Psych Disorders Final Exam

Trauma Related and Dissociative Disorders

•Trauma \n • Event of extreme distress that invokes remarkable \n danger and/or horror. \n • E.g., Military combat, rape, bombings, massacre, disasters, \n crashes \n • Post-traumatic Stress Disorder (PTSD) \n • Severe negative aftereffects longer than a month after a \n trauma \n • Acute Stress Disorder (ASD) \n • Severe negative aftereffects within a month of a trauma

Ways trauma may be experienced

According to DSM, may be experienced by:

\n • Direct exposure to the trauma \n • Witnessing it occur to someone else \n • Learning it occurred to close others \n • Repeated/extreme exposure to details \n of trauma.

Symptoms of ASD

traumatic stress, intrusive re-experiencing, avoidance, negative mood/thoughts, arousal/reactivity

Re-experiencing

Recurrent experiences reminiscent of the trauma

Flashbacks

Suddenly replaying the trauma in images or thoughts or \n • Re-experiencing the trauma as though it were actually \n happening \n • Can occur in a DISSOCIATIVE STATE: \n • Loss of awareness of the true, surrounding reality

Avoidance of internal & external experiences

•Persistent avoidance of stimuli associated with the \n trauma \n 1. Avoidance of distressing memories, thoughts, or feelings \n related to the event \n 2. Avoidance of external reminders that \n arouse distressing memories, \n thoughts, or feelings related \n to event \n • People, places, conversations, \n activities, objects, etc.

Negative mood symptoms of PTSD

•Persistent negative emotions like fear, horror, sadness, anger, \n shame \n • Persistent negative beliefs about oneself, others, or the world \n • Persistent, distorted cognitions about the cause of the trauma \n • Diminished interest or pleasure in activities \n • Detachment from others \n • General numbing of responsiveness: EMOTIONAL \n ANESTHESIA

Emotional anesthesia

a cognitive-behavioural treatment of prolonged grief in a client with complex comorbidities-the importance of reintegrating attachment, memory, and self-identity.

Arousal/Reactivity Symptoms of PTSD

•Unprovoked irritable behavior and angry outbursts \n • Usually against others \n • Hypervigilance \n • Exaggerated startle response \n • Reckless or self-destructive behavior \n • Problems with concentration \n • Sleep disturbance

Startle Response

The startle response, “an extreme response to an intense stimulus,” is the body's physical reaction to fear. With PTSD and other anxiety disorders, this response is often heightened, meaning a more pronounced response is elicited to a stimulus that likely would not affect other people the same way

PTSD Diagnosis

A. Exposure to actual or threatened death, serious

\n injury, or sexual violence by: \n • Directly experiencing it, witnessing it, learning it occurred \n to close others, or repeated/extreme exposure to details \n of trauma. \n B. Intrusive Re- \n experiencing (1) \n C. Avoidance (1) \n D. Increased Arousal \n or \n E. Negative Mood or \n Thoughts (2) \n F. Lasts for longer than on \n month. \n G.Distress or impairment

Acute Stress Diagnosis Diagnosis

•Nearly identical to PTSD, but lasts less than 1 \n month (but more than 3 days) \n • Must have 9 symptoms from any of 5 categories: \n • Intrusive re-experiencing \n • Avoidance \n • Increased arousal or reactivity \n • Negative mood \n • Dissociative symptoms

Interpersonal symptoms of PTSD

•PTSD is linked to interpersonal, marital, & sexual \n dysfunction \n • social withdrawal \n • interpersonal conflict / marital conflict \n • Diminished sexual drive and erectile dysfunction \n • Avoidance of sex due to aversion of arousal is common

Hardiness

the ability to endure difficult conditions

Causes/Risk factors of PTSD

--Factors of trauma that increase risk of developing PTSD 

\--Sexual violence statistics (not exact numbers but general rate estimates/facts).

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•Trauma is the main cause of PTSD \n • Of identical twins during Vietnam war, \n a twin who entered combat had a \n 9x greater likelihood of \n developing PTSD. \n • Victims more likely to develop PTSD \n when trauma is... \n • More intense \n • Life-threatening \n • Involves greater exposure to event

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•10 – 20.4% of women have been raped at least once in lifetime \n • 22% have been sexually assaulted in adulthood \n • Elliot, Mok, & Briere, ‘05; Humphrey & White, ‘00; Plitcha & Falik, ‘01 \n • Those victimized in youth are more likely to be assaulted as adults \n • Teenage victims are 4.4x more likely to be assaulted 1st yr of college \n • Most victims show PTSD and depression symptoms, commonly \n including self-blame \n • Symptoms increase when victim-blaming behaviors are \n encountered \n • 4/5 acquaintance rapes are not reported to authorities.

