeatedly cautioned about a particular danger.
i.e. Öst (1985) describes the case of a woman with an extremely severe snake phobia who had never encountered a snake. Rather, she had been told repeatedly while growing up about the dangers of snakes in the high grass
Specific Phobia Model (Pg 148)
The basic treatment of specific phobia is straightforward and involves
structured and consistent exposure
-based exercises in a supervised therapeutic context.
In addition, tension and release of muscle groups is
utilised to induce relaxation.
Social phobia refers to individuals who are extremely and shy in almost all social and performance-related situations
i.e. the inability of a skilled athlete to perform in front of an Olympic size crowd.
cognitive-behavioural treatment for social phobia includes
rehearsal or roleplay of feared social situations
in a group setting.
Evidence suggests that the
exposure component is more important
in treatment than the cognitive component.
In addition, intensive cognitive therapy and social support may be employed.
The causes of social phobia are complex.
It appears that humans may be
or prepared to fear angry, critical, or rejecting people or faces.
Some infants are predisposed to agitation and hyper-arousal when faced with new stimuli; such infants may also be predisposed to increased inhibition.
Social Phobia Model (Pg 152)
Unexpected (Uncued) Panic Attack
i.e. patient don’t have a clue when or where the next attack will occur. Hence the term 'unexpected' #YouDontSay
Panic Disorder and Agoraphobia (PAD)
occurs when a person experience an
unexpected panic attack and develop anxiety
about the possibility of another attack or the implications of the attack.
Many persons with panic disorder develop agoraphobia which is
fear and avoidance of ‘ unsafe’ situations
(i.e. fear and avoidance of situations which may induce a panic attack).
Some forms of agoraphobia involve
, or avoiding internal physical sensations that may mark onset of a panic attack
i.e. Avoiding exercise because it produces increased cardiovascular activity or faster respiration, which reminds them of panic attacks.
These factors may lead to
panic disorder with agoraphobia
(PDA) in which a person experience severe unexpected panic attacks during which time they feel a loss of control or endangered.
3 more items...
Causes of Anxiety and Related Disorders
Psychological contributions for anxiety and panic originated with Freud, who saw anxiety as a psychic reaction to danger surrounding the reactivation of an infantile fearful situation.
An integrated psychological model postulates that the
perception of uncontrollability
developed in the childhood - teenage years is a central psychological risk factor that
makes people vulnerable to anxiety
later in life.
This sense of uncontrollability emerges via interaction with parents who fail to provide a secure home and parents who are often overprotective and over intrusive.
Most psychologist view panic from the view point of conditioning.
A strong fear response initially occurs during extreme stress or perhaps as a result of a dangerous situation in the environment (a Unconditioned alarm).
This emotional response then becomes associated with a variety of external and internal cues (Conditioned stimulus).
These cues, or
conditioned stimuli, provoke the fear response and an assumption of danger
, even if the danger is not actually present so it is really a learned or conditioned alarm
Social contributions focus on the relation between
stressful life events as triggers
for biological and psychological vulnerabilities for anxiety and panic.
Many stressors that activate biological and psychological vulnerabilities to anxiety are interpersonal and domestic influences (e.g., marriage, divorce, work problems, death of a loved one, social pressures related to school, peers).
The same stressors can trigger physical reactions, such as headaches or hypertension, and emotional reactions, such as panic attacks
Biological contributions for anxiety and panic suggest that people
the tendency to be anxious or uptight. This is likely the result of weak
contributions from many genes that produce a vulnerability to a stress
response including excessive anxiety and panic.
Stress, as well as other psychological and social factors, may activate this vulnerability. The tendency to panic runs in families and seems to have a genetic component.
Brain circuits involved in Anxiety/Panic
Jeffrey Gray, identified a brain circuit in the limbic system heavily involved in anxiety and panic
For Anxiety, this circuit (AKA behavioural inhibition system - BIS) leads from the septal and hippocampal area in the limbic system to the frontal cortex.
When the BIS is activated by signals that arise from the brain stem or descend from the cortex, our tendency is to freeze, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present
For Panic, this circuit (originates fight/flight system - FFS).in the brain stem and travels through several midbrain structures, including the amygdala, the ventromedial nucleus of the hypothalamus, and the central grey matter.
When activated, this circuit produces an immediate alarm-and-escape response
One theory of the development of anxiety called the
triple vulnerability theory
intergrates the above three factors.
The first vulnerability (or diathesis) is a generalized biological vulnerability. (i.e. certain tandencies might be inherited).
