Psychopathology Exam 2 - Modules 5, 7, & 9

Bipolar & Related Disorders

• manic episode

• hypomanic episode

• Bipolar I disorder

• Bipolar II disorder

• Cyclothymic disorder

Bipolar I

• must have had at least one manic episode

Bipolar II

• must have had at least one hypomanic episode and at least major depressive episode

• has never had a manic episode

• depression symptoms/switching between hypomanic & depression symptoms cause clinically significant distress/impairment

Cyclothymic Disorder

• at least 2 years

  • numerous periods of hypomanic symptoms that do not meet criteria for an episode

  • numerous periods of depressive symptoms that do not meet criteria for a major depressive episode

• symptoms are present at least half the time and person is never without symptoms for more than 2 months

• never had a manic, hypomanic, or major depressive episode

Manic episode

• A distinct period of abnormally and persistently…

  • Elevated, expansive, or irritable mood

  • Increased activity or energy

  • Lasting at least 1 week (or less if hospitalization is necessary)

• 3 or more (or 4 or more if irritable mood):

  • Inflated self-esteem or grandiosity

  • Decreased need for sleep

  • Pressured speech (quick and a LOT)

  • Flight of ideas or racing thoughts

  • Distractibility

  • Increase in goal directed activity or psychomotor agitation

  • Excessive involvement in risky behaviors

Hypomanic episode

• A distinct period of abnormally and persistently…

  • Elevated, expansive, or irritable mood and…

  • Increased activity or energy

  • Lasting at least 4 consecutive days

• 3 or more (or 4 or more if irritable)

  • Inflated self-esteem or grandiosity

  • Decreased need for sleep

  • Pressured speech

  • Flight of ideas or racing thoughts

  • Distractibility

  • Increase in goal directed activity or psychomotor agitation

  • Excessive involvement in risky behaviors

Depressive Episode

• symptoms of depression

Bipolar I prevalence

~1% lifetime

Bipolar I Women Vs Men

women & men are equally likely to be diagnosed

Bipolar I development

• first manic episode can happen at any point in life

• most common onset in late teens/early 20s

Bipolar I course

episodic, most Bipolar I involves major depressive episodes

Genetic contribution to etiology of bipolar disorders

60-85% of differences in bipolar expression may be caused by genetics/heritability

amygdala and prefrontal cortex interaction in bipolar disorders etiology

people with bipolar often have an overactive amygdala and underactive prefrontal cortex

putamen in bipolar disorders etiology

important for reinforcement learning, unclear its role in bipolar, but perhaps reward & motivation in manic states

behavioral factors in bipolar disorders etiology

disturbances in sleep and circadian rhythm may trigger manic episodes (staying up very late, shifts in sleep-wake cycles)

cognitive factors in bipolar disorders etiology

for depressive episodes, same as MDD, negative triad

social factors in in bipolar disorders etiology

expressed emotion

expressed emotion

family members expressing critical comments and being emotionally overinvolved in individual’s life/treatment

expressed emotion’s contributions to bipolar disorder maintenance

leads to stress that may trigger manic or depressive episodes

hypomanic episode details

• Is an unequivocal change in functioning that is uncharacteristic of the person

• Disturbance in mood and change in functioning are observable by others

• Not severe enough to cause marked impairment in social or occupational functioning, does not necessitate hospitalization, and does not have psychotic features

panic disorder

• recurrent unexpected panic attacks

• at least one attack is followed by 1 month or more of one (or both) of following:

  • persistent concern or worry about additional attacks or their consequences (dying, “going crazy”, etc.)

• a significant, maladaptive change in behavior related to the attacks (avoiding driving, avoiding going to restaurants, etc.)

• attacks cannot occur due to another condition (medical, substance, specific phobia, social anxiety)

agoraphobia

• Marked fear or anxiety about two (or more) of the following:

  • using public transportation (buses, trains, etc.)

  • being in open spaces (parking lots, bridges)

  • being in enclosed spaces (shops, theaters, etc.)

