Behavior Disorders

Exam 3

EATING DISORDERS

is the first chapter

DSM 5 symptom profile of Anorexia Nervosa (AN)

– Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

• Significantly low weight defined as a weight that is less than minimally normal

– Intense fear of gaining weight or of 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 of AN (2)

– Restricting type: Person has not engaged in binge eating or purging. Weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise

– Binge-purging type: Individual has engaged in recurrent episodes of binge eating or urging behavior (e.g., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Bulimia symptom profile

– Recurrent episodes of binge eating, characterized by both of the following:

• Eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would ear in a similar period of time under similar circumstances.

• A sense of lack of control over eating during the episodes (e.g., feeling that one cannot stop eating or control what or how much one is eating)

– Recurrent inappropriate compensatory behaviors in order to prevent weight fain, such as self- induced vomiting, misuse of laxatives, diuretics, or other medications; fasting, or excessive exercise.

-once a week for 3 months

Crucial difference between AN and BN

The critical difference is that only AN patients suppress their weight below normal limits, whereas BN tend to be at least of normal weight

• In the DSM-IV-TR, AN had a cut-off of body weight less than 85% normal weight and amenorrhea.

general thesis for diff between AN and BN

– Anorexia and bulimia are the same disorder, expressed differently as a function of individual life experiences and temperament

• e.g., Impulsivity (BN) / self-control (AN)

Cultural Factors of EDs

– Ideals tend toward body shapes that are difficult to achieve under certain circumstances (e.g., an obsession with slimness in cultures where food is abundant)

– Exposure to the “thin ideal” may underscore greater body dissatisfaction and, in turn, engagement in behaviors that are aimed at attaining this ideal.

internalization of thin ideal

person assumes dominant cultural perspective on physical standards, internalizes societal attitudes, media and social comments perpetuate the ideal.

Body dissatisfaction

gap between one’s actual and ideal weight/shape, but more specifically how dissatisfied a person is with their bodies or parts thereof.

final common pathway for social risk factors; however, not all of those dissatisfied with their body develop EDs.

media vs peer influence

peer influences on body dissatisfaction appear stronger than media effects, whether verbally or passively. In fact, Meta-analytic work suggests only small effects for media exposure to thin ideal.

family influence

families/friends praise AN patients’ slenderness or self-control which is reinforcing.

Mothers of girls with EDs

1. think their daughters should lose more weight

2. are dissatisfied with function of family and have eat disorderly

3. direct maternal comments more powerful than modeling of weight…

4. mothers’ critical comments prospectively predicted ED outcomes

life history

there is a connection between childhood sexual abuse and bulimic symptamology, although its also associated with MDD etc.

childhood emotional abuse and its influence on self-esteem and anxiety is only type of childhood trauma that predicts eating pathology in adults.

identity concerns

refocusing one’s attention noto weight, shape, and eating grants some emotiional control by providing a stable identity to guide behavior

for both AN and Bn, obsessive focus on weight loss and its associated tactics provide a narrow, apparently viable way to channel identity concerns

Age of onset

symptoms of ED are evident in early adolescents, with actual emergence typical in early adulthood.

early personality and Temperamental differences

Individuals with either disorder tend to be:

– Perfectionistic:

• Tendency to pursue unrealistically high standards despite aversive consequences

– Note: Tends to be moderated by self-esteem

– Obsessive-compulsive traits:

• Doubting, checking, and need for symmetry and exactness

– High levels of self-criticism and sensitivity to social approval and prone to rapid deflation of self-concept and self-denigration in responses to lack of recognition from others.

anorexia specific early personality and temperamental differences.

high constraint

low novelty seeking

compliant, socially isolated, anxious female who gravitates towards orderliness and control

reserved, compliant child with marked conflicts around pubertal changes

Bulimia-specific personality factors

high impulsivity

sensation seeking

genetic “self soothing” deficits expressed through affective instability and impulsiveness

SCHIZOPHRENIA

is the next chapterp

psychotic disorders

involve severe impairment in individuals perception and understanding of reality

symptoms include:

delusional thought content

abnormalities in sensory perception.