The second vulnerability is a generalized psychological vulnerability. That is, you might also grow up believing the world is dangerous and out of control (hmm)
The third vulnerability is a specific psychological vulnerability in which you learn from early experience, such as being taught by your parents, that some situations or objects are dangerous (even if they really aren’t).
Anxiety and related
disorders often co-occur
. rates of comorbidity among anxiety disorders are high. Major depression is the most common secondary diagnosis in persons suffering from anxiety disorders (present in over 50% of cases).
Comorbidity with physical conditions is also common
, including thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraines, and allergies. Having an anxiety and related disorders in addition to one of these physical ailments results in a worse prognosis for the physical condition
SOMATIC SYMPTOM AND RELATED DISORDERS AND DISSOCIATIVE DISORDERS
Individuals with somatic symptom and related disorders are pathologically concerned with the appearance or functioning of their bodies (Soma means body)
They will raise these concerns to health professionals, who usually find no identifiable medical basis for the physical complaints.
DSM-V lists five basic somatic symptom and related disorders:
somatic symptom disorder
illness anxiety disorder
psychological factors affecting medical conditions
conversion disorder (functional neurological symptom disorder)
Somatic symptom and related disorders: An overview
Psychological factors affecting medical conditions
The essential feature of this disorder is the
presence of a diagnosed medical condition
such as asthma, diabetes, or severe pain clearly caused by a known medical condition such as cancer that is
adversely affected (increased in frequency or severity) by one or more psychological or behavioral factors.
These behavioral or psychological factors would have a direct influence on the course or perhaps the treatment of the medical condition.
One example would be anxiety severe enough to clearly worsen an asthmatic condition.
(functional neurological symptom disorder)
The term conversion was popularized by Freud, who believed the anxiety resulting from
unconscious conflicts somehow was “converted” into physical symptoms
to find expression. This allowed the individual to discharge some anxiety without actually experiencing it. The anxiety resulting from unconscious conflicts might be “displaced” onto another object.
In DSM-5, “functional neurological symptom disorder” is a subtitle to conversion disorder because the term is more often used by neurologists who see the majority of patients receiving a conversion disorder diagnosis, and because the term is more acceptable to patients.
“Functional” refers to a symptom without an organic cause.
Factitious disorder: Subset of Conversion Disorder
fall somewhere between malingering and conversion disorders
. The symptoms are under voluntary control, as with malingering, but there is no obvious reason for voluntarily producing the symptoms except, possibly, to assume the sick role and receive increased attention.
For example: An adult, almost always a mother, may purposely make her child sick, evidently for the attention and pity given to her as the mother of a sick child. When an individual deliberately makes someone else sick, the condition is called factitious disorder imposed on another.
Unconscious mental processes
are salient features of conversion disorders, as illustrated by the classic case of Anna O who upon days of experiencing immense physical and mental stress, had a horrific dream involving a snake. In that dream, Anna’s right arm was poisoned. As a result of this traumatic dream or hallucination, Anna O experienced periods of paralysis in her right arm each time she recalled this hallucination or dream.
Cause of Conversion Disorders
Freud described four basic processes in the development of conversion
Second, because the conflict and the resulting anxiety are unacceptable,
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.
This reduction of anxiety is considered to be the
or reinforcing event that maintains the conversion symptom
First, the individual experiences a
event—in Freud’s view,
an unacceptable, unconscious conflict
Fourth, the individual receives greatly
increased attention and sympathy
from loved ones and may also be allowed
to avoid a difficult situation
Freud considered such
attention or avoidance
to be the
, the secondarily reinforcing set of events
A principal strategy in treating conversion disorder is to
identify and attend to the traumatic or stressful life event
(Trying to detect and resolve Unconscious conflict) if it is still present either in real life or in memory.
Because conversion disorder has much in common with somatic symptom disorder, many of the treatment principles are similar. Therapeutic assistance in reexperiencing or “reliving” the event (catharsis) is a reasonable first step.
Removing the secondary gain, however, may be more challenging.
illness anxiety disorder
A.K.A hypochondriasis, illness anxiety disorder is characterized by anxiety or fear that one has a serious disease, even though they are not experiencing any notable physical symptoms at the time.
In illness anxiety disorder the concern is primarily with the idea of being sick instead of the physical symptom itself.
Somatic symptom disorder
Somatic symptom disorder is characterized by a
focus on one or more physical symptoms accompanied by marked anxiety and distress
focused on the symptom that is disproportionate to the nature or severity of the physical symptoms.
i.e. someone complaining of abdominal pains after undergoing a divorce.