  • standing in a line or being in a crowd

  • being outside of the home alone

• fear is due to thoughts that escape might be difficult/help might not be available if they panic or become incapacitated/embarrassed

specific phobia

• marked fear or anxiety about a specific object or situation

  • flying, height, closed spaces, animals, receiving an injection, blood

social anxiety

• marked fear or anxiety about one or more social situation in which the individual is exposed to possible scrutiny by others

  • social interactions, being observed, performing in front of others

• person fears that they will act in a way or show anxiety symptoms that will be negatively evaluated

  • will be humiliating or embarrassing, will lead to rejection

separation anxiety

• “major attachment figure” is usually a parent, but can be spouse or other caregiver

• developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached as evidenced by three or more of the following…

  • Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures

  • Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death

  • Persistent and excessive worry about experiencing an untoward event (e.g., getting kidnapped, lost, having an accident), that causes separation from major attachment figure

  • Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation

  • Persistent and excessive fear of, or reluctance about, being alone or without major attachment figures at home or in other settings

  • Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure

  • Repeated nightmares involving the theme of separation

  • Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea) when separation from major attachment figures occurs or is anticipated

  • fear, anxiety, or avoidance lasts at least 4 weeks in children and adolescents and at least 6 months in adults

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selective mutism

• consistent lack of speaking in specific social situations in which there is an expectation for speaking despite speaking in other situations

• is not attributable to a lack of knowledge or comfort with the spoken language required in the situation

• interferes with educational or occupational achievement or with social communication

• at least 1 month other than first month of school

• not better explained by another communication disorder

• this disorder assumes anxiety as communication with patient may not be possible

generalized anxiety disorder

• excessive anxiety and worry

  • occurring more days than not

  • for at least 6 months

  • about a number of events

• person finds it difficult to control the worry

• three or more of the following:

  • restlessness or feeling keyed up or on edge

  • being easily fatigued

  • difficulty concentrating or mind going blank

  • irritability

  • muscle tension

  • insomnia or restless, unsatisfying sleep

panic attack

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath or smothering

• Feelings of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, lightheaded, or faint

• Chills or heat sensations

• Numbness or tingling

• Feelings of unreality or being detached from oneself

• Fear of losing control or “going crazy”

• Fear of dying

common criteria for agoraphobia, specific phobia, and social anxiety

• the object or situation almost always provokes fear or anxiety

• the object or situation is actively avoided or is endured with intense fear or anxiety

• the fear or anxiety is out of proportion to the actual danger posed by the object or situation and the context

• fear/anxiety/avoidance is persistent and lasts for 6 months or more

anxiety disorders prevalence (know relative prevalence)

1. specific phobia 10%

2. social anxiety disorder 7%

3. Panic disorder 3%

4. GAD 3%

5. Agoraphobia 1.5%

6. Separation anxiety disorder 4% children, 1.5% adolescents, 1% adults

7. selective mutism 1%

genetic contributions to anxiety disorders

• 30% of differences in GAD expression may be causes by heritability

• 60% for specific phobia (not the same phobia)

heritability of anxiety disorders compared to MDD

GAD is about the same as MDD, but specific phobia is much higher (60% vs 30-40%)

classical conditioning’s contributions to etiology of anxiety disorders

pairing a certain object/situation etc. with fear

stimulus generalization in anxiety disorder etiology

things similar to conditioned stimulus may also evoke the conditioned response (white rat=all white furry things)

avoidance in maintenance of anxiety disorders

avoidance is negatively reinforced, “avoid bad, fear/anxiety goes away”

operant conditioning in maintenance of anxiety

Dog -> anxiety -> avoidance of dog ->reduction in anxiety -> negative reinforcement of avoidance

biased information processing in anxiety disorders

• people with anxiety are always vigilant for threat-relevant information

• they attend to it then avoid attending to it

biased information processing contributions to anxiety disorder maintenance

– Anxious -> attend to potentially threatening stimuli -> increased anxiety

– Socially anxious -> attend to potentially threatening stimuli -> distracts and interferes with performance -> increased anxiety because of worse performance

biased beliefs in anxiety disorder etiology and maintenance (overestimation)

overestimation of the likelihood and severity of a negative event happening

biased interpretation in anxiety disorder etiology and maintenance

those with anxiety tend to interpret neutral/ambiguous information negatively/threateningly

ACES in anxiety disorder etiology

are associated with an increased risk of anxiety, but are not destiny

medications for chronic anxiety

• tricyclic medications

• SSRIs, SNRIs, NDRIs, SARIs, SMSs

  • SNRIs are not used often, SSRIs may be more effective in anxiety than depression

• antihistamines

• benzodiazepines

medications for acute anxiety

• benzodiazepines

• beta blockers

antihistamines

• histamine is a neurotransmitter

• these are used for sedation side effect

• hydroxysine (Vistaril) is a histamine inverse agonist

• inverse agonist = attaches to receptor and creates opposite effect

benzodiazepines

• increases the effects of GABA activating GABA receptors

• effective in acute (and maybe chronic) anxiety

• intended for short-term use, may cause withdrawal/dependence

• diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin)

beta blockers

• first intended for cardiac arrhythmias

• beta adrenergic (epinephrine) receptor antagonist

• mostly inhibits physiological effects of anxiety

• propranolol (Inderal)

When we talk about psychotherapy in this course, why do we usually focus on CBT?

very few treatments have substantial evidence proving their effectiveness

exposure therapy (major difficulty, keys to success, inhumane?)

