Psych disorders exam 3

Class poll on sex-related disorders

• How do we define normal?

• Main point → have to ask many other clarifying questions, and identity what we define as normal

Main difference between men and women (sex related disorders)

• Frequency of masturbation 

Other U.S. gender differences

• Males are more permissive regarding premarital sex, but gap shrinking 

• Frequency of sex, number of partners, slightly greater in males

• Females are more likely to report passion and romance important for sexuality 

• Females are more likely to have self-conscious and negative schema about sex

Sex spectrum

• Homosexual used to be in DSM

• Not a binary thing

• Have to also think about gender identities 

• At what point is there a disorder

Sex

• Biological characteristics to delineate male and female

• Genitalia

• Sex chromosomes

• Internal organs

• Also on a spectrum → ex: intersex: born with characteristics that are not male nor female

Gender, gender identity, gender expression, sexual orientation

• Constructs, not as biological

• Gender identity: make sense of own gender

• Gender expression: how you convey to the world (cultural restraints)

• Sexual orientation: what gender you are attracted to

Gender dysphoria

• Controversial: and should it be a “disorder”? A DSM-5 change from gender identity disorder 

• Biological sex does not match gender identity and distress is the focus 

• Independent of sexual orientation 

• In what duration and severity should these lead to labels and transitions? No easy answers

• Higher risk for mood disorders and suicide 

Stages of sexual response

• Desire

• Arousal

• Plateau

• Orgasm

• Revolution

• Sometimes shortened to desire, arousal, orgasm

Sexual dysfunction

• Something is going wrong in one of the phases of the sexual response

Treatment of sexual dysfunction 

• Education

• Increased communication

• Sensate focus (non demand pleasuring)

  • Dysfunction involves performance anxiety

  • Performance plummets

  • Pleasure/be pleasured without demand of needing an orgasm

• CBT for performance anxiety

  • Ex: negative schemas about sex, shame, insecurities

• Self-pleasuring → exploring own body

• Possible medication

  • Erectile dysfunction drugs (psych disorder related)

  • Prescribed a lot so we have to ask if we have to change norms, does this change performance anxiety

Paraphilic Disorders 

• Definition: arousal to something deemed inappropriate, causing distress

• Fetishistic disorder

  • Attraction to (typically object) that is problematic

• Voyeuristic and exhibitionistic disorder 

  • V → someone looking at someone against their will

  • E → actual exposure of yourself to someone against their will

• Transvestic disorder 

  • Sexual gratification from clothing

• Sexual sadism and masochism disorder

  • S → infliction of pain

  • M → receiving the pain

• Frotteuristic disorder

  • Sexual gratification from rubbing up against someone who is unsuspecting and not consensual

• Sadistic rape

  • Violence and infliction of harm is whole point of sexual gratification

• Pedophilic disorder and incest

  • P → attraction to prepubescent children (attraction itself, do not always act on it)

  • I → attraction to someone to whom you are in a familial relationship with

Causes of paraphilic disorders

• Genetics? still unclear 

• Difficulty forming “normal” relationships 

  • Deficits in typical sexual experiences

  • Relationship difficulties in childhood or adolescence

• Early experiences may lead to sexual associations by chance > then reinforced through masturbation

• Often have very high sex drive

  • Suppressing unwanted fantasies may paradoxically increase them

Treatment of paraphilic disorders

• Covert sensitization 

  • Creating aversive stimuli

    • Negative effects of object and fantasy

    • Ex: mild electric schools - very controversial

• Orgasmic reconditioning

  • Insert a more positive and sexual stimulus

    • Last second → switch to a more positive stimulus

    • Will be gradually conditioned

• Coping and relapse prevention (most important) as there is a high rate of relapse

• Keep in mind → high comorbidity with mood, anxiety, and substance related disorders

Modern technology role in sex related disorders

• Ex: chat-roulette → placed randomly with a stranger on video chat 

  • A lot of exhibitionist

• Larger problems now than what it used to be due to access of technology

Causes of paraphilic disorders → book chart

Gender non-conformity in children

• Phenomenon in which prepubescent children do not identify with their biological sex, but instead identify strongly with the gender of the opposite sex and display varying degrees of behavior more characteristic of the opposite sex

