abpsych final exam

What are the core features of eating disorders?

- severe disturbance in eating behavior

- warped body image

- intense fear of becoming overweight or fat

- pursuit of thinness

What is anorexia?

relentless pursuit of thinness through behaviors that result in significant low body weight of what would be expected from patient's age, sex, and height

DSM criteria for anorexia

- restriction of food intake leading to weight loss or a failure to gain weight resulting in a significantly low body weight of what would be expected from someone's age, sex, and height

- intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain even though at a significantly low weight

- disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

Subtypes for anorexia

- restricting: patient has not engaged in recurrent episodes of binge-eating or purging for the last 3 months; weight loss accomplished primarily through dieting, fasting, and/or excessive exercise

- binging/purging: patient has engaged in recurrent episodes of binge-eating or purging for the last 3 months

Prevalence, gender, comorbidity, age of onset for anorexia

- prevalence — ~0.62% lifetime prevalence (~0.71% for females)

- gender — 3:1 female to male

- age of onset — can be exhibited in childhood but mostly late adolescence/early adulthood (16-20)

- comorbidity — high suicide risk (18x), high mortality rate (5x) due to medical complications (heart arrhythmias, kidney damage, renal failure), depression, OCD, anxiety disorders, mood disorders

Biological causes for anorexia

- genetics: highly heritable (on par with schizophrenia and bipolar)

- set point: significantly low body weight → physiological pushback from the body → constant hunger, thoughts of food, dieting → increase engagement in weight loss behaviors

- neurotransmitters: decreased serotonin levels

- reward sensitivity: restrictive eating maintained by positive reinforcement (deprivation of food → elevated happiness), heightened activity in reward pathways when patients view thinner models, OVERALL — reward and punishment systems get contaminated; normally rewarding stimuli such as food become aversive, and stimuli associated with self-starvation become valued

Psychological causes for anorexia

- body dissatisfaction

- perfectionism

- high negative affect (neuroticism)

- dieting

- self-objectification (regarding your body as an object to be scrutinized by others)

- family criticism about appearance

Treatments for anorexia

low rate of seeking help, high dropout rates

immediate goal is weight restoration

antipsychotics (olanzapine) effective for distorted thinking; common side effect is weight gain, which is good in this case

CBT

- treatment usually lasts 1-2 years

- focus on altering distorted beliefs on body image as well as food and weight

- only 17% show recovery

family therapy for adolescents

- 75-90% show recovery

- phase 1 — parents in charge of weight restoration

- phase 2 — parents hand control over eating back to adolescent

- phase 3 — discuss adolescent development issues

What is bulimia?

uncontrollable and recurrent episodes of binge-eating followed by compensatory behaviors (purging via vomiting, misuse of laxatives, excessive exercise, etc.)

DSM-5 criteria for Bulimia

recurrent episodes of binge-eating, which are characterized by both of the following —

(1) eating in a discrete period of time (within any 2-hour period) an amount of food much larger than what most individuals eat in that period of time

(2) a sense of lack of control over eating during the episode

- recurrent inappropriate engagement in self-compensatory behaviors in order to prevent weight gain such as self-induced vomiting, excessive exercise, fasting, or misuse of diuretics

- binge-eating and inappropriate self-compensatory behaviors both occur on average at least once a week for 3 months

- self-evaluation is unduly influenced by body shape and weight

Differences between Anorexia and Bulimia

- individuals with BN are either average weight or overweight, whereas individuals with AN have a significantly low body weight

- individuals with BN also tend to hide their behavior due to it being related to their own guilt, self-deprication, and shame

- AN has a higher rate of suicide, BN has a higher rate of suicide attempts

Prevalence, gender, comorbidity, age of onset for bulimia

- lifetime prevalence — 0.81%

- higher in women and sexual minorities (3:1 female to male)

- comorbidity — OCD, substance abuse disorders, anxiety disorders, mood disorders, cluster C personality disorders, cluster B personality disorders

- age of onset — early adulthood (20-24)

Biological causes for bulimia

genetics

- highly heritable (on par with bipolar disorder and schizophrenia)

- increased likelihood of developing dependence on alcohol and drugs

brain

- damage to front and temporal cortex linked to development of BN and AN

- hypothalamus may be implicated

- overeating in response to environmental cues and suppressing eating in response to fear still being studied

set point

- dieting → weight loss, body wants to recover that lost weight → overeating/binging

serotonin

- levels are normal in BN, but increase after recovery

Psychological causes for bulimia

- high levels of perfectionism

- body dissatisfaction

- high negative affect (neuroticism)