Effects of avoidance in PTSD

•Post-traumatic symptoms are common \n immediately following a trauma... \n • but most who experience a trauma do not develop PTSD \n • Alisic et al., 2014; Dai et al., 2016; Schnyder et al., 2001 \n •Natural recovery by EMOTIONAL PROCESSING: \n • Activation of trauma memory by repeated engagement with \n trauma-related stimuli, thoughts/feelings (E.g., Foa & Cahill,’01; \n Foa et al., 07) \n • Using AVOIDANCE to cope with trauma predicts later major \n increases in intrusive symptoms (Bryant & Harvey, 1995)

•Avoidance of trauma-related stimuli, thoughts, & feelings is a \n major factor determining who develops PTSD and who does not. \n • E.g., Resick, Monson, & Chard, 2017 \n •Avoidance PREVENTS \n • Emotional processing & \n • Disconfirmation of trauma beliefs. \n • Avoidance of experiences associated with the client’s trauma \n predicts and mediates (or explains) the development \n of PTSD later on.

Dysfunction neurobio. in PTSD

Faulty memory storage during trauma

Cognitive causes of PTSD

•Maladaptive, extreme beliefs formed due to the trauma \n • The world is unsafe; I’m incompetent; I’m at fault; people are \n vicious. \n • Trauma memories are encoded in a fragmented manner \n • High arousal interferes with full, coherent memory storage \n • This poor memory leads to poorer processing & exposure later \n • Attentional biases to threat \n • Difficulty recalling specific positive memories

Protective factors of PTSD (preparedness)

•Social support after trauma \n • Coping with trauma can be aided with: \n • Preparedness: \n • Knowledge, correct expectations, and sense of mastery \n concerning the type of traumatic event \n • E.g., Activists develop PTSD less than non-activists after \n torture \n • Purpose in life \n • Calmness and control during trauma \n • Sense of control in general

•Emotional Processing (see prev. slide) \n • Meaning Making \n • Finding some value or reason for having endured \n trauma \n • Often involves deciding on how to serve others \n because of it \n • Post-Traumatic Growth: \n • Positive changes following trauma

Adjustment Disorder

•“The presence of emotional and behavioral symptoms in \n response to an identifiable stressor(s)” (DSM-5) \n • occurring within 3 months of the stressor(s) \n • Distress is out of proportion with expected reactions to \n the stressor \n • Clinically significant: Marked distress and/or impairment \n • Once stressor stops, symptoms must subside \n within six months.

Resilience

Emotional Processing

Meaning Making

Post-traumatic Growth

Prevention/Treatments for PTSD

•Prolonged Exposure (by Foa; Powers et al., 2010 review) \n • Clients engage with traumatic memories and stimuli, \n reliving the trauma until they habituate \n • Likely most efficacious treatment (for all trauma types) \n • Imagery Rehearsal Therapy \n • Relive nightmares while awake, but rewrite the narrative as \n desired. \n • Eye-movement Desensitization and Reprocessing (EMDR) \n • Rapid back-and-forth eye movement while reliving images of \n trauma \n • Works because of exposure—no special effect of eye movement.

Prolonged exposure

Imagery rehearsal therapy

EMDR: Eye movement desensitization and reprocessing

EMDR Controversy and Evidence

Failing to prevent an outcome is not a cause of the outcome

Dissociation

Disruption or discontinuity in the \n integration of consciousness, memory, identity, \n emotion, body representation, motor control, and \n behavior

Derealization

Detachment from surroundings—

Feeling they are “unreal.” \n • Sense of being an \n “in a fog

* separated from what is outside of you

Dissociative amnesia

Characterized by an inability to recall autobiographical information. \n • Often lose time or have gaps in their memory. \n • Specifier: \n • Dissociative Fugue: \n • Sudden travel or bewildered wandering. \n • With inability to recall one’s past. \n SOME LIKE, SUPER

Dissociative Fugue

Dissociative Identity disorder

•Sense of self “fragments” into multiple senses of self, or \n even identities. \n • These identities are called ALTERS \n • At its extreme, multiple persons appear \n to co-exist in one individual. \n • Includes dissociative amnesia and \n depersonalization / derealization as well.

