Psych 115 - Exam 2
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Suicide
Suicide risk needs its own assessment, because no single condition accounts for it
Depression raises risk but does not explain suicide: suicidal thoughts and behavior occur across many conditions, in acute crises, and in people with no diagnosis
10th leading cause of death overall and 2nd among ages 10–34. Rate about 4× higher among males
Most people with depression do not die by suicide. Not everyone who does was depressed.
Recommended Language for Suicide
This is about precision, not politeness. Words carry assumptions
WRONG: Committed → Died by Suicide → “Committed” belongs to crimes and sins. The framing is leftover from when suicide was both.
WRONG: “Successful” → Suicide attempt or death by suicide → Calling a death “successful” makes survival a failure. It is exactly backwards from what we want the words to convey.
WRONG: “Threatened suicide” → Disclosed suicidal thoughts, suicidal communication → “Threat” frames a person in distress as coercive, which is precisely the reading that stops people from telling anyone
INSTEAD use died by suicide, suicide attempt, disclosed ideation.
Passive ideation of Suicide
a wish to be dead or not wake up, without active intent
Active ideation
thoughts of ending one's own life.
Plan and intent
clinicians assess specificity, means, timing, and stated intent.
Suicide attempt
non-fatal self-directed behavior with at least some intent to die.
The intent can be ambivalent, partial, or fluctuating — but it is present, and it is what makes the behavior a suicide attempt rather than something else
Death by suicide
death from self-directed injurious behavior with intent to die.
Know that these are not a linear conveyor belt: people move back and forth, skip stages, and stop. Most people with ideation never attempt.
Nonsuicidal self-injury (NSSI) vs. Suicide Attempt
it is a deliberate self-injury without intent to die, often used to manage overwhelming emotion, end numbness, or self-punish.
it is still clinically serious and is associated with elevated later suicide risk.
A attempt is a non-fatal self-directed behavior with at least some intent to die.
Risk is not prediction for Suicide
A variable can genuinely raise risk across hundreds of thousands of people and still be close to useless for identifying which individual will attempt suicide.
A large meta-analysis of fifty years of research found that prediction of suicidal thoughts and behaviors from risk factors was only slightly better than chance — and had not improved across those fifty year
Factors known that increase risk for suicide
Previous suicide attempt — among the strongest known associations.
Psychiatric symptoms and disorders.
Substance use, especially acute intoxication.
Hopelessness — and severe agitation or impulsivity.
Acute stressors: loss, humiliation, legal or financial crisis.
Social disconnection and isolation
Access to highly lethal means.
Factors known that decrease risk for suicide
Social connection — people who notice, and who can be told.
Reasons for living the person can name
Engagement with treatment and continuity of care.
Problem-solving skills and coping resources.
Reduced access to lethal means during acute risk.
Risk factors vs. warning signs.
RISK FACTOR: Changes probability across people or across a person’s life
a prior attempt, a psychiatric disorder, family history, chronic isolation, access to means.
Background. Often present for years. Tells you who is more likely, on average.
WARNING SIGN: A change suggesting concern may be elevated NOW
talking about wanting to die or being a burden, withdrawing, giving things away, a sudden calm after agitation, increased substance use.
Foreground. Recent. Tells you when to ask.
THE HEART-ATTACK VERSION: A triage nurse sees a smoker with high blood pressure and a family history. That is a risk. A person clutching their chest and sweating — that is a warning sign.
Nobody confuses the two in cardiology. In suicide prevention they get collapsed constantly.
Risk factors are background; warning signs are change. Neither predicts an attempt.
Interpersonal Theory of Suicide
THWARTED BELONGINGNESS:
“I am alone.”
A sense of disconnection from others — of not belonging to any group that would notice.
PERCEIVED BURDENSOMENESS
“I am a burden.”
The belief that one’s existence costs other people more than it gives them.
ACQUIRED CAPABILITY
“I am not afraid.”
A reduced fear of death and increased tolerance of physical pain, proposed to develop through repeated exposure to painful or provocative experiences
HOW THE PIECES COMBINE
Belongingness + burdensomeness → Desire to die (ideation) → + Acquired capability → Suicide attempt
THE EVIDENCE: Belongingness and burdensomeness reliably relate to ideation. Support for the full model predicting attempts is mixed
Know What helps for Suicide
Asking does not plant the idea. Reviews find no evidence that asking about suicide increases ideation or distress; some find it reduces distress.
Five things a friend can do:
ask
keep them safe (reduce access to means, don't leave them alone)
be there
help them connect (988, counseling, a clinician)
follow up.
Means safety works because many suicidal crises are acute and time-limited. Putting time and distance between a person and lethal means lets the crisis pass.
Fear and Anxiety are protective
neither is pathological by itself. Each anxiety disorder is built from a response that works.
Fear
danger is here and now.
Associated with an abrupt, intense surge to organize body for action, usually subsides once threat is gone.
Anxiety
danger is possible, later (“something bad might happen”).
Associated with sustained arousal and vigilance. Can last for months, because it doesn’t really resolve.
When Anxiety and Fear becomes a disorder
Persistence: it outlasts the situation; a new normal, not a bad week.
Excess: out of proportion to the real danger. Knowing this does not make it stop.
Avoidance: life is rearranged around the trigger.
Distress and impairment: it costs something in school, work, relationships, or health.
Context and culture: Proportion depends on where someone lives, vigilance in a dangerous places is not a disorder.
What raises the risk for anxiety disorders
Genetic and neurobiological: Anxiety runs in families. What is heritable looks like a general tendency toward anxiety, not fear of one thing.
Temperament and personality: Behavioral inhibition (distress and withdrawal with novelty, visible in infancy) and neuroticism.
Perceived lack of control: A history of outcomes that felt uncontrollable is one of the more reliable vulnerabilities.
Threat-focused cognition: Attention that spots threat fast, plus overestimating how likely and costly a bad outcome is.
Social and environmental stress: Adversity, instability, poverty, discrimination, unsafe environments. These are not evenly distributed.
A specific learning history: These set the odds. Something still has to teach a person what to fear. That is the rest of today.
Five key questions for Fear-based disorders
What exactly is feared? (the feared consequence)
What does the person do because of that fear?
What happens immediately after they do it?
What do they therefore never learn?
What experience would provide the missing evidence? (the intervention target)
Diagnose the feared consequence, not the situation, and the treatment follows.