The important factor in this condition is
, in this case, pain, has a clear medical cause or not,
psychological or behavioural factors,
particularly anxiety and distress, are compounding the severity and impairment
associated with the physical symptoms
Depending on the severity, this condition may dominate the individual’s life and interpersonal
Causes and treatment
Causes of Somatic symptom and illness anxiety disorder
The essential problem here is anxiety, but its expression is different from that of the other anxiety disorders.
In these two disorders, the individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease. Almost any physical sensation may become the basis for concern
Model of disorder on pg 188
taking the time to explain in some detail the nature of the patient’s disorder in an educational
framework was associated with a significant reduction in fears
Dissociative disorders are characterised by alterations or detachments in consciousness or identity involving either one of two experiences:
Dissociative Identity Disorder
adoption of new identities
(as many as 100),
all simultaneously coexisting
In some cases, these identities are complete, each with its own behaviours and characteristics.
But in many cases, only a few characteristics are distinct because identities are partially independent.
Terms to note
refers to the different identities or personalities in DID.
refers to the transition from one personality to another. Often a switch is instantaneous and may include physical transformations (e.g., posture, facial patterns).
is typically the identity that seeks treatment and the identity that tries to keep fragments of identity together, though the host often ends up becoming overwhelmed in the process. The host identity often develops later than the other identities.
DSM-5 criteria for DID include amnesia, as in dissociative amnesia. In DID, however, identity has also fragmented. How many personalities live inside one body is relatively unimportant;
the defining feature of this disorder is that certain aspects of the person’s identity are dissociated
There are several factors involved and explanation in regard to DID
DID is rooted in a natural tendency
to escape or “dissociate”
from the unremitting
negative affect associated with severe abuse
. This is supported by a study conducted by Putnam (1986) which revealed that almost all patients presenting with DID have histories of horrible, unspeakable child abuse, and usually sadistic sexual or physical abuse.
One perspective suggests that
DID is an extreme subtype of PTSD
, with a much greater
emphasis on the process of dissociation than on symptoms of anxiety
, although both are present in each disorder.
According to the autohypnotic model, people who are suggestible may be able to use dissociation as a
defence against extreme trauma
Evidence supporting the existence of distorted or illusory memories comes from experiments by Elizabeth Loftus and her colleagues. The evidence across numerous studies suggests that memories can be planted by strong suggestions by authority figures.
For DID, the focus of the treatment is on
reintegration of identities
and much of the treatment follows
similar treatments for PTSD.
The fundamental treatment goal with DID is to
identify cues or triggers that provoke memories of trauma and/or dissociation and to neutralise them.
The patient must also confront and relive the early trauma and gain control over memories of the horrible events. (Note that there is no evidence that hypnosis is a necessary part of treatment).
Experiences associated with Dissociative disorder
During an episode of derealization, your
sense of the reality of the external world is lost
. Things may seem to change shape or size; people may seem dead or mechanical.
These sensations of unreality are characteristic of the dissociative disorders because, in a sense, they are a psychological mechanism whereby one “dissociates” from reality.
During an episode of depersonalization,
your perception alters so that you temporarily lose the sense of your own reality
, as if you were in a dream and you were watching yourself
MOOD DISORDERS AND SUICIDE
mood disorders are characterized by
gross deviations in mood.
experiences of depression and mania contribute, either singly or together, to all the mood disorders.
that most importantly
describe mood disorders
severity and chronicity.
model of mood disorders on Pg 247
Note the two main subdivide for mood disorder:
A. Depressive disorders
B. Bipolar disorder
An Overview of Depression and Mania
Major depressive episode
The most common and severe form of depression.
DSM-5 criteria for major depressive episode includes:
i.e. feelings of worthlessness and indecisiveness.
i.e. loss of interest or pleasure in usual activities.
Disturbed physical functions
. i.e. altered sleeping patterns, significant changes in appetite and weight.
Extremely depressed mood
state lasting at least
Average duration of an untreated major depressive episode is four to nine months.
Mania refers to abnormally
, joy, or euphoria accompanied by extraordinary activity (
), decreased need for sleep
May include grandiose plans and rapid speech (speech may become incoherent).
May also involve a flight of ideas (i.e.,
attempt to express many ideas at once
DSM-5 criteria for a manic episode includes:
A duration of
; less if the episode is severe enough to require hospitalisation.
Average duration of an untreated manic episode is three to six months.
Anxiousness and depression
often accompanies the manic episode
toward the end of its duration
A hypomanic (hypo means below) episode is a
less severe version of a manic episode
that does not cause marked impairment in social or occupational functioning.
Structure and Types of Mood Disorders
alternates between depression and mania
is said to have a bipolar mood disorder travelling from one “pole” of the depression-elation continuum to the other and back again.
