Psychopathology of everyday life Post MST

Addiction

The disease process underlying SUD or problematic behavioral compulsions. Not a diagnosis or medical label.

History of addiction

Before 1800s, addition are viewed as a character flaw. Currently, SUD is still treated rather differently from other mental disorders, possibly due to this issue.

Substance use

any usage of substances

Substance misuse

using substances in a harmful way

Substance abuse

DSM IV idea, repeated usage of substance that interferes with normal functioning.

Substance dependence

DSM IV idea, experiences withdrawal state upon cession of substances.

Substance Use Disorder

DSM V idea that replaces abuse and dependence

SUD diagnostic criteria

A set of 11 criteria that indicates excessive, abnormal, or impairing patterns of substance use. Must meet at least 2 criteria within 12 months to be eligible for a diagnosis.

Severity measurement of SUD

Mild: 2-3 criteria

Moderate:4-5 criteria

Severe: 6+ criteria

Alternative measures include:

1. Extent of impairment

2. Amount of regular consumption

SUD DSM IV to DSM V

Combined abuse and dependence due to various reasons, "legal problem" removed and "craving" introduced.

Craving

A strong urge which interferes with normal functioning

Model of craving

1. Seeing a cue

2. The craving and coping strategies battle

3. Behavioral outcome

Life time drug use

Highest 3 include:

1. Alcohol (99.4%)

2. Tobacco (61.3%)

3. Cannabis (57.6%)

Drug use in Australia

Caffeine (90%)

Alcohol (80%)

Tobacco (15.1%)

SUD epidemiology

8.5% for alcohol, 2% for any illicit drugs

Gateway hypothesis

the idea that the abuse of a specific drug (usually marijuana as it is the easiest to get illicit drug) will inherently lead to the abuse of other, more harmful drugs

Risk of developing SUD

Substance type does not matter, the earlier first use is, the more likely a person will develop substance abuse disorder later. Peak age of usage around 18-20 years old.

Dependence on drugs

Tobacco the highest (>30%) . Unlike most drugs which plateau, tobacco continues to escalate as one use them more and more.

Abuse potential of drugs

Depends on the half-life and method of administration. The quicker a substance come into effect, the more likely it will be abused (e.g. inhalation has the fastest reaction time)

Withdrawal symptoms of coffeine

Occurs within nearly everyone who consumes of 100mg per day.

Symptoms include:

1. Headach

2. Fatigue

3. Anxiety

4. Inability to concentrate etc

Withdrawal symptoms of Alcohol

delirium tremens, sweating, trembling, anxiety, and hallucinations

Withdrawal symptoms of cannabis

occurs within 1/3 of user population and 0.5 to 0.99 of heavy users.

symptoms include:

1. Irritability

2. Anxiety

3. Restlessness etc

SUD treatment

Psychotherapy, medication, detoxification etc. No single treatment have a large effect size.

Treatment considerations for SUD

Some drugs are much more dangerous to treat than others (e.g. alcohol). Opoid is another example as it may lead to overdose upon discharge.

Psychotherapy approaches to SUD

1. Alcoholic/Narcotics Anonymous: Aim is 0

2. Behavioral therapy

3. CBT

4. Harm minimization: Aim is return to functional state

5. Motivational enhancement: Move from "not thinking change" to "think of change", then help plan and maintain change.

Aetiology of SUD

A combination of impaired control (e.g. biological deficit such as impaired cognitive control) and choice (e.g. personal choice)

Controversies of prohibition

Prohibiting alcohol in America actually lead to higher rates of death by substance abuse

Comorbidity of SUD

people of SUD often have much higher chance of developing other mental disorders, such as personality disorder, bipolar disorder and schizophrenia. However, the exact reason of which remain unknown.

Gambling disorder criteria

At least four of the criteria related to tolerance, withdrawal and loss of control within a year.

Stats of gambling

Around 70% of Australians gambled within a year. Estimated that 1% meet the criteria and 4% are at risk. Cross country variability between 1% to 5%, higher in countries where gambling have no relevant regulations.

Aetiology of gambling disorders

Apart from biological underpinnings, intermittent reinforcement is one of the most effective way of behavioral learning.

Neurodevelopmental disorders

1. Group of disorders that have an age of onset in childhood (though the diagnosis may not be given that early)

2. Have a high heritability

3. More common in boys than girls.

4. Rarely caused by a single factor.

5. High comorbidity with mental disorders of this type and also other types.

Intellectual disability

1. Deficit in intellectual functioning (e.g. reasoning)

2. Deficits in adaptive functioning (e.g. meeting expectations of developmental level)

Prevalence:1-3% of population, male to female is 1.5:1.