Three people can avoid the same restaurant for three different reasons, which means three different mechanisms, diagnoses, and treatments.
Person A: “Everyone will notice how awkward I look eating.”(Social evaluation)
Person B: “If I start choking, I won't be able to get help.” (Escape or help unavailable)
Person C: “What if the food is contaminated and I make my family sick?” (Preventing a feared catastrophe)
Same diagnosis? No. Person C is not even in today's section; we meet them next week. Diagnose the feared consequence, not the situation.
Specific phobia
Harm tied to one object or situation
The most contained version, and the one that teaches the question we use on everything else.
Phobias do not require one traumatic event.
Four routes: direct conditioning, vicarious learning, information and instruction, and biological preparedness (snakes and heights are learned more readily than outlets and cars).
Out of proportion; 6+ months; avoided or endured with intense anxiety; distress/impairment, avoidance keeps loop going
Graded exposure; drop safety behaviors, behavioral experiments: approach, drop the props, test the prediction
Social anxiety disorder
Marked fear of situations involving possible scrutiny
Feared outcome: being judged, humiliated, rejected, or seen as anxious
Situations avoided, or endured with intense distress, typically for 6+ months
Often starts in adolescence; narrows school, work, relationships
Specifier: performance only (public speaking, performing)
Maintained by: avoidance, self-focused attention, and in-situation safety behaviors
Intervention: behavioral experiments that drop the safety behaviors, so the prediction gets tested.
Agoraphobia
Escape is hard, or help unavailable, if symptoms hit
Graded exposure to the situations, alone, without the exit seat
Marked fear in 2 or more of: public transit, open spaces, enclosed spaces, lines or crowds, being outside the home alone
Feared outcome: escape might be hard, or help unavailable, if panic-like or embarrassing symptoms hit
Situations avoided, need a companion, or endured with intense fear, typically for 6+ months
Diagnosed separately from panic disorder; either can occur alone
Maintained by: avoidance, safe companions, and seats near the exit. Intervention: graded exposure to the avoided situations, alone and without the exit seat.
Panic disorder
Bodily sensations mean catastrophe (heart attack, dying, going crazy)
When the cue is the person's own body.
Recurrent unexpected attacks + 1 month of worry or behavior change
Interoceptive exposure; test the interpretation
Maintained by: catastrophic interpretation of bodily sensations, plus avoiding the sensations.
Intervention: interoceptive exposure: produce the sensation on purpose and test the interpretation.
Generalized Anxiety Disorder (GAD)
Worry as something a person does, across many possible threats.
Chronic: Six months or more, more days than not.
Often: "I have always been like this."
Excessive and hard to control: Controllability is the core: not "do you worry?" but "can you stop?"
Across everyday domains: Work, health, money, family, being on time. The topic moves.
Physical and cognitive costs: At least three of: restlessness, fatigue, poor concentration, irritability, muscle tension, poor sleep
Real interference: Procrastination, over-preparing, reassurance-seeking, waiting for a certainty that never comes
Social Anxiety vs. Shyness
Shyness is a temperament that eases with familiarity and rarely causes major avoidance or impairment
Social anxiety disorder is maintained by avoidance, self-focused attention, and safety behaviors.
Panic attack vs. panic disorder
A panic attack is an abrupt surge in fear peaking within minutes. It is common and is not a diagnosis by itself. Expected/predictable attacks can occur in specific phobias or agoraphobia.
The panic cycle: bodily sensation → catastrophic interpretation → fear → more arousal → more catastrophic interpretation ("See? It IS happening.").
Panic disorder requires recurrent, at least partly unexpected attacks plus a month of worry or behavior change to avoid having panic attacks.
DON’T USE Anxiety attacks as are not an official psychiatric term.
GAD: worry as avoidance
The avoidance is hard to see. Worry is mostly verbal, which pulls attention away from more distressing emotion.
It feels productive. And because feared catastrophes rarely happen, the worry seems to have worked. Controllability is the core question: not "do you worry?" but "can you stop?"
A CASE STUDY: Nadia (Phobia)
20 years old. Second-year student. No psychiatric history.
Afraid of dogs since childhood. No incident she recalls, but her mother is afraid of them too.
Checks the sidewalk on the way to class, and crosses the street when she sees a leash
Declined two invitations this semester because a dog would be there
When she can't avoid one, she stays, but grips her bag, keeps a wall behind her, and loses the conversation
Calls the fear “ridiculous,” and says knowing that has never helped
Three things to separate in Nadia's story
Fear: The surge when a dog is in front of her: heart, breath, the pull to get away. Immediate, and it ends when the dog leaves.
Anxiety: Checking the sidewalk on the way to class. Nothing is happening; she is preparing for something that might.
Avoidance and safety behavior: Crossing the street, declining invitations. When she stays: the bag, the wall, the vigilance. Both remove discomfort now.
Insight is not a treatment. She already knows the fear is disproportionate: that is a criterion, not a cure.
A CASE STUDY: Robbie (Social Anxiety)
Robbie: third-year student. Talkative with friends. Taking a seminar course this term.
With his roommates he is funny and unguarded. Nobody would call him quiet.
The seminar requires one presentation. He has rewritten it eleven times and rehearsed it alone in an empty classroom.
In discussion he speaks only when called on, and looks at his laptop when he answers
He has considered dropping the course, and is checking which courses next semester require presentations
Afterward he replays it for hours, cataloguing what people must have thought
Finish his sentence: “If I give this presentation, everyone will judge and ridicule me.”
Robbie is not shy. He is reorganizing his semester to prevent a specific social outcome
Taijin kyofusho
Described mainly in Japan and Korea
One form centers on fear of offending or discomfiting OTHER people (through one's gaze, blushing, or a perceived body odor), not on one's own embarrassment
Same territory as social anxiety, with the feared consequence inverted
Ataque de nervios
Described in many Latino and Caribbean communities
Intense emotional upset: shouting, crying, trembling, heat rising in the chest
Typically follows an identifiable family stressor
Overlaps panic, but panic disorder requires unexpected attacks
The question travels: what does this person believe will happen? The answer does not travel with it.
Safety behaviors
What people do before or during a feared situation to make it survivable. They work, and that is the problem.
Rehearsing far past preparation
Avoiding eye contact
Speaking as little as possible
Gripping notes, a cup, a bag
Checking the phone
Over-preparing every contingency
If each of these makes him feel better, why call them part of the problem?