- dieting / diet culture

- self objectification

- family criticism about appearance

Treatments for bulimia

- antidepressants, other meds

- CBT: lots of initial pushback, but patient eventually learns to understand

normalize eating patterns and restructure maladaptive thinking patterns:

regular eating/stop purging

alternatives to binge eating

examining food avoidance

challenging dysfunctional thought patterns

preventing relapse

regular weigh-ins

- 30-50% recovery and generally leads to symptom improvement

What is Binge Eating Disorder?

characterized by binge eating not accompanied by self-compensatory behaviors to limit weight gain

DSM-5 criteria for Binge Eating Disorder

- recurrent episodes of binge-eating

the binge-eating episodes are associated with 3 or more of the following —

(1) eating more rapidly than normal

(2) eating until uncomfortably full

(3) eating large amounts of food when not hungry

(4) eating alone due to embarrassment

feeling disgusted with self, depressed, or guilty after binging

- marked distress regarding binging is present

- binge eating occurs on average at least once a week for 3 months

- binge eating is not associated with recurrent inappropriate self-compensatory behaviors and does not occur exclusively during the course of anorexia or bulimia

Prevalence, gender, comorbidity, age of onset of Binge Eating Disorder

- lifetime prevalence — 2.21%

- gender — roughly equal

- comorbidity — obesity, anxiety disorders, mood disorders, substance use disorders, personality disorders

- age of onset — older adulthood (30-50)

Biological causes of Binge Eating Disorder

genetics

- more likely to experience MDD

set point

- chronic dieting → urge to eat more → can evolve into uncontrollable binging

reward sensitivity

- high-fat and high-sugar foods seen as more rewarding for the reward pathway in our brain; therefore, patients with BED consume more to feel happier

Psychological causes of Binge Eating Disorder

family

- lower levels of parental care

- more parental overprotection

- more conflict in the child-parent relationship regardless of age

low self-esteem

symptoms of depression

high negative affect (neuroticism)

- binge-eating as a distraction from stress, negative feelings, etc.

Treatments for Binge Eating Disorder

- CBT effective in decreasing binges

- similar interventions as in bulimia

- challenge of attempting to lose weight

- food diaries and exercise plans

Who is at a greater risk for EDs and why?

white Americans (for bulimia), women, athletes, and sexual minorities more at risk (excluding BED)

women — beauty standards value skinniness → desire to fit into society as the ideal figure

athletes — sports like hockey where players need to "make weight"; ballerinas required to be at a significantly low body weight to present "gracefulness"

sexual minorities — body dissatisfaction → desire for a better body → engagement in behaviors that alter the body/body image

*anorexia is not culturally bound whereas bulimia is (particularly to Western culture)

What are the most common comorbid disorders with eating disorders?

OCD, personality disorders, mood disorders, anxiety disorder, substance use disorders

Diagnostic crossover issues with EDs

- 70% of people with an ED have a comorbid disorder

- very common for someone with an ED to be diagnosed with another ED later down the line

- bidirectional transitions between the two subtypes of anorexia are most common

- shifts from anorexia to bulimia occur after an early transition into the binging/purging subtype of anorexia

- if an individual with anorexia gains weight, their diagnosis changes to bulimia; if an individual with bulimia loses weight, their diagnosis changes to anorexia

- bulimia → BED occurs in about 10.9% cases

- BED and anorexia tend to be completely separate (no overlap)

Sociocultural causal factors for EDs

thin ideal: the concept of the ideally slim female body (little to no body fat)

- Western culture in particular used to favor more curvaceous figures in the 50s-60s (i.e. Marilyn Monroe)

- now, we tend to favor skinniness → the thin ideal

- this is also propagated by the introduction and growth of social media

- we all encounter images of thin, attractive models and celebrities on a daily basis

- viewing these images inevitably leads to appearance comparisons that erode mood and facilitate body dissatisfaction

Fiji Study - influence of media on EDs

no eating pathology prior to 1995

- in Fijian culture, overweight women are favored in the realm of beauty standards

1995 - TV introduced → increase in EDs

- development of EDs in response to a desire to emulate the actors they had seen on TV

