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Week 5: Substance-Related Disoders, Week 5: Personality disorders - Coggle…

- - - - Substance use disorders
        
        Cluster of cognitive, behavioral and physiological symptoms indicating person continues to use the substances despite significant substance-related problems
      - Substance-induced disorders
        
        Problems arising from the impact of using a substances or discontinuing its repeated use
    - - Currently includes only Gambling disorder
      - Other excessive behavioural patterns (e.g internet gaming, shopping addiction, sex addiction) not included in DSM-5 due to insufficient research evidence
  - - - 2-3 criteria: mild disorder
      - 4-5 criteria: moderate disorder
      - More than 6 criteria: Severe disorder
- - - - Describe that it is physical torture, mental torture, "coming undone at the seams", crawling out of skin, etc (living like in hell)
      - Consumed Opioid (?) when he was 16
        
        When the first dose hits the bloodstream, the chemical attaches itself to opioid receptors in the brain, blocking pain signals
        
        The effect is immensely pleasurable and addictive
        
        With prolonged opioid use, the body gets used to a slower rate of functioning
      - When you remove the drug and the chemical from your system your body just unravels
    - - The part of the brain that handles emotions (the hippocampus) goes into overdrive
      - This causes feelings of extreme anxiety
      - Eg drenched in sweat - like all your bodily fluids are coming out of your body
      - The hypothalamus (body's thermostat) goes haywire
      - The sweat glands perspire heavily, regardless of body temperature.
      - Stomach is twisted in knots and a lot of people end up puking
        Some people had violent diarrheic
      - Opioids can also cause constipation - > but when the drug is not present, body expels waste through vomiting or diarrhea
      - Bones start to ache, land also have flu-like symptoms
      - Active users are accustomed to having their pain receptors blocked, but when they begin to function again, minor muscle aches and everyday discomforts feel extremely painful
- - - - Alcohol
- - - - Eg Focus alert feeling you experience the first time you drink a cup of caffeinated coffee in the morning
  - - - Many executive functions, like planning and goal-directed behaviours are localized in the prefrontal cortex
    - - The release of dopamine in the nucleus accumbens is maintained at a steady or tonic level
  - - - Normally we crave what we like and like what we crave
      - But if these two systems become uncoupled, then we may no longer like or enjoy what we crave
      - Eg Chronic drug users experience intense craving for a drug, but no longer experience the desired amount of pleasure following drug administration - the drug user can develop tolerance to the pleasurable effects of the drug
- - - - Persistent: Longstanding, relatively stable over time (from mid-adolescence onwards)
      - Pervasive: Affect entire life adjustment (e.g emotional functioning, social interactions, employment etc)
      - Problematic: Disturbed thinking and behaviour deviating markedly from social norms and causing distress to self/others
    - - " Enduring pattern of inner experience and behaviour that deviates markedly from expectations of individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment "
  - - - Cognition (i.e. ways of perceiving and interpreting self, other people & events
        
        Not in terms of memory, attention etc, but cognitive appraisal of situations
      - Affectivity (i.e., range, intensity, liability & appropriateness of emotional response).
      - Interpersonal functioning
      - Impulse control
- - - - Paranoid: Distrust and suspiciousness
      - Schizoid: Social detachment and Restricted emotions
      - Schizotypal: Social discomfort, Cognitive disturbance, Eccentric behaviour
    - - Histrionic: Excessive emotionality & Attention Seeking
      - Narcissistic: Grandiosity, Lack of Empathy
      - Antisocial: Disregard & Violation of others
      - Borderline: Instability (Interpersonal, personal, emotional and behavioural)
    - - Avoidant: Social inhibition, inadequacy, hypersensitive to criticism
      - Dependent : Excessive need to be taken care of
      - Obsessive-compulsive: Preoccupation with orderliness, Perfectionism , control
- - - - A. Pervasive distrust and suspiciousness of others such that motives are interpreted as malevolent,
        beginning by early adulthood and present in a variety of contexts, indicated by ≥ 4 of:
        
        Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him/her
        
        Preoccupied with unjustified doubts about loyalty or trustworthiness of friends / associates
        
        Reluctant to confide in others because of unwarranted fear that information will be used maliciously against him / her
        
        Reads hidden demeaning or threatening meanings into benign remarks or events.
        