Feared evaluation → Anxiety → Safety behavior → Relief → More safety
“The safety behavior saved me”: the prediction is never tested, so nothing new is learned
A CASE STUDY: Maya (Agoraphobia)
Maya: 19 years old. First-year student. Lives at home and commutes by train.
Felt faint on a packed train last spring and could not get off until the next stop. Now her father drives her.
Sits in the aisle seat of the back row in every lecture, closest to the door
Goes to the grocery store only with her sister, and only when it is nearly empty
Skipped orientation weekend and a concert: “If something happened, I couldn't get out.”
Not worried about what people think. An empty train, far from help, still feels unsafe.
finish her sentence: “If I get stuck on a crowded train, I won’t be able to escape.”
The basis of anxiety disorder treatments.
Avoidance loop: Cue (real or anticipated) → distress → avoid or escape → immediate relief → more future avoidance.
Mowrer's two-factor model:
Factor 1, classical conditioning, explains the origin: a neutral cue paired with something aversive comes to elicit fear.
Factor 2, operant conditioning (negative reinforcement), explains the durability: escape relieves fear, so the fear never extinguishes.
Escape prevents learning that the feared outcome might not happen; that if it did, they would have coped; that distress can change and be tolerated without escape; and that they can function while uncomfortable.
What Exposure is
Deliberately approaching a feared cue while reducing escape and safety behavior, so that new learning becomes possible. It does not require maximal terror, and anxiety does not have to reach zero.
In-vivo: real life (phobias, social anxiety, agoraphobia)
Imaginal: memory, image, or scenario (PTSD, certain fears that are unsafe to recreate or experience in real life)
Interoceptive: feared bodily sensations, produced on purpose, like spinning in chair, running in place, breathing through a straw (panic disorder)
Exposure and response prevention: trigger, without the ritual (OCD)
Exposure is a designed test of a belief. State the prediction so it could turn out false, identify the safety behaviors, design the experiment, decide what to measure, and name the outcome that would violate the prediction.
People still suffer through exposure therapy: Avoidance pays right now; approach is the opposite of what fear demands; the distress comes before the payoff; and it must be repeated places. Effective is not the same as easy.
It is voluntary and collaborative. The clinician explains the rationale, builds the ladder with the client.
How to build and exposure hierarchy.
Name the feared consequence.
List the situations: 10–15 situations avoided or endured with dread.
Rate each on scale of 0–100 of distress)
Fill the gaps: no jump bigger than about 20 points; steps of 10–15 usually work.
Dials create new steps: distance, duration, alone vs. with someone, size or intensity, how crowded or trapped, safety behaviors allowed.
Reading the ladder
Each rung is a real situation the client agrees to try
SUDS (Subjective Units of Distress) rates each rung from 0 to 100
Bottom rungs start around 20–30: hard, but doable
The top rung is the client's goal, around 90–100
Move up when a rung feels manageable, not when fear reaches zero
“How big should the jump between steps be?” There is no exact rule. Steps of roughly 10–15 SUDS points usually work. If there's a gap bigger than about 20 points, try to add a step in between by turning one dial.
“Does the client have to start at the bottom and go in perfect order?” No. The ladder is a guide, not a script. Current research suggests that mixing up the order and varying the setting can make learning stick better. Your ladder still needs to show a sensible progression.
“Can a step be imagined or on a screen instead of real life?” Yes. Imagining, pictures, videos, or virtual reality are fine lower steps, especially for animal phobias. The top of the ladder should be real life.
CASE STUDY: Jordan (Exposure)
20 years old. Sophomore biology major. Referred by the campus health center.
Has not eaten in the dining hall since first year; eats in his car or his room
Never raises his hand; dropped a seminar the week a class presentation was announced
Orders food only through apps and will not call to make appointments
Rehearses what to say before talking to anyone and keeps his hands in his pockets so no one sees them shake
“People will see I'm anxious and think I'm weird.”
His goal: give a 5-minute presentation in his lab course next semester
Example: Jordan's ladder, from a phone call to a presentation
Social anxiety. Feared consequence: “People will see I'm anxious and think I'm weird.”
20 | Call the campus health center to book an appointment | “I'll stumble over my words and they'll think I'm strange.” |
30 | Order lunch in person at the campus café | “The cashier will notice I'm nervous.” |
40 | Eat lunch in the dining hall for 15 minutes | “Everyone will stare at me eating alone.” |
50 | Ask a classmate a question about the homework | “They'll think I'm weird for talking to them.” |
60 | Ask the TA a question in lab without rehearsing it first | “If I don't rehearse, I'll say something stupid.” |
70 | Raise his hand and answer a question in seminar | “My voice will shake and everyone will notice.” |
85 | Give a 2-minute practice talk to his lab group | “They'll see my hands shake and judge me.” |
95 | 5-minute presentation in his lab course, hands out of his pockets | “Everyone will hear my voice shake and think I'm weird.” |
Cognitive restructuring
tests the same prediction by examining the evidence first.
Catch the thought. What am I telling myself will happen?
Rate it. How much do I believe it, 0–100%?
Name the thinking trap. Which pattern from the list is this?
Weigh the evidence. What supports it? What doesn't?
Decatastrophize. If it happened, how bad would it be, and could I cope?
Write a balanced thought. Then re-rate the original belief.
Exposure tests the prediction by doing. Cognitive restructuring tests it on paper first.
Common thinking traps in anxiety
Overestimating probability: “I'll definitely faint.”
Catastrophizing: “If I faint, it'll be a disaster.”
Mind reading: “They think I'm weird.”
Fortune telling: “I'm going to freeze.”
All-or-nothing: “One stumble ruins the whole talk.”
CASE STUDY: Sam (Cognitive restructuring)
24 years old. Graduate student. Referred by urgent care after his third ER visit. Three panic attacks in two months; the last started during a late-night study session
Each time: racing heart, tight chest, dizziness and tingling hands ER tests found nothing wrong with his heart each time Checks his pulse many times a day; has stopped drinking coffee and going to the gym “If my heart races like that again, I'm having a heart attack.”
Today: his heart started pounding while he climbed four flights of stairs to class
Worked example: Sam's belief drops from 90% to 20%
Panic disorder. Situation: his heart started pounding on the stairs to class
Catch the thought: “My heart is pounding. I'm having a heart attack.”