Schizophrenia

Behavioral manifestation of structural abnormalities in the brain and their

various consequences

◦ Characterized by severe impairment in several areas of functioning:

◦ Positive symptoms:

◦ The presence of symptoms indicative of psychosis (break with reality)

◦ Negative symptoms:

◦ The absence of normal traits or abilities

Positive Symptoms (manifestations of psychosis)

thought content

. -e.g. delusions

perception

. -e.g., hallucination/illusions

Form of thought

. e.g., vague, unfocused, and seemingly pointless discourse.

hallucinations

a hallucination is a false perception of objects or events involving the senses

• auditory (most common)

• visual

• tactile (someone touching you)

• olfactory (smell)

• somatic (whole body, bugs crawling, weightlessness)

• gustatory (taste)

delusions

a false belief that meets the following criteria

• Certainty

  • held with absolute conviction

• incorrigibility

  • not changeable by compelling counterargument or proof to the contrary

• preoccupation

  • delusional belief focus of thought and action

• impossibility or falsity of content

  • implausible or patently untrue

Bizarre and non-bizarre delusions

Non-bizarre: Theoretically possible but clearly untrue

Bizarre: Violate the accepted laws of nature

Negative symptoms (loss of normal traits)

Affect

◦ e.g., flat affect, mood lability

Volition

◦ e.g., loss of drive or motivation

Interpersonal relationships

◦ e.g., social withdrawal

Identity

◦ e.g., confusion of personal identity and confused boundaries

between internal and external world

Psychomotor behavior

◦ E.g., hyperactivity, catatonic rigidity

Subtypes of schizophrenia

paranoid:

• preoccupation with persecutory delusions or auditory hallucinations

Disorganized:

• prominent disorganized speech and behavior

• flat or inappropriate emotional expressions

Catatonic

• motor immobility or excessive motor activity

• waxy flexibility

Changes in DSM 5

o A greater number of symptoms are required to receive the diagnosis;

two (as opposed to one) of the following:

o Delusions, hallucinations, disorganized speech, disorganized/catatonic

behavior, and negative symptoms.

oIndividual must have one of the most blatant symptoms:

o Delusions, hallucinations, or disorganized speech

oSubtypes were removed

o Research has shown that these subtypes are not supported by research or

clinical evidence.

oDimensional approach was incorporated to rate the severity of the core

schizophrenic symptoms.

biological abnormalities

structural abnormalities

• increased volume of lateral ventricular areas

• decreased frontal, temporal, and whole brain volume

  • frontal=high order cognitive processes

  • hippocampus=long-term memory formation

biological abnormalities and neurotransmitters

◦ Dopamine (reward-circuitry):

◦ Increased brain levels of dopamine underlie schizophrenic symptoms

◦ Increased number of receptors for dopamine

◦ Dysfunction is dopamine release

◦ Glutamate:

◦ Most abundant excitatory neurotransmitter in the brain

◦ Glutamate is involved in cognitive functions such as learning and memory

in the brain

◦ Excess of glutamate can be neurotoxic and underlie problems seen in

schizophrenia

genetic factors

Risk elevated in biological relatives of Schizophrenics

◦ Identical Twins: 25% to 50%

◦ Non-identical: 10%-15%

◦ Closer the level of relatedness the higher the risk

problems with identifying specific genes in etiology of schizophrenia

extensive genetic heterogeneity

current broad concept of schizophrenia doesn’t demarcate a homogenous disease entity

parental insults and delivery complications as causes of schizophrenia

◦ Hypoxia

◦ Deprivation of oxygen during delivery

◦ Season-of-birth effect:

◦ Individuals born in late winter months more likely to develop schizophrenia

◦ Maternal Stress:

◦ Chronic prenatal stress or stressful life events associated with higher rates of

Schizophrenia

◦ Childhood trauma:

◦ Early trauma increases risk of later psychosis through sensitization of

the dopaminergic system or through lasting effects on the

hypothalamic-pituitary-adrenal (HPA) axis, which is associated with

stress reactivity

BIPOLAR DISORDER

is the 3rd chapter

bipolar disorder

characterized by sever changes in mood, thinking, and behavior extreme highs to lows.

classic presentation involves mania and depression alternating in distinct episodes lasting from a few days to a year or more.

depressive phases as defined by criteria for major depression.