        Persistently bears grudges (i.e., unforgiving of insults)
        
        Perceives attacks on his/her character or reputation that are not apparent to others and is quick to
        react angrily or to counterattack
        
        Recurrent suspicions, without, justification, regarding fidelity of spouse or sexual partner
      - B. Does not occur exclusively during course of another mental disorder (e.g., Schizophrenia, Bipolar Disorder) and not attributable to physiological effects of another medical condition
    - - 1%-2.5% general population, no gender difference, ↑ in clinical setting
    - - Modest genetic liability (↑ risk in relatives with Delusional Disorder & Schizophrenia)
      - Heritability of ↑ antagonism & neuroticism traits
      - Parental neglect/abuse & exposure to violent adults (though not specific to just this PD).
  - - - A. Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, indicated by ≥ 4 of:
        
        Neither desires nor enjoys close relationships, including being part of a family
        
        Almost always chooses solitary activities.
        
        Has little, if any, interest in having sexual experiences with another person
        
        Takes pleasure in few, if any, activities.
        
        Lacks close friends or confidants other than first degree relatives
        
        Appears indifferent to the praise or criticism of others
        
        Shows emotional coldness, detachment, or flattened affectivity
        
        B. Does not occur exclusively during course of another mental disorder (e.g., Schizophrenia, Bipolar Disorder, Autism Spectrum Disorder) and not attributable to effects of another medical condition
    - - Increase neuroticism trait, high heritability (55%), Increased risk in relatives of individuals with schizophrenia or Schizotypal PD, genetic link with Autism Spectrum Disorders
  - - - A. Pervasive pattern of social & interpersonal deficits marked by acute discomfort, ↓ capacity for close relationships, cognitive / perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, indicated by ≥ 5 of the following
        
        Ideas of reference (excluding delusions of reference)
        
        Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms
        (e.g., superstitiousness, telepathy, ‘sixth sense’, bizarre fantasies or preoccupations
        
        Unusual perceptual experiences, including bodily illusions
        
        Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate).
        
        Suspiciousness or paranoid ideation
        
        Inappropriate or constricted affect
        
        Behaviour or appearance that is odd, eccentric, or peculiar.
        
        . Lack of close friends or confidants other than first degree relatives
        
        Excessive social anxiety that does not diminish with familiarity and tends to be associated with
        paranoid fears rather than negative judgements about self
      - B. Does not occur exclusively during another mental disorder (e.g., Schizophrenia, Bipolar, Autism)
    - - 3%-4% of general populations;
    - - genetic abnormalities similar to
        Schizophrenia; moderate heritability, ↑ risk in 1 st degree relatives with Schizophrenia
- - - - Failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly
        performing acts that are grounds for arrest.
      - Deceitfulness, as indicated by repeated lying, use of aliases, conning others for personal profit or
        Pleasure
      - Impulsivity or failure to plan ahead
      - Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
      - Reckless disregard for safety of self or others
      - Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or
        honor financial obligations
      - Lack of remorse, as indicated by being indifferent to or rationalising having hurt, mistreated another
- - - - Recognise emotional experiences by how they manifest in the body (eg: butterflies in the
        stomach indicating anxiety).
      - Learning to experience emotions instead of pushing them away (“This feeling will come
        and go”)
      - Anticipate situations and hold a broader perspective through reframing meaning of events
        (“My anxiety is making this situation look scary. It is in fact no big deal”)
    - - Prefrontal cortex: regulates attention, impulse control, planning, cognitive reappraisal, and
        perspective-taking
      - Connection between prefrontal cortex and autonomic nervous system
        
        integrates appraisal of situation with awareness of physiological and psychological arousal, enabling one to meet life’s challenges with insight and ease
  - - - Emotional dysregulation occurs when child with high emotional vulnerability is exposed to invalidating environment
    - - Child’s personal expressions of needs, fears and desires are not accepted as accurate description of true feelings (eg: “No, that’s not painful. Don’t cry. That’s bad behaviour”. “You call that nice artwork?”)
        