Rate it: Belief in the thought: 90% Anxiety: 85 out of 100
Name the thinking trap: Catastrophizing and overestimating probability: he reads a normal body sensation as danger.
Weigh the evidence: For: heart pounding, chest tight. Against: he just climbed four flights; three ER visits found a healthy heart; past attacks passed in about 10 minutes
Decatastrophize: Worst realistic case: another panic attack. It is unpleasant, it peaks and passes, and he has gotten through three
Write a balanced thought: “My heart is pounding because I climbed stairs. It feels scary, but it isn't dangerous.” Re-rated belief: 20%
Next: test it with exposure. Sam runs up the stairs on purpose to bring on a racing heart and learn it passes.
OCD is not
The thought it not the disorder: Intrusive and odd thoughts are extremely common. The meaning the person gives it, the compulsion that follows, and the cost are where the disorder lives. DSM-5 moved OCD out of the anxiety chapter, but the machinery is the same.
“I’m so OCD — I like things neat and lined up.”: Neatness is a preference. OCD is an unwanted intrusion and a ritual done to end distress. Symmetry rituals feel like dread, not satisfaction.
“It’s just anxiety. High neuroticism.”: Neuroticism is a trait. OCD is a specific loop — obsession, distress, compulsion, relief — and DSM-5 moved it out of the anxiety chapte
“It’s about germs and hand-washing.”: Contamination is one theme. Harm, taboo sexual or religious thoughts, and “not just right” feelings are common — and far less recognized.
“You can see it — the washing, the checking.”: Many compulsions are invisible: counting, praying, reviewing, silent checking, reassurance. A person can ritualize for an hour without moving
“If they keep thinking it, part of them wants it.”: Obsessions go against what the person values (ego-dystonic): a fear, not a wish. Harm obsessions do not make a person dangerous.
OCD is not a preference or a personality type. It is an unwanted thought, plus a ritual to make it bearable
Obsession
A recurrent, intrusive, unwanted thought, image, or urge
Experienced as intrusive and unwanted; often inconsistent with the person's values or sense of self
Produces marked anxiety or distress
Common contents: contamination, harm, symmetry, taboo, sexual or aggressive thoughts
The person tries to ignore, suppress, or neutralize it
Compulsion
A repetitive behavior — or a mental act
Performed in response to an obsession, or by rigid rules
Aimed at reducing distress or preventing a feared outcome
Washing, checking, ordering, counting, repeating, praying, mentally reviewing
Not realistically connected to what it is meant to prevent, or clearly excessive
Common themes of OCD
Contamination: Germs, bodily fluids, chemicals, illness → Washing, cleaning, avoiding
Harm: Hurting someone, even a loved one → Avoiding knives, mental review
Responsibility: A fire, break-in, or accident I caused → Checking locks, stoves, the road
Symmetry / “just right”: Things feel uneven or incomplete → Arranging, repeating, and counting
Sexual: Unwanted sexual images or urges → Avoidance, mental checking, confessing
Religious (scrupulosity): Blasphemy, sin, damnation → Praying, confessing, reassurance
Moral: Having lied, cheated, or been unfair → Confessing, reviewing past actions
Relationship: “Do I really love my partner?” → Comparing, testing own feelings
Sexual orientation: What if I am not who I think I am?” → Testing reactions, reassurance
Existential: Meaning, reality, death → Endless mental analysis
Sensorimotor: Noticing breathing, blinking, swallowing → Monitoring, trying to stop noticing
Emotional contamination: Becoming like a disliked person → Avoiding their places and things
OCD cycle
The avoidance loop from the anxiety disorders. Same shape, new labels.
Obsession or doubt → distress → compulsion → relief → stronger compulsion
Relief negatively reinforces the compulsion ("Nothing bad happened because I checked, so I must check again"). The compulsion takes the credit.
What is the OCD equivalent of crossing the street to avoid a feared dog? The compulsion. It works in the short term — which is exactly why it persists
White Bear
For the next ten seconds, do NOT think about a white bear
WHAT HAD TO HAPPEN MENTALLY FOR YOU TO CHECK WHETHER YOU WERE SUCCEEDING? You had to hold the instruction in mind — which means holding the bear in mind
SO WHAT DOES SUPPRESSION APPEAR TO DO? It can make the thought more available, not less, and it teaches the mind to treat that thought as important.
THEN IF “TRY HARDER NOT TO THINK IT” IS NOT THE TREATMENT — WHAT WOULD THE TREATMENT HAVE TO DO DIFFERENTLY? You tell me. Two minutes. Do not turn the slide until you have an answer.
Suppression can function as a mental neutralization strategy or compulsion — when used to reduce distress or prevent a feared outcome.
Ego-dystonic
Obsessions go against what the person values
I do not actually want to harm my baby, and these intrusive images I have of harming my baby are extremely distressing
harm or violence related obsessions aren’t wanted and distressing
Ego-syntonic
behaviors, values, feelings, and beliefs that are in harmony with, or acceptable to, a person's self-image and core identity
I believe with conviction that it is the right thing to harm my baby because it is a demon
Might be the case in psychosis
Exposure + Response Prevention (ERP)
Exposure therapy from the anxiety unit, plus one key addition that you just worked out.
EXPOSURE
Deliberately trigger the obsession, the feared cue, or the uncertainty itself
Touch the doorknob. Leave without going back. Write the thought down and read it.
The target is often the UNCERTAINTY, not an object — the person has to be willing to not know
RESPONSE PREVENTION
Do not perform the compulsion that normally ends the distress
No washing, checking, counting, mental review, or asking anyone for reassurance
This is the addition. Exposure without it just becomes another occasion for the ritual
Which of the four things exposure lets a person learn becomes available here? For the first time, the feared outcome gets tested without the ritual present to take the credit
ERP works well, and it is hard. Tell patients both
CASE STUDY: Exposure and Response Prevention (ERP)
SCRUPULOSITY THE CASE: Priya, a devout Catholic, fears every unwanted thought is a mortal sin. She confesses daily, repeats prayers until they feel “pure,” and asks her priest whether she is forgiven.
THE TWIST: Prayer is also her genuine faith. How do you block the ritual without treating her religion as the symptom?
“JUST RIGHT” THE CASE: Marcus fears no disaster. Unless his steps, emails, and doorway crossings feel “even,” the discomfort is unbearable, so he redoes them until it clicks.
