MODULE 1 deviations from the mean), but this is an

entirely arbitrary cutoff.

INTRODUCTION 2. Tests that measure one’s deviation are

developed from within a particular cultural
Nature and History of Human Abnormality
framework. Hence, there is no objective,
scientific definition, only a definition that the
Mental disorder, mental illness, and
researchers developing the measure have
psychopathology are often used
interchangeably by those in psychology and
When viewing behavior, both sides of the
related fields; all terms refer to the study of
normal curve would be considered abnormal.
unusual or abnormal behaviors
Example: Someone with very high and very
low general anxiety would be considered
Mental disorder: characterized by a clinically
abnormal.
significant disturbance in an individual's
cognition, emotional regulation, or behavior. It
In the real world, it is usually only one tail of
is usually associated with distress or
the curve that is viewed as problematic or
impairment in important areas of functioning
abnormal.
Mental illness: are health conditions involving
Example: A person with an IQ of 70 and
changes in emotion, thinking or behavior
another person with IQ of 130. On a scale
where 100 is the average with a standard
Psychopathology: scientific study of mental
deviation of 15, both are equally deviated from
disorders
“normal” intelligence. Most people, however,
would only consider the person with an
1. Mental Disorders as Statistical extremely low IQ to have a mental disorder,
Deviance another problem with this conception,

Statistical Deviance perspective 2. Mental Disorders as Social

- common sense appeal
Deviance
- involves defining abnormal behavior by
comparing an individual’s behavior to the
Social Deviance perspective
frequency of occurrence of the same
- behavior is deemed abnormal if it deviates
behavior in the general population.
greatly from the accepted social standards,
values, and norms of an individual’s culture
When is a behavior considered abnormal?
- This method is uninterested in the actual
- if it occurs rarely or infrequently in the
normas of the population. Population may
general population
have accepted standards that the majority of
- with this, it lends itself very well to
the culture does not actually meet
measurement, as research and clinicians can
administer objective assessment to clients
Example: Use of alcohol and tobacco prior to
and get accurate measurements of just how
the legal age of use. Though considered
far depression, anxiety, hyperactivity, and so
unlawful and socially unacceptable, major
on are from the norm.
surveys show that over 75% of high school
seniors have consumed alcohol
Problems emerging from this perspective
1. Who determines how far from the norm is
Problems emerging from this perspective
too far from the norm? It is not set in stone to
1. There is little to no object validity, due to
identify this and instead, researchers and
individuals and groups even within the same
clinicians make that decision. Behaviors are
culture having different ideas of what is
considered abnormal if they occur in less than
socially acceptable.
5% of the population (1.645 standard
2. What is acceptable at one point in time Example: in many Native American tribes, it is
can become unacceptable with the passage considered disrespectful to look an elder
of time, or vice versa directly in the eye when talking to them.

Example: in 1973, homosexuality was 3. This perspective clashes mightily with the
classified as a diagnosable mental disorder by statistical deviance perspective, in that
the American Psychiatric Association, rather statistically deviant behaviors (e.g an IQ higher
than being recognized as a normal variation of than 99% of the population) can be highly
sexual orientation adaptive, and that numerous maladaptive
behaviors (such as public speaking) are quite
3. Different morals and standards of disparate common in the population as a whole
cultural groups would mean that what was
normal in one country or region would be ____________________________________
considered abnormal in another
Dimensional vs. Categorical Models
3. Mental Disorders as Maladaptive of Mental Disorders
Behavior
Categorical model
Maladaptive behavior perspective - psychopathology is dichotomous, either
- attempts to classify as mental disorders being present or not being present. (e.g
those behaviors that are dysfunctional having a mental disorder or not)
- refers to the effectiveness or
ineffectiveness of behavior in dealing with Dimensional model
challenges or accomplishing goals - acknowledges that the vast majority of
- typically discussed maladaptive behaviors human behavior exists on a continuum,
include: rather than the polarized view of the
- physically harmful behaviors that categorical model. What tends to be labeled
prevent the person from taking care of as abnormal and unusual are merely the far
themselves ends of this normal curve of behavior
- prevent communication with others - mental disorders are just extreme
- interfere with social bonding and variations of normal psychological
relationships phenomena or problems that may or most of
us experience
Problems emerging from this perspective - has a very large amount of scientific
1. Adaptive behavior is hard to objectively support, particularly in the area of
quantify. Any particular is based on both the personality disorders including:
situation and one’s subjective judgment. - anxiety
- depressive episodes
Example: a person engaging in coercive - even psychotic disorders
behaviors, stealing, and lying to others, most
people would say it can be classified as Unfortunately, however, the real world often
maladaptive behaviors (age-dependent, requires caseness or non-caseness. In many
qualified for a diagnosis of Conduct Disorder instances, one must be diagnosed with a
or Antisocial Personality Disorder). In this particular mental disorder to obtain certain
case, what if they were doing this to obtain things, such as insurance reimbursement,
necessities for their family? Would that still be special services at school, or disability
maladaptive? benefits. This, subsequently, creates a tension
between the need for categories and the lack
2. One’s culture also plays a large role in of scientific support for them.
determining the adaptiveness of a behavior
DSM Definitions of Mental Disorder Considerable concerns:
1. What exactly does “clinically significant”
mean?
Diagnostic and Statistical Manual of Mental
2. How much distress is enough to distress
Disorders (DSM) is published by the
and who determines that?
American Psychiatric Association and is the
3. Who says what is or is not “culturally
most widely used classification system of
sanctioned?”
mental disorders in the United States. It
4. What defines a behavioral or psychological
provides diagnostic criteria for almost 300
syndrome or pattern
mental disorder