Symptoms serving FUNCTIONS

Systems resulting from FLAWS

Trauma model of dissociation --evidence for trauma model, including Briere, 2006 and Khalill, 2013 studies

Recovered memory debate and why it matters

\-People may claim a memory returned after it was kept \n out of awareness due to trauma. \n • Dissociation is blamed for “blocking” the memory. \n • Yet these memories can be false. \n • They may result from a therapist’s suggestion that they \n exist. \n • Memory is re-writable and very often inaccurate

Fantasy model of dissociation --Evidence related to fantasy model

•Proposes that dissociation is causally unrelated to trauma. \n • Dis. is related to tendencies to engage in fantasy-making, \n being suggestible, & thought distortion (found in \n correlational studies).

\- dissociation more prevelant in highly fantasy prone individuals

\-Thus, dissociators may be prone to ”make up” false trauma memories, believe therapist suggestions, and \n fake suggested behavior.

\-•Dissociation is a FLAW that becomes worse when \n therapists suggest wrong causes for the flaw.

Alternate explanations of dissociative disorders/dissociative amnesia (know some possibilities, but don’t need to memorize all)

latrogenic effects

latrogenic alters

Controversy/debate over existence of dissociative identity disorder and evidence for and against its existence

schizophrenia and psychosis

•Fundamental breakdown in basic cognitive processes \n • Experience of reality is warped in either one’s senses or \n beliefs \n • Can present very differently for different people \n • Dimensional and varying in timescale (continual or \n episodic) \n • Highly debilitating: Low quality of life, job/school difficulties, \n impaired relationships, very hard for families \n • 10% of those with schizophrenia commit suicide (Heisel, \n 2008)

Negative personal impact of psychosis

Symptoms of schizophrenia & psychosis

1. Positive symptoms \n • Presence of PSYCHOSIS: \n • False sensory experiences and beliefs \n 2. Negative Symptoms \n • Absence of certain responses: \n • Reductions/deficits in motivation, social interaction, \n emotional responding \n 3. Disorganization \n • Verbal communication problems and odd behaviors

Difference between pos & neg symptoms

Positive symptoms

DELUSIONS \n • Highly unlikely beliefs that are strongly-held \n and resistant to change \n • Often obviously absurd to most people \n • Typically personal and not shared by anyone else \n •Clients often defend delusions despite strong \n contradictory evidence

•Clients often unable to take perspective of another \n person regarding the belief. \n • Often incoherent, complex, bizarre, and hard to \n understand.

Hallucinations

Delusions: Paranoid, Grandiose, Preoccupying

• Paranoid Delusions: Beliefs expecting danger or harm to

oneself \n • Grandiose Delusions: Beliefs that oneself or others are highly \n special, powerful, or endowed with exceptional abilities

Preoccupying: Cannot stop thinking or talking \n about delusion

Negative symptoms

•Responses/functions missing from or reduced in the \n person \n • Diminished Emotional Expression \n • Flattened nonverbal display of emotional responses \n • “blunted affect” \n • Faces are expressionless & apathetic (“blank-faced”) \n • Monotone voice, no emotional inflection, stable pitch \n • Anhedonia: Lack of pleasurable feelings

Diminished emotional expression / blunted affect

Avolition

(neg symptom) Lack of will/motivation

\n • Apathy, indecisiveness, ambivalence, and loss of will power

Alogia

(neg symptom) Reductions in speech from ”impoverished \n thinking” \n • Having nothing to say \n • Thoughts may come to a halt before they’re completed.

Social Withdrawal

(neg symptom) Socially withdrawn \n • Isolation often develops before positive symptoms \n • May withdraw to lessen stimulation (stim. increases pos. \n symptoms)

Disorganization symptoms

Think in disconnected, loosely-associated ideas (thought \n disorder) \n • Train of thought may be impossible to understand

Disorganized speech: --Tangentiality 

\--Loose associations 

\--Perseveration

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word salad/

Statements that don’t make sense to others

•Tangentiality: Irrelevant responses to questions \n • Loose Associations: Bizarre, abrupt shifts in topic

Abnormal motor behaviors

•Those with schizophrenia have unusual motor \n behaviors \n • Rigid posturing, repetitious hand movements, pacing, \n facial ticks

Catatonic behavior --Stuporous State

Immobility and fixed posturing \n • Stuporous State: Reduce responsiveness to stimuli \n • Yet are still aware of their surroundings

Inappropriate Affect

Emotional reactions are inconsistent with the event/situation

Diagnosis of psychotic disorders

Schizophrenia

•Two or more of the following symptoms for at least 1 month: \n 1. Delusions \n 2. Hallucinations \n 3. Disorganized speech \n 4. Grossly disorganized/catatonic behavior \n 5. Negative symptoms \n • Level of functioning is significantly lower than before onset \n • Continuous signs of disturbance last for at least 6 months

Delusional Disorder

•Preoccupied with delusions that are not \n especially bizarre for at least one \n month. \n • DO NOT meet criteria for schizophrenia \n • Presence of hallucinations, disorganized speech \n speech, catatonic behavior, or negative \n symptoms rules out this diagnosis \n • Social/occupational functioning is ONLY impaired in \n areas directly affected by the delusional belief.