THE TWIST: There is no catastrophe to test. What does exposure test when the fear is a feeling, not an outcome?
HARM & MAGICAL THINKING THE CASE: Leo believes thinking something bad can make it happen. When an image of his sister in a car crash appears, he cancels it with a “safe” thought and texts her to make sure she is okay.
THE TWIST The thing he fears is his own thought. What exposure would test whether thinking something can make it happen?
Body Dysmorphic Disorder
Preoccupation with a perceived defect others see as slight or absent; checking, comparing, camouflaging)
Hoarding Disorder
Persistent difficulty discarding possessions; distress at parting; living areas unusable
Trichotillomania
Recurrent hair pulling causing hair loss; repeated attempts to stop
Excoriation disorder
Recurrent skin picking causing lesions; repeated attempts to stop)
Trauma ≠ PTSD
Most people who experience a traumatic event do not develop PTSD. Distress afterward is common and expected.
Distress afterward is common and expected. A lasting disorder is not the usual outcome. Getting this wrong treats normal recovery as illness, and hides the real question:
Why do some people not recover?
What counts as exposure to a traumatic event (Recognize the four routes — do not memorize the wording.)
Recognize the four routes — do not memorize the wording.
Actual or threatened death, serious injury, or sexual violence, through:
(1) directly experiencing it
(2) witnessing it
(3) learning it happened to someone close (must be violent or accidental)
(4) repeated or extreme occupational exposure to aversive details (first responders, investigators, medical and forensic personnel).
PTSD — four clusters
Exposure, plus symptoms in all four, persisting more than one month, with distress or impairment.
INTRUSION: Involuntary memories, nightmares, flashbacks, intense distress or physical reactivity at reminders. The event keeps arriving uninvited.
AVOIDANCE: Effortful avoidance of external reminders — places, people, conversations — and of internal ones: thoughts, feelings, memories.
NEGATIVE ALTERATIONS IN COGNITION & MOOD: Persistent negative beliefs about self or world, distorted blame, persistent negative emotion, detachment, loss of interest, memory gaps.
ALTERATIONS IN AROUSAL & REACTIVITY: Hypervigilance, exaggerated startle, irritability, recklessness, concentration problems, disturbed sleep.
Avoidance is only one of the four clusters, but it does more work than it looks
CASE STUDY: Ray (PTSD)
Thirty-four. Worked eight years as a paramedic. Left the job in March.
Since a call that went badly last winter, the scene returns to him without warning — driving, eating, most often at night.
He has changed his route to work to avoid the intersection, and stopped watching anything with sirens in it.
He has told his brother he should have moved faster, and does not know why anyone would trust him.
He sleeps four hours, sits facing the door, and a dropped pan put him on his feet.
It has been nine months. His wife says he is not in the room even when he is.
Find all four clusters. Name the sentence that shows each one
Time matters for Trauma and PTSD
Distress after a stressor is not one thing on a severity dial. Duration and stressor type both do diagnostic work.
IMMEDIATE POST-TRAUMA REACTIONS (Days): Intrusive memories, hyperarousal, numbness, disturbed sleep. Common, expected, and in most people they resolve. Not a disorder.
ACUTE STRESS DISORDER (3 days to 1 month): A qualifying trauma plus a required number of symptoms before PTSD can be diagnosed. Most people with ASD do not go on to develop PTSD.
PTSD (More than 1 month): The four clusters, persisting past a month, with distress or impairment. Onset can also be delayed.
ADJUSTMENT DISORDER (A different kind of response): Clinically significant distress out of proportion to an identifiable stressor that need NOT be traumatic — a divorce, a job loss, a move.
Adjustment disorder is not “PTSD lite” — its stressor need not be traumatic at all — that is the entire point of having the category
Issues in the PTSD diagnosis
Issue 1 is the definition of trauma as Criterion A only counts actual or threatened death, serious injury, or sexual violence leaving out
Emotional abuse or neglect
Bullying, harassment, or discrimination
A loved one’s death from natural causes
Divorce, job loss, or a breakup
Seeing trauma through media (outside work)
Another issue is PTSD a Disorder, or expectable response to DISordered events? Effects of trauma?
The third issue is where the line falls in the DSM-5-TR that symptoms last more than a month and cause distress or impairment. Is that line in the right place?
Should Criterion A be narrow or broad
KEEP IT NARROW: Keeps PTSD a specific diagnosis, and avoids treating ordinary hardship as a disorder
BROADEN IT: Some studies find similar symptoms after excluded events like divorce or job loss, and those people may lose access to diagnosis and care
Complex PTSD
Exposure to multiple traumatic events — often of an invasive, interpersonal nature — usually during early childhood
PEOPLE MAY EXPERIENCE
Relationship problems
Chronic or recurrent physical complaints, such as headaches or stomachaches
Hypersensitivity to sounds, smells, touch, or light
Unawareness of pain, touch, or internal physical sensations
Difficulty identifying, expressing, and managing emotions
Severe dissociation
Self-regulation and impulse control problems
Problems thinking clearly, reasoning, or problem solving
Poor self-esteem and negative beliefs about the future
ICD-11 lists complex PTSD as its own diagnosis. DSM-5-TR does not
Etiology of PTSD
PTSD requires trauma exposure, but exposure alone is not enough.
THE EXPOSURE ITSELF: Severity, duration, proximity, and whether it was interpersonal and intentional — assault and combat carry higher risk than accidents or disasters.
PREEXISTING VULNERABILITIES: Prior psychological disorder, high trait anxiety, and prior trauma all raise conditional risk.
DEVELOPMENTAL HISTORY: Early adversity, childhood abuse, instability — and when in a life something happens changes what it does.
COPING & APPRAISAL: How the event is interpreted afterward — particularly self-blame — and whether the response is approach or avoidance.
SOCIAL SUPPORT: One of the more consistent protective factors here. Its absence afterward predicts worse outcomes.
BIOLOGICAL VULNERABILITY: Heritable contributions and differences in stress-system regulation. Real, partial, not deterministic.
Equifinality: many routes to the same diagnosis. Multifinality: the same trauma, many outcomes.
Avoidance maintains PTSD
The same loop, running on a memory rather than an obsession.
INTRUSION or reminder → DISTRESS → AVOIDANCE or numbing → RELIEF → MORE FUTURE AVOIDANCE
RELIEF → LESS OPPORTUNITY FOR NEW LEARNING
MAINTAINING PROCESS: Avoiding reminders, memories, and feelings, so the memory never gets processed differently.