        Physical and/or sexual abuse
        
        Neglect and seperation
        
        Erratic and inconsistent responses by significant others
      - What this results in
        
        Child is unable to label and understand own feelings appropriately
      - Oscillates between emotional inhibition to gain acceptance and extreme displays of emotions in order to have feelings acknowledged
      - Often associated with self-harm and suicide attempts
- - - - Frantic efforts to avoid real or imagined abandonment
      - Pattern of unstable and intense interpersonal relationships characterised by alternating
        between extremes of idealisation and devaluation *
        
        Splitting: Inability to reconcile positive and negative aspects of self and others resulting in sudden shifts between positive and negative feelings
      - Identity disturbance: markedly and persistently unstable self-image or sense of self
      - Impulsivity in ≥ 2 areas that are potentially self-damaging (e.g., spending, sex, binge-eating).
      - Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
      - Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
        irritability, or anxiety, lasting few hours and rarely more than few days
      - Chronic feelings of emptiness
      - Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
        constant anger, recurrent physical fights).
      - Transient, stress-related paranoid ideation or severe dissociative symptoms
    - - Individuals with BPD may engage in impulsive acts of self-mutilation, such as cutting themselves, perhaps as a means of temporarily blocking or escaping from deep, emotional pain
      - Self-mutilation is sometimes an expression of anger or a
        maladaptive way to change interpersonal dynamics.
      - Such acts may be intended to counteract self-reported feelings of
        “numbness,” particularly in times of stress
    - - 2% of general population; 10% outpatient mental health clinics; 20% psychiatric inpatients
      - 70% will make at least 1 suicide attempt
      - 8%- 10% will complete suicide
      - Suicide rate more than 50 times than general population
    - - Genetic vulnerability: account for 40% of the variance in the condition
      - Environmental: childhood trauma and/or abuse; invalidating environment
- - - - A. Pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by ≥ 5 of the following
        
        Uncomfortable in situations in which he/she is not the centre of attention
        
        Interaction with others often characterised by inappropriate sexually seductive or provocative behaviour
        
        Displays rapidly shifting and shallow expression of emotions
        
        Consistently uses physical appearance to draw attention to self
        
        Has style of speech that is excessively impressionistic and lacking in detail
        
        Shows self-dramatization, theatricality, and exaggerated expression of emotion
        
        Is suggestible (i.e easily influenced by others or circumstances)
        
        Considers relationships to be more intimate than they actually are
    - - Little over 1% in general population; more common in females
  - - - A. Pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by ≥ 5 of:
        
        Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents)
        
        Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
        
        Believes he/she is ‘special’ and unique and can only be understood by, or should associate with, other special or high status people (or institutions)
        
        Requires excessive admiration
        
        Has a sense of entitlement (i.e., unreasonable expectations of especially favourable treatment of automatic compliance with his/her expectations
        
        Interpersonally exploitative (i.e., takes advantage of others to achieve his/her own ends).
        
