psychopathology Exam #3

What is Personality Disorder

• a characteristic way of thinking, feeling, and behaving; moods, attitudes, opinions, interactions with others

• the “disorder” is the meeting point between you and your environment (ie, not you)

• “enduring pattern, pervasive, across context”

• Age 18+, long documentation (ie, not just over the last few weeks)

• 3 Clusters: A, B, and C

Characteristics of cluster A

• odd and eccentric

• evokes schizophrenia, ASD

• leads to interpersonal deficits

names of the cluster A disorder

• schizoid

• paranoid

• schizotypal

Schizoid Personality Disorder

• not to be confused with schizophrenia, moreso ASD

• “Schiz” here = schism between you and others

• Characterized by poor relationships, lack of interest in social relationships (including sexual), prefers solitary activities

  • disordered for not wanting social relationships?

• Not shyness/enxiety: cold/distant affect, anhedonia

• DSM: “great difficulty differentiating individuals with schizoid personality disorder from individuals with autism spectrum disorder … autism spectrum disorder may be differentiated by stereotyped behaviors and interests” + theory of mind/empathy

Paranoid Personality disorder

• not schizophrenia

• characterized by: Distrust, suspiciousness, in absence of evidence, believing people trying to mistreat you, out ot get you

• often bears grudges

• ultimately, trust/attachment issues

  • trust and original sin?

• treatment → perspective-taking

Schizotypal Personality Disorder

• more similar to “schizophrenia,” although more relational, and more emphasis on “oddness” or eccentricity

• acute discomfort and lack of capacity with relationships

  • lack of close friends, social anxiety

• odd perceptions, thinking, speech, affect, clothing/appearance

  • eg, ideas of reference (this happened because I did something), “paranormal” (telepathy) or superstitious, magical thinking

Characteristics of Cluster B

• dramatic, emotional, relational extremes

• tend to be quite common in counseling

• more “famous” or well known

• lots of bipolar overlap

cluster B disorders

• histrionic

• narcissistic

• borderline

• antisocial

Histrionic personality disorder

• attention-seeking, dramatic, excessive emotion, sexual/provocative (comments/appearance), suggestible, misreads relationships, impressionistic speech

• more commonly diagnosed in females; sexism?

narcissistic personality disorder

• grandiosity (inflated sense of achievement), fantasies of success, need to be around other successful people, need for acknowledgement, entitled, exploitative, lack of empathy, envious, arrogant

• most common “vicarious diagnosis”?

  • people we don’t like

• Quite rare (1%), why is it so commonly assumed?

borderline personality disorder

• instability of self, emotions, others

• fear of abandonment, reckless impulsivity, chronic feelings of emptiness, recurrent suicidal threats/behavior, transient psychotic/dissociative states, anger outbursts

  • cutting; to feel something, make self feel real

• manipulation: not (necessarily) intentional

• suicide risk

Antisocial Personality Disorder

• reckless disregard for the rights of others/their property/authority, etc

• not abiding by laws, deceptive, impulsivity, aggressiveness, disregard for safety, irresponsibility, lack of remorse 

• manipulation

• must be 18+ (conduct disorder present prior to age 15)

  • killing animals, disobeying parents

characteristics of cluster C

• characterized by anxiety, low self-esteem

• avoidant, dependent, perfectionistic

cluster C disorders

• avoidant

• dependent

• obsessive compulsive

avoidant personality disorder

• social inhibition, low self-esteem, hypersensitivity

  • avoids due to fear of rejection, avoids risks

  • painful shyness

• different from social anxiety disorder?

