AthenaSummary

Chapter 1: Introduction and Historical Overview

Explain stigma and application to psychological disorders

Psychopathology = study on the nature, development and treatment of psychological disorders.
Stigma = destructive beliefs and attitudes held by society that are ascribed to groups
Stigma has 4 characteristics:
1. Distinguishing label is applied
2. Label refers to undesirable attitudes
3, People with the label are seen as different
4. People with the label are discriminated against

Psychological disorders remain the most stigmatized condition in the twenty-first century. If
anything, stigma appears to have increased, when the opposite trend would be expected with more
knowledge on psychological disorders

Fighting stigmas strategically can be done through

1. Lobbying for adequate housing for people with mental disorders
2. Education and training strategies on the topic
3. Promoting personal contact (where status is relatively equal)
4. Promote preventative efforts for psychological disorders among children and adolescents
through rating scale assessments
5. Support and advocacy groups
a. Social media

Compare different definitions of psychological disorder

What is a psychological disorder? The three key characteristics are personal distress,
disability/dysfunction, and violation of social norms.

Personal distress refers to if the behavior causes the person great distress. However, not all
psychological disorders cause distress -- people with antisocial personality may be socially
incapacitated without experiencing any guilt, remorse, or anxiety. Inversely, not all distress is
classified as a disorder -- the distress of hunger due to religious fasting, for example.

Disability and Dysfunction has two aspects that need to be defined. Disability refers to an
impairment in some important area of life, while dysfunction refers to something having gone wrong
and not working as it should. Not all disorders involve disability -- people with bulimia nervosa do not
necessarily have an impairment in an important area of life, as they purge (throw up) and continue
this practice in private.

Violation of Social norms refers to a widely held standard being violated. For example, someone
with obsessive compulsive disorder performing repetitive rituals violates social norms. However, this
aspect is both too broad and too narrow. It’s too broad in that criminals, for example, violate social
norms but are typically not studied through the lens of psychopathology -- inversely, highly anxious
people usually do not violate social norms. It is important to keep in mind the context of the person,
as cultures differ vastly from region to region.
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Explain how the causes and treatments of psychological disorders have changed over the
course of history
Before the scientific inquiry into psychological disorders, supernatural explanations were considered
-- for example, the belief that odd behavior was caused by possession was treated using exorcism,
the ritual casting out of evil spirits. Early biological explanations, such as Hippocrates’ division of
psychological disorders into mania, melancholia, and phrenitis (brain fever) led them being studied
through the lens of physiology rather than religion.

The Dark Ages prompted the return of supernatural explanations for psychological disorders, which
led to developments such as lunacy trials, which was a trial of a person’s day to day habits, intellect
etc., with the result being ‘lunatics’ being held until ‘they were restored to reason’. Asylums were
also later developed in the fifteenth century, as refuges for the housing and care of people with
psychological disorders. Later, there were reforms for the humane treatment of people with
psychological disorders in asylums. This approach was later known as moral treatment in the 19th
century, but was somewhat abandoned as it was impossible to keep it up with a large number of
people in the asylums and small staff.

Describe the historical forces that helps to shape the current view of psychological
disorders (biological, psychoanalytic, behavioral, and cognitive views)
Multiple historical forces come into play when shaping the current view we have on psychological
disorders, which came about with the popularity of the empirical approach to medical science. For
the biological view, the turning point was the discovery of the nature and origin of syphilis, a sexually
transmitted disease. Syphilis was known to have a connection with general paresis, a psychological
syndrome, yet the nature of the link was unknown. Using the empirical method, a causal link was
established between infection, damage to certain areas in the brain, and form of psychopathology
(general paresis). Genetics rose in popularity with Galton, who is considered the original researcher
on twins and coined the terms nature and nurture. He was also, however, a proponent of eugenics,
which is the movement that sought to eliminate undesirable characteristics from the population by
restricting the ability for certain groups to have children.

For psychological approaches, relevant figures are Mesmer and Charcot. Mesmer conducted
hypnosis (mesmerism) type routines in an attempt to eliminate hysteria, which is physical
incapacities for which no physical cause could be found. Charcot later was also persuaded by the
psychological explanation of hypnosis, despite still thinking that hysteria has biological roots.
in the 19th century, the physician Breuer promoted the cathartic method, an example of the method
being him treating a young woman with hysteria using hypnosis and urging her to express and
release previously forgotten thoughts and emotions. However, the woman, named Anna O., was only
temporarily cured.

Freud’s psychoanalytic theory postulated that psychopathology results from unconscious conflicts in
the individual. He divided the mind into three principal parts: id, ego, superego. The id seeks
immediate gratification of its urges, the ego deals with reality and mediates the demands of reality
and the id, and the superego is considered the human conscience, which is developed throughout
childhood.
Freud also stated that the conflict between the three principal parts can be reduced through the use
of defense mechanisms, strategies used by the ego to protect itself from anxiety. The defense
mechanisms are outlined below:
Defense Mechanism Biscay
¢ ummary
a
etter id

Repression Keeping unacceptable impulses or wishes from A professor starting a lecture she dreaded giving
conscious awareness says, “In conclusion.”
Denial Not accepting a painful reality into conscious Avictim of childhood abuse does not acknowl-
awareness edge it as an adult.
Projection Attributing to someone else one’s own unaccept- Aman who hates members of a racial group
able thoughts or feelings believes that itis they who dislike him.

Displacement Redirecting emotional responses from their real Achild gets mad at her brother but instead acts
target to someone else angrily toward her friend.

Reaction formation Converting an unacceptable feeling into its A person with sexual feelings toward children
opposite leads a campaign against chiid sexual abuse.
Regression Retreating to the behavioral patterns of an earlier An adolescent dealing with unacceptable feelings
stage of development of social inadequacy attempts to mask those
feelings by seeking oral gratification.
Rationalization Offering acceptable reasons for an unacceptable A parent berates a child out of impatience, then
action or attitude indicates that she did so to “build character.”
Sublimation Converting unacceptable aggressive or sexual Someone who has aggressive feelings toward his
impulses into socially valued behaviors father becomes a surgeon.

Freud’s psychotherapy is referred to as psychoanalysis -- the goal is for the therapist to understand
the person’s early experiences, nature of key relationships, and core emotional and relationship
themes. To do this, techniques such as free association, interpretation and analysis of transference
were used. Free association was simply the person saying whatever comes to mind without
censoring anything. Interpretation is when the analyst points out the meaning of the patient’s
behavior, and Analysis of transference is when the analyst/therapist looks at how the patient
responds to them, and suggests that it has an implication for the patient's behavior toward someone
important in the person’s past.

Freud’s views were not founded on empirical research and are not used widely today, but three
assumptions held on to current practices:

1. Childhood experiences help shape adult personality

2. There are unconscious influences on behavior
3. The causes and purposes of human behavior are not always obvious

After Freud’s psychoanalytic approach, there was a rise in behaviorism, which focused on
observable behavior rather than on consciousness or mental functioning. Classical conditioning is
outlined below:

Before learning, the unconditioned stimulus

Initial bell (CS) —+ no salivation elicits an unconditioned response. When
situation | meat powder (UCS) —————> salivation (UCR)
paired with a bell, the conditioned stimulus,
(a) the response of salivation is seen at the
presentation of the bell even without the meat
bell (CS) powder. This new response is the conditioned
Training
response. If repeatedly done with no
meat powder (UCS) unconditioned stimulus, extinction is seen,
which is fewer salivation and gradual
(b) _______}~=disappearance of response.

Conditioning bell (CS) ———————+ salivation (CR)

established
{c)
*

Operant Conditioning focuses more on the effects of consequences on behavior. Thorndike helped
discover this learning by establishing the law of effect, which is that behavior that is followed by
consequences satisfying to the organism will be repeated, and behavior followed by unpleasant
consequences discouraged. Skinner later introduced the concept of operant conditioning, and
elaborating on the law of effect by stating two types of reinforcements. Positive reinforcement is
action/event that strengthens the tendency of a response by its presentation. Negative
reinforcement also strengthens the tendency of a response, but does so by the removal of an
aversive effect, such as the beeping noise in the car stopping when you fasten your seatbelt

Modeling also stems from the behavioral approach, and states that witnessing someone perform
certain activities can increase/decrease diverse kinds of behavior -- basically that you learn by
observation.

Behavior therapy is therapy applied on the principles of classical and operant conditioning. It
involves systematic desensitization, which is still relevant in treating phobias and anxieties today.
Operant techniques have also been used in terms of rewarding desirable behavior and extinguishing
undesirable behavior in children. To maintain these effects, however, it is suggested to give
intermittent reinforcement rather than every time, so that the wanted behavior is more enduring
and not fully extrinsically motivated.

Cognitive Therapy focuses on the idea that people not only behave, but they think and feel as well -0
behaviorism has rather ignored the cognitive aspect of human behavior. Cognitive therapy place an
emphasis on how people see themselves and the world and state that these are major determinants
of psychological disorders

Describe different mental health professions, including the training involved and expertise
developed
Clinical Psychologists: Psychiatrists:
a. needaPh.D degree a. M.D degree and postgraduate training
i. conducting independent research (residency)
b. Heavy emphasis on research, statistics b. can also function as physicians
i. giving physical examinations,
empirically based studies
diagnosing medical problems, etc
c. Learn techniques of assessments and most often engage in prescribing medication
o

diagnosis of psychopathology d. may receive some training in psychotherapy

d. Learn how to practice psychotherapy as well
e, alternatively, the Psy.D
i. same principles, but less research | Psychiatric nurse:
focused , ,
a. bachelor’s or master’s level
b. can receive more specialized training as well
Social Workers i, eg nurse practitioner allows to
M.S.W (master of social work) prescribe psychoactive medication
qu

b training shorter than Phd programs

c. focus on psychotherapy
d no training on psychological assessment
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Chapter 2: Current Paradigms in Psychopathology

Describe the essentials of the genetic, neuroscience, and cognitive behavioral paradigms
A paradigm is a conceptual framework or approach within which the scientist works -- a set of
assumptions, a general perspective, etc.