Manic episodes

manic episodes that include elated, expansive, or irritable mood, or increased goal directed activity, with at least three of the following:

• inflated self-esteem (grandiosity)

• decreased need for sleep

• racing thoughts or flight of ideas

• rapid or pressured speech

• reckless and impulsive behavior

  • e.g., indiscreet sexual liaisons, spending sprees, reckless driving

• enhanced energy

• distractibility

subtypes of bipolar disorder

Bipolar I:

Presence of 1 manic or mixed episode

Bipolar II:

Presence of MDD and one hypomanic episode

• other distinctions:

  • only about 1 in 10 bipolar II patients ever experience a manic or mixed episode

  • bipolar II patients spend more time depressed (37:1) weeks vs. hypomanic; vs (3:1) for Bipolar II

Cyclothymia

two or more years switching between hypomanic and depressive symptoms that do not meet criteria for a hypomanic or major depressive episode

hypomania

The mood disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features

Bipolar, NOS (not otherwise specified)

Patients with manic symptoms that do not meet criteria for any of the other bipolar disorders

epidemiology

2-1% lifetime prevalence (cyclothymia 4.2%)

age of onset: late childhood and early adolescence, getting younger

most frequent comorbid disorders:

• impulse control disorders (63%)

• substance use disorders (42%)

• ADHD (60-90%, in youth)

• Anxiety Disorders (75%)

suicidality

–15 times greater risk for

completed suicide than

general population

–4 times greater risk than

patient with depression

risk factors for completed suicide

Younger age, recent illness onset, male

gender, prior suicide attempts, family history

of suicide, comorbid substance abuse

problems, rapid cycling course, social

isolation, anxious mood, and impulsive

aggression

–Patients with more depressive course than

more severely manic course are more likely

to commit suicide

impairment in functioning

Occurs even between episodes; consequences of behavior can be observed up to 5 years after episode

Only about 1 in 3 Bipolar patients maintain full-time employment

etiology

focus on etiology swings back and forth between genetic/biological factors and social/environmental factors.

biological and genetic factors

Family, twin, and adoption studies highlight that bipolar disorder aggregates in families

Genetic Studies:

Among the most heritable disorders

Estimates are as high as 85% to 93% for concordance

medication

lithium and anticonvulsant medications are successful in controlling cycling.

neurotransmitter regulation

major role of dopamine and serotonin dysfunction in bipolar.

dopamine

Plays role in the reward and/or incentive motivational circuitry

Dopamine function is enhanced during mania and diminished during depression

Dopaminergic agonists are found to trigger episodes

serotonin

Plays an important role in the modulation of anger/aggression, body temperature, mood, sleep, sexuality, and appetite

Diminished functioning of serotonin in bipolar

Deficits believed to allow for greater variability in the function of dopamine

social and environmental factors

Two main factors:

Stressful life events

Social support processes

vulnerability-stress model

chronic stress or more severe stressors are predictive

stress ties with both depressive and manic episodes with equal frequency

life events stress:

onset of bipolar through the effect of life events on sleep-wake (circadian rhythms) cycles:

Disruption in daily routines (social rhythms) can impact sleep-wake cycles through two pathways:

• Presence of zeitstorers

• loss of zeitgebers

zeitstorers vs zeitgebers

Presence of zeitstorers: disrupt established social/circadian rhythms

• e.g., caretaking an infant

loss of zeitgebers: factors that maintain stability of rhythms

• e.g., job loss

more life events stress

• manic, but not depressive episodes can be triggered by minor changes in sleep patterns

• events that disrupt social rhythms are linked with manic episodes in particular

Social support processes:

the presence of supportive vs. non-supportive persons in the environment link with risk for relapse.

• social support appears to buffer against life stress

• interpersonal distress ties with greater risk of relapse

PTSD

is the next chapter

what is PTSD

a cluster of physiological, psychological, and behavior symptoms that can occur following a traumatic event

PTSD is not new (traumatic neurosis, gross stress reaction, war neurosis, combat fatigue, nostalgia, shell shock, soldier’s heart, Da Costa’s syndrome)

types of traumatic experiences

natural disaster:

• e.g., hurricanes, earthquakes, etc.