Categorical nature of the DSM-IV is a

DSM and ICD (International Classifications
concern and authors even state that they
of Disorders): used outside of the United
recognize the actual, dimensional nature of
States
mental disorders but due to the need for
caseness must operate in a categorical nature.
Considered descriptive of a mental
In turn, this contributes to the high amount of
disorder (1994)
diagnostic overlap, or comorbidity, present in
- A clinically significant behavioral or
clinical populations. In one of the most
psychological syndrome or pattern that occurs
well-conducted studies to examine this issue,
in an individual
Ronald Kessler and his research team (2005)
found that 26.2% of Americans met the criteria
- Is associated with
for a mental disorder; of these, 45% met
- present distress (e.g., a painful
criteria for two or more disorders.
symptom) or,
- disability (i.e., impairment in one or
more important areas of functioning) or, DSM5 (reworked the definition of a
- or with a significantly increased mental disorder)
risk of suffering death, pain, disability, or - A behavioral or psychological syndrome or
an important loss of freedom pattern that occurs in an individual
- That reflects an underlying
- Must not be merely an expectable and psychobiological dysfunction
culturally sanctioned response to a - The consequences of which are clinically
particular event, for example, the death of a significant distress (e.g., a painful symptom)
loved one or disability (i.e., impairment in one or more
important areas of functioning)
- A manifestation of behavioral, - Must not be merely an expectable
psychological, or biological dysfunction in the response to common stressors and losses
individual (for example, the loss of a loved one) or a
culturally sanctioned response to a
- Neither deviant behavior (e.g., political, particular event (for example, trance states in
religious, or sexual) nor conflicts that are religious rituals)
primarily between the individual and - That is not primarily a result of social
society are mental disorders unless the deviance or conflicts with society
deviance or conflict is a symptom of a
dysfunction in the individual

DSM-IV states that no definition adequately

specifies precise boundaries for the concept of
mental disorder and the concept of mental
disorder lacks a consistent operational
definition that covers all situations
LESSON 1 - causes and treatment of abnormal
behavior varied widely, depending on the
Abpsych Nature and History context

Understanding Psychopathology: What is a Supernatural Tradition

psychological disorder and what is not? - Deviance: Battle of “Good” vs. “Evil”
- Etiology: devil, witchcraft, sorcery
How do we describe people with mental 1. Great Persian Empire (900 to 600 BC)
illness? 2. 14th and 15th century Europe
- Lazy, crazy, dumb? 3. Salem witch trials in United States
- Weak in character? 4. Demons and witches
- Dangerous? - Treatments - exorcism, torture, and crude
- Hopeless? surgeries

What is a Psychological Disorder? Stress and melancholy

- It is a psychological dysfunction that causes - Etiology: natural, curable phenomenon
significant distress and that is considered - Illness model
deviant in that person’s culture or society - Still connected with sin
- Breakdown in function - Treatments for possession
- Cognitive - Mass hysteria: states are voluntarily
- Behavioral elicited in religious or healing ceremonies, with
- Emotional incessant drumming, excitement and
suggestibility as one person after another falls
into a trance or possession state.
- Response is atypical or culturally expected
- Deviations from “average” - St. Vitus’ dance (Sydenham’s
- Violation of social norms Chorea): a disease affecting the brain,
- Harmful dysfunction particularly causing unusual movements,
unsteadiness and poor coordination.
An accepted definition - Tarantism: a psychological condition
- DSM-5 describes behavioral, psychological, characterized by an irresistible urge to dance
or biological dysfunctions that are unexpected - Modern Mass hysteria: Mass
in their cultural context and associated with hysteria is also described as a “conversion
present distress and impairment in functioning disorder,” in which a person has physiological
or increased risk of suffering, death, pain, or symptoms affecting the nervous system in the
impairment absence of a physical cause of illness, and
which may appear in reaction to psychological
Clinical Description distress.
- Course - Emotion contagion: occurs when
- Chronic someone's emotions and related behaviors
- Episodic lead to similar emotions and behaviors in
- Time-limited others.
- Onset - Mob psychology (mob mentality):
- Acute vs. insidious when people adjust their personal views to fit
- Prognosis the group they're in.
- Good vs. guarded
- The Moon and The Stars
Historical Conceptions of Abnormal - Paracelsus: Philippus Aureolus
Behavior Theophrastus Bombastus von Hohenheim,
- major psychological disorders have existed pioneered the use of minerals and other
across time and cultures chemicals in medicine.
- Lunacy
- Modern examples Development of Biological
-Astrology Treatments
- Mental Illness = Physical Illness
The Biological Tradition - The 1930
1. Hippocrates (460-377 BC) - Insulin shock therapy
- Father of Modern Western Medicine - Brain surgery
- Etiology: physical disease - ECT
- Precursor to somatoform (somatic symptom - Benjamin Franklin (1750s)
disorder): is a mental health condition that - Treatment for depression
causes an individual to experience physical - The 1950s
bodily symptoms in response to - Psychotropic medications
psychological distress. - Increasingly available
- Hysteria - Systematically developed
- Neuroleptics
2. Galen (129-198 AD) - Reserpine and psychosis
- Hippocratic foundation - Tranquilizers
- Galenic-Hippocratic Tradition - Benzodiazepines and anxiety
- Humoral theory of mental illness
- Black, blue, yellow, and phlegm biles The Psychological Tradition
- Etiology: brain chemical imbalances
- Plato, Aristotle, and Greece
- Treatments: environmental regulation
- Etiology: social and environmental factors
- Heat, dryness, moisture, cold
- Treatment:
- Bloodletting, induced vomiting
- rededucation via discussion
- therapeutic environments
19th Century
- Similar practices in ancient Muslim countries
- Syphilis: bacterial infection usually spread
by sexual contact. The disease starts as a
Moral Therapy
painless sore — typically on the genitals,
- Moral = emotional or psychological
rectum or mouth
- Treating patients normally
- General paresis: weakening of a muscle or
- Encouraging social interaction
group of muscles
- Focus on relationships
- STD with psychosis-like symptoms
- Individual attention
- Delusions
- Education
- Hallucinations
- Etiology: bacterial microorganisms
- Louis Pasteur’s germ theory: He proved
that food spoiled because of contamination by
invisible bacteria, not because of spontaneous
generation
- Biological basis for madness