• person is exposed to their conditioned stimulus without their unconditioned stimulus (fear)

  • helps person learn a new association

• effective for panic, specific phobia, social anxiety, separation anxiety, and selective mutism

• keys to success

  • hierarchical (graduated) exposures

  • staying in situation long enough for fear to do down

  • repetition

  • multiple objects, situations, and settings

• not inhumane, if done properly (i.e. not taken to the too extreme)

cognitive techniques applied to anxiety disorders

• often applied alongside exposure therapy

• for all anxiety disorders

  • challenging overestimations

• for social anxiety

  • challenging interpretations of others’ words and actions

PTSD age diagnostic criteria

patient must be 6 years or older t

PTSD 5 criteria

• Experiencing, witnessing, or being exposed to a traumatic event

• Intrusion symptoms

• Avoidance symptoms

• Alterations in cognition and mood

• Alterations in arousal and reactivity

Traumatic event

Exposure to actual or threatened death, serious injury, or sexual violence

• Direct experience

• Witnessing in person

• Learning that it happened to a close friend/family member

• Experiencing repeated or extreme exposure to averse details of traumatic event

Intrusion symptoms

At least one

• Recurrent, involuntary, and intrusive distressing memories of the event

• Recurrent distressing dreams related to the event

• Flashbacks in which the person feels or acts as if the event were reoccurring

• Intense psychological distress when exposed to internal or external cues related to the event

• Marked physiological reactions to internal or external cues related to the event

Avoidance symptoms

At least one

• Avoidance of (or efforts to avoid) distressing memories, thoughts, or feelings about the event

• Avoidance of (or efforts to avoid) external reminders (e.g., people, places, conversations, activities, objects, situations) that bring up distressing memories, thoughts or feelings about the event

Cognition and Mood symptoms

At least 2

• Inability to remember important aspects of the event (not due to head trauma)

• Persistent, exaggerated negative beliefs about the self, others, or the world (e.g., “I am bad”)

• Persistent, distorted thoughts about the cause or consequences of the event that lead to self-blame

• Persistent, negative emotional state (e.g., fear, horror, anger, guilt, or shame)

• Markedly diminished interest or participation in significant activities

• Feelings of detachment or estrangement from others

• Persistent inability to experience positive emotions

Arousal & Reactivity symptoms

At least 2

• Irritable behavior and angry outbursts

• Reckless or self-destructive behavior

• Hypervigilance

• Exaggerated startle response

• Problems with concentration

• Insomnia or restless sleep

Acute stress disorder

• Requires having experienced a traumatic event

• Lasts between 3 days and 1 month

• Slightly different symptoms and number of symptoms needed to meet criteria

Adjustment disorders

Development of emotional or behavioral symptoms in response to an identifiable stressor (moving, going to collegr, etc.)

• Symptoms are clinically significant

• At least one of these

– Marked distress out of proportion to the

severity or intensity of the stressor taking into

account context and culture

– Significant impairment in social, occupational,

or other areas of functioning

Prolonged grief disorder

12 months after the death of someone close the person experiences persistent grief with at least one of these:

– Intense yearning or longing for the deceased

– Preoccupation with thoughts or memories of the deceased

• Several other symptoms that go beyond “typical” grief (e.g., identity disruption, feeling life is meaningless)

• Duration & severity must exceed expected social, cultural, or religious norms

Reactive attachment disorder

Results in inhibited, emotionally withdrawn behavior toward adult caregivers (both of these):

– Child rarely or minimally seeks comfort

– Child rarely or minimally responds to comfort

• Child also has at least two of these:

– Minimal social and emotional responsiveness

– Limited positive affect

– Episodes of unexplained irritability, sadness, or fearfulness

Disinhibited Social Engagement Disorder

Results in a pattern of behavior of approaching or interacting with unfamiliar adults (at least two of these):

– Reduced or absent hesitation in approaching and interacting with unfamiliar adults

– Overly familiar verbal or physical behavior

– Diminished or absent checking back with caregiver after venturing away in unfamiliar settings

– Willingness to go off with unfamiliar adults with minimal or no hesitation

How have the definitions of a traumatic event changed over time?

• Was originally battle/war related “battle fatigue” or “shell shock”

• Expanded to other experiences with actual/threatened death

• Then included sexual assault

• Then included those who frequently see the aftermath (first responders)

• DSM-IV “threat to physical integrity”

What are some things that would and would not “count” as a traumatic event for the context of PTSD in DSM-5-TR?