Modern day influence of social media on EDs

- compared to women who post travel-related images on Instagram, women who post "fitspiration images" scored higher on measures of disordered eating and compulsive exercise

- higher risk of developing EDs, especially in younger girls

Family influences on EDs

overcontrolling parents and families who are critical about appearance tend to facilitate environments where the risk of developing EDs increase

Information about EDs and suicide

AN - increases your suicide risk by 18x

BN - not associated with increased risk of suicide, but 25-30% increased attempts; high rates of comorbidity, more than 50% of people with BN attempt

Why is treating ED very difficult?

patients with EDs often don't see an issue with their behavior, therefore there's a very low rate of patients seeking treatment and a very high dropout rate

Addictive behavior, Substance-related disorders, tolerance, withdrawal

- addictive behavior: behavior based on the pathological need for a substance

- substance-related disorders: using substances in excessive amounts that result in impairment

- tolerance: the need for increased amounts of a substance to achieve the desired effect

- withdrawal: physical symptoms such as sweating that accompany abstinence from a drug

General information about prevalence of AUD and comorbidity in the general US population and also in US college students

- ~30% of US adults will meet criteria for alcohol use disorder at some point in their lives

- heavy drinking is associated with higher mortality (accidents, homicide, suicide, etc.) and higher healthcare costs

- not specific to educational, occupational, and socioeconomic divides

- more frequent in males; highest rates in drinking seen in 18-34 years of age

- high comorbidity between alcohol use and all other mental illnesses including other substance use disorders

college students

- ~50% of college students engage in drinking, ~30% engage in binge drinking

- 1 in 5 women report being sexually assaulted with majority of sexual assaults involving alcohol or other substances

Common "myths"/misconceptions about alcohol

- Alcohol is a stimulant.

- You can always detect alcohol on the breath of a person who has been drinking.

- Alcohol can help a person sleep more soundly.

- Impaired judgment does not occur before there are obvious signs of intoxication.

- An individual will get more intoxicated by mixing liquors than by taking comparable amounts of one kind, e.g., bourbon, scotch, or vodka.

- Drinking several cups of coffee can counteract

the effects of alcohol and enable a drinker to

"sober up."

- Exercise or a cold shower helps speed up the

metabolism of alcohol

- People with "strong wills" need not be concerned about becoming substance abusers

- Alcohol cannot produce a true addiction in the

same sense that heroin can

- One cannot become a substance abuser by

drinking just beer

- Alcohol is far less dangerous than marijuana.

In a heavy drinker, damage to the liver shows up

long before brain damage appears.

- The physiological withdrawal reaction from heroin is considered more dangerous than is withdrawal from alcohol

- Everybody drinks.

What is Alcohol Use Disorder?

a problematic pattern of alcohol use leading to marked distress or impairment; 2-3 symptoms = "mild"

DSM-5 criteria for Alcohol Use Disorder

a problematic pattern of alcohol use leading to clinically significant distress or impairment as manifested by at least 2 of the following within a 12-month period:

- alcohol is often taken in larger amounts or over a longer period than was intended

- persistent desire or unsuccessful efforts to cut down or control alcohol use

- a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects

- craving, or a strong desire or urge to use alcohol

- recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home

- continued alcohol use despite having persistent or recurrent interpersonal or social problems caused by or exacerbated by the effects of alcohol

- important social, occupational, or recreational activities are given up or reduced because of alcohol use

- recurrent alcohol use in situations in which it is physically hazardous

- alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol

- tolerance, as defined by either of the following:

(1) a need for markedly increased amounts of alcohol to achieve intoxication or the desired effect

(2) a markedly diminished effect with continued use of the same amount of alcohol

- withdrawal, as manifested by either of the following:

(1) the characteristic withdrawal symptom for alcohol

(2) alcohol (or a related substance) is taken to relieve or avoid withdrawal symptoms

What are the effects of alcohol on the brain?