  • mostly due to low self-esteem features, may simply be more “severe,” age criteria

Dependent personality disorder

• need to be taken care of, submissive/clinging behavior

  • difficulty making decisions without excessive comfort/assurance, others responsible for major areas of life, helpless, not able to care for self, fear of being left alone to take care of self

  • also low self-esteem, self-efficacy

  • families

obsessive compulsive personality disorder

• not obsessive-compulsive disorder

• preoccupation with orderliness, perfectionism, control, even when inefficient, etc

  • details, rules, not completing tasks, workaholism, scrupulosity, hoarding tendencies, wants things a particular way, stingy, rigid/stubborn

about sexual disfunction disorders

• Impaired/disordered interest/ability in sexual gratification

different categories of sexual labeling for men and women

• premature/delayed ejaculation/orgasm, erectile disorder, vs. pain, hypoactive sexual arousal/interest

How do we know that Sexual disfunction disorders are psychological?

many with these disorders can experience arousal, orgasm, etc., while sleeping

are sexual dysfunction disorders common clinically?

No, because of shame

“get rid of sex, get rid of shame”

paraphilic disorders and time criteria

6 + months

• voyeuristic disorder

• exhibitionist disorder

• frotteuristic disorder

• Sexual sadism/masochism disorder

• Fetishistic disorder

• transvestic disorder

• pedophilic disorder

Voyeuristic disorder

peeping Tom

Exhibitionist disorder

• flashing

• common in Japan

Frotteuristic disorder

rubbing agianst

Sexual sadism/masochism disorder

dominance, humiliation

Fetishistic disorder

inanimate object necessary/preferred (often item of clothing)

Transvestic disorder

• arousal while “crossdressing” + distress

• “often accompanied by autogynephilia (i.e., being sexually aroused by thought of oneself as opposite sex). Autogynephilic fantasies/behaviors exhibit female physiological functions (e.g., lactation, menstruation), stereotypically feminine behavior (e.g., knitting), or possessing female anatomy (e.g., breasts)”

pedophilic disorder

Gender Dysphoria

• “Incongruence between experienced/expressed gender and primary/secondary sex characteristics”

• Desire to be rid of characteristics, to have those of the other, to be treated as the other, conviction that one has the feelings/reactions of the other

• Clinical distress + impairment

• Psychological vs biological (anatomical)

• Separate categories for adults/children

  • 70-90% of children do not persist into adulthood, end up identifying as LG or B

  • Prevalence: 0.1%-.05%, Autism

  • Clinically, more common w adolescents

Schizophrenia

• harrowing, clinically

• Schiz = schism, split (ie., from reality)

• Coined by Egen Bleuler (1857-1939)

  • C.G. Jung: dreaming? hallucinations =

    • Hypnopompic: waking up

    • Hypnagogic: falling asleep

• Criteria A: Positive and Negative Symptoms

  • presence vs absence

Positive Symptoms (criteria A)

• need two+ of the following positive/negative symptoms (any combination)

  • Delusions

  • Hallucinations

  • Disorganized thought/speech

  • Disorganized/abnormal behavior

delusions

firmly held beliefs despite evidence to the contrary, often bizarre and harmful

• very common symptom

• eg, mind control, being followed

Hallucinations

sensation in the absence of stimuli, auditory most common

• voices, reality testing NOT intact

Disorganized thought/speech

incoherent, tangentiality

Disorganized/abnormal behavior

• catatonia (lack of responsiveness)

Negative symptoms of schizophrenia

• Avolition

• Alogia

• Anhedonia

• Affective flattening

Avolition

significant lack of goal-directed activity, stupor

Alogia

minimal speech, mutism

Anhedonia

blunted/flat affect, unexpressive

affective flattening

• persons face appears immobile and not responsive

• range of emotions is diminished

• lack of eye contact

Schizophrenia spectrum disorders

• If Criteria A is met:

  • <1 month brief psychotic disorder, 1-6 months: schizphreniform, 6+ months: schizophrenia

• Delusional disorder: criteria A is NOT met, 1+ month

  • specifiers: erotomanic, jealous, persecutory, somatic, mixed, “bizarre,” grandiose

• Schizoaffective: mood symptoms + schizophrenia criteria A, psychotic symptoms present both concurrently and even in the absence of mood symptoms.