3. John Grey (1850s)

- American proponent of the biological tradition
- Etiology: always physical
- Treatments: as is physically ill
- Rest
- Diet
- Room temperature
- Improved hospital conditions
LESSON 2
An Integrative Approach to
Psychopathology

Biological dimensions include

causal factors from the fields of genetics and
neuroscience.

Psychological dimensions include causal

factors from behavioral and cognitive
processes, including:
- learned helplessness,
- social learning,
- prepared learning, and One-Dimensional Multidimensional
- even unconscious processes (in a different Model Model
guise than in the days of Sigmund Freud).
- Single cause, operating - Systemic
in isolation - Several independent
Emotional influences contribute in a variety - Linear causal model inputs that become
of ways to psychopathology, as do social and - Ignores critical interdependent
interpersonal influences. information - Causes cannot be
considered out of context
Finally, developmental influences figure in In the given case, what caused Judy’s phobia?
any discussion of causes of psychological 1. Behavioral factors
disorders. Each dimension—biological or 2. Biological factors
psychological—is strongly influenced by the - Genetics
others and by development, and they weave - Physiology
together in various complex and intricate ways - Neurobiology
to create a psychological disorder. 3. Emotional Influences
4. Social factors
5. Developmental factors
= All of these interact interdependently
_____________________________________

The Nature of Genes

What are genes?
- Long molecules of DNA
- Double helix structure
- Located on chromosomes
- 46 chromosomes in 23 pairs
- Pairs 1-22: body and brain development
- Pair 23: gender
- Determine physical characteristics
- Importance of contextual factors
- Single-gene determinants
- Polygenic (two or more genes) influences
- Rule, not the exception

Genetic Contributions to
Psychopathology
- Evidence of the complexity and the
contextual nature of genetics::
1. Quantitative genetics accounts for the Genetic Contributions to
small, individual effects of several genes Psychopathology
2. Gene expression and gene environment
- ~50% of variance in personality or cognitive
interactions
characteristics
- complex gene-environment relationships
New Developments in the Study of - Genes:
Genes and Behavior - behavior, cognition, emotions
- Behavioral genetics - “bounds” of environmental impact
- Role of genes and psychological disorders - Environment:
- Genetic structure and activation
Interaction of Genes and the - May override genetic diathesis
Environment
- Eric Kandel: learning affects genetic Neuroscience and its Contributions
structure of cells to Psychopathology
- Activation of dormant genes - The field of neuroscience
- Continued development in the brain - The role of the nervous system in disease
- Plasticity vs. hardwired and behavior
- Diathesis-Stress model - The Central Nervous System
- CNS: brain and spinal cord
- Diathesis: Inherited tendency to express - PNS: somatic and autonomic branches
traits/behaviors, which is basically genetic
- Stress: life events or contextual variables;
environmental

= Combining both yields activation under

the right conditions

- Gene-environment correlation model

- Gene shape how we create our
environments
- Inherited predispositions or traits that
increase one’s likelihood to engage in activities
or seek out situations
- Example: divorce

CNS:
- The neuron-basic building block
- soma
- Overemphasis on the role of genes?
- dendrites
- Environment and early learning
- axon
- cross fostering studies of development
- axon terminals
- critical vs. sensitive periods
- synaptic cleft
Function: electrical - Frontal: thinking and reasoning abilities,
Communication: chemical memory
(neurotransmitters) - Temporal: sight and sound recognition,
long-term memory storage
- Parietal: touch recognition
- Occipital: integrates visual input

The Structure of the Brain

- Two main parts:
- Brain stem: basic functions
- Forebrain: higher cognition

- Hindbrain Peripheral Nervous System

- Medulla: heart rate, blood pressure, - Somatic system: voluntary muscles and
respiration movement
- Pons: regulates sleep stages - Autonomic system:
- Cerebellum: physical coordination - Sympathetic: activating
- Parasympathetic: normalizing
- Midbrain - Both divisions regulate:
- coordinates movement with sensory input - Cardiovascular system or body
- contains parts of the reticular activating temperature
system - Endocrine system or digestion
- Endocrine system: hormones
- Thalamus and hypothalamus - Hypothalamic-pituitary-adrenocortical
- relays between brainstem and forebrain (adrenalcortical) axis
- behavioral and emotional regulation - Integration of endocrine and nervous
system
- Limbic system
- Emotions, basic drives, impulse control Neurotransmitters
- Associated structures and psychopathology - production
- uptake and reuptake
- Basal ganglia - functions:
- Caudate nucleus - agonists: drug that binds to the receptor,
- Motor activity producing a similar response to the
intended chemical and receptor;
- Forebrain (cerebral cortex) inverse agonists: ligand that binds to the
- most sensory, emotional, and cognitive same receptor-binding site as an
processing agonist
- two specialized hemispheres: - antagonists: bindi to synaptic receptors but
- left: verbal, math logic decrease the effect of the
- right: perceptual neurotransmitters