The core identifying feature of bipolar disorders is the
tendency of manic episodes to alternate with major depressive episodes.
During manic or hypomanic phases, patients
often deny they have a problem
The high during a manic state is so pleasurable that people may
stop taking their medication
during periods of distress or discouragement
in an attempt to bring on a manic state again
; this is a serious challenge to professionals.
Bipolar II Disorder
In bipolar II disorder,
major depressive episodes alternate with hypomanic
episodes instead of a full manic episode
Cyclothymic disorder is a more chronic version of bipolar disorder.
Here manic and major depressive episodes are less severe. Such persons
tend to remain in either a manic or depressive mood state for several years
with very few periods of neutral mood.
For the diagnosis, the pattern must last for at least two years (one year for children and adolescents). Such persons are also at increased risk of developing bipolar I or II disorder
Bipolar I Disorder
Bipolar I disorder is the
alternation of full manic episodes and depressive
Full blown both ways
Basic Specifiers/features of Bipolar Disorders
All of the same specifiers listed for depressive disorders apply to bipolar disorders.
There is one specifier that is unique to bipolar I and II disorders:
Characterized by the relatively
rapid transition between and manic episodes
An individual with bipolar disorder who experiences at least four manic or depressive episodes within a year is considered to have a rapid-cycling pattern, which appears to be a severe variety of bipolar disorder that does not respond well to standard treatments
3. Mixed features
Note that depression and elation may not be at exactly opposite ends of the same mood state.
i.e. An individual can experience
manic symptoms but feel somewhat depressed
or anxious at the same time, or be depressed with a few symptoms of mania.
This episode is characterized as having “mixed features”
1. Unipolar - One Pole
experience either depression or mania
are said to suffer from a unipolar mood disorder, because their
mood remains at one “pole”
of the usual depression-mania continuum.
Mania by itself (unipolar mania) does occur but seems to be rare, because most people with a unipolar mood disorder eventually develop depression.
DSM-5 describes several types of depressive disorders. These disorders differ from one another in the frequency and severity (chronic—meaning almost continuous—or nonchronic). Types include:
Major depressive disorder
Persistent depressive disorder
Premenstrual dysphoric disorder
1. Major depressive disorder
Defined by the absence of manic, or hypomanic episodes before or during the disorder
Major depressive disorder, recurrent
requires that two or more major depressive episodes occur and are separated by a period of at least two months during which the individual is not depressed
Major depressive disorder, single episode
is the occurrence of one isolated depressive episode in a lifetime
2. Persistent depressive disorder (dysthymia)
It is defined as a depressed mood that
continues at least 2 years
, during which the patient cannot be symptom-free for more than 2 months at a time even though they may not experience all of the symptoms of a major depressive episode.
Shares many of the symptoms of major depressive disorder, but unlike major depression, the
symptoms in dysthymia tend to be milder and remain relatively unchanged over long periods of time
, as many as 20 or 30 years
3. Double depression
It refers to
both major depressive episodes and dysthymic disorder.
Typically, a few depressive symptoms develop first, perhaps at an early age, and then one or more major depressive episodes occur later only to revert to the underlying pattern of depression once the major depressive episode has run its course
4. Premenstrual dysphoric disorder (PMDD)
PMDD and disruptive mood dysregulation disorder have both been added to DSM-5. PMDD is
marked by severe and sometimes incapacitating mood-related symptoms that precipitate a woman’s menstrual period
Disruptive mood dysregulation disorder is
marked by frequent temper outbursts
that involve extreme verbal and/or physical acts of aggression, an absence of indications of manic episodes that would indicate a bipolar-related illness, and presence of symptoms prior to the age of 6 years.
Basic Specifiers/features of Depressive Disorders
In addition to rating severity of the episode as mild, moderate, or severe, clinicians use
eight basic specifiers
or features to describe depressive disorders.
Some of these specifiers apply particularly to major depressive disorder. Others apply to both major depressive disorder and persistent depressive disorder.
Also note that all listed are applicable to Bipolar disorder.
They are as follow:
with psychotic features (mood-congruent or mood-incongruent)
with anxious distress (mild to severe)
with mixed features
with melancholic features
with atypical features
with catatonic features
with peripartum onset
with seasonal pattern.
8. Seasonal pattern specifier.
This temporal specifier applies to recurrent major depressive disorder (and also to bipolar disorders). It accompanies episodes that occur during certain seasons (
for example, winter depression
most usual pattern is a depressive episode that begins in the late fall and ends with the beginning of spring
. (In bipolar disorder, individuals may become depressed during the winter and manic during the summer.)