The Genetic Paradigm

The decoding of the human genome and current research has allowed researchers to understand
that there is an interplay between genes and environment, namely “nature via nurture”. In terms of
genetic makeup, the order of the genes in chromosomes matter more than the number. Also, gene
expression is guided by proteins that are able to switch certain genes on or off. With respect to
psychopathology, there is no one gene that contributes to vulnerability -- psychopathology is
polygenic, so several genes are responsible. An important term is heritability, which refers to the
extent to which variability in a particular behavior or disorder in a population can be accounted for
by genetic factors. Heritability measures range from 0.0 to 1.0, higher number = higher heritability.
And heritability is on a population level, not a biological measure. Environmental factors such as
shared environment ( environment shared with family or community) and nonshared environment (
unique environment to you, your friends and support etc) are very important.

Behavior Genetics is the study of the degree to which genes and environmental factors influence
behavior. Genotype is the total genetic makeup of the individual, and cannot be observed outwardly.
Phenotype is the totality of observable behavioral characteristics, such as level of anxiety.
Turkeihmer et al, (2003) found that in twins of families of lower socioeconomic status, 60% of the
variability of children’s |Qs was due to the environment. The opposite effect, that is, high variability
of IQ being due to genes, was found in twins in families of higher socioeconomic status.

Molecular genetics studies specific genes and their functions. Humans have 23 pairs of
chromosomes, each made up of hundreds or thousands of genes that contain DNA. Different forms
of the same genes are called alleles. A polymorphism is a difference ina DNA sequence on a gene
that has occurred in a population. One area of interest is single nucleotide polymorphism studies,
which looks at differences between people in a single nucleotide (A,T,G,C) in the DNA sequence of a
particular gene. Other research looks at copy number variations, which is the study of additions or
deletions of certains sections of DNA in individuals. Genome-wide association studies is a way to
study these SNPs and CNVs.

The study of how gene-environment interactions can alter gene expression is called epigenetics.
These look at markers on top of DNA rather than within the sequences that control for which genes
are expressed,

The two challenges of the genetic paradigm is that:

1. the specification of how exactly the genes and environment reciprocally influence one
another
2. complexity of genetic explanations, as many genes can be implicated in a behavior
__s ° =

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Neuroscience Paradigm
The neuroscience paradigms are centered around the idea that psychological disorders are linked to
aberrant processes in the brain. A neuron is a cell in the nervous system, and consists of four parts
1. cell body
2. dendrites
3. axon
4. terminal buttons on the end of the axon
The gap between neurons is called the synapse. Signals are sent from one neuron to another using
chemicals called neurotransmitters. The communication can be excitatory, promoting the message,
or inhibitory, the opposite. The lingering neurotransmitters in the synapse are either broken down by
enzymes or taken up by the sending neuron by reuptake. Key neurotransmitters are dopamine,
serotonin, norepinephrine, gamma-aminobutyric acid (GABA).

Early theories within this paradigm proposed that a given disorder was caused by either too much or
too little of a neurotransmitter. This view is too simplistic however, as an error could occur at any
stage of the metabolic process of neurotransmitter synthesis.

The brain consists of gray and white matter. The cortex is the outer thin layer of the brain, and
consists of six layers of tightly packed neurons. The ridges in the brain are gyri and the depressions
(infoldings) sulci. The frontal lobe is in front of the central sulcus, the parietal behind it and above
the lateral sulcus.

White matter is made up of large tracts of myelinated fibers that connect cell bodies in the cortex
with those in the spinal cord and other areas in the brain. Ventricles are hollow spaces in the brain
filled with cerebrospinal fluid. Subcortical structures, those beneath the surface of the brain, are
mostly implicated in psychological disorders. Currency research focuses most on the connectivity
between different areas of the brain, or brain networks. For example, people with schizophrenia
have been found to have enlarged ventricles, the size of the hippocampus is reduced among people
with PTSD, brain size in children with autism expands at much greater rate than in typical
development.

The neuroendocrine system contains the HPA axis, which is the

connection between hypothalamus, pituitary gland, and adrenal
cortex, and is central to the body’s response to stress.
Hypothalamus releases CRF, which communicates with the pituitary
gland, which in turn releases adrenocorticotropic (ACTH) which
activates the adrenal cortex, which then secretes cortisol.

The immune system is also affected by stress. When fighting off

infections, the body releases white blood cells. Activation of macrophages specifically stimulates
release of cytokines, which help initiate responses such as fatigue, inflammation and stress. Some of
these cytokines have been implicated in depression and schizophrenia.
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The possible criticism of the neuroscience approach is that it is very reductionist, the view that
everything can be explained by evaluating its individual, most basic constituents.

Cognitive Behavioral Paradigm

This paradigm is rooted in learning principles and cognitive science. An influence on this paradigm is
from behavior therapy, specifically operant conditioning, which focuses on rewarding and punishing
certain behaviors. Another influence from behavior therapy is exposure, which continues to be
useful today. Influences from cognitive science is knowledge of schema, or organized set of mental
representations and their effect on interpretation. Another important aspect is attention, namely
problems with attention or attention bias on specific aspects of situations. The role of the
unconscious is also studied currently by cognitive neuroscientists, concepts such as implicit memory,
which is that a person can be influenced by prior learning without being aware of it.

Cognitive Behavioral Therapy stems from this paradigm, as it incorporates theory and research of
cognitive processes. The central belief is that using cognitive restructuring and essentially changing
people’s cognition would allow for people to change their behavior, feelings and symptoms, Beck’s
cognitive therapy, for example, is centred around the idea that depression is centred around
negative cognitive distortions, and by guiding the patient and providing counter examples to their
negative biases, depression can be alleviated.

When evaluating cognitive behavioral paradigms, it is important to keep in mind that some cognitive
explanations do not appear to explain much. It is hard to differentiate negative thoughts, for
example, as a cause or a symptom of depression as under this paradigm, it appears to be both.

Describe the concept of emotion and how it may be relevant to psychopathology

Emotions influence how we respond to problems and challenges in our environment. Disturbances in
emotions result in widespread influence, and are seen in many different forms of psychopathology.
Emotions can be roughly defined as short-lived states. Moods in comparison are emotional
experiences that endure for a longer period of time. The expressive component of behavior refers to
the facial expressions of emotion. The experience/subjective feeling refers to how a person reports
they feel at any given moment. The physiological component involves changes in the body , such as
those due to the autonomic nervous system activity. Emotional disturbances in psychopathology are
considered in terms of which emotions in particular are disturbed. Emotions are relevant across all
paradigms, but an important thing to consider is the ideal affect, or the kinds of state people ideally
want to feel. In Western cultures, happiness is the most sought out feeling, while in Eastern cultures,
calmness seems to prevail.

Explain how culture, ethnicity and interpersonal factors figure into the study and
treatment of psychopathology
Studies show that some disorders affect men and women differently. Depression is nearly twice as
common in women than men, but antisocial personality disorder and alcohol use disorder is more
common around men. Researchers currently seek out to find if there are risk factors that affect men
and women differently -- for example, father-to-son genetic transmission appears to be a risk factor

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in development of alcohol use disorder, while societal expectations of thinness may promote the
development of eating disorders in women.
Poverty is another factor that is a major influence of psychological disorders, and is related to anxiety
disorders, antisocial personality disorder, and depression. Cultural and ethnic factors may hinder our
cross-cultural understanding of disorders. For example, schizophrenia is observed in diverse cultures,
but the symptoms and names and attitudes towards it differ. Some disorders, however, are culture
bound. For example, a unique condition hikikomori is observed in Japan, with (predominantly men)
completely shutting off from society, in some cases for many years, living in their room or house. The
role of race and ethnicity is also profound, but the mechanism is not well understood. For example,
eating disorders and body dissatisfaction is more common in white women than black women, but
the differences in actual eating disorder prevalence is not as great. Cultural factors are just getting
more traction in clinical research and are integrated in neuroscience,

Interpersonal factors refer to quality of relationships, social support, and even casual social contact
and its effects on psychopathology. Other factors relevant to this are trauma, serious life events, and
stress. Transference refers to the person’s responses to the analyst/therapist that seem to reflect
attitudes and ways of behaving towards people that are important in the patient's past. One theory
relating to this is the object relations theory which basically states that people come to understand
themselves in terms of how their relationship is with other people -- like a girl thinking she is
worthless due to her cold relationship with her mother. Attachment Theory grew out of this object
relations theory. It states that the type of attachment an infant has to their caregivers can set the
stage for psychological health and problems later in life. Social psychologists have integrated the two
above theories into the relational self, which is the self in relation to others. Studies show that
people will associate more positive feelings with a stranger if they are asked to describe them
similarly to the person’s significant other.