  • Specify: bipolar or depressive

Cannabis and schizophrenia

• "approximately 15% of recent cases of schizophrenia among males would have been prevented in theabsence of cannabis use disorder (CUD) ... For younger males, the proportion of preventable CUD-associated cases may be as high as 25% or even 30%." (Hjorthøj et al., 2023)

Genetic and Biological Factors of schizophrenia

• Tend to have enlarged ventricles (hydrocephalus) in brain

  • reduced white matter (myelin)

• concordance rate: about 10% between parent or sibling, 40-60% identical twins

• dopamine hypothesis: excessive D4 receptors = hallucinations/delusions rewarded? Drug use

• Medication = 1st gen atipsychotics (neuroleptics): extrapyramidal side effects, tardive dyskinesia (long term)

  • eg, ability = less side effects

• urban living: cities?

about personality disorder and criteria

• a characteristic way of thinking, feeling, and behaving; moods, attitudes, opinions, interactions with others

• The “disorder” is the meeting point between you and your environment (i.e., not you)

• “Enduring pattern, pervasive, across context”

• Age 18+, long documentation (i.e,. Not just over the last few weeks)

• 3 Clusters: A, B, and C

About cluster A

• Odd, eccentric

• Evokes schizophrenia, ASD

• Lead to interpersonal deficits

• schizoid, paranoid, and schizotypal

Schizoid Personality Disorder

• Not to be confused with schizophrenia, moreso ASD

• “Schiz” here = schism between you and others

• Characterized by poor relationships, lack of interest in social relationships (including sexual), prefers solitary activities

  • Disordered for not wanting social relationships?

• Not shyness/anxiety: cold/distant affect, anhedonia

• DSM: “great difficulty differentiating individuals with schizoid personality disorder from individuals with autism spectrum disorder … autism spectrum disorder may be differentiated by stereotyped behaviors and interests” + theory of mind/empathy

paranoid personality disorder

• Again, not exactly schizophrenia…'

• Characterized by: Distrust, suspiciousness, in absence of evidence, believing people trying to mistreat you, out to get you

• Often bears grudges

• Ultimately, trust/attachment issues

  • Trust & original sin?

• Treatment? Perspective-taking

schizotypal personality disorder

• More similar to “schizophrenia,” although more relational, and more emphasis on “oddness” or eccentricity

• Acute discomfort and lack of capacity w relationships

  • Lack of close friends, social anxiety

• Odd perceptions, thinking, speech, affect, clothing/appearance

  • E.g., Ideas of reference (this happened because I did something), “paranormal” (telepathy) or superstitious, magical thinking

Cluster B

• Dramatic, emotional, relational extremes

• Tend to be quite common in counseling

• More “famous” or well known

• Lots of bipolar overlap

• histrionic, narcissistic, borderline, and antisocial

Histrionic personality disorder

• Attention-seeking, dramatic, excessive emotion, sexual/ provocative (comments/ appearance), suggestible, Misreads relationships, impressionistic speech

• More commonly diagnosed in females; sexism?

Narcissistic personality disorder

• Grandiosity (inflated sense of achievement), fantasies of success, need to be around other successful people, need for acknowledgement, entitled, exploitative, lack of empathy, envious, arrogant

• Most common “vicarious diagnosis”?

  • People we don’t like

• Quite rare (1%), why is it so commonly assumed?

borderline personality disorder

• Instability of self, emotions, others

• Fear of abandonment, reckless impulsivity, chronic feelings of emptiness, recurrent suicidal threats/behavior, transient psychotic/dissociative states, anger outbursts

  • Cutting: to feel something, make self feel real

• Manipulation: not (necessarily) intentional

• Suicide risk

antisocial personality disorder

• Reckless disregard for the rights of others/their property/authority, etc.