Risk factor for intellectual disability

Over 500 known causes, including:

1. Birth complications such as parental exposure to alcohol.

2. Environmental factors such as acquired brain injury.

3. Medical condition such as Epilepsy etc.

Autism Spectrum Disorder

A disorder characterised by:

1. Persistent deficit in social interactions across contexts

2. Restricted and repetitive patterns of activities.

Prevalence: 1/54, males are 4 times more likely than females. However, there is a risk of under identification in girls due to gender stereotypes.

Risk factors for ASD

Aetiology is poorly understood despite extensive research. Some known causes include:

1. Familial influence (family members have autistic features)

2. Early brain overgrowth, especially in the frontal brain

3. Advanced parental age

Attention Deficit Hyperactive Disorder

A persistent pattern of inattention or hyperactivity/impulsivity across context and interferes with normal functioning.

Subtype and prevalence of ADHD

Subtypes include:

1. Predominantly inattentive (boys=girls)

2. Predominantly Hyperactive (more common in boys)

3. Combined (75% of the children) (more common in boys)

Overall, the prevalence rate is 5-7%, where in general boy is 3 times more likely than girls.

Risk factors for ADHD

1. High heritability (70%)

2. Multiple related genes

3. Neurobiological causes

4. Environmental factors (maternal smoking for example)

Prevalence rate of mental disorders in youth

13.9% in past twelve months and 20% life time.

Anxiety disorder (6.9%) and ADHD(7.4%) most prevalent.

40% comorbidity (specific data refer to slide 27)

High comorbidity thought to be explained by shared aetiology, challenge with drawing categorical boundaries etc.

Overall, more disorders are prevalent in adolescence than childhood (but there are exceptions). Some disorders are more prevalent in boys and some more prevalent in girls. [There may be an interaction effect between age and gender]

Barrier of help seeking

Only half of the people seek help, some reasons might include:

Stigma, availability, under-identification (e.g. he is just being childish)

Prevalence of mental disorders over time

Over the recent decade, mental disorders become more and more prevalent, possible reasons include increasing awareness, decreased stigma, changed diagnostic criteria and risk factors became more prevalent.

Pros of having categorical definition of abnormality

1. Shared language of understanding

2. Guide intervention

3. Provide validation

Cons of having categorical definition of abnormality

1. Sub-clinical presentations can be impairing but will not gain attention

2. Locates the problem within the child

3. Labelling can have adverse effects

Homotypic continuity

The stability of specific diagnoses and symptom patterns over time. For example anxious and internalizing symptoms present during preschool, childhood, and adolescence for the same individual.

heterotypic continuity

The manifestation of psychopathology change over time.

Issue with diagnosing children

Young people can struggle to report their internal state, but parental report may not be accurate.

Determining normality in youths

1. Frequency and intensity

2. Deviation from the norm

3. Deviation from developmental level

4. Contextual appropriateness

Developmental psychopathology

Children are shaped by shape their own environment. Many factors have cascading effect which leads to other factors. Understanding abnormality requires understanding of normality.

Each developmental stage have their own stage-salient issues, failure to meet those standards lead to psychopathology.

Multifinality

The same precursor can lead to different outcomes.

Equifinality

Different precursors can lead to the same outcome

Vulnerability vs risk factor

The former is biologically based, the latter it more based on environment

Adverse Childhood Experiences

Stressful or traumatic experiences. Occur to 66% of children in some form, the most prevalent being substance abuse and divorce.

Protective factors

The polar opposite of risk factors.

e.g.

-Good intellectual functioning

-Easy temperament

-Authoratative parenting style

-Resilience (a context dependent trait)

OCD diagnostic criteria

Persistent and recurrent patterns of obsession and compulsion, where the individual realizes it is excessive and that the obsession or the compulsion cause significant impairment.

Obsession

Intrusive thoughts and is persistent and causing anxiety. The individual realizes that it is excessive.

Common obsessions

Fear of contamination,

repeated doubts,

orderliness

sexual imagery

Compulsion

repetitive behaviour or mental act performed to reduce or prevent stress.

Can be rigid or stereotyped according to elaborate rules, the act performed may be totally irrational.

Common compulsions

cleaning, checking, repeating, ordering/arranging, counting

Prevalence rate of OCD symptoms

80% population experienced intrusive thoughts, more than half of the population engage in ritualised behaviours. Most common type is regarding harm and somatic obsession.

OCD prevalence rate

12 month: 1.2%

Life time: 2.3%

No gender difference (but female more likely of aggression and contamination symptoms whereas males more likely of sex symptoms)

Age of onset ~19

Fluctuating course with 50% of the cases being chronic

Childhood onset of OCD

Much more common in boys, around 1/3 to 1/2 of the patients report first development of the disorder in childhood.