Interpersonal therapy emphasizes the importance of current relationships in a person’s life and how
problems in relationships can contribute to psychological symptoms. Four interpersonal issues are
examined in IPT
1. Unresolved grief = incomplete grieving over a loss
2. Role transitions = transitioning from child to parent ,for example
3. Role disputes = resolving relationship expectations between romantic partners
4. Interpersonal or social deficits = for example not being able to begin a conversation with an
unfamiliar person

Recognize the limits of adopting any one paradigm and the importance of integration
across multiple levels of analysis, as in the diathesis-stress integrative paradigm
The diathesis-stress integrative paradigm links genetic, neurobiological, psychological and
environmental factors. The model looks at the interaction between a predisposition towards a
certain state (strengths and vulnerabilities = a diathesis) and environmental and life disturbances
(the stress). Possessing a diathesis can be from any realm, like oxygen deprivation during birth as a
neurobiological diathesis, or negative cognitive schemas in the psychological realm. The key point is
that both diathesis and stress must be present for the development of disorders. It also understands
that psychological disorders are unlikely to appear from one single factor.

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Chapter 3: Diagnosis and Assessment

Describe the purposes of diagnosis and assessment, and distinguish the different types of
reliability and validity
The purpose of a diagnosis is that it allows the clinician to describe base rates, causes and treatment
for a psychological disorder. It allows a person to begin their situation and state. Furthermore, it
allows for clinicians and scientists to communicate accurately with one another about
cases/research. Assessment tools are used to make a correct diagnosis. These are formal ways of
finding out the state of the person,

Reliability refers to consistency of measurement. The types of reliability are

1. Inter-rater reliability
a. the degree to which two independent observers agree on what they have observed
2. Test-retest reliability
a. extent to which people being observed twice or taking the same test twice, receive
similar scores
3, Alternate-form reliability
a. the extent to which scores on the two forms of the test are consistent
4. Internal consistency reliability
a. assesses whether the items on a test are related to one another

Validity is related to whether a measure measures what it is supposed to measure. Reliability does
not guarantee validity.
1. Criterion validity
a. whether a test predicts related measures
2. Content validity
a. if measures adequately samples the domain of interest
b. @.g. questionnaire on social anxiety touching on all aspects of anxiety
3. Construct validity
a. how well the measure translates into some characteristic of construct that is not
overtly observed
b. e.g. ifa questionnaire scores on anxiousness reflect the level of anxiousness
i. if one person scores low, they are low on inferred anxiousness
ii. if one scores high on the questionnaire, they are high in the inferred
construct of anxiousness

Identify the basic features, strengths, and weaknesses of the DSM, and concerns about
diagnosis more broadly.
The Diagnostic and Statistical Manual of a Mental Disorder, Fifth Edition, or the DSM-5, is a
diagnostic system used in many mental health professions. It provides information about each
disorder, with symptoms for a given diagnosis. It provides detailed and concrete information on how
many symptoms, for how long need to be present for a diagnosis.

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The DSM-5 does not consider causes, only symptoms. Some people argue that etiologies need to be
included as social context is important in the onset of certain symptoms. Others argue that biology
should be considered more, as there seem to be genetic origins to many disorders. There are no
laboratory tests, neurobiological markers, or genetic indicators in making a diagnosis using the DSM-
5.

Culture impacts the risk factors for psychological disorders. Previous versions of DSM were criticized
for their lack of attention to cultural and ethnic variations in psychopathology. DSM-5 has several
features to enhance cultural sensitivity:
1. Culture-related issues are discussed in the text for almost all disorders
Zi Cultural formulation interviews are integrated for clinicians to better understand how culture
may be shaping the clinical presentation
Appendix describing syndromes that may appear in particular cultures, different ways of
showing distress across cultures
a. includes nine cultural concepts of distress to describe syndromes that are observed
within specific regions or cultural groups

Criticisms of DSM-5 are as follows

i Some people argue that there are too many diagnoses
a. effect of this is high comorbidity, as some disorders have minute differences
between symptoms
2. Categorical Classification vs Dimensional Classification
a. categorical classification in the DSM forces clinicians to work within a certain
threshold
b. adimensional system would allow for degree of a symptoms that is present.
3. Reliability of DSM in everyday practice
a. low reliability as clinicians have to include own judgements
4. Validity of categories

General Criticisms of Diagnosing Psychological disorders

di; Life could significantly change by receiving a diagnosis and associated stigma
a. but sometimes labels can be seen as less negative than an overview of symptomatic
behavior
b. Nevertheless, we might lose sight of the uniqueness of the person
2. Worry of someone recognizing your disorder, fear of onset of another episode

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Chapter 6: Anxiety Disorders

Define emotions of anxiety and fear and their adaptive benefits

Anxiety is defined as apprehension over an anticipated problem. Fer is defined as a reaction to
immediate danger. Both can involve arousal (sympathetic nervous system activity). Anxiety usually
involves moderate, while fear involves high arousal. These two emotions are adaptive -- fear is
fundamental for fight or flight, while anxiety is adaptive in helping us notice and plan for future
threats by increasing preparedness. Anxiety has an inverted U shaped curve in performance — too
much or too little is detrimental.

Describe clinical features of the anxiety disorders, the prevalence of the anxiety disorders, and
how much anxiety disorders co-occur with one another
Anxiety disorders as a group are the most common types of disorder. Below is the lifetime
prevalence in Netherlands:
Some things to note
NEMESIS—2 ree liceiels 1. More in females than men,
prevalence
almost two to 1
earne GS0rGer 38 2. Percentages somewhat
Agoraphobia without panic 0.9 0.4 1.4 higher in US, but same order of
magnitude and gender
Specific phobia 7.9 5.5 10.3 difference
Social anxiety disorder 9.3 ey 10.9 3. High comorbidity with
Gegeneralised anxiety 4.5 3.6 5.4 depression ;
disorder 4. Inrelapse, often a different
- anxiety disorder arises
| anxiety disorder 19.6 15.9 23.4

Disorder iTcrimgi ates)

Specific phobia Fear of objects or situations that is out of proportion to any real danger

Social anxiety disorder Fear of unfamiliar people or social scrutiny

Panic disorder Anxiety about recurrent panic attacks

Agoraphobia Anxiety about being in places where escaping or getting help would
be difficult if anxiety symptoms occurred

Generalized anxiety disorder | Uncontrollable worry

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DSN-5 Criteria
Specific Phobia Social Anxiety Disorder Panic Disorder
1. Marked and disproportionate 1. Recurrent unexpected panic
1. marked and disproportionate fear fear consistently triggered by attacks
consistently triggered by specific exposure to potential social 2. At least 1 month of concern or
objects or situations scrutiny worry about possibility of more
2. The object or situation is avoided 2. Exposure to trigger leads to attacks occurring of the
or else endured with intense intense anxiety about being consequences of an attack, or
anxiety evaluated negatively maladaptive behavior changes
3. Trigger situations are avoided because of attacks
or else endured with intense
anxiety

Agoraphobia Generalized anxiety Disorder

Disproportionate and marked fear or anxiety about at
least two situations where it would be difficult to 1. Excessive anxiety and worry at least 50 percent of days
escape or receive help in the event of about a number of events or activities (e.g., family,
incapacitation, embarrassing symptoms, or panic- health, finances, work, and school)1
like symptoms, such as being outside the home 2. The Person Finds It Hard To Control The Worry
alone; traveling on public transportation; being in 3. The anxiety and worry are associated with st least thre=
open spaces such as parking lots and marketplaces; (or one in children) of the following:
being in enclosed spaces such as shops, theatres, or restlessness or feeling keyed up or on edge
cinemas; or standing in line or being in a crowd. easily fatigued
>oanow

difficulty concentrating or mind going blank

These Situations Consistently Provoke Fear Or Anxiety irritability
muscle tension
These situations are avoided, require the presence of a sleep disturbance
companion, or are endured with intense fear or anxiety

Discuss how gender and culture influence prevalence of anxiety disorders

Women are more vulnerable to anxiety disorders than are men, usually to a 2 to 1 ratio.
1. Women may be more likely to report their symptoms
2 Gender roles > males being expected to face their fears
3, Difficult life circumstances > women and sexual assault
4. Men may be raised to believe more in their personal control over situation

Culture also plays a role

1. Cultural concepts of distress
a. in Japan, taijin kyofusho involves fear of displeasing or embarrassing others
2. The prevalence of anxiety disorders vary across cultures
a. cultural attitudes can dictate how comfortable someone is disclosing symptoms
b, higher in Europe and US than in other regions

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Explain commonalities in etiology across the anxiety disorders

;4 Factors That Increase General Risk for Anxiety Disorders

Behavioral conditioning (classical and operant conditioning)

Genetic vulnerability
Disturbances in the activity in the fear circuit of the brain
Decreased functioning of gamma-aminobutyric acid (GABA) and serotonin; increased norepinephrine
activity
Increased cortisol awakening response (CAR)
Behavioral inhibition
Neuroticism
Cognitive factors, including sustained negative beliefs, perceived lack of control, over-attention to
cues of threat, and intolerance of uncertainty

Fear conditioning is one commonality in cause across anxiety disorders. Mowrer’s two factor model
of anxiety states that development follows two steps
1. Classical conditioning of fear
2. Operant conditioning resulting in avoidant response that reinforces the fear

The two criticisms are:

a. many people do not remember any exposure to threatening event that triggered the
symptoms
b. not all people that experience serious threat develop any anxiety disorders

These gaps are explained by:

1. Classical conditioning of fear doesn’t have to occur through direct experience, but can also
be conditioning through modelling (seeing another person affected) or verbal instruction
(hearing a parent always warn against a stimulus)
2. People with anxiety disorders seem to acquire fears more readily through classical
conditioning, and these fears are more persistent once conditioned
a. people with anxiety disorders also appear to experience some types of threats as
particularly powerful > sensitive to unpredictability
i. | Tested using the neutral predictable unpredictable (NPU) threat task
1. for the condition where an aversive stimulus is presented
unpredictably, people with anxiety disorders have a stronger
affective and physiological response

There are genetic factors as well > anxiety disorders seem to be somewhat heritable.
Neurobiological factors include the fear circuit and activity of neurotransmitters. The fear circuit’s
most important component is the amygdala, and studies show that people with anxiety disorders
respond with greater activity in the amygdala than people without the anxiety disorder. The medial
prefrontal cortex helps regulate amygdala activity, and people with anxiety disorders display less
activity there when appraising threatening stimuli. Other brain regions involved are the stria
terminalis, anterior cingulate cortex, insula, locus coeruleus and hippocampus. Neurotransmitters
involved are:

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s

Serotonin: GABA: Norepinephrine: HPA system: system of

modulate emotions involved in modulating increased levels of it in direct influences and
activity in amygdala people with anxiety feedback between
and fear circuit disorders and hypothalamus,
increased sensitivity of pituitary gland and
their receptors adrenal glands.