- Lobes of the cerebral cortex

Neurotransmitters
Glutamate Gamma-Aminobutyric Acid

Excitatory; major Inhibitory; lessens a nerve cell;s

role in learning and ability to receive, create, or send
memory chemical messages to other
nerve cells

- fast acting
- complex subsystems
- implicated in anxiety
- benzodiazepines: type of sedative
medication that slows down body and brain’s
functions

Serotonin (5HT: biosynthesized from

tryptophan amino acid)
- monoamine class
- widespread, complex circuits ____________________________________
- regulates behavior, moods, thought
processes Implications for Psychopathology
- low levels and vulnerabilities - brain and abnormal behavior
- implicated in several psychopathologies - studying images: obsessive-compulsive
disorder
Psychosocial Factors: stress,
hostility, depression, hopelessness,
and job control

Psychosocial Influences on Brain

Structure and Function
- Psychosocial influences on the brain
- functional normalization in OCD
- placebo
- psychotherapy
- stress and early development
- Interactions of psychosocial factors with
brain structure and function
- developmental disorders
- environment and brain structures

Interactions of Psychosocial
Factors and Neurotransmitter
Systems
- Some research indicates that psychosocial
factors directly affect levels of
neurotransmitters
Norepinephrine
- stimulation of alpha- and beta-adrenergic
receptors
- respiration, reactions, alarm response
- implicated in panic
- fight or flight
Psychosocial Effects on the COGNITIVE SCIENCE AND THE
Development of Brain Structure and UNCONSCIOUS
Function - Blind sight: psychological defense
- The structure of neurons themselves, mechanism, caused by a self-protective need
including the number of receptors on a cell, to deny visual information that might cause
can be changed by learning and experience fear, anxiety, or shame.
during development - Stroop paradigm: delay in reaction time
between automatic and controlled processing
Behavioral and Cognitive Sciences of information, in which the names of words
interfere with the ability to name the color of
- Conditioning and cognitive process
ink used to print the words. (example: “green”
- Respondent and operant learning (operant
word written in “red” ink)
conditioning BF Skinner)
- Environmental relationships
Emotions
- the nature of emotion
- fight or flight response
- fear response (amygdala)
- cardiovascular
- cortical
- emotional response is error, motivation for
action
- short-lived, temporary states
- different from mood or affect
The dog became conditioned that they will be
given food if they hear a specific sound.

- Learned helplessness
- Perceptions of control
- Implicated in depression
- negative attributions, associated with
anger responses and lower life satisfaction

- Learned optimism

- Social learning by Albert Bandura

- Modeling
- Observational learning
- Interactive and contingent on perceptions of
similarity
________________________
- Prepared learning
- Evolutionary basis: all species are related
and gradually change over time
LESSON 3
- Increases survival Diagnosing Abnormal Behavior
- One trial learning: learning takes place in using Clinical Assessment
a single pairing of a response and stimulus
and is not strengthened over time by repeated The processes of clinical assessment and
exposure to a stimulus diagnosis are central to the study of
psychopathology and treatment of
psychological disorders.
Clinical assessment is the systematic - attitudes
evaluation and measurement of - emotions
psychological, biological, and social factors in - detailed history
an individual presenting with a possible - presenting problem
psychological disorder. - Mental Status Exam
- appearance and behavior
Diagnosis is the process of determining - thought processes
whether the particular problem afflicting - mood and affect
the individual meets all criteria for a - intellectual functioning
psychological disorder, as set forth in the - sensorium: the entire sensory apparatus
fifth edition of the Diagnostic and Statistical of an organism
Manual of Mental Disorders, or DSM-5
(American Psychiatric Association, 2013).

Assessing Psychological Disorders

- Clinical assessment
- Systematic evaluation and measurement
- psychological
- biological
- social
*overt behavior: observable and measurable
- Diagnosis: degree of fit between symptoms *covert behavior: opposite of overt
and diagnostic criteria *oriented times three: Awake, Alert and Oriented or
AAOx3 refers to the patient being alert and oriented to
person, place and time: respectively, does the person
- Purpose
know who they are (their name); where they are (in their
- understanding the individual apartment, in a hospital, in the particular city); and
- predicting behavior approximate time (hour, part of the day, or calendar
- treatment planning date).
- evaluating outcomes
Other interviews
- Unstructured
- Funnel analogy
- Semi structured
- from broad, multidimensional start then
- assess most critical items
narrows to specific problems
- departures from format

Physical examination
-diagnose or rule out physical etiologies
- toxicities
- medication side effects
- allergic reactions
- metabolic conditions

Behavioral assessment
- Identification and observation of target
behavior
- “here and now” focus
- direct observations
- minimally inferential