These episodes must have occurred for at least two years with no evidence of nonseasonal major depressive episodes occurring during that period of time. This condition is
called seasonal affective disorder (SAD)
1. Psychotic features specifiers.
Some individuals in the midst of a major depressive (or manic) episode may experience psychotic symptoms,
specifically hallucinations and delusions
Psychotic features, in general, are associated with a poor response to treatment, greater impairment, and fewer weeks with minimal symptoms, compared with nonpsychotic depressed patients
Mood-incongruent hallucination and/or delusion
On rare occasions, depressed individuals might have other types of hallucinations or delusions such as delusions of grandeur (believing, for example, they are supernatural or supremely gifted) that
do not seem consistent with the depressed mood
. This is a mood-incongruent hallucination or delusion
Mood-Congruent Hallucinations and/or delusions
Hallucinations and delusion which seem directly related to the depression
are called mood congruent.
For example, patients may have somatic (physical) delusions, believing that their bodies are rotting internally and deteriorating into nothingness. Some may hear voices telling them how evil and sinful they are (auditory hallucinations).
7. Peripartum onset specifier.
Peri means “surrounding”, in this case the period of time just before and just after the birth. This specifier
can apply to both major depressive and manic episodes
. Typically a somewhat higher incidence of depression is found postpartum (after the birth) than during the period of pregnancy itself.
, most people, including the new mother herself,
have difficulty understanding why she is depressed, because they assume this is a joyous time.
(Many people forget that extreme stress can be brought on by physical exhaustion, new schedules, adjusting to nursing, and other changes that follow the birth.)
During the peripartum period (pregnancy and the 6 month period immediately following childbirth) there have been cases of mothers in the midst of a psychotic depressive episode killing her newborn child.
2. Anxious distress specifier.
The presence and severity of accompanying anxiety, whether in the form of comorbid anxiety disorders (anxiety symptoms meeting the full criteria for an anxiety disorder) or anxiety symptoms that do not meet all the criteria for disorders.
This is perhaps the most important addition to specifiers for mood disorders in DSM-5. For all depressive and bipolar disorders,
the presence of anxiety indicates a more severe condition
, makes suicidal thoughts and completed suicide more likely, and
predicts a poorer outcome from treatment.
6. Atypical features specifier.
This specifier applies to both depressive episodes, whether in the context of persistent depressive disorder or not. While most people with depression sleep less and lose their appetite, individuals with this specifier consistently oversleep and overeat during their depression and therefore gain weight, leading to a higher incidence of diabetes. Although they also have considerable anxiety, they can react with interest or pleasure to some things, unlike most depressed individuals. In addition, depression with atypical features, compared with more typical depression, is associated with a greater percentage of women and an earlier age of onset. The atypical group also has more symptoms, more severe symptoms, more suicide attempts, and higher rate of comorbid disorders including alcohol abuse
3. Mixed features specifier.
depressive episodes that have several
(at least three) s
ymptoms of mania
as described above would meet this specifier, which applies to major depressive episodes both within major depressive disorder and persistent depressive disorder.
5. Catatonic features specifier.
This specifier can be applied to major depressive episodes whether they occur in the context of a persistent depressive order or not, and even to manic episodes, although it is rare—and rarer still in mania. This serious condition
involves an absence of movement (a stuporous state) or catalepsy
, in which the muscles are waxy and semirigid, so a patient’s arms or legs remain in any position in which they are placed.
may also involve excessive but random or purposeless movement
. Catalepsy was thought to be more commonly associated with schizophrenia, but some recent studies have suggested it may be more common in depression than in schizophrenia.
4. Melancholic features specifier.
applies only if the full criteria for a major depressive episode have been met
, whether in the context of a persistent depressive disorder or not.
include some of the more severe somatic (physical) symptoms
, such as early-morning awakenings, weight loss, loss of libido (sex drive), excessive or inappropriate guilt, and anhedonia (diminished interest or pleasure in activities). The concept of “melancholic” does seem to signify a severe type of depressive episode.
Causes of Mood Disorders
Stressful and traumatic events
Stressful and traumatic events influence mood disorders
, although the context, meaning, and memory of an event must be considered. In general, a marked relationship has been found between severe life events, onset of depression, poorer response to treatment, and longer time before remission.
New research suggests that one-third of the association between stressful life events and depression is due to vulnerability whereby depressed persons place themselves in high-risk stressful situations (i.e., reciprocal gene-environment model).
stressful life events and circadian rhythm disturbances may trigger manic episodes
. However, only a minority of people experiencing a negative life event develop a mood disorder; therefore,
interaction with a biological vulnerability is likely.
Learned helplessness theory of depression.