Types of sexual dysfunction

• Desire

  • Men → male hypoactive sexual desire disorder (little or no desire to have sex)

  • Women → female sexual interest/arousal disorder (little or no desire to have sex)

• Arousal

  • Men → erectile disorder (difficulty attaining or maintaining erections)

  • Women → female sexual interest/arousal disorder (little or no desire to have sex)

• Orgasm

  • Men → delayed ejaculation; premature (early) ejaculation

  • Women → female orgasmic disorder

• Pain

  • Women → Genito-pelvic pain/penetration disorder (pain, anxiety, and tension associated with sexual activity; vaginismus, that is muscle spasms in the vagina that interfere with penetration

Cultural differences in sexuality 

• The Sambia in Papau New Guinea believe semen is an essential substance for growth and development in young boys of the tribe

  • They also believe semen is not produced naturally; that is, the body is incapable of producing it spontaneously

  • Therefore all young boys in the tribe, around age 7, become semen recipients by engaging exclusively in oral sex with teenage boys

  • Masturbation is forbidden and absent

  • Then will switch roles

  • Heterosexual relations are prohibited until boys become teenagers

• In contrast, the Munda of northeast India require adolescents and children to live together

  • But in this group, both male and female children live in same setting, and sexual activity is all heterosexual

• Western cultures there is still variation

  • Premarital sexual behavior is culturally accepted and encouraged in about half of 100 societies surveyed

Sexual orientation

• Some reports suggest that sexual orientation is mediated by early actions of sex steroids, the direct actions of sex specific genes, and epigenetic mechanisms 

• In two twin studies, same-sex sexual orientation was shared in approximately 50% of identical twins, compared with 16% to 22% of fraternal twins

• Other studies reveal that genes account for approximately 34% to 39% of the cause in men and 18% to 19% of the cause in women, with the remainder accounted for by environmental influences 

• Overall some genetic basis but not overly strong 

• Some of the identified genetic loci are linked to hormone regulation identified with male patterned balding 

• Some support to the theory of differential hormone exposure in utero 

• No factor, biological or psychological, can predict the outcome

• Likely that sexual orientation can change over time

Substance abuse statistic

• Abuse of drugs and alcohol kills 500,000 annually

Substances

• Chemical compounds that are ingested to alter mood or behavior

Psychoactive

• Have an effect on the mind, typically can lead to intoxication or being high, possibility of addiction 

Levels of interaction with substance use

• Use, with different methods of ingestion

• Intoxication → under influence somehow

• Abuse → clear DSM disorder → used in a way that causes distress and impairment

• Dependence/addiction → physiologically and psychologically need drug

Dependence

• Physiological: tolerance and withdrawal

  • Tolerance → feel less over time → need more to get same effect, matter of conditioning

  • Withdrawal → no substance in system - system cannot get back to normal → nervous system out of control trying to compensate

• Psychological: drug-seeking behavior

  • Shown with cocaine

Diagram of tolerance and withdrawal

• Ultimately tolerance and withdrawal work together to get someone really stuck → video of bird example

Five categories of substance

• Depressants “downers'“: include sedation (sedatives, alcohol, muscle relaxers, benzodiazepine, some sleeping pills)

• Stimulants “uppers”: increase alertness (caffeine, nicotine, adderall, cocaine)

• Opiates: produce analgesia (pain reduction), induce feeling of wellbeing/euphoria such as heroine

  • Opioids include synthetic drugs as well such as Percocet and oxytocin

• Hallucinogens: alter sensory perception (LSD, ketamine, marijuana, psychedelics)

• Other: a variety of effects

  • Inhalants, anabolic steroids, cough syrup with DMX, ecstasy, MDMA, Molly)

Substance related disorders

• New DSM-5 term

• Sometimes other disorders can interfere with symptomology 

• Gambling disorder is now added in within this (develop tolerance and withdrawal)