• Not abiding by laws, deceptive, impulsivity, aggressiveness, disregard for safety, irresponsible, lack of remorse

• Manipulation

• Must be 18+ (conduct disorder present prior to age 15)

  • Killing animals, disobeying parents

Cluster C

• Characterized by anxiety, low self-esteem

• Avoidant, dependent, perfectionistic

• avoidant, dependent, obsessive compulsive

avoidant personality disorder

• Social inhibition, low self-esteem, hypersensitivity

  • Avoids due to fear of rejection, avoids risks

  • Painful shyness

• Different from social anxiety disorder?

  • Mostly due to low self-esteem features, may simply be more “severe”, age criteria

dependent personality disorder

• Need to be taken care of, submissive/clinging behavior

  • Difficulty making decisions without excessive comfort/assurance, others responsible for major areas of life, helpless, not able to care for self, fear of being left alone to take care of self

  • Also low self-esteem, self-efficacy

  • Families

obsessive compulsive personality disorder

• NOT obsessive-compulsive disorder (misnomer?)

• Preoccupation w orderliness, perfectionism, control, even when inefficient, etc.

  • Details, rules, not completing tasks, workaholism, scrupulosity, hoarding tendencies, wants things a particular way, stingy, rigid/stubborn

about working with children/adolescents

• Quite difficult: more directive, being their friend

• Parents are involved: the parent is legally the client

  • Confidentiality?

  • Often have boundary issues w parents

• Behavior that is problematic for a child of one age is normal behavior for a child of a different age

  • Play therapy?

• Manifestations:

  • Depression often manifests as anger (esp in boys)

  • Anxiety more common in girls

Etiology of neurodevelopmental disorders: the great rewiring

• Social media (not technology): deleterious to relationships and mental health/sleep/cognitive functioning (especially Gen Z) Since 2010

  • Drop in 1) embodied 2) synchronous 3) one-to-one (or several) and 4) high bar for entry/exit relationships vs. digital, asynchronous, one-to-many, low bar/low risk = communities vs. “networks”

  • Increase in anxiety, depression, suicide, eating disorders

  • Dopamine: designed to be addictive (craving/seeking “hit”), causes ADHD symptoms

  • Presence of phone reduces attention/quality of social interactions

• Benefits? Perception vs. reality

  • Smartphone: unique (constant) vs. flip-phone, computer, TV, etc

Neurodevelopmental Disorders

• Includes ADHD, ASD, and LDs

  • “Neurodivergent” = not a DSM term

• Early onset (i.e., before age 12, typically age 4-6), persistent course (i.e., long term), involves disruption in normal brain development

• Specific Learning Disorder: math, reading, writing

  • E.g., dyslexia (reading)

  • Tested by intelligence tests and achievement tests

    • Discrepancy?

attention-deficit and hyperactivity disorder

• Inattention: e.g., distractibility, difficulty/dislike sustaining attention, not listening when spoken to, racing thoughts, losing things, forgetting appointments

• Hyperactivity: difficulty waiting/sitting, talkative, restless, disorganized/messy, impulsivity

  • “ADHD,” regardless (combined or predominantly inattentive/hyperactive)

• Symptoms MUST be present prior to age 12

ADHD diagnosis/treatment/etiology

• Misdiagnosed? Overdiagnosed?

  • Comorbidity, sleep issues

  • Women present differently

• Treatment: adderall, ritalin, concerta, focalin, etc.

• Why stimulants?

  • Dopamine deficit in PFC

  • Why deficit in dopamine??

autism spectrum disorder

• Develops relatively young (age 4ish)

• 3 main features: Social deficits, trouble recognizing emotion/empathy/theory of mind, inflexible interests/behaviors

• Spectrum: mild (aspergers), moderate, severe (i.e., caregiver)

attachment issues in children

• separation anxiety disorder

• reactive attachment disorder

separation anxiety disorder

• Being separated from attachment figure (parent, partner, etc)

  • Leading to: excessive anxiety, physical health issues, nightmares, worry, dependance