Clinical Interview The ABCs of observation

- Clinical core, structured - Antecedents: what precedes the behavior
- assesses multiple domains: - Behavior: disruptive behaviors
- current and past behavior - Consequences: what follows the behavior
DSM-5
- ICD-10 (International Classification of
Diseases)
- DSM-5 is largely unchanged from DSM-IV
although some new disorders are introduced
and other disorders have been reclassified
- Three main sections:
- How to use the manual
- Disorders
- Description of disorders
- Most notable change is the removal of the
multiaxial system (5 axis)
- Axis I: Mental Health and Substance Use
Disorders
Psychological Testing - Axis II: Personality Disorders and Mental
- Specific tools for assessment Retardation (now Intellectual Development
- Cognition Disorder)
- Emotion - Axis III: General Medical Conditions
- Behavior - Axis IV: Psychosocial and Environmental
- Neuropsychological testing (examples are Problems
memory, cognition, verbal, and motor test) - Axis V: Global Assessment of Functioning
- Neuroimaging: the process of producing (GAF)
images of the structure or activity of the brain - introduces cross-cutting dimensional
or other part of the nervous system by symptom measures
techniques such as magnetic resonance - evaluating a global sense important
imaging or computerized tomography. symptoms that are often present across
disorders in almost all patients such as
Projective tests anxiety, depression, and problems with
- Presentation of ambiguous stimuli: aspect sleep
of stimulation and occurs where aspects of a - Social and cultural considerations in DSM-5
stimulus can be open to interpretation
- Projection of personality and the unconscious Criticisms of DSM-5
- Psychoanalytic roots - Comorbidity
- Examples: Rorschach Inkblot Test, - Emphasize reliability, sometimes at the
Thematic Apperception Test expense of validity
- Complexity of categorizing psychopathology
Personality inventories
- face validity (extent to which the items or
content of the test appear to be appropriate DSM-IV (Addtl. Reading)
for measuring something; lack empirical
validity) vs. construct validity (the degree to
which a test or instrument is capable of
measuring a concept, trait, or other
theoretical entity)
- empirically-based
- minimally ambiguous stimuli
- minimal inference
- scoring
- interpretation
AXIS I: Mental Health and There were a number of reasons that
Substance Use Disorders healthcare professionals found that the
multi-axial system was unnecessary.
The classification of Mental Disorders Due to a
General Medical Condition was dropped in the
Many felt that the distinction was arbitrary
DSM-5 and Factitious Disorders and
between diagnoses in Axis I and Axis II. There
Adjustment Disorders. Conditions listed under
were concerns that some diagnoses didn't fit
those categories were recategorized in the
"cleanly" into either category. In addition, there
DSM-5; eating disorders was renamed to
was concern that the GAF (Axis V) didn't take
Feeding and Eating Disorders
into account suicide risk and disabilities in
individual patients.
Mood disorders was broken into two separate
categories
Overall, healthcare professionals can
1. Bipolar and Related Disorders
successfully diagnose patients—and account
2. Depressive Disorders
for the nuances of each person they
diagnose—without the use of the multiaxial
Sexual and Gender Identity Disorders was
system.
revised to Sexual Dysfunctions, Gender
Dysphoria, and Paraphilic Disorders.
_____________________________________

AXIS II: Personality Disorders and

Mental Retardation MODULE 2
This was then changed to Intellectual Disability
in DSM-5. In DSM-5-TR (text revision), it was
again changed to Intellectual Development LESSON 1
Disorder. Intellectual disability is still included The Complexity of Anxiety Disorders
in parentheses for continued use. 1. Fear
- Immediate, present oriented
AXIS III: General Medical Conditions - Sympathetic, nervous system
Any conditions that were previously activation
categorized in Axis III are still documented as
mental health concerns in the DSM-5.
2. Anxiety
Clinicians can simply make note of this in
- Apprehensive, future-oriented
order of priority.
- Somatic symptom: tensin
AXIS IV: Psychosocial and
Anxiety and fear both produce negative
Environmental Problems
effects.
Information from Axis IV is now included in
separate notations in the DSM-5. These
notations can be added on to diagnoses as 3. Panic attacks
needed. - Abrupt experience of intense fear
- Symptoms: palpitations, chest
AXIS V: Global Assessment of pain, dizziness
Functioning (GAF) - Two types: expected and
Similar to information previously in Axis IV, unexpected
information in Axis V is now included in the
DSM-5 as separate notations of psychosocial
and contextual factors

Pitfalls
- Noradrenergic: These cells reside in
the locus ceruleus in the floor of the fourth
ventricle. The locus ceruleus is concerned
with general arousal, vigilance and the
response to interesting stimuli. It also
generates anxiety. It has an important role
in development.
- Serotonergic systems: collection of
neurons and nuclei distributed along the
brainstem in two groups sending
projections in many direction, located in
brainstem
- CRF and the HPA axis: cascade of
endocrine pathways that respond to
specific negative feedback loops involving
the hypothalamus, anterior pituitary gland,
and adrenal gland.