• Definition does not apply to those who experience repeated or extreme exposure to averse details on the Internet (i.e. content mods)

• Learning of a traumatic event occurring to a loved one only includes “violent and/or accidental” events

• Does not include the death of a pet

Attachment disorders insufficient care criteria

A child experienced a pattern of extreme insufficient care (at least one of these):

– Social neglect or deprivation (not having basic emotional needs for comfort and affection met)

– Changes in primary caregivers that limits opportunities to form stable attachments

– Being raised in unusual settings that severely limit opportunities to form attachments

Prevalence of PTSD

• 5% lifetime

• 10% military veterans

• 80-95% of those who experience trauma WON’T develop PTSD

• Women 2x as likely to be diagnosed

PTSD Development & Course

• Can happen at any point in life after a traumatic event

• Highest rates are in people 15-24

• 33% of those with PTSD will improve without treatment

Genetic contributions to PTSD

30-40% of differences in expression of PTSD are due to genetics (about the same as MDD & anxiety)

Neurotransmitters in PTSD

Serotonin, dopamine, epinephrine, norepinephrine, GABA

Brain structure in PTSD

• Amygdala, prefrontal cortex, hippocampus are often under active in PTSD

• Hippocampus - memory formation & storage

• Sign of impaired emotion regulation and dysregulated memory function

How is classical conditioning related to PTSD etiology?

After repeated pairings, the neutral stimulus will evoke the reflexive behavior – [driving, certain cars, etc.] -> fear

How is avoidance related to PTSD maintenance?

avoidance is negatively reinforced (pstd)

How is operant conditioning (especially negative reinforcement) related to PTSD maintenance?

Avoidance of thoughts, memories, places, people, etc. keeps the person from experiencing extinction of the association

How is information processing biased in PTSD and how might it contribute to maintenance?

People with PTSD are vigilant for threat-relevant information – They attend to it and then avoid attending to it and may engage in behavioral avoidance as well

Anxious -> attend to potentially threatening stimuli -> increased anxiety -> avoid situation -> reduced anxiety -> avoidance more likely

How is overestimation involved in PTSD maintenance?

overestimation of likelihood & severity of negative events (ptsd)

How are beliefs about the self, world, and future related to PTSD etiology and maintenance?

• People who have beliefs like “the world is safe” and “good things happen to good people” before a traumatic event are more likely to develop PTSD after a traumatic event

  • dramatic worldview shift

• Beliefs like “I can never be safe” or “No one can be trusted” may maintain PTSD

How is biased interpretation involved in PTSD maintenance?

People with PTSD tend to interpret neutral or ambiguous information (e.g., a car driving fast) as negative and/or threatening (e.g., they will crash into us)

What medications are used to treat PTSD? How is this similar and different from MDD and anxiety disorders?

• Tricyclic medications

• SSRIs, SNRIs, NDRIs, SARIs, SMSs

• Benzodiazepines

What types of cognitive behavioral therapies are used to treat PTSD?

CBT; sub categories: Prolonged Exposure & cognitive processing therapy

What is prolonged exposure and what does it involve?

• Exposure-based therapy

• Four main elements

– Breathing retraining - helps reduce anxiety

– Imaginal exposure - exposure to memories of traumatic event

– In vivo exposure - Exposure to (actually safe) people, places, situations, objects, etc. associated with the trauma

– Cognitive restructuring - challenging and rethinking thoughts like “i can trust no one”

What is cognitive processing therapy and what does it involve?

• A primarily cognitive therapy

• Writing about the impact of the trauma on the person’s beliefs and emotions – Helps identify beliefs created by the trauma (“stuck points”) – E.g., “I cannot protect myself or my loved ones”, “I can trust no one”

• learning about the relationships between events -> beliefs -> emotions/behaviors

• coming up with alternate beliefs

In what ways is PTSD different from an anxiety disorder? In what ways is it similar?

• PTSD & anxiety are treated with the same medications

• different therapies, PTSD centered on specific event more so than anxiety disorders

• exposure therapy in both

• PTSD has mood/emotion symptoms

• hippocampus involvement in pstd

• similar etiologies

Obsessive-compulsive disorder

Diagnostic criteria

– Obsessions, compulsions, or both

– The obsessions or compulsions are time consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other areas of functioning

obsessions

– Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that (in most individuals) cause marked anxiety or distress

– The individual attempts to ignore or suppress these thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion)

compulsions

– Repetitive behaviors (e.g., hand washing, checking, ordering) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession

– The behaviors or mental acts are aimed at preventing anxiety, distress, or some dreaded event or situation

– They are not realistically connected with what they are trying to prevent or are clearly excessive