SO WHAT INTERVENTION FOLLOWS? Treatments that face the trauma memory and its meaning instead of working around them.
You cannot cross the street away from your own memory. That is why the avoidance broadens.
Treatment for PTSD
TRAUMA-FOCUSED PSYCHOTHERAPIES ARE THE FIRST-LINE TREATMENTS Approaches that engage the trauma memory and the beliefs attached to it rather than working around them — exposure-based therapies, trauma-focused cognitive therapies, and EMDR are the commonly cited examples.
MEDICATION HAS A ROLE AND A SMALLER ONE Certain antidepressants outperform placebo and are widely prescribed, but generally show smaller effects than trauma-focused psychotherapy. Know the category; do not memorize a drug list.
EMERGING RESEARCH IS NOT ESTABLISHED PRACTICE Trials of psychedelic-assisted and other novel approaches have drawn considerable attention. An active research area with unsettled results — not an established first-line option
First-line treatments engage the trauma memory and its meaning in a structured, supported way — rather than organizing life around avoiding it.
Prolonged Exposure (PE)
Developed by Edna Foa. About 8–15 weekly sessions of 60–90 minutes. Targets the avoidance that keeps PTSD going
HOW IT WORKS
Psychoeducation: Common reactions to trauma, and why avoidance keeps them going.
In vivo exposure: Graded approach to safe situations the person has been avoiding.
Imaginal exposure: Retelling the trauma aloud, in present tense, repeatedly; the recording is replayed at home.
Processing: Talking through what changed in how the memory is understood.
CPT
Cognitive Processing Therapy, developed by Patricia Resick. About 12 weekly sessions. Targets beliefs about the trauma.
HOW IT WORKS
Impact statement: The person writes what the trauma means about themselves, others, and the world.
Find stuck points: Beliefs that keep recovery from happening, often about blame, safety, or trust.
Question them: Worksheets and Socratic questions examine the evidence for each stuck point.
Rework the themes: Safety, trust, power, esteem, and intimacy, one at a time.
APPLIED TO RAY
Stuck point: “I should have moved faster”
Stuck point: “No one should trust me”
Question: what could he actually have known, and done, in that moment?
CPT works on what the memory means, not on the memory alone
EMDR
Eye Movement Desensitization and Reprocessing, developed by Francine Shapiro. An eight-phase protocol
HOW IT WORKS
Target the memory: Pick the worst image, the negative belief attached to it, and the distress it brings.
Dual attention: Hold the memory in mind while following side-to-side eye movements, taps, or tones.
Repeat sets: Brief sets continue until the memory's distress rating drops.
Install a new belief: Pair the memory with a more adaptive belief about the self.
EMDR works about as well as other trauma-focused therapies. Whether the eye movements add anything is still debated.
Dissociation
A description of an experience — not a diagnosis, and not by itself evidence of anything.
THE TECHNICAL DEFINITION: A disruption of, or discontinuity in, the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.
THE VERSION TO REMEMBER: Things that normally fit together stop feeling connected. Usually your sense of self, memory, perceptions and actions hang together without effort. In dissociation, one or more of those threads comes loose.
WHAT THIS IS NOT: It is not automatically caused by trauma. Trauma is often reported and may matter, but the evidence does not support a single cause. “They dissociate, so something must have happened to them” is not a fair conclusion.
Dissociation describes an experience. What caused it is a separate question.
Does experiencing dissociation mean you have a dissociative disorder?
No. And you have answered a version of this question in every unit so far.
ORDINARY AND COMMON: Driving a familiar route and arriving with no memory of the middle of it. Losing an hour inside a book or a game. Feeling unreal after two nights without sleep, or during a very long shift.
THE PATTERN YOU ALREADY KNOW: Fear is not an anxiety disorder. · A trauma is not PTSD. · An intrusive thought is not OCD. · A dissociative experience is not a dissociative disorder.
WHAT WOULD HAVE TO BE TRUE: It lasts rather than passing · it causes distress or impairment · nothing else explains it better: substances, a medical or neurological condition, lack of sleep, or another disorder.
WHY THIS MATTERS TODAY: Dissociative experiences are common. If the experience alone counts as a diagnosis, you will over-diagnose and label a lot of tired people as ill.
The experience is common; the disorder is not. What matters: how long, what it costs, what else explains it.
Dissociative Amnesia
Inability to recall aspects of personal life history
Depersonalization/Derealization Disorder
Persistent and recurrent episodes of detachment or estrangement from oneself or the world.
Dissociative Identity Disorder (DID)
Two or more distinct identity states, with gaps in memory
Controversial and contested
Other Specified / Unspecified Dissociative Disorder:
Predominant feature is a dissociative symptom
Depersonalization
MY SELF DOES NOT FEEL REAL
Detachment from your own self, body, thoughts, or actions.
A sense of watching yourself from outside, or of going through motions.
Emotional numbing, or a body that feels distorted.
I could see myself talking, but it did not feel like me doing it”
Derealization
THE WORLD DOES NOT FEEL REAL
Detachment from surroundings.
Things look unreal, dreamlike, foggy, flat, or artificial.
People may seem lifeless, or distances and sizes may seem off.
“The room looked like a set. Everything was somehow too far away.”
Psychosis
An experience, not a diagnosis: losing touch with reality in specific ways
Hallucinations: sensory experiences without sensory input
Delusions: strong false beliefs that do not change with evidence
Common: about 1 in 20 adults has one, usually brief, with no disorder
Psychosis is the category. Schizophrenia is one thing inside it.
One specific disorder: disturbed thinking, emotion and behavior
Symptoms plus a decline in daily functioning, lasting at least 6 months
All schizophrenia involves psychosis. Most psychosis is not schizophrenia.
Schizophrenia
One specific disorder: disturbed thinking, emotion and behavior
Symptoms plus a decline in daily functioning, lasting at least 6 months
All schizophrenia involves psychosis. Most psychosis is not schizophrenia.
Myths about Schizophrenia
“Split personality.”: That is DID. The name “schizophrenia” meant a split between thinking, emotion and behavior
“People with schizophrenia are dangerous.”: Most are never violent, and they are far more often victims of violence
“They have lost touch with reality in every way.”:Psychosis is usually limited to certain areas. Many people still work and follow conversations.