Personality plays a role, particularly behavioral inhibition, which is the tendency to become agitated
and cry when faced with novel toys/people/stimuli in infants. It seems to be predictive of anxiety
symptoms later in age.

Cognitive factors include: Sustained negative beliefs about the future, Perceived lack of control,
Attention to threat and Intolerance of Uncertainty.

Describe the factors that shape the expression of specific anxiety disorders

Specific Phobia: Sacial Anxiety Panic Disorder: Agoraphobia: Generalized Anxiety

Disorder: Disorder
Mowrer’s two factor Locus coeruleus > Genetic
model is the most Two-factor model major source of vulnerability and Tends to co-ocour with
common also applies neurotransmitter life event other anxiety disorders |
explanation, but norepinephrine >
factors such as Cognitive factors people with panic Cognitive model: Contrast avoidance
genetic vulnerability such as too much disorder have a dramatic fear-of-fear model = people with
neuroticism, focus on negative response to surges of hypothesis=> driven GAD find it highly
negative cognition self-evaluation are norepinephrine. by negative aversive to experience
etc also play a role. relevant, as well as thoughts about rapid shifts in
attending more to Interoceptive consequences of emotions, rather a
Possibly also internal cues conditioning : a person experiencing chronic state of worry
prepared learning, rather than experiences somatic anxiety in public and distress.
which is that external (social) signs of anxiety,
evolutionarily we cues. followed by person’s
may be prepared to first panic attack, panic
learn to fear certain attack becomes
stimuli. conditioned response to
somatic changes

Cognitive factors: person

interpreting bodily
sensations as a sign of
impending doom >
measured by Anxiety
Sensitivity Index

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Discuss Psychological and medication treatment approaches that are common across the
anxiety disorders and how the modification of psychological treatment for the specific
disorder
Exposure therapy: behavioral view of exposure focused on extinguishing the fear response. The
cognitive view of exposure treatments focuses on helping people correct their mistaken beliefs about
the stimulus. Internet-based programmes of CBT have widespread, sustained effects in treating a
variety of anxiety disorders. Other treatments are: mindfulness meditation in combination with other
CBT techniques such as exposure treatment. Phobias are mainly treated using exposure treatments.
Social Anxiety disorder is treated with CBT, with exposure being a core aspect, Panic disorder
treatment is yet again focused on exposure, from a behavioral perspective, people are promoted to
see their physiological sensations using coping tactics in a safe environment. Agoraphobia treatment
focused on CBT that has systematic exposure to feared situations. For Generalized Anxiety Disorder.
relaxation training is used to promote calmness, as well as broader forms of CBT that help improve
problem solving.

Medication most commonly used are:

1. anxiolytics > drugs that reduce anxiety
a. benzodiazepines
i. minor tranquilizers/sedatives
b. antidepressants

Generally antidepressants are preferred over benzodiazepines as they have fewer side effects.

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AthenaS
Chapter 5 - Mood Disorders
Mood Disorders involve profound disturbances in emotion—from the deep sadness and
disengagement (depression) to extreme elation and irritability (mania).

Clinical Descriptions of Depressive Disorders

Depressive disorders are characterised by The inability to experience pleasure and/or experiencing
extreme sadness. Symptoms in depression vary. People with depression often show physical
symptoms as well. Major Depressive Disorder (MDD) is an episodic disorder, because symptoms tend
to be present for a period of time and then clear. Chance of relapse increases after every episode.

DSM-5 Criteria for MDD is;

e@ Sad mood or loss of pleasure in usual activities.
@ At least five symptoms (including sad mood and loss of pleasure):
© Sleeping too much or too little
Psychomotor retardation or agitation
ooo0;$0

Weight loss or change in appetite

Loss of energy
Feelings of worthlessness or excessive guilt
Difficulty concentrating, thinking, or making decisions
© Recurrent thoughts of death or suicide
e Symptoms are present nearly every day, most of the day, for at least 2 weeks. Symptoms are
distinct and more severe than a normative response to significant loss.

People with persistent depressive disorder (PDD) are chronically depressed—more than half of the
time for at least 2 years.

DSM-5 Criteria for Persistent Depressive Disorder (Dysthymia);

e Depressed mood for most of the day more than half of the time for 2 years (or 1 year for
children and adolescents).
@ Atleast two of the following during that time:
© Poor appetite or overeating
Sleeping too much or too little
ooo0°0

Low energy
Poor self-esteem
Trouble concentrating or making decisions
© Feelings of hopelessness
@ Thesymptoms do not clear for more than 2 months at a time.
e Bipolar disorders are not present.

Epidemiology and Consequences of Depressive Disorders

The prevalence of depression varies considerably across cultures (lifetime prevalence of 16.2% in the
United States). Women are twice as likely as men are to experience major depression and persistent
depressive disorder, this gap becomes especially prevalent in adolescence. Biological, social and stress
reactivity factors play a role in this gap. The symptom profile ofa depressive episode also varies across
cultures. Seasonal affective disorder is a subtype of depression that occurs usually during winter, which
is thought to be related to how melatonin functions change from summer to winter seasons.
Ethnic minorities tend to focus on their physical symptoms of depression, this could be due to the
stigmatisation of mental health in certain cultures. Most people with MDD later meet criteria for PDD.
Consequences of depression include treatment costs, lost productivity, death from medical diseases
(especially cardiovascular), and of course suicide.

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Clinical Descriptions of Bipolar Disorders

The DSM-5 recognizes three forms of bipolar disorders: bipolar | disorder, bipolar II disorder,
and cyclothymic disorder. Manic symptoms are the defining feature of each of these disorders, and
differentiation is based on episode length and severity. Mania is a state of intense elation or irritability,
along with activation and other symptoms shown in the diagnostic criteria.

DSN 5 Criteria for Manic and Hypomanic Episodes;

e Distinctly elevated or irritable mood.
e@ Abnormally increased activity or energy.
e Atleast three of the following are noticeably changed from baseline (four if mood is irritable):
© Increase in goal-directed activity or psychomotor agitation
Unusual talkativeness; rapid speech
oa 00

Flight of ideas or subjective impression that thoughts are racing

ooo

Decreased need for sleep

Increased self-esteem; belief that one has special talents, powers, or abilities
Distractibility; attention easily diverted
Excessive involvement in pleasurable activities that are likely to have painful
consequences, such as reckless spending, sexual indiscretions, or unwise business
investments
© Symptoms are present most of the day, nearly every day
@ Foramanic episode:
o Symptoms last 1 week, require hospitalisation, or include psychosis
o Symptoms cause significant distress or functional impairment
e@ Fora hypomanic episode:
© Symptoms last at least 4 days
oO Clear changes in functioning are observable to others, but impairment is not marked
© No psychotic symptoms are present

For Bipolar 1 disorder, 1 manic episode is sufficient, for bipolar 2 disorder, one depressive and one
hypomanic episode is necessary (and no mania, then it’s bipolar 1). Cyclothymic disorder is a chronic
mood disorder. The DSM-5 criteria require that symptoms be present for at least 2 years among adults.

DSM-5 Criteria for Cyclothymic Disorder;

e For atleast 2 years (or 1 year in children or adolescents):
© Numerous periods with hypomanic symptoms that do not meet criteria for a
hypomanic episode
o Numerous periods with depressive symptoms that do not meet criteria for a major
depressive episode
e The symptoms do not clear for more than 2 months at a time.
e Criteria for a major depressive, manic, or hypomanic episode have never been met.
e Symptoms cause significant distress or functional impairment.

Epidemiology and Consequences of Bipolar Disorders

Bipolar | disorder is much rarer than MDD (prevalence 0.6-1% depending on the country), bipolar 2
disorder has a prevalence between 0.4-2% and cyclothymic disorder around 4%. Bipolar disorders are
being seen with increasing frequency among children and adolescents. Bipolar disorders are seen
equally among men and women, but women experience more depression and men more mania.
Bipolar 1 is seen as a severe psychological disorder.

20
AthenaSummary
_ e
Epidemology of Mood Disorders
The heritability estimates for major depressive disorder are 37%. Estimates get higher in more severe
samples. The heritability estimates for bipolar disorder is 93 percent. There is not one single gene that
explains mood disorders, rather many, because the symptom constellations in patients can differ
greatly. Environmental factors also influence genetic predispositions.