According to this theory, people
and anxiety when they assume they have
no control over life stress
Depression results from a tendency to
interpret life events in a negative way.
Persons with depression often engage in several cognitive errors and think the worst of everything.
In family studies, we
look at the prevalence
of a given disorder in the first-degree relatives of an individual known to have the disorder (the proband). We have found that the
rate in relatives of probands with mood disorders is consistently about 2 to 3 times greater than in relatives who don’t have mood disorders.
if one identical twin presents with a mood disorder, the other twin is three times more likely than a fraternal twin to have a mood disorder
, particularly for bipolar disorder.
Data from family and twin studies also suggest that the
biological vulnerability for mood disorders may reflect a more general vulnerability for anxiety disorders
low levels of serotonin as a cause of mood disorders
in relation to other neurotransmitters,
including norepinephrine and dopamine.
of depression has implicated the endocrine system, particularly
elevated levels of cortisol
Sleep disturbances are a hallmark of most mood disorders.
move into the period of rapid eye movement sleep
(REM) more quickly than non-depressed persons and also show diminished slow wave sleep
(i.e., the deepest and most restful part of sleep).
Brain Function: Brain Wave Activity Different
Alpha electroencephalogram (EEG) values have been reported in the two hemispheres of brains of depressed persons.
Depressed persons show greater right-side anterior activation
of the cerebral hemispheres (i.e., less left-side activation and hence less alpha wave activity) than non-depressed persons.
This type of brain function may be
an indicator of a biological vulnerability for depression
, as it is seen in adolescent offspring of depressed mothers.
Social and Cultural Dimensions
Marital dissatisfaction and depression are strongly related
, and marital disruption often precedes depression.
Lack of social support
appears to predict the later onset of depressive symptoms, and high expressed emotion or dysfunctional families may predict relapse.
Current data suggest that combining medication and psychosocial treatments may provide an added benefit over providing each treatment alone.
Electroconvulsive therapy (ECT)
Electroconvulsive therapy (ECT) is the treatment of
choice for very severe depression
. Approximately 50% of persons not responding to medication benefit from ECT. However,
relapse is extremely common
, necessitating follow-up with antidepressant drugs.
Transcranial magnetic stimulation (TMS)
is a new procedure that is related to ECT, but
involves setting up a strong magnetic field around the brain
. Mixed data exist regarding whether TMS is superior to ECT.
At least three major psychosocial treatments are available for depressive disorders.
Cognitive-behaviour therapy (CBT)
Lewinson and Rehm developed a form of cognitive-behaviour therapy (CBT) for depression that focused initially on
reactivating depressed patients
countering their mood
by bringing them in contact
with reinforcing events.
It is possible that increased activities alone may improve self-concept and lift depression, suggesting that the behavioural component of CBT may be the active ingredient of treatment.
Interpersonal therapy (IPT)
IPT focuses on resolving problems in existing relationships and/or building skills to develop new relationships.
Aaron Beck’s cognitive therapy involves teaching clients to
the types of
they engage in while depressed and
recognise cognitive errors
when they occur.
Correct cognitive errors
Substitute more adaptive thoughts
Identify errors in thinking
Correct negative cognitive schemas
Three basic types of antidepressant medications used to treat depressive disorders:
monoamine oxidase (MAO) inhibitors
selective-serotonin reuptake inhibitors (SSRIs)
Note that approximately 30% of depressed persons do not respond to these medications, and females of childbearing age must avoid conceiving while taking antidepressants.
Monoamine oxidase (MAO)
MAO inhibitors work by
blocking an enzyme
that breaks down serotonin and norepinephrine.
MAO inhibitors are slightly more effective than tricyclics and have
MAO inhibitors are
used far less often because of two potentially serious consequences
Eating and drinking foods beverages containing tyramine, (i.e.cheese, red wine, or beer) can lead to severe hypertensive episodes and even death.
other drugs that people take daily, such as cold medications, are dangerous and even fatal in interaction with an MAO inhibitor
Therefore, MAO inhibitors are usually prescribed only when other antidepressants are not effective
Tricyclic antidepressants are widely used treatments for depression, and include imipramine (Tofranil) and amitriptyline (Elavil).
Tricyclic antidepressants seem to have their greatest effect by
systems, particularly serotonin, are
Also note that apart from these four antidepressants, Lithium has been the primary drug of choice in the treatment of bipolar disorder. Lithium is a common salt found in the natural environment, including drinking water. About 30% to 60% of persons with
bipolar disorder respond well to lithium treatment
Serotonin-specific reuptake inhibitors (SSRIs)
reuptake of serotonin
increasing levels of serotonin at the receptor site.