• Amount of substance are not specific

• 11 symptoms that presents the range of severity

  • 2-3 symptoms are mild

  • 4-5 moderate

  • 6 or more severe

Symptoms of substance related disorders

• Substance taken in larger amounts or over longer period than intended 

• Persistent desire to cut down/unsuccessful efforts

• Lots of time on activities related to obtaining, using, or recovering

• Strong cravings

• Disruption in fulfilling obligations, due to use

• Social or interpersonal problems due to use

• Activities given up or reduced because of use

• Use when physically hazardous 

• Use despite knowledge of having physical or psychological problems related to it 

• Tolerance (may vary by substance)

• Withdrawal (may vary by substance)

Method of ingestion does…

• Affect potency - getting into bloodstream

Alcohol

• A depressant, but initial depression of inhibitory centers

• Central nervous system → relaxed muscle tension, less coordinate, bad reaction times

• Body → heart, lungs, liver

• Brain → glutamate, GABA, serotonin, neuron communication

• Fetal alcohol syndrome is an issue → facial development, developmental delays

• Long term-effects on brain like dementia, but does it cumulatively kill brain cells?

  • Data is mixed

  • Lately → data shows even small amounts are not good

  • Hard because there is no controlled randomized experiments, most of time it is correlational

Brain effects (alcohol)

• Glutamate → encoding memory

• GABA → inhibitory neurotransmitter

• Serotonin → sleep, mood, eating

• Neuron communication → alcohol slows this down

Combination of alcohol + other classes of drugs

• Ex: four look → caffeine + alcohol = poisoning can happen more easily 

  • Caffeine: stimulant (artificially prop you up) to probably keep drinking

  • Alcohol: depressant

• If in same class → could magnify effects

Alcohol use in the United States

• Most adults: light drinkers or abstainers

• Overall use has done down since mad men area, but binge drinking has gone up

• Current use = around 50% of Americans drink

• Binge drinking = around 24.6% of Americans had 5+ drinks one on occasion in past month

• Rates are higher in males than females

Millions of American Adults Alcohol Dependent

• Cultural differences worldwide

• Role of genetics and alcohol dehydrogenase 

  • Ex: “Asian flush”

Heaviest drinking 10% of Americans

• This group of adults, over age 18, consume on average, 74 alcoholic drinks per week, that works out to a little more than four and a half 750 mL bottles of Jack Daniels, or 18 bottles of wine, or three 24 Cana cases of beer in one week

• Or 10 drinks per day

Alcohol withdrawal effects

• Body is trying to compensate

• Tremors

• Nausea/vomiting

• Anxiety

• Transient hallucinations

• Agitation

• Insomnia

• DTs (delirium tremors) are life threatening → likely to go into seizures or cardiac arrest)

The Pickle Hypothesis

• Once you turn something into a pickle you cannot unpickle it

• Does tolerance ever go back down?

Opioids/opiates

• Opioid dependence is considered an epidemic, especially in certain hard hit areas

• Prescription painkiller abuse a serious problem

• Uptick in heroin deaths related

• Overdose happens when breathing slows to a stop

• Withdrawal effects: nausea/vomiting, chills, muscle aches, diarrhea, insomnia

• Naloxone (narcan) can save lives in overdose disputations, but availability is controversial

  • Some believe that people will not help if narcan is available

Marijuana (hallucinogen) 

• Potency depends on THC levels - what we have now is a lot larger than before 

• Some research linking teenage use with increased risk of psychosis 

• Research is hard to come by 

• Mixed data on tolerance, but psychological addiction can occur 

• Often used to mask depression and anxiety 

• Can still impair driving skills, but many variables exist 

Other hallucinogens

• LSD, mescaline, psilocybin, PCP, DXM (active compound in cough syrup), ketamine (potential role for depression therapy)

Psilocybin (shrooms)

• Potential therapeutic role → clinical usage

• Problem: hard to get rid of confounds because there are no placebos

Stimulants

• Turning up nervous system 

• Ritalin and adderall abuse is a major issue 

• Tolerance and withdrawal can happen in non therapeutic  doses (fatigue, sluggish, not motivated)

• Methamphetamine is a growing problem in rural areas → potent, gives buzz/high energy - bad for heart 

• Ecstasy and MDMA not typical of this category, more of a hallucinogen 

• Cocaine shows a different early pattern of tolerance and dependence, but boredom and apathy at withdrawal 