- alcohol triggers the mesocorticolimbic dopamine pathway (MCLP) - pleasure/reward pathway

- alcohol is a depressant, inhibiting areas of the brain to make it function slower (impairment in learning, judgment, self-control, and other rational processes)

- tolerance results from habituation

Physical consequences of chronic alcohol use

- liver damage / cirrhosis of the liver

- damage of organic brain tissue

- fetal alcohol syndrome (if pregnant)

- malnutrition

- gastrointestinal symptoms

Alcohol Flush Reaction

~40% of East Asian people have a hypersensitive reaction that includes skin flushing, drop in blood pressure, heart palpitations and nausea when they ingest alcohol

- results from genetic trait that prevents the breakdown of alcohol molecules in the liver

- may be protective against developing alcohol use disorder

Psychological consequences of chronic alcohol use

chronic fatigue, oversensitivity, symptoms of depression

Societal consequences of chronic alcohol use

damage to interpersonal relationships

- impaired judgment, relinquishment of responsibility, neglecting family, etc.

personality deterioration

inability to work

Biological factors in alcohol and other substance use disorders

neurobiology

- MCLP pathway (reward pathway) — involved in functions such as control of emotions, memory, and gratification

- alcohol stimulates this leading to an increase in dopamine → we feel happy → consistent alcohol use, especially in the face of stress

genetics

- 40-70% heritability rate

- polygenic

- personality traits associated with substance misuse

- having an alcoholic parent increases the risk of alcoholism

GxE interactions

- learning plays an important role

- classical conditioning

- operant conditioning (positive reinforcement): increase in substance-use behavior due to the pleasure it brings

Psychosocial factors in alcohol and other substance use disorders

- unsupportive relationships often lead to indulgence in substances

- coping with stress, trauma

Psychological factors in alcohol and other substance use disorders

- behavioral theories - substance abuse is modeled by parents

- cognitive theories - expectancies, tension reduction, coping motives

- personality trait theories - behavior undercontrol, impulsivity, sensation-seeking, and antisocial behavior increase risk

Medications used to treat alcohol use disorders

medications to block the desire to drink - antabuse, naltrexone

- antabuse triggers vomiting when alcohol is consumed (deterrent therapy, seldom-used)

- naltrexone is an opiate that suppresses the pleasure reaction the brain produces in response to alcohol

medications to lower the side effects of acute withdrawal - valium, diazepam

- while helpful, there's some concerns that these don't help in the long run

- detoxification specialists looking into a gradual way off of substance abuse instead of consuming more substances to suppress withdrawal symptoms

AUD Treatment: Alcoholics Anonymous, Cognitive Behavioral Therapy, Motivational Interviewing

alcoholics anonymous — self-help therapy

- provides emotional support, close counseling

- spiritual development is key

- "alcohol abuse is a disease that cannot be cured"

- by far the most accessible resource for alcoholics

CBT — stress management/life skills/relapse prevention

- focus on what is going to happen/how to prepare for withdrawal symptoms

- skills training procedure - aimed at younger drinkers at risk for developing more severe drinking problems

- self-control / self-monitoring techniques

motivational interviewing — extremely important!

- people generate their own reasons to motivate themselves to become sober

- can be applied to anything but is particularly effective with substance use disorders

Controlled drinking vs. abstinence

current evidence suggests no difference in terms of effectiveness following successful treatment for AUD

What is meant by relapse prevention?

preventing patients in remission for alcohol use disorder from falling back into the pattern of excessive drinking/prevent people from violating abstinence from drinking

- most effective prevention is done when family is involved

- clients are taught to recognize the apparently irrelevant decisions that serve as early warning signals of the possibility of relapse

- planned relapse phase in CBT

- results in successful abstinence in the long run

Different classes of drugs

- sedatives: alcohol, barbiturates, benzodiazepines, inhalants

- anti-anxiety drugs: valium, xanax

- stimulants: cocaine, amphetamines, nicotine, caffeine

- opiates: heroin, morphine

- hallucinogens: LSD, cannabis

- pain medications: OxyContin

Understand how criteria for substance use disorders and alcohol use disorders relate

- same diagnostic criteria, but withdrawal syndromes vary widely song substance categories

- similar causal factors (genetics, personality, SES, availability, peer pressure, drug properties)

treatments

- detoxification

- motivation building (often involves feedback)

- CBT: relapse prevention, try to alleviate cravings

- group therapy, support groups (ex. NA)

- medications, replacement therapies (ex. methadone, nicotine patch)

- treatment drop-out and relapse rates generally high

What is the role of the MCLP system in drug use?

MCLP system (pleasure pathway) is triggered when substances are used → elicit a feeling of pleasure, happiness → increased use of substances to trigger MCLP system

What is Gambling Disorder?

progressive disorder characterized by loss of control over gambling, preoccupation with gambling and obtaining money for gambling, and irrational gambling behavior in spite of adverse consequences

DSM-5 criteria for Gambling Disorder

persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting 4 (or more) of the following in a 12-month period:

- needs to gamble with increasing amounts of money in order to achieve the desired excitement.