• 4 weeks in children, 6 months in adults

reactive attachment disorder: trauma

• Neglect > poor attachment to caregivers (not seeking comfort, not being comforted), negative affect

behavioral disorders

• oppositional defiant disorder

• conduct disorder

oppositional defiant disorder

: defiant, disobedience, hostile towards authority (typically parents, sometimes generalized)

• More rooted in rebellion/control than malice/lack of empathy

conduct disorder

: similar, but more severe, aggressive/violent (people/animals/property), deceptive

• often precursor to antisocial personality

Elimination disorders

• “whatever goes into a person from outside cannot harm them, because it does not go into their heart, but into their stomach, and is eliminated…” Mark 7

• enuresis

• encopresis

Enuresis

: i.e., persistent bedwetting after age 5

• Bell and Pad: classical conditioning = bell + peeing = awake

encopresis

: Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional…. At least one such event occurs each month for at least 3 months.” > age 5

Tic disorders

: persistent, involuntary, intermittent twitch/spasm

• Tourette’s disorder: motor and vocal

The talking cure

“In psychoanalytic treatment, nothing happens but an exchange of words between the patient and the physician. The patient talks, tells of his past experiences and present impressions, complains, and expresses his wishes and his emotions. The physician listens attempts to direct the patient’s thought-processes, reminds him, forces his attention in certain directions, gives him explanations and observes the reactions of understanding or denial thus evoked.”

what does therapy look like?

• Therapy modalities: Individual, group, couples, family therapy, telehealth

• Numerous theoretical orientations, various common factors:

  • Often intake questionnaire: demographics, severity of symptoms, etc.

  • Introductions, confidentiality, what brings you in today?

  • Sitting, in a room, talking

  • Empathy, reflection, open-ended questions, active listening, humor (?), silence

  • Schedule next session

  • Take notes (50 mins)

why not just talk to your friend?

• Question: why don’t YOU just talk w friend about issues?

  • Advice,” Bias, Confidentiality

• Therapy helps (that’s why insurance pays for it)

  • Provided you’re using an evidence-based practice (like those described below)

• Someone who is trained to listen, empathize, understand, has experience w numerous situations, accountability

• Theoretical orientations: the counselor’s philosophical assumptions of etiology/treatment/etc.

  • Varies from therapist to therapist

psychodynamic perspectives

• Goal = make the unconscious conscious to resolve conflicts (id/ego/superego)

• Techniques: dream analysis, free association

  • Defence mechanisms (e.g., resistance, projection)

  • Transference: unconscious transfer of emotion regarding another person (often parent) towards therapist

    • Countertransference: therapist > patient

• Analyst is expert, interprets each of the above = provides insight into dreams, behaviors, slips, forgetfulness, transference, defence mechanisms, etc, to strengthen client’s ego and help them work through the conflict

analytical psychology

• Not psychoanalytic (Freud), Analytical

• Carl Gustav Jung (1875–1961)

• Broke off from Freud

• Collective unconscious > individual unconscious

  • Archetypes = George Lucas

  • Explains the sameness of experience

  • Individuation = making collective unconscious conscious

Behavior Therapy

• Once again, dysfunction = due to behavioral issues

• ABA therapy (applied behavioral analysis):

  • Applies principles of learning to behavior management, elimination of unwanted behaviors

• Counterconditioning:

  • Exposure therapy (unpair unhelpful conditioned pairings)

    • Systematic desensitization: incremental exposure to the feared stimulus, becomes “paired” with neutrality, etc.

• Interventions work best for: ASD, ADHD, phobias, addiction

Cognitive Therapy

• Cognitive (Aaron Beck): cognitive distortions (e.g., all or nothing), automatic negative thinking/pessimism leads to negative feelings (e.g., depression/ anxiety). Interventions =

  • Change to realistic thinking or “the power of non-negative thinking”

  • The 3 Ds = disputation, distraction, and distancing

  • The double column technique

cognitive-behavioral therapy

• Cognitive-behavioral = the way you think and behave affects how you feel

  • Perhaps the most common form of therapy

  • Spinoffs: Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT - Marsha Linehan)

Cynic therapy

• Cynic: Fake it til you make it? Optimist: mind over matter

  • Still an emphasis on the working relationship

Relation Emotive Behavior Therapy

• Albert Ellis (1913–2007): REBT, similar to CBT

  • ABC =

    • A(ctivating event)

    • B(elief about the event)

    • C(onsequence of that belief; anxiety, guilt, sadness, etc.)