• Not great longitudinal research on e-cogs, but some major concerns (not just used with stimulants)

Issues with e-cigs

• Amount of nicotine + additives

• In theory: remove what makes smoking bad for lungs by vaporizing, removing carcinogenic effects, and people would stop smoking cigarettes

• Companies hooked in new people who would not have smoked in the first place → overall not universally better from a lungs and cardiovascular standpoint

• Also harder to regulate since it is easier to do in secret

• This was a way that the government was able to regulate behavior on smoking cigarettes in the 80s → taxations, laws, warning messages

Behavioral techniques for quitting (nicotine)

• Gradually cutting down is best way to go

• Nic withdrawal → sluggish, uneasy, headaches 

• But tend to save for when they most need it → psychological conditioning worsens 

• Much more advise a random schedule to eventually, learn to break conditioning and find new coping mechanisms 

Amphetamines physiological effects

• Effects of amphetamines:

  • Produce elation, vigor, reduce fatigue

  • Such effects can be followed by extreme fatigue and depression

• Amphetamines stimulate CNS by

  • Enhancing release of norepinephrine and dopamine

  • Reuptake is subsequently blocked

Kratom

• Properties of both an opiate and a stimulant

• Comes from leaves from a topical tree 

• Toxicity is possible - death has occurred in high dosages 

• Withdrawal symptoms are possible

• Often chewed, powder, liquid form

Tianeptine

• Tricyclic antidepressant - risk of overdose

• Recreationally used for potential effects as an opioid agonist

• “gas station heroin”

2C-B

• Synthetic psychedelic

• “Nexus” “Bromo” “Venus” “Pink cocaine”

• Powder, pills, sometimes mistaken for ecstasy

• Not a lot of research but there seems to be similar psychological risks as other psychedelics and physical risks as stimulants such as cardiovascular issues and stroke

Poppers - Alkyl nitrates

• Inhalants 

• Liquid, but then inhaled as vapor 

• Other category

• Vasodilators: relax and widen blood vessels 

• Fast acting and short lived effects, sometimes paired with sexual activity 

• Been around for decades as club drugs

• Chemical burns, eye damage

• Cardiovascular effects

• Not sold as recreational drugs to try to get around regulations 

Etiology of substance abuse disorders

• Diathesis stress and gene environmental correlation model

• Psychosocial stressors

• Social and cultural expectations for use

• Exposure to drug

• Psychological influences:

  • Positive reinforcement (feel good and confidence), negative reinforcement (removing anxiety), cognitive influences (what you believe you need and how you view the substance)

• Biological influences: sensitivity to drug, rate of metabolism, base levels of arousal, co-occurring disorders, personality

Treatment for substance abuse disorders

• Biological treatments: agonists (e.g. methadone - substitute drug and suboxone- treat opioid dependence), antagonists (e.g. naltrexone- blocks feeling), aversive treatments (Antabuse)

• Psychological treatments: counseling, 12 step programs

• Much controversy, and one size does not fit all

• Many treatments should be tried, relapse risk can be high 

• Co-existing disorders need to be treated

Alcoholic anonymous: a 12 step program

• A lot in common with CBT

• Abstinence: learn to give up substance

• Meeting with other people who struggle as well

• Decentralized and deregulated

• Social connection model

Integrative model for substance abuse disorders

Hallucinogen- related disorders (book)

• Albert Hoffmann → created and recorded first trip of LSD

• LSD (also known as acid) is the most common hallucinogenic drug 

  • Synthetically produced

  • Used to be used as truth serum by CIA

• Psilocybin (shrooms), DMT, PCP

• Perceptual changes such as subjective intensification of perceptions, depersonalization, and hallucinations

• Physical symptoms: pupillary dilation, rapid heartbeat, sweating, and blurred vision

• Increased reports of mystical experiences

• Tolerance developed quickly

• No withdrawal symptoms are reported

• Possibility of psychotic reactions

• Chemically similar to neurotransmitters

Role of prevention (substance abuse disorders)