“It's caused by bad parenting.”: The “schizophrenogenic mother” idea was discredited. Family climate affects relapse, not cause
“Nobody recovers.”: Outcomes vary widely. Many people have long periods of doing well
“It's all hallucinations and delusions.: Negative symptoms and thinking problems often cause more disability than voices or delusions.
Schizophrenia is not a split self, and it is not a sentence.
What is schizophrenia
Three symptom domains, plus cognition. None of them alone is the disorder.
Positive = added to experience. Negative = taken away. Disorganized = the structure breaks down
POSITIVE SYMPTOMS: Delusions and hallucinations. Daniel's coded lectures and the commenting voice.
NEGATIVE SYMPTOMS: Avolition, asociality, anhedonia, blunted affect, alogia. Daniel's “didn't see the point.”
DISORGANIZATION: Disorganized speech and behavior; catatonia. Not prominent in Daniel, yet.
COGNITION: Attention, memory, speed of thinking, reading others. Not a DSM criterion, but key to daily life.
“Positive” and “negative” mean added and missing, not good and bad.
CASE STUDY: Daniel (Schizophrenia)
A CASE STUDY · 21 years old. Junior, engineering major. No prior psychiatric history.
Over the past year, grades slid from As to Ds. He stopped going to the gym, then to the dining hall.
Since spring he has believed professors embed coded messages in their lectures meant only for him.
He hears a man's voice commenting on what he does: “Now he's opening the door.”
His roommate says he answers questions slowly, in few words, and his face rarely changes expression.
He hasn't showered in a week. When asked, he says he “didn't see the point.”
A, D, F: are negative
B, C: are positive
Categories of delusions
Persecutory: Others intend harm
“The cashier is reporting where I go.”
Reference: Ordinary events carry a message for me
“Daniel's coded lectures”
Grandiose: Special powers, identity or mission
“I was chosen to fix the economy.”
Erotomanic": Someone, often famous or of higher status, is secretly in love with me
“The news anchor sends me signals that she loves me.”
Thought insertion / withdrawal: Thoughts are placed in, or taken from, the mind
“Those thoughts aren't mine.”
Thought broadcasting: Thoughts are audible to others
“Everyone on the bus can hear me think.”
Control: Actions or feelings are controlled by an outside force
“A signal moves my arm.”
When is it a delusion
Strong belief is not enough. Clinicians weigh several features together.
CONVICTION: Held with certainty, not as a hunch or a worry
CANNOT BE CHANGED: Clear evidence against it does not change it.
NOT CULTURALLY SHARED: Not explained by the person's culture, religion or community.
IMPACT: Preoccupation, distress, and action taken on the belief.
Cultural context comes first: a belief shared by a community is not a delusion.
Hallucinations
perception without a stimulus, experienced as real and external.
WHAT THEY ARE LIKE:
Experienced as real and from outside, not imagined; senses can feel overloaded.
Voices may comment, command, converse or insult.
Visual, tactile and other types occur less often
A CLUE TO MECHANISM
Brain imaging during voices shows activity in speech-production areas, including Broca's area.
One idea: the person's own inner speech is heard as coming from outside.
CULTURE SHAPES CONTENT
Luhrmann and colleagues found U.S. voice-hearers described voices as harsh and violent.
Many in Ghana and India described voices as kinder, more like relationships.
A hallucination is a perception, not a belief. Daniel hears the voice; the coded lectures are a belief.
Disorganization
DISORGANIZED SPEECH
Loose associations / derailment: ideas slip off track.
Tangentiality: answers drift away from the question.
Made-up words and, at the extreme, “word salad.”
Rhyming by sound: “Well, hell, it’s well to tell.” Also called formal thought disorder.
DISORGANIZED BEHAVIOR:
Difficulty with goal-directed tasks: hygiene, meals, getting dressed.
Unpredictable agitation or silliness.
Emotions or behavior that don't fit the situation.
CATATONIA
Greatly reduced response to the surroundings.
Holding stiff poses for a long time, or lots of movement with no purpose.
Can occur in other disorders too.
Disorganized speech is about whether you can follow it, not whether the ideas are unusual.
Negative symptoms
Two groups: motivation and pleasure (first three), and expression (last two).
THE FIVE
Avolition: trouble starting and finishing things
Asociality: little interest in relationships
Anhedonia: less pleasure, especially in looking forward to things
Flat affect: little expression in face, voice or eye contact
Alogia: says little, with little detail
WHY THEY MATTER
They predict long-term daily functioning better than positive symptoms do
Medication helps them much less than it helps positive symptoms
They make independent living hard long after the voices have quieted
Positive symptoms get someone admitted. Negative symptoms keep their life from restarting.
Cognitive symptoms
They start before the first episode, last after recovery, and best predict whether someone can work
ATTENTION AND MEMORY: Trouble focusing, holding information for a few seconds, and learning new things.
PROCESSING SPEED: Slower thinking; often the biggest gap compared with peers.
PLANNING AND SOCIAL SKILLS: Trouble planning and switching tasks, and reading other people’s emotions and intentions.
ANOSOGNOSIA: Not knowing you are ill: not denial, but being unable to see it. Common, and a major reason people stop treatment
There is still no approved medication for these thinking problems.
Schizophrenia: DSM-5-TR criteria
Know the structure and time thresholds; don't memorize the exact wording.
1. Two or more symptoms for most of at least one month during the active phase:
Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behavior
Negative symptoms (avolition, anhedonia, reduced emotional expression).
2. At least one symptom must be:
Delusions
Hallucinations
Disorganized speech.
3. Signs of the disorder for at least 6 months total, including the three phases:
Prodromal (before): Early, milder warning signs, such as social withdrawal, reduced motivation, and suspiciousness.
Active (during): Full-blown symptoms, especially psychosis (delusions, hallucinations, disorganized speech).
Residual (after): Symptoms decrease, but some signs remain, such as avolition, anhedonia, or social withdrawal. Milder psychotic symptoms can also remain.
4. Functioning declines in areas such as work, relationships, school, or self-care.
5. Symptoms are not better explained by a mood disorder, drugs, or a medical condition.
Important reminders:
The 1-month requirement refers to the active phase.
The 6-month requirement includes the prodromal, active, and residual phases combined. Not all 6 months need to involve full-blown psychosis.
DSM-5 dropped the old schizophrenia subtypes (paranoid, disorganized, catatonic) because they were not considered useful or reliable.