A few neurotransmitters have been studied a lot for their role in mood disorders, such as;
e Dopamine (sensitivity of the reward system in the brain). Researchers believe that dopamine
levels are low in depression. For bipolar disorders, researchers believe that the dopamine
receptors might be overly sensitive (manic episodes especially).
e Serotonin. People vulnerable to depression (and bipolar disorders) may have less sensitive
serotonin receptors. The serotonin transporter gene does appear to be related to MDD.
@ Norepinephrine.

Neural Regions Involved in Emotion and Reward Processing

Functional brain-imaging studies suggest that MDD is associated with changes in neural systems
involved in experiencing and regulating emotion and in responding to rewards. Activation patterns are
summarised below;
@ amygdala: elevated in depression and mania
anterior cingulate: elevated in depression and mania
regions of the prefrontal cortex: diminished in depression and mania
hippocampus: diminished in depression and mania
striatum: diminished in depression, elevated in mania

Cortisol Dysregulation
The HPA axis (hypothalamic—pituitary—adrenocortical axis) may be overly active during episodes of
MDD, which is consistent with the idea that stress reactivity is an important part of depression
(cushing's patients experiencing depression due to elevated cortisol levels). excess cortisol can damage
the hippocampus, thus lowering its volume. Cortisol is also linked to proinflammatory cytokines.

Social Factors in Depression: Childhood Adversity, Life Events, and Interpersonal Difficulties
Childhood adversity, such as early parental death, physical abuse, or sexual abuse, increases the risk
that depression will develop later, in adolescence or adulthood (also anxiety). stressful life events and
certain types of stressors (interpersonal loss and humiliation) can trigger depressive episodes. Some
people are more vulnerable to stress than others, thus get affected way more easily, such as
neurological predispositions. Lack of social support may worsen the individual’s ability to handle
stressful life events. Social support seems to protect against severe stressors. A family member's
critical comments toward or emotional overinvolvement with the person with depression is defined
as expressed emotion (EE). Interpersonal problems can trigger the onset of depressive symptoms, but
once depressive symptoms emerge, they can create interpersonal problems, since depressive
symptoms often elicit negative reactions from others.

Psychological Factors in Depression

Neuroticism is a personality trait that is defined by the tendency of an individual to experience
frequent and intense negative feelings. Research shows that this trait predicts the onset of depression.
It also explains a part of the genetic vulnerability to depression.
In cognitive theories, the pessimistic thoughts and self-critical thoughts a person has can be one of the
causes of depression. Three cognitive theories of depression are;
@ Beck’s theory. Aaron Beck linked depression to a negative triad. The negative triad consists of
negative views of the self, their world and the future. In childhood, people with depression

21
AthenaSummaes

acquire negative schemas through experiences such as loss of a parent, the social rejection of
peers, or the depressive attitudes of a parent. Schemas are different from conscious thoughts.
The negative schema is activated whenever the person encounters situations similar to those
that originally caused the schema to form. Once activated, negative schemas are believed to
cause information-processing biases, or tendencies to process information in certain negative
ways. Cognitive biases are often present. These are tendencies to process information in
negative ways.
e Hopelessness theory. The most important trigger of depression is hopelessness. Hopelessness
is defined as the belief that desirable outcomes will not occur and that there is nothing a
person can do to change this. Attributions are the explanations a person forms about why a
stressor has occurred. Two dimensions here are emphasised: stable (permanent) versus
unstable (temporary) causes and global versus specific causes. Someone is more likely to
become depressed if his attributional style makes him feel hopeless due to attribution of
events as stable and global.
@ Rumination theory. Rumination may increase the risk of depression according to this theory.
A tendency to dwell on sad experiences and thoughts is how rumination is defined.

Social and Psychological Factors in Bipolar Disorder

Depression in Bipolar disorders are triggered by similar factors of depression in unipolar depression.
Research suggests that two factors may predict increases in manic symptoms over time:
e Reward sensitivity. Mania is due to a disturbance in the reward system according to this model
(dopamine). Patients might be highly reward sensitive.
e@ Sleep deprivation. There is a relation between mania and disruptions in sleep.

Treatment of Mood Disorders

Depression
@ Interpersonal psychotherapy (IPT). The core of the therapy is to examine major interpersonal
problems, such as role transitions, interpersonal conflicts, bereavement, and interpersonal
isolation.
@ Cognitive therapy. This theory focuses on negative schemas and cognitive biases. An
adaptation of cognitive therapy is mindfulness-based cognitive therapy (MBCT) which focuses
on preventing relapse.
e@ Behavioral Activation (BA) therapy. The goal here is to increase participation in positively
reinforcing activities, so negative spirals of depression, withdrawal and avoidance can be
disrupted.
@ Behavioral Couples therapy. This therapy helps with relieving depression when a person has
depression along with marital distress.

Bipolar disorders
The following may be necessary and/or very helpful in the treatment of bipolar disorder;
e Medication.
@ Psychoeducational approaches.
@ Cognitive therapy.
@ Family-focused therapy.

Biological treatment of mood disorders

Drugs and electroconvulsive therapy (ECT) are the two major biological treatments used to treat
depression and mania. ECT involves deliberately causing momentary seizures through electrical
stimulation. This treatment is controversial, but more powerful than antidepressant, so it is used as a

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AthenaSummary
s

last resort. For depression, drugs are the most used and best-researched treatments. There are three
major categories: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and selective
serotonin reuptake inhibitors (SSRIs). The best chance of recovering from depression is to combine
psychotherapy and antidepressant medications. Medication is most helpful for immediate relief.
Psychotherapy is done to protect against relapse. Transcranial magnetic stimulation (rTMS) is a
treatment that is used for depression, much less invasive than ECT. ‘r’ in rTMS stands for repetitive.
Mood-stabilising medications are medications that reduce manic symptoms, such as lithium.
Anticonvulsants and antipsychotics are also used in treating mania.

Suicide
Behaviors that are intended to cause death to the self and do so, are named suicide. Behaviours that
are intended to cause harm, but are not meant to cause death, are named nonsuicidal self-injury.
Suicidal ideation occur at least once in a lifetime for about 9% of people worldwide. In areas where
more people own guns, the rates are higher. Suicide is four times more common in men than in
women. Suicide attempts that do not result in death are more common among women than among
men, This could be due to the use of less lethal methods among women. Rates of suicide are higher in
older age. More and more children and adolescents are committing suicide. Suicide risks elevates four-
or fivefold for divorced people or widowed people.

Risk factors for suicide

About 50% of the people attempting suicide is depressed and about 90% of the people attempting
suicide has some form of psychological disorder. If a disorder is comorbid with depression in an
individual, suicide is very likely. The heritability for suicide attempts is about 48%. Other factors that
influence suicide rates are economic and social events. Media reports of suicide is often followed with
an increase in suicides.

People can have many different reasons to choose suicide, such as:
@ To induce guilt in others.
To get love from others.
Making amends for wrongs.
To get rid of unacceptable feelings.
To escape emotional pain.
To rejoice a deceased loved one.

Some researchers link suicide to poor problem-solving skills, since poor problem-solving skills can make
people more vulnerable to hopelessness, which is related to suicidal ideation, Actually committing
suicide is related to impulsivity.

Prevention of suicide
Talking openly about suicide helps. Most people who kill themselves have a form of psychological
disorder, thus treating the disorder reduces the risk of suicide. The use of medications in mood
disorders also reduces the risk (when used accordingly). The most promising therapies for reducing
suicidal ideation are the cognitive behavioural approaches. These treatments include strategies to
decrease the motive to commit suicide. It is important to help patients understand the emotions and
thoughts that triggers suicidal ideation. Together with clinicians, patients need to challenge their
negative thoughts and need to find effective ways to tolerate emotional distress. Clinicians also help
clients solve the problems they are having. The goal is to reduce feelings of hopelessness by improving
problem-solving skills and improving social support.

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AthenaSummary
Chapter 7 - Obsessive-Compulsive-Related and Trauma-Related
Disorders
Clinical Descriptions and Epidemiology of Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder
The presence of either obsessions or compulsions is necessary for the diagnosis of obsessive-
compulsive disorder. Most people experience both. Obsessions are persistent and uncontrollable
impulses, thoughts or images that are intrusive and recurring. These impulses, thoughts and images
often appear irrational to the person themselves. examples are fear of contamination from germs or
illnesses. Compulsions are the experiences when a person feels the need for repetitive and clearly
excessive behaviour and mental acts to decrease the anxiety caused by obsessive thoughts or to
prevent some terrible event from happening. It is hard for them to stop, even though they realise their
behaviour is illogical. common compulsions include decontamination, checking, intense routines,
ordering and mental rituals.

DSM-5 Criteria for Obsessive-Compulsive Disorder:

Obsessions and/or compulsions.
Obsessions are defined by:
e Recurrent, intrusive, persistent, unwanted thoughts, urges, or images.
e The person tries to ignore, suppress, or neutralise the thoughts, urges or images.

Compulsions are defined by:

@ Repetitive behaviours or thoughts that the person feels compelled to perform to prevent
distress or a dreaded event.
e@ The person feels driven to perform repetitive behaviours or thoughts in response to obsessions
or according to rigid rules.

The acts are excessive or unlikely to prevent the dreaded situation.

The obsessions or compulsions are time consuming (e.g., at least 1 hour per day) or cause clinically
significant distress or impairment.