• Education about drug risks

• DARE program → encourages a no drug use message through fear of consequences, rewards for commitments not to use drugs, and strategies for refusing offers of drugs → not always helpful

• More comprehensive programs that involve skills training to avoid or resist social pressures (such as peers) and environmental pressures (such as media portals of drug use) can be effective in preventing drug misuse among some 

Etiology of impulse control disorders

• neurotransmitter dysfunction

• stress

• genetics

Impulse control disorders - related to substance abuse

• Intermittent explosive disorder

  • Exploding with rage

  • Adults

  • Cannot manage impulse to act out on anger

• Kleptomania

  • Steal because they cannot stop

  • Rush of stealing

• Pyromania

  • Spark from starting fires

  • Impulse to be around fire

How psychological factors affect biology and physical health 

• Through underlying physiological process 

  • Ex: bp, immune system, inflammation, gut microbiome

• Through behavior and lifestyle factors

  • Ex: accident control, smoking cigs, exercice

Lifestyle factors

• Account for as many as fifty percent of deaths from the top 10 leading causes of death

• Smoking, substance overdose, poor nutrition, lack of exercise, inadequate safety

For some health issues, both mechanisms at work

• Ex: genital herpes, shingles

  • Stress levels can worsen outbreaks

Behavioral medicine

• Knowledge derived from behavioral science is applied to prevention, diagnosis, and treatment of medical problems

Health psychology

• Study of psychological factors that promote and maintain health as well as healthcare systems and health policy

Stress

• Boys response to a stressor

• Ex: cannot sleep well, getting rashes

• Bridge analogy:

  • Bridge around for 50 years

    • Dust, crack, fractures (stress)

    • Cars going over, wind, rain (stressor)

General adaptation syndrome

• Alarm: detected a stressor, under threat 

• Resistance: how body manages and withstand threat, coping mechanisms 

• Exhaustion: depleted damage (too severe and too long)

HPA axis

• Stress activates HPA axis

• Hypothalamus releases CRF and stimulates pituitary gland

• Pituitary gland activates adrenal glands, secreting cortisol (stress hormone)

• Ordinarily hippocampus turns off stress response, but can be damaged by excessive or chronic stress

What determines your stress response

• Psychosocial factors: predictability and controllability (ex: having a schedule)

• Ability to find coping mechanisms → social connection is key

• Physical health: a vicious cycle (already in exhaustion phase, harder to get back)

• Attributions/ability to be optimistic

Psychoneuroimmunology (PNI)

• Very hot field

• Studies psychological influences on the neurological responses and its relationship to the immune system 

HIV (virus) and AIDs (syndrome from HIV, life threatening)

• High priority of public health system

• Exclusively lifestyle related - not just if you get it, but lifespan after

• A lot of medications developed now

• Because some promising medications can extend life, awareness/concern has plummeted

• HIV in DC remains an extremely serious problem (1 in 20 people)

• Median time from HIV infection to development of AIDS 7-10 years, with great variability

• In developing countries, death occurs frequently even within a year

Cancer

• Psychoncology

• Psychological factors play role in development in disease

• Psychological factors play role in treatment and recovery

• Psychological and behavioral contributions to the etiology and maintenance of cancer

  • Perceived lack of control

  • Poor coping responses (e.g. denial)

  • Stressful life events

  • Life-style risk behaviors

• Mechanism: psychological factors impact cancer risk by impacting functions such as:

  • Immune function

  • Viral activity

  • DNA repair processes

  • Gene expression

• Younger people are getting colon cancer more frequently

Psychological treatment implications

• Psychosocial treatment for cancer improve:

  • Health habitats

  • Treatment adherence

  • Endocrine function

  • Stress response and coping

• May lead to better remission and decreased mortality

Cardiovascular issues and hypertension (high BP)

• Psych factors like personality, coping style, social support, and levels of stress can explain individual differences in bp

• Warm touch and laughter can reduce bp

• Type A behavior, especially hostility and impatience, matters, but maybe it is more about chronic negative emotions

• Coronary heart disease also linked to chronic negative affect, low socioeconomic status, and stressful experiences 

Psychological and social aspects of pain

• Severity of the pain does not seem to predict the reaction to it, primarily as a result of psychological factors