Perhaps the best-known drug in this class is fluoxetine (
Factors related to suicide have been investigated through the use of a
, studying conditions related to an individual’s suicide.
Risk factors for suicide include the following
Existence of a psychological disorder is related to suicide, as over 90% of people who kill themselves suffer from a psychological disorder. As many as 60% of suicides occur in persons suffering from a mood disorder.
Note that depression and suicide are still considered independent, as suicide can occur without a mood disorder, and not all persons with mood disorders try to kill themselves
Alcohol use and abuse are associated with 25% to 50% of suicides.
Low levels of serotonin – associated with impulsivity, instability, and the tendency to overreact to situations.
Past suicide attempts is another strong risk factor in predicting subsequent suicide attempts; one study found a 30-fold increase in the risk of completed suicide among individuals with prior deliberate self-harm
If a family member commits suicide, there is an increased risk that someone else in the family will also do so.
Both learned behaviour and inherited traits, such as impulsivity, may account for this finding.
Most important risk factor for suicide is a severe, stressful event that is experienced as shameful or humiliating.
Treatments for persons at risk for suicide may employ a problem-solving cognitive-behavioural intervention, coping-based interventions, and stress reduction techniques.
Freud believed that suicide was the result of
expressed inwardly to the self.
about committing suicide
surviving an attempted suicide
Threshold model for suicidal behavior on pg 261
Males are four to five times more likely to commit suicide than females, although females are three times more likely to attempt suicide than men. This is explained by the fact that men choose more lethal methods of suicide than women.
Major Types of Eating Disorders
Note that both anorexia and bulimia are marked by a morbid fear of gaining weight and losing control over eating. The major difference is whether the person is successful in losing the weight. Persons with anorexia nervosa, unlike bulimics, are highly successful at losing weight
An integrative causal model of eating disorders Pg 285
2. Anorexia Nervosa
The core feature of anorexia nervosa is an
intense fear of obesity
relentless and successful pursuit of thinness
This disorder often begins with normal dieting but evolves into an obsessive preoccupation with being thin. Rigorous exercise and dramatic weight loss are seen.
Anorexia is less common than bulimia; however, many individuals with bulimia have a history of anorexia.
The DSM-5 specifies the following
of anorexia nervosa
, individuals diet to limit caloric intake.
persons rely on purging to limit caloric intake. Unlike bulimics, the binge and purge in this subtype involves small amounts of food and the purges occur more consistently
of anorexia nervosa include the following:
Amenorrhea, or the cessation of menstruation (most common complication). However, this feature is inconsistently present.
Other medical consequences include dry skin, brittle hair or nails, and sensitivity to and intolerance for cold temperatures.
Lanugo, or downy hair on the limbs and cheeks, is also common.
Cardiovascular problems (e.g., low blood pressure and heart rate).
Vomiting in anorexia results in similar medical problems as bulimia.
3. Binge-Eating Disorder
Persons with binge eating disorder (BED) experience
due to binge eating
but do not engage in extreme compensatory behaviours
Binge eating disorder appeared in the appendix of the DSM-IV-TR as a potential new disorder requiring further study.
Persons with BED are found in weight control programmes and show the following characteristics:
Such persons show an increased frequency of other comorbid psychological disorders and more psychopathology in general than obese people who do not binge.
About 50% of such persons try dieting before resorting to binging, while half start with binging.
Like anorexics and bulimics, persons with binge-eating disorder share similar concerns with shape and weight.
Recent studies have indicated that BED and obesity are caused by separate factors, and that BED is associated with more severe obesity. Approximately 20% of obese individuals in weight-loss programmes binge eat
1. Bulimia Nervosa
Marked by three key characteristics:
an excessive concern with body shape
Unplanned, characterised by stress (i.e. interpersonal stress)
The hallmark of bulimia nervosa is binge eating.
A binge is defined as “a larger amount of food than most people would eat under the circumstances”.
A binge is also marked by uncontrollability, with an average binge consisting largely of junk food.
persons with bulimia attempt to compensate for binge eating by engaging in purging techniques.
Common techniques include self-induced vomiting immediately after eating, laxative abuse, and diuretics (i.e., drugs that result in loss of fluids through greatly increased frequency of urination). Some persons with bulimia exercise excessively, whereas others fast.
Bulimia is subtyped as either purging or nonpurging types.
includes vomiting, laxatives,
or diuretics to compensate binge eating
associated with chronic bulimia of the purging type:
Salivary gland enlargement caused by repeated vomiting. The result is a chubby facial appearance.
Erosion of dental enamel on the inner surface of the front teeth.
May produce an electrolyte imbalance (i.e., disruption of sodium and potassium levels) which can lead to potentially fatal cardiac arrhythmia and renal failure.