Limbic System
- Behavioral inhibition system (BIS):
said to regulate aversive motives, in which
the goal is to move away from something
unpleasant.
- brain stem: basic functions (breathing,
consciousness, blood pressure, heart rate,
and sleep)
- septal-hippocampal system:
mediates anxiolytic drug action and hence
at least some aspects of anxiety.
1. Biological Contributions - amygdala: responsible for the
- increased physiological vulnerability perception of emotions such as anger,
- Polygenetic influences: corticotropin fear, and sadness, as well as the
releasing factor (CRF) peptide hormone controlling of aggression.
that activates the synthesis and release
of adrenocorticotropic hormone - Fight/flight system (FFS)
(ACTH) from the pituitary gland. In this - panic circuit: may explain panic
way, CRH affects our response to stress, disorder, according to a theoretical
addiction and depression, amongst neuroanatomic model
others - alarm and escape response
- Brain circuits and neurotransmitters
- GABA: Gamma-aminobutyric acid is an - Brain circuits are shaped by
amino acid that functions as the primary environment
inhibitory neurotransmitter for the central - example: teenage cigarette smoking
nervous system (CNS). It functions to - interactive relationship with somatic
reduce neuronal excitability by inhibiting (physical symptoms like pain or fatigue)
nerve transmission. symptoms
2. Social Contributions ___________________________
- Biological vulnerabilities triggered by
stressful life events Comorbidity of Anxiety and
- family
Related Disorders
- interpersonal
- High rates of comorbidity: 55% to 76%
- occupational
- Commonalities:
- educational
- Features
- Vulnerabilities
3. Psychological Contributions - Links with physical disorders
- Freud - Physical disorders
- Anxiety: psychic reaction to danger
- Reactivation of infantile fear situation
- Behaviorists
- Classical conditioning (Ivan Pavlov): The Anxiety Disorders
learning process focused more on - Types of anxiety disorders
involuntary behaviors, using associations - Generalized Anxiety Disorder
with neutral stimuli to evoke a specific - Panic Disorder and Agoraphobia
involuntary response - Specific Phobias
- Operant conditioning (B.F Skinner): - Social Anxiety Disorder
method of learning that employs rewards - Separation Anxiety Disorder
and punishments for behavior. Through - Selective Mutism: severe anxiety
operant conditioning, an association is disorder where a person is unable to
made between a behavior and a speak in certain social situations
consequence (whether negative or
positive) for that behavior
1. Generalized Anxiety Disorder
- Modeling (Albert Bandura): behavior
can be learned through observation of (GAD)
others. Also known as the Social Learning - Clinical description: shift from possible
Theory crisis to crisis; worry about minor,
everyday concerns like job, family, chores,
- Triple Vulnerabilities: and appointments; problem sleeping
- Generalized biological vulnerability: - In children: need only one physical
diathesis (tendency to suffer from a symptom; worry: academic, social,
particular medical condition) athletic performance
- Generalized psychological
vulnerability: beliefs and perceptions
- Specific psychological vulnerability:
learning/modeling
- Cognitive-behavioral treatments
- exposure to worry process,
confronting anxiety-provoking images,
coping strategies
- acceptance
- meditation
- similar benefits
- better long-term results

2. Panic Disorder and

Agoraphobia
- Clinical description
- Unexpected panic attacks
- anxiety, worry, or fear of another attack
- Agoraphobia: fear or avoidance of
situations or events

Treatments
- Pharmacological
- Benzodiazepines: type of sedative
medication. (risk vs benefits)
- antidepressants
- Psychological
- caused by deep relaxation
- sensations of letting go
- sleep terrors
- isolated sleep paralysis

Causes
- Generalized biological vulnerability:
alarm reaction to stress
- Cues get associated with situations:
conditioning occurs
- Generalized psychological
vulnerability: anxiety about future
attacks, hypervigilance, increase
interoceptive awareness

Treatment
- Medications
- Multiple systems
-serotonergic
-noradrenergic
-benzodiazepine GABA

- SSRIs (e.g Prozac and Paxil): Selective

serotonin reuptake inhibitors are the
most commonly prescribed antidepressant
- high relapse rates

Cultural Influences - Psychological intervention

- Culture bound syndromes - Exposure-based
- Susto: 'fright sickness', is indigenously - Reality testing
attributed to 'soul loss' resulting from - Relaxation
traumatic experiences - Breathing
- Ataque de nervios (attack of nerves):
an illness category used frequently by -Panic control treatment (PCT)
Hispanic individuals to describe one or - exposure to Interoceptive cues– are
more particular symptom complexes. questions directed toward the somatic
- Kyol goeu (wind overload): an manifestations of anxiety
orthostatically triggered syncopal - cognitive therapy
syndrome often found among Khmer - relaxation/breathing
refugees in the US.
- High degree of efficacy
Nocturnal Panic
- 60% with panic disorder experience 3. Specific Phobias
nocturnal attacks -Clinical description: extreme and
- non-REM sleep irrational fear of a specific object or
- delta wave: integral part of REM sleep situation; significant impairment;
in humans
recognizes fears as unreasonable; - Animal phobia: dogs, snakes, mice,
avoidance insects; may be associated with real
dangers; onset approximately 7 months

Causes
- Direct experience
- Vicarious experience: experienced in
the imagination through the feelings or
actions of another person.
- Information transmission
- “Prepared”: biologically prepared to learn
to fear objects and situations that
threatened the survival of the species
throughout its evolutionary history

Treatment
- Cognitive-behavior therapies
- Exposure
- Graduated: process of exposing the
patient slowly and methodically to more
4. Specific Phobias and more raw aspects of those
-Blood injection injury phobia: experiences.
decreased heart rate and blood pressure, - Structured: psychological treatment
fainting, inherited vasovagal (occurs when that was developed to help people
you faint because your body overreacts to confront their fears
certain triggers, such as the sight of blood - Relaxation
or extreme emotional distress. It may also
be called neurocardiogenic syncope); 5. Separation Anxiety Disorder
onset approximately 9 months - Clinical description: characterized by
-Situational phobia: fear of specific children’s unrealistic and persistent worry
situations like transportation and small that something will happen to their parents
places, no uncued panic attacks; onset or other important people in their life or
early to mid 20s that something will happen to the children
-Specific phobias to the children themselves that will
-Natural environment phobia; heights, separate them from their parents
storms, water; may cluster together; (example: will be lost, kidnapped, killed,
associated with real dangers; onset or hurt in a accident)
approximately 7 months
- 4.1% for children, 6.6% for adults meet Treatment
criteria - Medications
- Beta blockers, SSRI (Paxil, Zoloft, and
Social Anxiety Disorder (Social Phobia) Effexor), and D-cycloserine– may help
- Clinical description: extreme and patients with anxiety disorders, or it might
irrational fear/shyness; social or make their anxiety worse.
performance situations, significant - Psychological
impairment, avoidance or distressed - Cognitive-behavioral treatment
endurance; generalized subtype - Exposure
- Rehearsal
Causes - Role-play
- Generalized psychological - Highly effective one study 84%
vulnerability improvement
- Generalized biological vulnerability
6. Selective Mutism (SM)
- Clinical description: rare childhood
disorder characterized by a lack of
speech; must occur for more than one
month and cannot be limited to the first
month of school
- comorbidity with Social Anxiety Disorder
- Treatment: cognitive-behavioral like the
treatment for social anxiety
________________________________