Brief Psychotic Disorder

•Exhibit psychotic symptoms for at least one day, \n but no more than one month \n • Hallucinations, delusions, disorganized speech, \n or disorganized behavior \n • Accompanied by confusion and emotional turmoil \n • Often follows a very stressful event \n • After psychotic episode, experience returns to \n normal

Schizoaffective Disorder

•Combination of a mood disorder & schizophrenia. \n 1. Uninterrupted period of psychosis during which there is a major mood \n episode at the same time. \n 2. Must have delusions or hallucinations for 2 + weeks in the absence of \n mood episode at some point across lifetime duration of illness. \n 3. Symptoms meeting criteria for a mood episode are present for \n majority of the period of psychosis. \n • If delusions/hallucinations are present ONLY during a depressive or \n manic episode, it is NOT schizoaffective disorder (see point 2 above).

Inappropriate Affect

Age of Schizophrenia Onset

Onsets in late adolescence or early adulthood (full range: ages 15 - 35)

Time Course and Outcomes of Schizophrenia (know stages defs)

• Schizophrenia progresses in three stages: \n • 1. PRODROMAL PHASE \n • Lowering role function, personality changes, odd behaviors, outbursts, \n restlessness, and unusual perceptual experiences \n • 2. ACTIVE PHASE \n • Full psychotic symptoms (hallucinations, delusions, word salad) \n • 3. RESIDUAL PHASE \n • Pos. symptoms lessen, neg. symptoms may remain; similar to \n prodromal

Gender differences in schizophrenia

Cross cultural comparisons of scizophrenia

Causes of schizophrenia (Bio-psych-social)

Bio: •Schizophrenia appears to run in families (closer relation, higher risk)

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Genetic contribution to schizophrenia

Inherited schizophrenia spectrum symptoms

Molecular genetics

•Recently, researchers has been attempting to determine \n which specific genes are responsible for schizophrenia. \n • Thus far, they have only found a few genes that \n make a reliable, small-but-significant impact

COMPT

•Gene responsible for an enzyme involved in breaking \n down dopamine, catechol O-methyltransferase (COMT) \n • One form of this gene puts a person at a small increased \n risk for schizophrenia

Pregnancy and Birth Complications (malnutrition, pre-birth infections/disease, labor and delivery complications)

•Problems with pregnancy and birth are associated \n with later development of schizophrenia \n • Pregnancy risks: \n 1. severe maternal malnutrition early in pregnancy; \n 2. disease/infections in the mother prior to birth \n • Labor and Delivery Complications: \n • Birth records show mothers of later schizophrenia patients \n experienced more complications in labor and delivery such as: \n • Extended labor, breech delivery, umbilical cord choking \n • May reduce availability of oxygen to newborn’s brain

Neurobiology of schizophrenia

•Schizophrenia affects many different regions \n of the brain, but generally with the disorder: \n • Have lower total volume of brain tissue over all \n • Have enlarged ventricles (fluid-filled cavities in brain) \n • Decreased size of limbic system, a set of brain areas \n responsible for regulation of emotion and integration of thought \n and feeling. \n • Malfunctioning temporal lobes (perceiving and creating speech) \n • Decreased frontal lobe activity.

Ventricles

The dopamine hypothesis

•Proposal that those with schizophrenia may have \n overactive or excessive dopamine activity in the limbic \n system \n • Likely due to high numbers of post-synaptic dopamine \n ”D2” receptors \n • Yet recent research suggests many aspects of \n schizophrenia cannot be attributable to only excess \n dopamine reactivity

Influence of social class

•Social Class: Influence & status in community \n • Those of lower socioeconomic status (SES) are exposed to more stress \n • Highest prevalence of schizophrenia is in areas of lowest SES

Social causation hypothesis

•Social Causation Hypothesis (Class  Schizophrenia) \n • Stress/events associated with low SES are a causal factor for schizoph. \n • Poor nutrition, higher stress, social isolation, etc.

social selection hypothesis

(Schizophrenia  Class) \n • Schizophrenia may lead a person to have lower SES by impairing \n education and job success, forcing them into lower social classes.