  • Same factors as those in stress response and other negative emotional states

• Determining factor → individuals general sense of control over situation

  • Positive → associated with active attempts to cope and exercise

• Phillips and Grant example → lookout at patients who suffered from back and neck pain after an injury

  • Almost all expected to recovery quickly, but 40% of them still reported substantial pain in 6 months (chronic pain)

    • Related to personality, socioeconomic differences, lawsuits

• Phantom limb pain: people who have lost a limb still feel pain there

  • Changes in sensory cortex of brain

• Social factors:

  • Family members who were formerly critical and demanding may become caring and sympathetic (operant control of pain behavior)

  • Strong network of social support may reduce pain

Chronic fatigue syndrome 

• Originally neurasthenia (ack of nerve strength) 

• Prevalent throughout the Western world 

• Symptoms initially attributed to XMRV (xenotropic murine leukemia virus related virus) a retrovirus with some similarities to HIV

• Suffer considerably and often must give up their careers 

• Less use of sedating medications and a more psychological approach led to better outcomes 

• Attributed to extremely stressful environment, changing roles of women, rapid dissemination of new technology and information 

• Nonspecific response to stress 

• Michael Sharpe → developed one of the first models of the causes 

  • Theorizes that individuals with particular achievement oriented lifestyles undergo a period of extreme stress or acute illness → results in behavioral avoidance, helplessness, depression, and frustration

  • Genetic factors influence as well

  • Core beliefs → beliefs → lifestyle → trigger → symptoms → thoughts, mood, behavior, physiology

Tensing and relaxing muscles 

• People purposefully tense different muscle groups in a sequential fashion followed by relaxing each specific muscle group → learn to recognize tension in different muscle groups and how to reduce it 

Antigens

• Immune system identifies and eliminates foreign materials called antigens in the body

• Antigens can be any of a number of substances, usually bacteria, viruses, or parasites

Antibodies

• B cells produce highly specific molecules called immunoglobulins that act as antibodies which combine with the antigens to neutralize them

Leukocytes

• White blood cells

• Multiple types:

  • Macrophages might be considered one of the body’s first line of defense

  • They surround identifiable antigens and destroy them

  • Also signal lymphocytes which consist of two groups, B cells and T cells

Branches of immune system

• Cellular branch 

• Humoral branch 

Treatments → health disorders

• Biofeedback → ex: watch BP monitor as you do muscle tension relaxation practices, some video games

  • Be cautious of wearables that track what you do

• Relaxation techniques (including progressive muscle relaxation)

  • Slow and deepen breath, reduce stress response

  • Breathing through nose (inhale)

• Meditation

  • Love and kindness → putting goodness out into world

  • Associated with slowing of aging process

  • Controlled trial experiments - telomere length

• A lot of pain in labor and delivery

• Why zebras do not get ulcers

Personality disorders is study of 

• Why individual people behave differently - opposite of social psych 

Personality

• Characteristic ways that people think and behave

Distinction between personality and disorders

• Personality:

  • Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contacts

• Disorders:

  • Such patterns are also inflexible, maladaptive, harmful, and cause either significant functional impairment or subjective distress

Personality disordes and childhood

• Personally disorders originate in childhood and continue but cannot be diagnosed as a kid since personality is still forming

Five factor model

• Neuroticism (renamed emotional stability)

  • If you scored high before, now score low (valence has changed)

  • How easily distressed, anxious, angst, easily upset

• Extraversion

  • Are you energized by other people

• Agreeableness

  • How polite, do not want conflict

  • Not just about being nice

• Conscientiousness

  • Punctual, tidy, organized

• Openness to experience

  • Willingness to try new things, risk taking

  • Only factor that has correlation with intelligence

• What other factors could be involved?