Trauma and
Stressor-Related Disorders
1. attachment disorders
2. posttraumatic stress disorder

1. Posttraumatic Stress Disorder

(PTSD)
- Clinical description: trauma exposure;
extreme fear, helplessness, or horror
- continued re-experiencing (e.g
memories, nightmares, flashbacks)
- avoidance; emotional numbing; reckless
or self-destructive behavior; interpersonal
problems; dysfunction
- onset: one month

Causes
- trauma intensity
- Generalized biological vulnerability:
- twin studies
- reciprocal gene-environment
interactions
- Generalized psychological
vulnerability: uncontrollability and
unpredictability
- Social support

Treatment
- Cognitive-behavioral treatment
-exposure
- imaginal
- graduated or massed
- Increase positive coping skills
- Increase social support
- Highly effective

- Psychoanalytic therapy, catharsis (the

- Neurobiological model: process of reducing or eliminating a
- Threatening cues activate CRF system complex by recalling it to conscious
(peptide hormone that activates the awareness and allowing it to be
synthesis and release of expressed.)
adrenocorticotropic hormone (ACTH) from
the pituitary gland. In this way, CRH -Medications: SSRIs
affects our response to stress, addiction
and depression, amongst others) Adjustment Disorders
- CRF system activates fear and anxiety - Anxious or depressive reactions to life
areas stress that are generally milder than one
- Amygdala (central nucleus) would see in acute stress disorder or
- Increased HPA axis activation PTSD but are nevertheless impairing in
- Cortisol (steroid hormone that terms of interfering with work or school
regulates a wide range of vital processes performance, interpersonal
throughout the body, including metabolism relationships, or other areas of living
and the immune response; primary
stress hormone)
2. Attachment Disorders
- Clinical description: disturbed and
developmentally inappropriate behaviors
in children, emerging before five years of
age, in which the child is unable or
unwilling to form normal attachment
relationships with caregiving adults

Reactive Attachment Disorder

- The child will very seldom seek out a
caregiver for protection, support, and
nurturance and will seldom respond to
offers from caregivers to provide this kind
of care

Disinhibited Social Engagement

Disorder
- A pattern of behavior in which the child
shows no inhibitions whatsoever to
approaching adults

_________________________________

Obsessive-Compulsive Disorder
(OCD)
- Clinical description:
1. Obsessions:
- intrusive and nonsensical
- Thoughts, images, or urges
- Attempts to resist or eliminate

- 60% have multiple obsessions

- need for symmetry
- forbidden thoughts or actions
- cleaning and contamination
- hoarding

2. Compulsions:
- Thoughts or actions
- Suppress obsessions
- Provide relief

- Four major categories:

1. Checking
2. Ordering
3. Arranging
4. Washing/cleaning

- Association with obsessions

_________________________________ - Comorbid with OCD 10%
- Course lifelong
Tic Disorder - Onset: early adolescence through 20s
- Clinical description: characterized by - Reaction to a horrible or grotesque
involuntary movement (e.g sudden jerking feature
of limbs) to co-occur in patients with OCD
Treatment
Causes - SSRIs
- similar generalized biological - Exposure and response prevention
vulnerability

- specific psychological vulnerability

- early life experiences and learning
- thoughts are dangerous or
unacceptable
- thought-action fusion

- distraction temporarily reduces anxiety

- increases frequency of thought

Treatment
- Medications: SSRIs (60% benefit, high
relapse when discontinued)

- Psychosurgery (30% benefit):

cingulotomy– a neurosurgical procedure
in which doctors use specialized tools to
inactivate brain tissue in areas that are
associated with a variety of debilitating
diseases, including chronic pain and
obsessive-compulsive disorder (OCD).

- Cognitive-behavioral therapy
- Exposure and ritual prevention (ERP)
- Highly effective, 85% benefit
- No added benefit from combined
treatment with drugs

_________________________________

Body Dysmorphic Disorder

(BDD)
-Clinical description: a preoccupation
with some imagined defect in appearance
by someone who actually looks
reasonably normal
_________________________________ LESSON 2
Somatic Symptom and Related
Hoarding Disorder Disorders and Dissociative Disorders
- Clinical description: estimates of
prevalence range between 2% and 5% of Soma = body
the population, which is twice as high as - preoccupation with health or appearance
the prevalence of OCD - physical complaints
- Prevalence equal to men and - no identifiable medical condition
women
- Individuals usually begin acquiring Types of disorders
things during their teenage years 1. Somatic symptom disorder
and often experience great 2. Illness Anxiety Disorder
pleasure, even euphoria, from 3. Conversion Disorder
shopping or otherwise collecting 4. Factitious Disorder
various items
- OCD tends to wax and wane
1. Somatic Symptom Disorders
(definition: delirium as a medical
- Formally Briquet’s syndrome where
condition that causes a patient's
patient feel continually feel weak and ill;
mental status to shift back and
feeling severe physical pain and
forth), whereas hoarding behavior
symptoms
can begin early in life and get
worse with each passing decade

_________________________________

Trichotillomania (Hair Pulling

Disorder) and Excoriation (Skin
Picking Disorder)
- Trichotillomania: the urge to pull out
one’s own hair from anywhere on the
body, including the scalp, eyebrows, and
arms