Time matters for Schizophrenia
Brief psychotic disorder: Psychotic symptoms only; often after a major stressor
Under 1 month; most fully recover
Schizophreniform disorder: Same symptoms as schizophrenia; decline in daily life not required
1 to 6 months
Schizophrenia: Symptoms plus decline in daily life
6 months or more; generally chronic
Schizoaffective disorder": Schizophrenia symptoms plus a major mood episode; psychosis also occurs without mood symptoms
Outcome similar to schizophrenia
Delusional disorder: One or more delusions only; daily life mostly fine
1 month or more; rare; better outcome
Schizotypal personality disorder: Odd beliefs and perceptions, social discomfort; no full psychosis
Long-lasting; also a personality disorder
Attenuated psychosis syndrome: Milder, brief psychotic-like symptoms with distress
Not an official diagnosis
Schizophrenia epidemiology and course:
HOW COMMON: About 1 in 100 people, similar across many countries.
WHEN: Usually late teens to 20s: about 19–20 in men, late 20s in women.
SEX DIFFERENCES: Women tend to have later onset and a somewhat better course.
COURSE: Varies widely: about 1 in 4 recover fully; others have repeated episodes or ongoing symptoms.
HEALTH: People live about 15 years less, mostly because of heart disease and diabetes.
DIAGNOSTIC BIAS: Black Americans are diagnosed more often, partly because clinicians misread mood symptoms.
Psychosis that is not a psychiatric disorder
SUBSTANCE OR MEDICATION-INDUCED: Psychosis during or soon after drug use, withdrawal or a medication. Examples: stimulants, cannabis, hallucinogens, alcohol withdrawal, steroids.
DUE TO ANOTHER MEDICAL CONDITION: Epilepsy, brain tumors, brain inflammation (encephalitis), thyroid disease, vitamin B12 deficiency, HIV, delirium.
HOW YOU TELL: Timing. If symptoms last long after the drug wears off, or have happened before without drugs, a separate disorder is more likely.
A brain inflammation misdiagnosed as schizophrenia gets the wrong treatment.
Three phases of Schizophrenia
Each phase can last days or years. The lines between them are only clear looking back.
PRODROMAL (Early decline) → ACTIVE (Clear psychotic symptoms) → RESIDUAL (Milder symptoms remain)
THE PRODROME: The prodrome is the best chance for prevention, and the hardest to act on. Most people with early warning signs never develop psychosis, so treating early means treating many who would never have become ill.
About 1 in 4 patients fully recover. The rest keep some symptoms
Proposed causes of Schizophrenia
Genetics. Heritability was about ~70% (which is pretty high), polygenic
Dopamine hypothesis
Glutamate. Excitatory neurotransmitter. NMDA-receptor blockers (ketamine, PCP) produce positive, negative, and cognitive symptoms in healthy people.
Brain structure. Enlarged ventricles; reduced gray matter.
Environmental risk factors (each shifts probability; none is necessary or sufficient): prenatal maternal infection or famine; obstetric complications involving low oxygen; older paternal age; urban upbringing; migration and discrimination; heavy adolescent cannabis use; childhood adversity.
Family: expressed emotion (EE). Criticism, hostility, and emotional overinvolvement in the family predict relapse, not onset.
Dopamine hypothesis
Too much dopamine.
Evidence: antipsychotics block D2 receptors, and amphetamines that produce Dopamine can produce psychosis-like symptoms.
VERSION I (1960s–70s): Too much dopamine and worked backwards from the drugs. That is like saying headaches are caused by too little aspirin.
VERSION II: Too much in one area, too little in another, too much in the striatum, too little in the prefrontal cortex
VERSION III: Too much dopamine made and released
The glutamate hypothesis
Good evidence that glutamate plays a role. So far, no treatments have come from it.
THE EVIDENCE FOR IT
Ketamine and PCP, which block glutamate, cause all three symptom types in healthy volunteers; amphetamine causes only positive symptoms
An immune attack on glutamate receptors in the brain looks like psychosis
Large genetic studies point to glutamate receptor genes
Weak glutamate signaling may in turn throw dopamine off balance
THE PROBLEM
Several drugs designed to boost glutamate signaling have failed in trials
The most recent was stopped in January 2025
None has reached patients
Knowing how an illness works does not guarantee a treatment
If this model is right, dopamine problems may be a result of glutamate problems.
Cannabis and Schizophrenia
Heavy cannabis use is consistently associated with psychosis. Does it cause it?
POINTS TOWARD CAUSATION
More use, more risk: daily and high-potency use carry the highest risk.
Use usually precedes onset.
THC can cause brief psychotic symptoms in lab studies.
ALTERNATIVE EXPLANATIONS
Reverse cause: early symptoms may lead people to use cannabis.
Other factors: hardship, other drugs, city life.
Shared genes: genetic risk for schizophrenia also predicts cannabis use.
A CAREFUL CLAIM
“Heavy cannabis use, especially as a teen, likely contributes to psychosis in some people, but does not cause it alone.”
Most heavy users never develop psychosis.
Medications for Schizophrenia
First generation (Chlorpromazine (1950s), haloperidol)
Helps most with positive symptoms
Main side effects are movement problems: stiffness, restlessness, twitching
Negative and cognitive symptoms is little benefit
Seconds generation (Risperidone, olanzapine, aripiprazole)
Helps most with positive symptoms
Main side effects are Weight gain, diabetes, high cholesterol
Negative and cognitive symptoms is little benefit
Clozapine (Second generation, set apart)
Helps most with when other drugs fail; lowers suicide risk
Main side effects are rare but dangerous drop in white blood cells; needs blood tests
Negative and cognitive symptoms is little benefit
Psychosocial treatments for Schizophrenia
Family psychoeducation: Expressed emotion, problem-solving
CBT for psychosis (CBTp): Distress about voices and beliefs
Social skills training: Conversation, assertiveness, daily living
Know recommended Language and stigma for disorders like Schizophrenia
AVOID
“A schizophrenic,” “psycho,” “crazy.”
Linking schizophrenia to violence in casual talk.
“Split personality.”
Treating recovery as impossible.
PREFER
“A person with schizophrenia,” “a person experiencing psychosis.”
Accurate risk: people with schizophrenia are more often victims of violence.
Specific symptoms instead of labels.
Stories that include treatment and recovery.
Stigma makes people wait to get help, and waiting makes outcomes worse