- is restless or irritable when attempting to cut down or stop gambling.

- has made repeated unsuccessful efforts to control, cut back, or stop gambling

- is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)

- often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)

- after losing money gambling, often returns another day to get even ("chasing" one's losses)

- lie to conceal the extent of involvement with gambling

- has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

- relies on others to provide money to relieve desperate financial situations caused by gambling

the gambling behavior is not better explained by a manic episode

What is personality?

enduring, relatively consistent patterns of thinking, feeling, and behaving across situations

The Big Five personality traits

- Openness to experience: dreamers, adventure, open-minded, variety of experience

- Conscientiousness: disciplined, planned behavior, efficient, reliable

- Extrovertedness: energy, positive emotions, seek stimulation in company of others

- Agreeableness: compassionate, cooperative, empathetic, trusting

- Neuroticism: tendency to experience unpleasant emotions or not

What are Personality Disorders?

enduring, stable, inflexible, and pervasive pattern of thinking, feeling, and behaving

Overall DSM-5 criteria for PDs

marked deviation from expectations of person's culture in at least 2 of the following areas —

- thinking about self or others (cognition)

- emotional functioning (affectivity)

- interpersonal functioning

- impulse control

clinically significant distress or impairment in functioning

What are the criticisms of the PD diagnoses?

- Most people with one PD tend to meet criteria

for at least one other PD

- High levels of comorbidity: 60-85% with one PD have at least one more

- Hard for clinician to obtain all of the information needed (especially about childhood)

- PDs are not actually all that stable over time

What factors have made it difficult to study the causes of PDs?

- Relatively enduring, pervasive and inflexible

- Most with a PD enter treatment at someone's request

- Difficulty forming relationship with a therapist

Cluster A Personality Disorders

ODD/ECCENTRIC → unusual behaviors, e.g., distrust, suspiciousness, social detachment

Paranoid PD

Cluster A

- suspiciousness and mistrust of others

tendency to see self as blameless

- on guard for perceived attacks by others

- interpersonal behavior — withdraw or act aggressively or arrogantly

- 1:1 male to female

Schizoid PD

Cluster A

- impaired social relationships

- inability and lack of desire to form attachments to others

- interpersonal behavior — withdrawn, show little emotion in interpersonal interactions

- NOT anxious (how to distinguish between social anxiety disorder; being anxious vs. not actually caring)

- more males diagnosed than females

Schizotypal PD

Cluster A (odd-eccentric)

- peculiar thought patterns

- superstitious thinking

- ideas of reference

- oddities of perception and speech that interfere with communication and social interaction

- unusual perceptual experiences

- interpersonal behavior — blunted affect, tangential speech

- more males diagnosed than females

- genetically most closely related to schizophrenia (it's basically a milder version of schizophrenia)

Cluster B Personality Disorders

dramatic/emotional

Histrionic PD

Cluster B

- self-dramatization and theatricality

- over-concern with attractiveness

- discomfort if not the center of attention

- physical appearance used to draw attention

- more females diagnosed than males

Narcissistic PD

Cluster B

- grandiosity

- preoccupation with receiving attention

- beliefs in "specialness"

- self-promoting

- lack of empathy and perspective taking

- sense of entitlement

- more males diagnosed than females

Antisocial PD

Cluster B ( (dramatic-emotional)

- pervasive disregard for and violation of the rights of others

- *repeatedly performing acts that are grounds for arrest

- deceitfulness

- impulsivity or failure to plan ahead

- irritability and aggressiveness

- *reckless disregard for safety of self or others

- consistent irresponsibility

- lack of remorse

- 3:1 male to female

- high rate of incarceration

*conduct disorder before age 15

- childhood version of antisocial PD

- must be a pattern of behavior in childhood in order for it to be diagnosed in adulthood

Psychopathy

- not a DSM diagnosis

- not everyone with ASPD is a "psychopath"

characteristics of people with high levels of psychopathy (according to Hare's checklist):