  • Independence, passive/active, sense of humor, honesty, humility/arrogance

Three personality disorder clusters

• A: odd or eccentric 

• B: dramatic, emotional, or erratic

• C: anxious or fearful 

Gender bias for personality disorders

• Criterion gender bias (criteria is biased)

• Assessment gender bias (measures are biased)

A → Paranoid personality disorder

• Mistrust

• So suspicious of other people - causing problems

• Not psychosis

• Inherently mistrustful, suspicious without reason

• Might lose job after job, relationship with family tanked

• Pretty unhappy

A → Schizoid personality disorder

• Detachment

• Severe detachment from other people and emotions

• Cannot make a living, no relationships

• Not social anxiety

• No desire/completely detached

• Anhedonia typically

• Some think has something to do with autism

• Pretty unhappy because narrow emotional range

A → Schizotypal personality disorder

• Odd

• Distress and impairment

• A lot of magical thinking

• Not psychosis

• Likely to be homeless

• Might be a different type of psychotic disorder, but data unsure now 

B → Antisocial personality disorder

• Violation

• Violating others to get what they want

• Many are slick charmers

• Lack empathy and remorse

• Not “antisocial” in the stereotypical sense

• Substance abuse heavily prevalent

• Not just psychopathy but also need behavioral component

• Under arousal hypothesis → act in cold blood, will not get distressed or feel guilt

• Hard to treat because they will manipulate therapist, been like this their whole life

  • Need to create prosocial relationships

  • Prevention is the most important

Psychopathy, sociopath, conduct disorder

• Psychopathy: personality trait - do not naturally have level of thinking of other people, feeling guilt

  • All on a spectrum

  • Also involves arousal

• Sociopath: not a clear definition in the way that psychopathy does

• Conduct disorder: in children, precursor to antisocial personality disorder

Richard Lee McNair

• Shot someone in a robbery and escaped prison

• When caught, able to talk his way out of it

• Under arousal hypothesis in play

B → Borderline personality disorder

• I hate you do not leave me

• Erratic relationship history

• Not bipolar

• Reactive to other people (external)

• Most common personality disorder (50% of personality disorders)

• More treatable → we have more longitudinal data, more likely to go to therapy, but likely to turn on therapist

• Might be a gender bias

• Tumultuous and unstable relationships 

• Rage to a deep depression

• Fear of abandonment 

• Pushing people away out of fear 

• Cutting is common 

How did BPD get its name

• Used to be thought of as border of neurosis and psychosis

Comborbid disorder - BPD

• 80% borderline patients also have major depression; 10% suffer from bipolar

  • Suicide attempts - 10%

• 67% are diagnosed with at least one substance use disorder

• Eating disorders

  • 25% of bulimia patients have borderline personality disorder

  • 20% have anorexia

Etiology potential - BPD

• Strong genetic component 

  • Also linked to depression genetically

• High emotional reactivity may be inherited

• May have impaired functioning of limbic system

• Early trauma/abuse increase risk

• Many BPD patients have high levels of shame and low self-esteem

• More female but gender bias?

• From reactivity standpoint (more reactive)

Treatment for BPD

• Antidepressant meds provide some short term relief 

• DBT (dialectical behavior therapy) → most promising 

  • Focus on dual reality of acceptance of difficulties, and need for change

  • Focus on interpersonal effectiveness and coping mechanisms

  • Focus on distress tolerance to decrease reckless and self-harming behavior

Ex provided in class

• Someone with BPD dating someone

• Date is late to restaurant → thoughts are spiraling → he then comes in → but relationship already wrecked

• DBT would have her shit with feelings, increase distress tolerance in that moment, effective coping mechanism, less likely to damage relationship 

Case study on BPD

• Young women came in for problems with dating

• Saw 7-8 therapists - said they were all fraud, elevated new one at first

• Trauma in her life

• Start establishing relationship

• Introducing DBT

• Leaves session, confirm next appointment, no availability within a week

• End of day - 7 messages from her raging

• Returned call calmly → no response → eventually gets a message back

• 3 months of no therapy because her reactivity → have her realize and see this, but also not shaming her

• She was able to see how she had wrecked the situation and relationship

B → Histrionic personality disorder

• Dramatic 

• Attention seeking - even if they do not believe it themselves 

• Black and white 

• Exaggerate everything 

• Lying and grandiosity 

• Impulsivity and sexually provocative 

• Won’t have meaningful relationships 

• Love therapy (built in audience)

  • Barrier to therapy

  • No vulnerability