-Excoriation: characterized by repetitive

and compulsive picking of the skin,
learning to tissue damage
- 1-5%
- Habit reversal training show best
results

_________________________________
2. Illness Anxiety Disorder
- Formerly known as hypochondriasis
- Less concerned with any specific
physical symptoms and more worried
about the idea that they are either ill or
developing an illness
- Reassurances from numerous doctors
has little effect Treatment
- Psychodynamic: uncover unconscious
Causes conflict; limited efficacy data
- Disorder of cognition or perception, - Educational and supportive:
physical signs and sensations - Ongoing and sensitive
- unlikely to be found in isolated biological - Detailed and repeated information
or psychological factors - Beneficial for mild cases
- familial history of illness and learning - Cognitive-behavioral
-identify and challenge
Three factors that may contribute to misinterpretations
etiology - “symptom creation”
1. Stressful life events - stress-reduction
2. High family disease incidence - best efficacy data vs. SSRI
3. “Benefits” of illness medications; immediate and 1 year
follow-up

3. Conversion Disorder
(Functional Neurological
Symptom Disorder)
- Generally have something to do with
physical malfunctioning, such as paralysis,
blindness or difficulty speaking (aphonia
or loss of voice: inaudible due to hoarse
voice or cannot speak above a whisper;
may cannot speak at all sometimes)
without any physical or organic pathology

- Clinical description: physical

malfunctioning of sensory-motor areas
- Lack physical or organic pathology, lack
awareness
- “La belle indifference”: defined as a
paradoxical absence of psychological
distress despite having a serious medical
illness or symptoms related to a health
condition; possible but not always
- Intact functioning
- Malingering (faking): an act, not a
psychological condition. It involves
pretending to have a physical or - More prevalent to female than male
psychological condition in order to gain a - Onset during adolescence
reward or avoid something. - Chronic (persisting), intermittent (random
interval) course

Special populations
- Soldiers
- Children: better prognosis
(likelihood of healing, rebuilding, or
cure)

Cultural considerations
- Religious experiences
- Rituals

Causes
Freudian psychodynamic view
- Trauma, conflict experience
4. Factitious Disorders
- Repression
- Munchausen’s syndrome
- Primary gain: “Conversion” to
(Munchausen syndrome by proxy) is a
physical symptoms
psychological disorder where someone
- Secondary gain: attention and
pretends to be ill or deliberately produces
support
symptoms of illness in themselves. Their
main intention is to assume the "sick role"
Behavioral
so that people care for them and they are
- Traumatic event must be escaped
the center of attention.
- Avoidance is not an option
- Social acceptability of illness
- Negative reinforcement

Family/Social/Cultural
- Low SES (Socioeconomic status)
- Limited disease knowledge
- Family history of illness

Treatments
-similar to somatic symptom disorder
- attending to trauma
- remove secondary gain
- reduce supportive consequences
- reward positive health behaviors
- no “cures”
- cognitive-behavioral interventions
- initial reassurance
Statistics - stress-reduction
- Rare, prevalence depends on setting
- reduce frequency of help-seeking
behaviors
- “gatekeeper” physician: reduce visits to
numerous specialists

_________________________________

Depersonalization-Derealization
Disorder
- Severe alterations or detachments:
normal perceptual experiences

- Clinical description:
- feelings of unreality and detachment
- severe/frightening
- depersonalization
- derealization
- significant impairment
_________________________________
- Cognitive deficits
- attention Dissociative amnesia
- short-term memory - Generalized type: lack of memory for
- spatial reasoning the life history and identity
- easily distracted - Localized or selective type: lack of
memory for specific parts/aspects of an
-Significant impairments: event
- identity
- memory
- consciousness

- Depersonalization

- Derealization

Types of disorders
1. Depersonalization Disorder
2. Dissociative Amnesia
3. Dissociative Fugue
4. Dissociative Trance Disorder
5. Dissociative Identity Disorder
Dissociative Fugue Can DID be faked?
- a temporary state where a person has - Real vs. false memories
memory loss (amnesia) and ends up in an - Suggestibility
unexpected place. - Hypnosis studies
- Flight or travel - Simulated amnesia
- Demand characteristics
- memory loss - Physiological measures
- Retrograde amnesia: refers to the - Eye movements
loss of information that was acquired - EEG (electroencephalogram):
before the onset of amnesia recording brain activity
- Anterograde amnesia: refers to an
impaired capacity for new learning

- Assumption of new identity

- Amonk as in “running amok”: going
berserk

Statistics
- Tends to occur in adulthood
- Rapid onset
- Rapid dissipation
- Females > males

Causes
- Little is known
- Trauma and life stress

Treatment
- Resolution without treatment
- Memory returns
Causes
_________________________________ - Biological vulnerability
- reactivity
- hippocampus (learning and memory)
Dissociative Identity Disorder and amygdala (processing fearful and
(DID) threatening stimuli)
- Clinical description: amnesia, - brain damage
dissociation of personality that causes - Severe childhood abuse/trauma
them to adopt several new identities or history
“alters” - Links with PTSD
- 2 to 100 - Highly suggestible: autohypnotic
- Average: 15 (self-hypnosis) model
- Unique characteristics - Real memories and false

-Characteristics Treatment
- Host: main personality - Similar to PTSD treatment: reintegration
- Switch: the alter of identities, identify and neutralize
cues/triggers; visualization, coping, and
hypnosis

- Antidepressant medications:
Benzodiazepines (minor tranquilizers)

- Accumulated clinical wisdom