- callous

- superficial charm

- grandiose

- manipulativeness

affective and interpersonal factor —

- lack of remorse and guilt

- callousness/lack of empathy

- glib and superficial charm

behavioral factor —

- impulsive, antisocial acts

- socially deviant lifestyle

- about half of people in prison with ASPD test high for psychopathy

- 80% with high levels of psychopathy meet criteria for ASPD

- overall, psychopathy is the best predictor for violence and recidivism

Research on fear responding and emotional blunting

- skin conductance reactivity at age 3 predicted ASPD at age 28

- low baseline levels of skin conductance

Borderline PD

- impulsiveness

- rocky interpersonal relationships

- fear of abandonment

- inappropriate anger

- drastic mood shifts

- chronic feelings of emptiness

- non-suicidal injury and/or suicidal behavior

- affective instability

- identity disturbance

- 1:1 female to male

Cluster C Personality Disorders

anxious/avoidant

Avoidant PD

Cluster C

- avoids social contact

- hypersensitivity to rejection or social derogation

- shyness

- insecurity in social interaction and initiating relationships

- feelings of inadequacy

- *desire relationships

- more females diagnosed than males

- likely a more extreme manifestation of social anxiety disorder

Dependent PD

Cluster C

- difficulty making decisions without input from others

- difficulty separating in relationships

- discomfort at being alone

- subordination of needs in order to keep others involved in a relationship

- indecisiveness

- more females diagnosed than males

- being a victim in an abusive relationship incredibly common

Obsessive-Compulsive PD

- excessive concern with order, rules, and trivial details

- perfectionism

- rigid, stubborn, inflexible

- lack of expressiveness and warmth

- difficulty relaxing and having fun

- more males diagnosed than females

- do NOT have clinically significant obsessions or compulsions

What factors make PDs difficult to treat?

- high comorbidity with other disorders; high overlap with each other (60-85%) → difficult to diagnose

- patients often don't seek help / don't recognize that there's a problem

- relatively enduring, pervasive and inflexible

- difficulty forming relationship with therapist

- most patients with PDs seek treatment at someone else's request

Types of treatments for PDs

CBT

- focus on schemas associated with the PD

- very challenging; basically asking people to change the way they've been thinking since they were born

Dialectical Behavior Therapy

- initially created for BPD, expanded to other PDs

decrease problem behaviors

- target 1 — life-threatening behaviors

- target 2 — therapy-interfering behaviors

- target 3 — quality-of-life interfering behaviors

increase behavioral skills

- core mindfulness

- distress tolerance (low levels → susceptible to overreaction)

- interpersonal effectiveness

- emotion regulation

lower rates of therapy dropout, comorbidity, suicide attempts

improved social adjustment

Medications

- antidepressants (SSRIs), antipsychotics, mood stabilizers

ASPD Causal Factors

heritability estimates moderate to high

- genetic risk for ASPD, psychopathy, conduct disorder, and substance abuse related ("externalizing behavior")

family environment

- lack of warmth, negativity, and parental inconsistency (abuse, neglect)

- poverty, exposure to violence

- family environment interacts with genetics

neuroanatomy

- hypoarousal in amygdala

- lack of sensitivity to emotional stimuli

- prefrontal cortex — reduction in volume and activation

- impairment in executive functioning, impulsivity, planning

emotion and psychopathy

- lack of fear or anxiety

- show less skin conductance reactivity to others' distress

- lack of empathy

BPD and challenges with therapy

- clingy dependency

- manipulativeness with high stakes (e.g., suicidal gestures)

- need for exclusive relationship

- issues with separation/abandonment

- extreme devaluation

- testing boundaries

- splitting of the treatment team

Linehan's Biosocial Theory of BPD

biopsychosocial, developmental, diathesis-stress theory

- individuals with BPD have difficulty controlling their emotions (possible biological diathesis)

- family invalidates or discounts emotional experiences and expression

- interaction between extreme emotional reactivity and invalidating family → BPD

Multidimensional diathesis-stress theory of BPD

Genetic and Biological Vulnerabilities → Affective Instability, Impulsivity + Trauma and/or Parental Psychopathology/Failure and/or Loss/Rejection → Dysphoria and Emotional Liability, Impulsive Acting Out and Chaotic Interpersonal Relationships → BPD

IN SUMMARY:

Genetic and Biological Vulnerabilities → Personality Traits as a Diathesis → Nonspecific Psychological Environmental Risk Factors → Emotions and Behavior → Personality Disorder

What leads to worse outcome in PDs?

when people have a personality disorder as well as another disorder, they tend to do less well