Body Dysmorphic Disorder

People with body dysmorphic disorder (BDD) are preoccupied with one or more imagined or
exaggerated defects in their appearance, even when others would not share this perception. It
typically emerges around adolescence. social and cultural factors both influence the emergence and
projection of BDD.

DSM-5 Criteria for Body Dysmorphic Disorder:

e@ Preoccupation with one or more perceived defects in appearance.
e@ Others find the perceived defect(s) slight or unobservable.
@ The person has performed repetitive behaviours or mental acts (e.g., mirror checking, seeking
reassurance, or excessive grooming) in response to the appearance concerns.
e@ Preoccupation is not restricted to concerns about weight or body fat.

Hoarding Disorder
Hoarding disorder involves the excessive need to collect objects despite the complications it might
cause. One of the biggest risks hoarding poses is health/hygiene related.

24
¢ e 2

DSN-5 Criteria for Hoarding Disorder:

e Persistent difficulty discarding or parting with possessions, regardless of their actual value.
e Perceived need to save items.
e Distress associated with discarding.
@ The symptoms result in the accumulation of a large number of possessions that clutter active
living spaces to the extent that their intended use is compromised unless others intervene.

Prevalence and Comorbidity of Obsessive-Compulsive and Related Disorders

The prevalence estimates for OCD and BDD are about 2%, for hoarding disorder it is about 1,5%. All
three disorders are often comorbid with depression and anxiety disorders.

Epidemiology of the Obsessive-Compulsive and Related Disorders

Genes play a moderate role in these disorders. Some brain regions are involved in the three disorders:
the orbitofrontal cortex, the caudate nucleus and the anterior cingulate.

The main goal of cognitive behavioural theory is to understand why a patient with OCD keeps showing
behaviours or thoughts well after the perceived threat is gone. Researchers argued that previous
functional responses for threat become habitual for patients with OCD and therefore they have trouble
overriding the behaviours once the threat is gone.

A cognitive model suggests that people with OCD may try harder to suppress their obsessions and by
doing so, worsening their situation. Research shows that they are more likely to attempt thought
suppression. It is difficult to suppress a thought, because we often keep thinking the thought, to
Raat

remind ourselves to suppress that thought. Several researchers have shown that people with OCD tend
to believe that thinking about something is as morally wrong as engaging in the action, or thinking
Seto

about an event can make it more likely to occur (thought-action fusion). Patients with BDD are often
detail oriented. This affects the way they look at facial/physical features. They consider one feature at
a time, and by doing so, it is more likely they become engrossed while considering a flaw. Being
attractive is more important to these patients than people without this condition. Many theorists take
an evolutionary perspective when considering hoarding. The cognitive behavioural model suggests a
few factors might be involved, such as;
@ Poor organisational skills.
problems with attention.
difficulty with categorising objects and making decisions about them.
Unusual beliefs about possessions.
extreme emotional attachment to the objects.
Avoidance behaviours.

Treatment of the Obsessive-Compulsive and Related Disorders

The most often used medications for these disorders are antidepressants. Exposure and response
prevention (ERP) is the most often used therapy in these disorders. The response prevention
component of ERP is often used in treating OCD, because people with this disorder believe that their
compulsive behaviour will prevent catastrophes from happening. In this kind of treatment, patients
will be left with situations that elicit their compulsive behaviours and have to refrain from performing
those behaviours. The person will feel the full force of the anxiety due to not performing their
compulsive behaviours. The anxiety will become less as treatment progresses, because of exposure (to
a non-catastrophic outcome). Research has shown positive effects of ERP for BDD as well. With
hoarding disorder ERP is a bit adapted. Getting rid of their object is the exposure aspect of the
treatment, because they fear that situation the most. Stopping the behaviours that patients use to
reduce their anxiety, is the response prevention part. First, patients need to get some insight into the

25
Q
SDE UDED ALY
s
severity of their problems. About 10% of those with OCD will not respond to multiple pharmacological
treatments. For those patients, randomised controlled trials support the efficacy of deep brain
stimulation, a treatment that involves implanting electrodes into the brain.
Clinical Description and Epidemiology of Posttraumatic Stress Disorder and Acute Stress Disorder
PTSD is an extreme response to severe stressors. for a diagnosis, a set of symptoms should be present

DSM-5 Criteria for Posttraumatic Stress Disorder:

A. &xposure to actual of threatened death, serious injury or sexual violence, in one or more of
the following ways: experiencing the event personally, witnessing the event in person, learning
that a violent or accidental death or threat of death occur to a close other, or experiencing
repeated or extreme exposure to aversive details of the event(s) other than through the
media.
B. Atleast 1 of the following intrusion symptoms:
a. Recurrent, involuntary, and intrusive distressing memories of the trauma(s), or in
children, repetitive play regarding the trauma themes.
Recurrent distressing dreams related to the event(s)
c.
Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
trauma(s) were recurring, or in children, re-enactment of trauma during play.
C. Atleast 1 of the following avoidance symptoms:
a. Avoids internal reminders of the trauma(s).
b. Avoids external reminders of the trauma(s).
D. Atleast 2 of the following negative alterations in cognition and mood began after the event:
a. Inability to remember an important aspect of the trauma(s).
b. Persistent and exaggerated negative beliefs or expectations about one’s self, others
or the world.
c. Persistently negative emotional state, or in children younger than 7, more frequent
negative emotions.
d. Markedly diminished interest or participation in significant activities.
e. Feeling of detachment or estrangement from others, or in children younger than 7,
social withdrawal. Persistent inability to experience positive emotions.
E. Atleast 2 of the following changes in arousal and reactivity:
Irritable or aggressive behaviour.
anooo

Reckless or self-destructive behaviour.

Hypervigilance.
Exaggerated startle response.
e. Problems with concentration. Sleep disturbance.
F. The symptoms began or worsened after the trauma(s) and continue for at least one month.
G. Among children younger than 7, diagnosis requires criteria A, B, E and F, but only 1 symptom
from either category C or D.

Sometimes PTSD symptoms can develop years after the traumatic event. A diagnosis for acute stress
disorder (ASD) is included in the DSM-5. It is diagnosed when symptoms develop after a trauma, but
the duration is shorter than the duration of the symptoms in PTSD (3 days to a month). PTSD comorbid
highly with other disorders, such as: major depression, anxiety disorders, conduct disorder and
substance abuse. Among people exposed to trauma, women are 1.5 to 2 times as likely to develop
PTSD as are men. Culture may shape the risk for PTSD.

Epidemology of Posttraumatic Stress Disorder

Many risk factors of PTSD overlap with the risk factors for anxiety disorders. Whether or not an
individual develops PTSD is influenced by the severity of the trauma and the nature of the trauma.

26
6.2.
AthenaSummary
.

PTSD develops more often after a trauma caused by humans than caused by natural disasters. PTSD
appears related to genetic risk for anxiety disorders. Like those with anxiety disorders, those with PTSD
show elevated tendencies to develop and sustain conditioned fears. The function of the hippocampus
is linked to PTSD. The volume appears smaller for those with the disorder than for those without it.
This can indicate psychological! vulnerability, because even in a safe context, the risk that an individual
will react to reminders of the trauma could increase due to deficits in the hippocampus. Interference
may occur with organising coherent narratives about the trauma due to deficits in the hippocampus.
Several types of studies suggest that people who cope with a trauma by trying to avoid thinking about
it are more likely than others to develop PTSD. Much of the work on avoidance coping focuses on
symptoms of dissociation.

Treatment of Posttraumatic Stress Disorder and Acute Stress Disorder

SSRI medication seems to be helpful in treating PTSD. People often relapse, if they stop taking the
medication. The most commonly used psychological treatment of PTSD is exposure therapy. There a
different types of exposure:
e@ Reminders of the traumatic event.
@ imaginal exposure.
@ Exposure via virtual reality technology.
@ Cognitive behavioural approaches appear to prevent the development of PTSD in patients with
ASD.

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AthenaSummary
Chapter 8 - Dissociative Disorders and Somatic Symptom-Related
Disorders
Clinical Descriptions and Epidemiology of the Dissociative Disorders
The DSM-5 includes three major dissociative disorders: depersonalization/derealization disorder,
dissociative amnesia, and dissociative identity disorder (formerly known as multiple personality
disorder). Depersonalisation is a sense of being detached from one’s self, and derealisation is a sense
of being detached from one’s surroundings. The trigger is often stress.

DSM-5 Criteria for Depersonalization/Derealization Disorder:

@ Depersonalization: Experiences of detachment from one’s mental processes or body, as
though one is in a dream, or
Derealization: Experiences of unreality of surroundings.
Symptoms are persistent or recurrent.
Reality testing remains intact.
Symptoms are not explained by substances, another dissociative disorder, another
psychological disorder, or by a medical condition.

DSM-5 Criteria for Dissociative Amnesia:

@ Inability to remember important autobiographical information, usually of a traumatic or
stressful nature, that is too extensive to be ordinary forgetfulness.
e The amnesia is not explained by substances, or by other medical or psychological conditions.
® Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently
purposeful wandering.

The period of amnesia may last from several hours to several years. The amnesia can cause
disorientation. Severe stress can cause this kind of memory loss. dissociative amnesia can be explained
through how memories encode during stress. People under stress tend to focus on the central features
of the threatening situation and to stop paying attention to peripheral features (this is an automatic
process that often can’t be controlled). As a consequence, people tend to remember emotionally
relevant material more than the neutral details surrounding an event.