Abuse:

• e.g., rape, childhood sexual abuse (CSA)

War-related

• e.g., combat, prisoner of war, civil wars

Common Trauma:

• e.g., car accident, sudden and unexpected death of a loved one

What is a traumatic event

An event involving actual or threatened death, serious injury, or threat to physical integrity to self or others

 Typically associated with fear, helplessness, or horror

Criterion A

 Must have experienced, witnessed or learned about a traumatic event of a loved one

 Repeated exposure to the aftermath of a trauma

Course

Symptoms typically emerge shortly after trauma (about 1 month), but delayed expression is possible (6 months).

 Cases of true delayed expression are rare likely reflect reactivation or exacerbation of prior symptoms.

Schemas

Internalized cognitive frameworks for organizing, processing, and understanding the self, others, and the world.

schema disconfirmation

Sometimes our experiences are inconsistent with what would be expected on the basis of our schemas.

• When confronted with schema inconsistent information, individuals either:

assimilate

accomodate

assimilation

Inconsistent information is made consistent with existing schemas

 Denial is a core component of assimilation.

accommodation

Existing schemas are altered to account for

inconsistent information

 Traumas or so salient that they force individuals to in

some way accommodate the experience

examples of especially fundamental schemas

 Personal invulnerability

 The world as a meaningful and predictable place

 e.g., “Just World” assumption

 Self as positive and worthy

consequences of having these assumptions challenged

e.g., Just world assumption:

 Perhaps the assumption is false, and bad things can happen to good people, as well as vice versa.

 Criterion E (Hyperarousal and Reactivity):

 Hypervigilance

 Exaggerated startle response

 Sleep difficulties

 Concentration impairments

again

 e.g., Just world assumption:

 Perhaps the assumption is true, but assumptions

about the self as positive and worthy are false (i.e.,

Maybe I did something to deserve this).

 Criterion D (Strong Negative Emotions):

 Guilt

 Distorted self-blame

 Responsibility for outcome

 Shame about behavior during the event

again

 Perhaps the assumption is false because assumptions

about self are false (i.e., Maybe I’m the bad person

that allowed this to happen).

 Criterion E (Hyperarousal and Reactivity):

 Self-destructive behavior

main idea of what makes something traumatic

 How people integrate the traumatic experience into their preexisting worldview may determine symptom profile

A traumatic event may solidify or exacerbate pre-existing schemas that associate with psychopathology (i.e., schema-confirmation)

Other Consequences to Trauma

• Criterion B (Intrusions):

 Intense physiological and psychological response when exposed to trauma-related cues

• Criterion C (Avoidance):

 Effortful avoidance of cues related to the traumatic event; such as persons, places, or situations.

• Criterion D (Negative Alterations in Cognition/Mood):

 Emotional numbing

 Feeling distant from others, lacking positive emotions, inability to express of feel happiness or love

risk factors

• Not everyone exposed to a trauma develops PTSD!

 Then what predicts who will and who will not develop PTSD following a traumatic experience?

risk factors within demographics

men are more likely to experience trauma but owmen are more likely to develop PTSD, even controlling for type of trauma experienced

other studies show that rates of trauma and PTSD are roughly equal.

characteristics of the trauma

“Personal trauma”

• e.g., sexual assault, physical assault, combat

  • more likely to result in PTSD (specifically rape)

“Impersonal” trauma

• e.g., natural disasters, accidents

Multiple Traumas:

• “complex” PTSD

Cognitive risk factors

lower cognitive ability a risk for PTSD development

e.g., verbal ability, processing speed, retrieval of autobiographical memory

Coping styles as risk factors

Negative cognitive bias, rumination, and avoidant coping styles

personality

neuroticism/negative affectivity, trait anger/hostilitiy, harm avoidance, and trait dissociation

pretrauma psychopathology

having some form of pre-trauma psychopathology is a risk for PTSD development

e.g., individuals who are already experiencing symptoms of anxiety and depression are more likely to develop PTSD than those not already anxious and depressed

Social and ecological factors

social support networks (lack thereof)

poverty

main idea of risk factors

it is not just the occurence of a trauma, but to whom it occurs and under what circumstances