        Lacks empathy: is unwilling to recognise or identify with the feelings and needs of others
        
        Often envious of others or believes others are envious of him/her
        
        Shows arrogant behaviours, or attitudes
    - - Thick-skinned (grandiose) sub-type
        
        Extreme grandiosity, aggression and dominance
        
        Tendency to overestimate own abilities and accomplishments while underestimating the abilities and accomplishment of others
        
        Sense of entitlement
        
        Need for claiming recognition
      - Thin-skinned (vulnerable) sub-type
        
        Fragile and unstable sense of self-esteem
        
        Arrogance and condescension is a facade for intense shame and hypersensitivity to rejection and criticism
        
        May become preoccupied with fantasies of outstanding achievement but experience profound shame about their ambition
        
        High levels of negative affectivity
        
        Unwilling to take the perspectives of others
- - - - A. Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, indicated by ≥ 4 of:
        
        Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection
        
        Unwilling to get involved with people unless certain of being liked
        
        Shows restraint with intimate relationships because of fear of being shamed or ridiculed
        
        Preoccupied with being criticised or rejected in social situations
        
        Inhibited in new interpersonal situations because of feelings of
        inadequacy
        
        Views self as socially inept, personally unappealing, or inferior to others
        
        Unusually reluctant to take personal risks or to engage in any new activities because they may be embarrassing
      - Prevalence
        
        2-3% of general population, no gender difference
      - Causal Factors
        
        Inhibited temperament and introversion all moderately heritable
  - - - A. Pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears pf separation, beginning by early adulthood and present in a variety of contexts, as indicated by ≥ 5 of the following:
        
        Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
        
        Needs others to assume responsibility for most major areas of his or her life.
        
        Has difficulty expressing disagreement with others because of fear of loss of support or approval
        
        Has difficulty initiating projects or doing things on his / her own due to lack of self- confidence
        
        Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
        
        Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to take care of himself or herself.
        
        Urgently seeks another relationship as source of care and support when a close relationships ends
        
        Unrealistically preoccupied with fears of being left to take care of himself or herself
    - - Less than 1% in general population but quite common in mental health clinics
    - - Inheritance of increased neuroticism and agreeableness, authoritarian or overprotective parenting style
  - - - A. Pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by ≥ 4 of the following:
        
        Preoccupied with details, rules, lists, order, organisation, or schedules to the extent that the major point of the activity is lost
        
        Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his / her own overly strict standards are not met).
        
        Excessively devoted to work & productivity to the exclusion of leisure activities & friendships.
        
        Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.
        
        Unable to discard worn-out or worthless objects even when they have no sentimental value
        
        Reluctant to delegate tasks or to work with others unless they submit to exactly his / her way of doing things
        
        Adopts a miserly spending style toward both self and others; money viewed as something to be hoarded for future catastrophes
        
        Shows rigidity and stubbornness
    - - 2.1% - 7.9% in general population
      - Causal factors: Increased levels of conscientiousness; OCPD traits modest genetic influence
- - - - Developed by Marsha Linehan (Professor of Psychology) At University of Washington
      - Combines cognitive behaviour techniques for emotion regulation, reality testing and mindful awareness
      - Shown to be effective in treating borderline personality disorder, self-injurious behaviour and mood disorders
    - - DBT stems for Linehan's observation that suicidal patients are often raised in non-validating environment and usually sabotage treatment
      - Hence DBT strives to enable patients to be committed to therapy, by positioning therapists as an ally and provides unconditional validation
      - Dialectics: acceptance versus change
    - - Weekly, 45-60 minutes
      - Follow target hierarchy
        
        Self injurious and suicidal behaviour
        
        Behaviour that interferes with treatment
        
        Quality of life issues
      - Promotes the use of skills to manage difficult emotions
      - Skills training group
        
        Group: Weekly for 2-2.5 hours, where they learn specific skills broken down into 4 modules
        
        Mindfulness (used throughout)
        
        Interpersonal effectiveness
        
        Emotion regulation
        
        Distress tolerance
  - - - Behavioural Techniques: Modelling and Reinforcement used to help clients develop more adaptive behaviours
      - Cognitive Techniques: Identify, Challenge and Modify dysfunctional core beliefs
  - - - Has been used particularly for Cluster B personality disorders
      - Idealization, abandonment contempt, control etc are some of the phenomena that may occur during psychodynamic therapy, to be "worked through"