Intestinal problems resulting from laxative abuse.
calluses on the fingers and backs of hands resulting from efforts to vomit by stimulating the gag reflex.
includes exercise and/or fasting to compensate binge eating
Causes of Eating Disorders
The typical family of someone with anorexia tends to be successful, hard-driving, concerned with external appearances, and eager to maintain harmony. Family members often deny or ignore conflicts and have communication problems
Anorexia and bulimia tend to be
and are found
more so in
cultures or groups that have become more
acculturated or Westernised
, particularly in those who identify with Caucasian middle class values.
Several factors, in addition to cultural considerations, have been implicated
as causes of anorexia and bulimia
Cultural imperative for thinness
directly results in dieting, the first step down the slippery slope toward bulimia and anorexia.
of ideal body size change as much as fashion style in clothes.
Magazines and the
glorify slenderness. Resulting in a skewed perception of ideal weights for men and women.
If members of one’s social group resort to extreme dieting or other weight loss techniques, there is a greater chance that others in the group will do the same
Treatments of social influences
Inoculation should begin at a young age. As such, early education should be important.
Observe how they cope with stress and stressor as eating disorder patients are perfectionist.
some neurobiological abnormalities do exist in people with eating disorders but that they may be a result of semistarvation or a binge–purge cycle rather than a cause, although they may well contribute to the maintenance of the disorder once it is established.
(Neurobiological abnormalities associated with eaiting disorders include Low serotonergic activity)
Anorexia and bulimia are strongly related to developmental considerations.
Differential patterns of
in girls and boys seem to
interact with cultural influences
create eating disorders
. i.e. looking tall and muscular for males and prepubertal for females.
Poor self esteem coupled with perfectionist self perception
Many females with eating disorders have a diminished sense of personal control and confidence in their abilities and talents.
They are also perfectionists, but more importantly show an intense preoccupation with how they appear to others, and perceive themselves as frauds in the process
An integrative model is proposed that emphasises the following shared characteristics across eating disorders:
Similtude to mood disorders & anxiety
Eating disorders share many of the same biological and psychological vulnerabilities as the anxiety and mood disorders, with anxiety and fear focused on becoming overweight.
Cultural and social pressures to be thin motivate significant restriction of eating, usually via severe dieting; this, coupled with familial pressures to succeed and emphasis on physical appearance, may activate the psychological vulnerability
Treatment of Eating Disorders
Focus on the process not the outcome
Psychosocial treatments that target a patient’s low self-esteem or family interaction problems are largely ineffective for eating disorders.
Cognitivebehavioural therapy (CBT)
targets problematic eating behaviour and associated attitudes about body weight and shape.
Interpersonal psychotherapy (IPT)
focuses on interpersonal relationships and functioning.
Psychosocial treatment of binge-eating disorder follows CBT for bulimia
. Patients who are able to stop binging show the most substantial and lasting weight loss. IPT is also as effective as CBT as a treatment.
The most important initial goal (and often the easiest goal to meet) in the treatment of anorexia involves weight restoration. Long-term outcome for anorexia is poorer than outcomes for treatment of bulimia.
been shown to be
for the treatment of anorexia nervosa.
for bulimia are
similar to those used for anxiety and mood disorders
Antidepressants can reduce binging and purging; however,
antidepressant drugs alone do not have a substantial long-lasting impact on bulimia nervosa
Obesity is not formally considered an eating disorder in the DSM. But in the year 2000, the number of adults with excess weight worldwide surpassed the number of those who were underweight.
The prevalence of obesity is so high that one might consider it statistically “normal” if it weren’t for the serious implications for health, as well as for social and psychological functioning.
Obesity epidemic is clearly related to the spread of modernization. That is, the promotion of an inactive, sedentary lifestyle and the consumption of a
high-fat, energy-dense diet is the largest single contributor to the obesity epidemic.
Genes are thought to account for about 30% of the variance in the
causation of obesity.
The treatment of obesity is only moderately successful at the individual level, with somewhat greater long-term evidence for effectiveness in children and adolescents, compared to adults.
Treatment for obesity can take the form of self-directed weight-loss programmes, commercial self-help programmes, professionally directed behaviour modification programmes, or bariatric surgery.
Disordered Eating Patterns in Cases of Obesity
There are two forms of maladaptive eating patterns in people who are obese
Binge eating disorder (BED)
Night eating syndrome
Individuals with night eating syndrome consume a third or more of their daily intake after their evening meal and get out of bed at least once during the night to have a high-calorie snack.
Sense of self-worth based on weight
Use food as a means to feel in control