    • Nothing that happens to you necessarily results in a given emotion

  • Language: “have to,” “musterbating”

  • “Catastrophizing”: devastating vs. “hassle”

  • Rational Emotive Hymn Book: Rate Your Worth

  • Atheist

Client/person-centered

• Carl Rogers (1902–1987)

  • Healing occurs when the client feels heard/understood/empathized with

  • Interventions: active listening, empathy, unconditional positive regard, congruence

  • Non-directive (?): clients have a self-actualizing tendency, find their own solutions, therapist isn’t “the expert”

Gestalt Therapy

• Fritz Perls (1893-1970)

• Organisms (humans) naturally have an undifferentiated field of environment (figure and ground) = this is ideal

  • what comes into focus = a “Gestalt”; the rest is background

  • We have separate “gestalts” of various things (e.g. cats/ dogs/animals, trees/sky, love/hate, good/bad, conservative/liberal)

  • Goal is holism and integration: tearing down artificial boundaries > problems result from these social constructs

  • We want “empty” or pure perception, without reference to external standards/philosophies = Rousseau, Nietzsche? Buddhism?

  • product of its time (60s, early 70s) = anarchism, anti-institutional, nudity

Reality Therapy

• Reality Therapy (William Glasser): full view of human agency = we are in charge of mental illness

  • “Depressing” as a verb; labelling: acting out a role

Logotherapy

• Logotherapy (Viktor Frankl): focus on meaning, the afterlife

  • Man’s Search for Meaning

  • Holocaust survivor: those who survived had meaning

  • Humans have an innate drive towards meaning making

  • Meaning is objective, from God (i.e., not made up)

  • Paradoxical intention interventions

Couples/Family Counseling

• Emotionally-Focused Therapy: Sue Johnson

  • Can be used in individual therapy as well

  • Experiencing, feeling, and expressing emotion helps to deal with it

  • Work with the underlying emotion, not the cognitive/details

    • EFT Tango

    • E.g., taking out the trash

  • Pursue & withdraw

Group Therapy

• Group therapy (6+ people):

  • Process what’s in the room, can’t get into personal details

  • Harder than individual?

  • Heal together, vicariously

    • People adopt roles (e.g., Joker, shy one, overshare, etc)

  • Just as helpful as individual

psychiatric treatment

• Psychopharmacology: prescribing medication for mental health

• In order of efficacy (40-80%): least to greatest

  • Anxiolytic drugs: ativan, xanax, valium, for anxiety and panic disorder

  • Antidepressants: fluoxetine, zoloft, lexapro, paxil, cymbalta, wellbutrin, for depression, anxiety, OCD

  • Antipsychotics: 2nd gen = seroquel, lamotrigine, risperdal, abilify, 1st gen = thorazine for schizophrenia spectrum

  • Mood stabilizers: lithium, depakote, lamictal, tegretol for bipolar I & II

  • Psychostimulants: adderall, ritalin, focalin, concerta, for ADHD

Research on Treatment

• Best: medication + therapy > -5, 0 to +5: no perfect intervention

• Dodo bird effect: all theoretical orientations are helpful

  • Hans Eysenck (1916-1997): specifics of theory don’t matter as much as the clinical relationship - the therapeutic/working alliance

• Most improvement: first session = placebo?

• Other ethical considerations:

  • Confidentiality: Tarasoff decision

  • dual relationships

• What did you like/dislike about the theories covered (e.g., CBT, psychodynamic, client-centered, EFT, logotherapy, reality, etc).

  • Which seem best suited to a Christian worldview?