Expressed Emotion (EE)

1\.Repeatedly communicating hostility \n & criticism toward patient OR \n 2. Excessive expression of overprotection, worrying, & concern. \n • Those who return home to relatives high in EE have a \n higher 9-month relapse rate

Vulnerability Markers

General Principles of treatments of schizophrenia/psychosis

•Treatment is generally long-term & intensive. \n • Psychotic episodes need to be treated and \n future episodes prevented. \n • Inpatient / hospitalization is common. \n • Often requires provision of housing, community support, \n special job training, help w/ disability benefits, \n transportation. \n • Many different professionals must work together in such \n cases (case managers, therapists, psychiatrists, social \n workers).

Antipsychotic Medication

•Specifically reduce severity of psychosis (mostly positive \n symptoms) \n • Require 2 – 3 weeks of use to take effect on \n hallucinations/delusions

Maintenance Medication

• Should be taken even when psychosis is not active, for prevention:

• “MAINTENANCE MEDICATION” \n • On antipsychotics, \~ half of patients are very improved after 1 to \n 1.5 months, yet 25% do not improve. \n • Work (partly) by blocking post-synaptic dopamine “D2” receptors.

Chlorpromazine (Thorazine)

Side effects of Anti-psychotics

--Extrapyramidal symptoms 

\--Tardive dyskinesia

•Antipsychotics have strong side effects that \n generally effect motor behavior. \n • Extrapyramidal Symptoms (short-term response) \n • Muscular rigidity, tremors, restless agitation to be \n moving (Akathisia), peculiar involuntary postures. Milder. \n • Tardive Dyskinesia (long-term syndrome) \n • More severe motor symptoms from prolonged \n antipsychotic use \n • Spasmodic face and limb movements, jerking and \n writhing \n • Irreversible in some patients

Assertive Community treatments

Institutional Programs

Personality Disorders

•Personality disorders are largely EGO-SYNTONIC \n • Because their patterns are intrinsic and common to who \n they are, often only bothering others, they are acceptable \n to the client. \n • Lack of insight \n • Do not view themselves realistically and fully \n • They tend not to see and own their problems, \n believing others are the real problem / at fault

Personality

•Patterns of thinking, feeling, \n and behaving that define a person across \n time and situations. \n • Also, the characteristic ways a person \n relates and reacts to others. \n • Distinguishes one person from another. \n • If one’s usual way of behaving and expressing \n prevents a person from maintaining close \n relationships, their personality may be their biggest \n problem (i.e. disordered)

General Definition of Personality Disorders (general criteria across the disorders)

10 disorders based on exaggerated personality traits that \n are frequently disturbing, harmful, or annoying to other \n

people.All personality disorders share a GENERAL DEFINITION:“An enduring pattern of inner \n experience and behavior that \n deviates markedly from the \n expectations of the individual’s \n culture” (DSM)

Relevance of Social Disruption in PDs

The relevance of social disruption in PDS is

Do personality disorders tend to be egosyntonic or egodystonic? (Think, which parts may be egosyntonic and which may be egodystonic? Why?)

Lack of Insight

•Do not view themselves realistically and fully \n • They tend not to see and own their problems, \n believing others are the real problem / at fault

Symptoms of PDs: --Strong harmful traits (what does this mean?) 

\--Social Motives: 

\--Communion 

\--Agency 

\--The Interpersonal Circumplex 

\--Rigid personality style 

\--Self & Other Misperceptions

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Unbalanced Social Motivations \n • Humans have two primary social motives: \n • Communion: \n • Desire for closeness, intimacy, connection \n • A.K.A. Affiliation, Love, Warmth  \n • Agency: \n • Desire for influence, dominance, prestige \n • A.K.A. Power, Dominance  \n • A person’s interpersonal style can be captured by how much \n of each of these motivations they have—two dimensions of \n motivation

•If you have too much or too \n little motivation for communion \n or agency, it can cause serious \n interpersonal problems. \n • ESPECIALLY if your style is too RIGID— \n inflexible, “stuck” \n • Ex: Dependent PD \n • Overly affiliative (warm) \n • No drive for any power \n (submissive)

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Distorted understanding of SELF—Who am I? How worthy am I? \n • Skewed, unstable, or absent concept of identity, values, esteem. \n • May have overly high/low self-esteem, change self-evaluations quickly, \n depend on others for all self-understanding, or not know self at all. \n • Distorted understanding of OTHERS–What are their intentions? \n What is the reason for him or her acting this way? \n • May misperceive others to be trying to be hurtful, abandoning, \n criticizing, rejecting, uncaring, incredibly amazing, or terribly horrible. \n • Deficits in being able to understand others’ emotions (empathy)