The diagnosis of dissociative identity disorder (DID), formerly labelled multiple personality disorder,
requires that a person have at least two separate personalities, or alters—different modes of being,
thinking, feeling, and acting that exist independently of one another and that emerge at different
times. Each determines the person’s nature and activities when it is in command. The primary alter
may be totally unaware that any other alter exists and may have no memory of what those other alters
do and experience when they are in control.

DSM-5 Criteria for Dissociative Identity Disorder:

e@ Disruption of identity characterised by two or more distinct personality states (alters) or an
experience of possession. These disruptions lead to discontinuities in the sense of self or
agency, as reflected in altered cognition, behaviour, affect, perceptions, consciousness,
memories or sensory-motor functioning. This disruption may be observed by others or
reported by the patient.
e Recurrent gaps in memory for events or important personal information that are beyond
ordinary forgetting.
@ Symptoms are not part of a broadly accepted cultural or religious practice.
@ Symptoms are not due to drugs or a medical condition.

28
e
&2.
Inchildren, symptoms are not better explained by an imaginary playmate or by fantasy play.
DID is much more common in women than in men. Other diagnoses are often present, including
posttraumatic stress disorder, major depressive disorder, somatic symptom disorders, and personality
disorders.

The Epidemiology of Dissociative Disorders:

The epidemiology of dissociative disorders is not well researched. The number of diagnosed cases of
DID surged during the 1970s, and some attribute this to the increased media and professional
attention to the syndrome.

Epidemiology of DID
The posttraumatic model and the sociocognitive model are two major models that explain DID. The
former model suggests that the key element for developing DID is the use of dissociation to cope with
trauma. According to the latter model, it is very likely that alters appear in response to suggestions by
clinicians (iatrogenic), media or cultural influences in people who have been abused and seek
explanations for their symptoms. This means that DID could be iatrogenic, which in turn means that it
could have been created by treatment. It is possible that people role-play the symptoms of DID.
Therapists who diagnose more people with DID tend to use hypnosis, to urge clients to try to unbury
unremembered abuse experiences, or to name different alters. One of the defining features of DID is
the inability to recall information experienced by one alter when a different alter is present. One way
to test whether alters share memory is to use implicit tests of memory.

Treatment of DID
The patient should be convinced that splitting into multiple personalities is no longer necessary in
dealing with traumas. therapists can help teach the person more effective ways to cope with stress,
such as adaptive emotion regulation strategies. Antidepressants have no effect on DID, but can be
necessary in the treatment of anxiety and depression, which often comorbid with DID. Psychodynamic
treatment is probably used more for DID and the other dissociative disorders than for any other
psychological disorder. The goal of this treatment is to overcome repressions.

Clinical Description of Somatic Symptom and Related Disorders

Somatic symptom and related disorders are defined by excessive concerns about physical
symptoms or health. They are commonly known as hypochondriacs. People with such disorders tend
to pay frequent visits to a medical doctor, and often have a negative opinion about their doctors,
because no medical explanation can be found.

There are several criticisms on the diagnostic process:

® Thesymptoms are varied.
e The criteria are too subjective.
@ Patients often think the diagnosis stigmatises too much.

Clinical Description of Somatic Symptom Disorder

The key feature of somatic symptom disorder is excessive anxiety, energy, or behaviour
focused on somatic symptoms that persists for at least 6 months.

DSNM-5 Criteria for Somatic Symptom Disorder:

® Atleast one somatic symptom that is distressing or disrupts daily life.
e Excessive thought, distress, and behaviour related to somatic symptom(s) or health concerns,
as indicated by at least one of the following:
oO Health-related anxiety.

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AthenaSummary
e

© Disproportionate and persistent concerns about the seriousness of symptoms.

© Excessive time and energy devoted to health concerns.
@ Duration of at least 6 months.
@ Specify if predominant pain.
Somatic symptom disorder can be diagnosed regardless of whether symptoms can be explained
medically.

Clinical Description of Illness Anxiety Disorder

The main feature of illness anxiety disorder is a preoccupation with fears of having a serious
disease despite having no significant somatic symptoms.
DSM-S Criteria for Illness Anxiety Disorder:
@ Preoccupation with and high level of anxiety about having or acquiring a serious disease.
e@ Excessive illness behaviour (e.g., checking for signs of illness, seeking reassurance) or
maladaptive avoidance (e.g., avoiding medical care).
e Nomore than mild somatic symptoms are present.
@ Not explained by other psychological disorders.
@ Preoccupation lasts at least 6 months.

Clinical Description of Conversion Disorder

In conversion disorder, the person suddenly develops neurological symptoms, such as blindness,
seizures, or paralysis (used to be known as hysteria). The symptoms suggest an illness related to
neurological damage, but medical tests indicate that the bodily organs and nervous system are fine.

DSM-5 Criteria for Conversion Disorder:

@ One or more symptoms affecting voluntary motor or sensory function.
® The symptoms are incompatible with recognized medical disorders.
@ Symptoms cause significant distress or functional impairment or warrant medical evaluation.

Symptoms of conversion disorder usually develop in adolescence or early adulthood. Onset is usually
rapid, with symptoms developing in less than one day.

DSM-5 Criteria for Factitious Disorder:.

e Fabrication or induction of physical or psychological symptoms, injury, or disease
e Deceptive behaviour is present in the absence of obvious external rewards
e In Factitious Disorder Imposed on Self, the person presents himself or herself to others as ill,
impaired, or injured
e@ In Factitious Disorder Imposed on Another, the person fabricates or induces symptoms in
another person and then presents that person to others as ill, impaired, or injured

The difference between malingering and factitious disorder is that malingering involves faking
symptoms where in factitious disorder, symptoms are created.

Epidemiology of Somatic Symptom-Related Disorders

Heritability does not seem to be a factor in these disorders. Understanding why some people are more
aware of and distressed by somatic symptoms is essential in understanding somatic symptom
disorders. The focus lies on brain regions that are activated by unpleasant body sensations in
neurobiological models of somatic symptom-related disorders. Heightened activity in the anterior
insula, anterior cingulate cortex and somatosensory cortex is linked to greater chance for somatic
symptoms. Pain and somatic symptoms can be increased by anxiety, depression and stress hormones.

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&2.
The focus with cognitive behavioural models is on mechanisms that could contribute to the major
focus on and fear over health concerns, cognitive biases play a role.
Research gives evidence for automatically focusing on hints of physical health problems in people with
excessive distress about their somatic symptoms. Two behavioural reinforcers might be given to the
person having an excessive fear about their somatic symptoms:
@ The person might take the role of being ill and the avoidance behaviours that might follow
this, can intensify symptoms, because it limits healthy behaviours.
@ The person may seek reassurance and this behaviour can be reinforced if the person receives
attention or sympathy because of the behaviour.

Epidemiology of Conversion Disorder

In conversion disorders, according to psychodynamic theories, an unconscious psychological conflict
causes the physical symptom. Patients may also have an unconscious motivation for having certain
symptoms. Social and cultural factors shape the symptoms of conversion disorder. For example,
symptoms of conversion disorder are more common among people from rural areas and people of
lower socioeconomic status.

Treatment of Somatic Symptom and Related Disorders

People with these disorders usually want medical care and not psychological treatment. This is one of
the major obstacles to treatment. A reminder of the mind-body connection might help to get patients
to consider mental health care. People first go to their general practitioners with their complaints
about somatic symptoms. It is therefore important that general practitioners can tailor care for people
with somatic symptom-related disorders.

To help people with somatic symptom-related disorders, cognitive behavioural clinicians apply
different techniques:
e identifying and changing the emotions that trigger the patient's concerns.
@ Change their cognition about their symptoms.
e@ Changing the behaviours that come with playing the role of a sick person.
® Gaining more reinforcement for engaging in different social interactions.

Because these disorders often comorbid with anxiety and depression, it is not surprising that somatic
symptoms are reduced if anxiety and depression are successfully treated. When pain is the focus of
somatic symptom disorder, multiple techniques can be helpful:
@ Cognitive behavioural techniques.
@ Hypnosis.
e Acceptance and commitment therapy.
e Antidepressants.

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AthenaSummary

Chapter 9 - Schizophrenia
Clinical Descriptions of Schizophrenia
Schizophrenia is a disorder characterised by disordered thinking, in which ideas are not logically
related, faulty perception and attention, a lack of emotional expressiveness, and disturbances in
behaviour, such as dishevelled appearance. the prevalence is 1%, men slightly more than women. It
can sometimes begin in childhood but usually emerges during adolescence or early adulthood.

DSN-5 Criteria for Schizophrenia:

e Two or more of the following symptoms for at least 1 month; one symptom should be either
1, 2, or 3:
© delusions
Oo hallucinations
© disorganised speech
© disorganised (or catatonic) behaviour
© negative symptoms (diminished motivation or emotional expression)
e Functioning in work, relationships, or self-care has declined since onset
e Signs of disorder for at least 6 months; or, if during a prodromal or residual phase, negative
symptoms or two or more of symptoms 1-4 in less severe form.

Positive symptoms
Positive symptoms comprise excesses and distortions, which include hallucinations and delusions.
Acute episodes of schizophrenia are mostly characterised by positive symptoms.

Delusions= beliefs contrary to reality and firmly held in spite of disconfirming evidence.
@ Persecutory delusions: the belief that people plot acts against them.
@ Thought insertion: the belief that thoughts are not your own but placed in your mind by an
external source.
@ Thought broadcasting: the belief that your thoughts are broadcast or transmitted, so that
others know what you're thinking.
e External force: the belief that an external force controls your feelings or behaviour.
e@ Grandiose delusions: an exaggerated sense of his or her own importance, power, knowledge,
or identity.
e Ideas of reference: the incorporation of unimportant events within a delusional framework
and reading personal significance into the trivial activities of others.

Delusions are found in more than half of the people with schizophrenia, but are also part of other
disorders such as MDD, bipolar and other psychotic disorders.

Hallucinations= sensory experiences in the absence of any relevant stimulation from the environment.
More often auditory than visual. Most auditory hallucinations are the person's own thoughts in
someone else's voice. Broca’s area has been found to be active during auditory hallucinations.
hallucinations are common in other disorders too (like delusions are).

Negative symptoms
Negative symptoms are deficits in motivation, pleasure, social closeness, and emotional expression,
they take away from reality. These symptoms tend to continue beyond an acute episode.
e Avolition (apathy): a lack of motivation and a seeming absence of interest in or an inability to
persist in what are usually routine activities.

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AthenaS:
2

e Asociality: severe impairments in social relationships (few friends, poor social skills, very little
interest in being with other people).
e@ Anhedonia: a loss of interest in (or a reported lessening of) the experience of pleasure. There
are two domains of pleasure experiences in this construct:
© Consummatory pleasure: the amount of pleasure experienced in the moment or in the
presence of something pleasurable (ex. eating).
© Anticipatory pleasure: the amount of expected or anticipated pleasure from future
events or activities (ex. graduating).
mw People with schizophrenia appear to have a deficit in anticipatory pleasure but
not in consummatory pleasure.
e Blunted affect: lack of outward expression of emotion. A person with these symptoms may
stare vacantly, the muscles of the face motionless, the eyes lifeless. When spoken to, the
person may answer in a flat and toneless voice and not look at the conversational partner.
inner emotions seem to be unaffected.
e Alogia: a significant reduction in the amount of speech. People with these symptoms don’t talk
much,

Disorganised symptoms
Disorganised symptoms include disorganised speech and disorganised behaviour.
e@ Disorganised speech refers to problems with organising ideas and in speaking so that a listener
can understand
© Loose associations/derailment: the person may be more successful in communicating
with a listener but has difficulty sticking to one topic.
e Disorganised behaviour: loss of the ability to organise one's behaviour and make it conform to
community standards.
© Catatonia: rapid gesturing, increased overall activity.
subtypes of Schizophrenia have been removed from the DSM-5 due to poor reliability and validity.
Other, similar disorders include;
@ Schizophreniform disorder: same symptoms as schizophrenia, but only last 1 to 6 months.
e@ Brief psychotic disorder: same symptoms, but lasts from 1 day to a month, and is often brought
on by extreme stress, such as bereavement.
e Schizoaffective disorder: a mixture of symptoms of schizophrenia and mood disorders. It also
requires either a depressive or manic episode.
@ Delusional disorder: persistent delusions.

Epidemiology
Genetic factors include;
@ Behaviour genetics research: Family, twin and adoption studies support the idea that genetic
factors play a role in schizophrenia. The risk for MZ twins (44.3 percent), though greater than
that for DZ twins (12.08 percent), is still much less than 100 percent. The study of children
whose biological mothers had schizophrenia but who were reared from early infancy by
adoptive parents without schizophrenia is another useful behaviour genetics study method.
Such studies eliminate the possible effects of being reared in an environment where a parent
has schizophrenia.
e@ Familial high-risk study: the offspring of one or two biological parents with schizophrenia are
followed longitudinally, in order to identify how many of these children may develop
schizophrenia and what types of childhood neurobiological and behavioural factors may
predict the disorder’s onset. offsprings of people with schizophrenia are at higher risk.
e Molecular genetics research: There are multiple common genes associated with schizophrenia
and bipolar disorder, genes such as DRD2 and COMT were identified.

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oe
AthensSummary
The Role of Neurotransmitters
Dopamine Theory: The theory that schizophrenia is related to excess activity of the neurotransmitter
dopamine is based principally on the knowledge that drugs effective in treating schizophrenia reduce
dopamine activity, but treatment drugs did result in symptoms of Parkinson’s in some patients.
Amphetamines in healthy samples can result in schizophrenia-like symptoms, which relates to the
dopamine theory, but this theory is thought to be too simplistic. Other neurotransmitters such as
GABA, glutamate and serotonin are seen to be related to schizophrenia.
Enlargement of the ventricles and dysfunction in the prefrontal cortex (reductions in grey matter) and
temporal cortex, as well as surrounding brain regions is seen in schizophrenia patients. A variety of
evidence suggests that the prefrontal cortex is of particular importance in schizophrenia, due to
differences in speech, decision making, emotion, and goal-directed behaviour, which are disrupted in
schizophrenia. Dendritic spines are lost, meaning that there is less communication between neurons.
Problems in the temporal cortex and surroundings (temporal gyrus, hippocampus, amygdala, anterior
cingulate) are seen too. The HPA axis is related to this area, which may explain stress relations.

Connectivity in the Brain

Structural connectivity explains how different structures of the brain are connected via white matter
(axon fibres). schizophrenia patients have less white matter.
Functional connectivity explains the connectivity between brain regions based on correlations
between their blood oxygen level measured with fMRI. We see reduced FC in schizophrenia patients.
Effective connectivity combines both types, revealing correlations in blood oxygen and the direction
and timing of those activations as well. This is also diminished in schizophrenia patients.

Environmental Factors Influencing the Developing Brain

e@ deafness and environmental deprivation
e@ brain abnormality during gestation or birth
© maternal infections during pregnancy
© adolescence stress, leading to hyperactive HPA, leading to high cortisol thus high
dopamine.
© extensive synaptic pruning
© cannabis use

Psychological Factors
@ SES (socioeconomic status)
© sociogenic hypothesis: this is less supported, but it explains that stress is associated to
poverty
© social selection hypothesis: this is more supported, it explains that when developing
schizophrenia, people drift into poor neighbourhoods because the illness impairs their
earning power. (rates of schizophrenia are higher in urban areas)
@ migrants have a high predisposition of developing schizophrenia (while they are in a foreign
country).
e family factors:
© Expressed emotion: critical comments, hostility and emotional overinvolvement
characterise EE, and have a profound impact on how the condition worsens or heals
in the individual. (high EE leads to higher relapse rate)

Developmental Factors
@ Retrospective studies (starting point is adults with schizophrenia, then they follow back to
their early childhood): kids who developed schizophrenia had lower IQ, and were more
withdrawn.

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———_— ® ———

AthenaSummary
.

e Prospective studies: lower IQ scores predicted onset of Schizophrenia (controlled for low SES).
© Clinical high-risk study: a design that identifies people with early signs of schizophrenia
that cause impairment.

Treatment of Schizophrenia
@ Medications (antipsychotic drugs)
e About 30 percent of people with schizophrenia do not respond favourably to the first-
generation antipsychotics, and about half the people who take any antipsychotic drug quit
after 1 year and up to three-quarters quit before 2 years because the side effects are so
unpleasant. the side effects include sedation, dizziness, blurred vision, restlessness, sexual
dysfunction, but also some extrapyramidal side effects. These resemble the symptoms of
Parkinson’s disease.
© Tardive dyskinesia (the mouth muscles involuntary make sucking, lip-smacking and
chin-wagging motions)
© Neuroleptic malignant syndrome (severe muscular rigidity develops, accompanied by
fever. This may be fatal).
© some first generation antipsychotics are:
mw chlorpromazine : Thorazine
m= = fluphenazine : Prolixin
mg Haldol : haloperidol
mg Navane: thiothixene
gm Stelazine : trifluoperazine
@ Second generation antipsychotic drugs have mixed success. They can also help with negative
symptoms, which first generation ones can't. Some second generation drugs are:
© clozapine : Clozaril
aripiprazole : Abilify
0 0

olanzapine : Zyprexa
oo

risperidone : Risperdal
ziprasidone : Geodon
© quetiapine : Seroquel
e At this point, antipsychotic drugs are an indispensable part of treatment for schizophrenia. A
recent review of 60 years’ worth of clinical trials with these drugs found that just over half of
the people with schizophrenia had a minimal response compared with placebo, but only 23 %
had a good response.
@ Psychological treatments
© Social skills training consists of teaching people with schizophrenia how to successfully
manage a wide variety of interpersonal situations. These can help people achieve
fewer relapses, better social functioning, and a higher quality of life.
o Family therapies: these vary in length, setting and specific techniques, but have several
features in common, aiming to decrease EE:
m Education about schizophrenia
Information about antipsychotic medication
Blame avoidance and reduction
Communication and problem-solving skills within the family
Social networks expansion
Hope

@ CBT: People with schizophrenia can be encouraged to test out their delusional beliefs
in much the same way as people without schizophrenia test out their beliefs. Through
collaborative discussions, some people with schizophrenia have been helped to attach

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AthenaSummary
e

a nonpsychotic meaning to paranoid symptoms and thereby reduce their intensity and
aversive nature
Cognitive remediation training/ cognitive enhancement therapy (CET)= treatments
that seek to enhance basic cognitive functions such as verbal learning ability.
Psychoeducation: educating people about their illness, including symptoms, the
expected time course, the biological and psychological triggers and treatment
strategies.
Case management: a service for people with schizophrenia to connect with them,
provide them essential clinical, vocational, employment etc needs.
Residential treatment: alternatives for people who do not need to be in a hospital
setting, but aren’t in a position to do well alone as well.

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