OCD symptom profiles

90% have obsession and compulsion,

8-20% have mental rituals and obsessions only, but no behavioral compulsions

[The data came from different studies, therefore they don't quite add up]

OCD comorbidity

~20% with MDD and multiple anxiety disorders

Aetiology of OCD

No definite answer, possibly learned responses, possibly mutation in gene linked with OCD, possible early life experience and possibly brain structure influence.

Cognitive behavioural model for OCD

They start with normal intrusive thoughts,

but then they place specific meanings to it

and consequently increases the vigilance of those ideas.

cognitive model for OCD

An initial trigger leads to obsession, then a cycle of obsession, anxiety, compulsion （or possible avoidance), relief and obsession will go on.

Cognitive factors of OCD

Rating the intrusive thoughts as:

1. overly important

2. Overly threatening

3. requiring complete control etc

Body Dysmorphic Disorder

involves excessive preoccupation with perceived defects in physical appearance that leads to repeated behaviours or thoughts and is causing stress or dysfunction.

Course of BDD

Age of onset~17, usually diagnosed 10-15 years later when patient present to clinic for secondary complications.

Suicide rate: 25%

Course generally chronic and those whose age of onset before 18 is generally more severe.

Prevalence rate of BDD

Prevalence rate: 0.7-2.4% (higher in those people who undertake plastic surgery)

No gender difference, but male have preoccupation in genitals and females having comorbid eating disorders.

However: Muscle dysmorphobia only in males (almost)

Impact of BDD

Often repeated surgery (23%)

Dermatological treatment (45%)

A lot of make up

Cover up of perceived defect

Can be moderate to incapacitating (hospitalisation)

Cognitive process of BDD

Evaluate their own appearance worse than others would evaluate

Evaluate their own appearance worse than others evaluate their own

Believe appearance is linked with other values, overvalue attractiveness

Discomfort of mirror gazing

More likely to recall appearance related experiences

Hoarding disorder

Inability to discard items regardless of their value in the faith of saving them and consequently result in stress.

Prevalence rate of hoarding disorder

Estimated 2-6% adults in EU and US

Newly appear in DSM V

Conjecture is no gender difference

more common in older adults than younger adults (possibly because no one will tell them off anymore)

Cognitive factors of hoarding disorder

Control over possession

Some level of memory impairment

Attaching responsibility to possessions

Impact of hoarding disorder

Causing problems for fire brigades

A variation is animal hording (May result in accidental or unintentional neglect)

trichollomania

Can pull out of anywhere, not only from head

Can be due to stress

They may experience rituals like eating their hair

We don't know much above prevalence and gender difference

Can have physical consequences (e.g. inflammation)

They may not be even aware

Psychological consequences: Shame and distress but also effectively reduces unpleasant emotions.

Excoriation disorder

Skin picking, very similar to trichollomania

motivated by stimualtion of positive mood

General feature of OCD related disorders

They are grouped together because they all feature intrusive thoughts and repetitive bahvior, highly distressing but amendable to psychological treatments (CBT). But the individual need to be cooperative in changing the motivation.

General treatment for OCD related disorders

1. Realise the problem

2. Stop the behaviour

3. Find an alternative way to reduce anxiety/distress

Personality disorder

Long-standing, pervasive and inflexible patterns of behaviour and inner experience. Patterns influence at least two of cognition, emotion, relationships and impulse controls.

Characteristics include:

Functionally inflexible,

Rigidly apply behavioural strategies even when inappropriate

Typical ways of responding that damages the person will not learn from experience

Marked instability in the mood when under stress

clusters of personality disorders

A: Eccentric

B: Dramatic

C: Anxious

Used to be considered as axis 2 disorders, now no longer classified this way in the DSM.

Epidemiology of personality disorders

6.5% in Australia, 12% in western countries.

A: More prevalent in males

B: More prevalent in females

C: Generally equal

Diagnostic criteria for Personality Disorders

Enduring pattern of internal experience or behavior that deviates remarkably from the cultural expectations

Inflexible and pervasive across a broad range of areas

Stable and long duration, can be traced back to adolescences or early adulthood.

The 3 Ps: Pathological, Persistent, Pervasive

Issues with diagnosing personality disorders

How to establish prevalence over time

how to determine the age of onset

role of gender and cultural norms

Paranoid PD

Cluster A PD,

Characterised by a pattern of distrust that does not occur exclusively during schizophrenia or other psychotic disorders.

Prevalence rate 2.3%-4% but aetiology is largely unknown, except that it occurs more in people with schizophrenia, and that people tend to have deficit in self-esteem.

Schizoid PD

cluster A PD;

characterized by emotional detachment, disiniterest in close relationships, and indifference to praise or criticism; often uncooperative.

Does not occur exclusively during schizophrenia or other psychotic disorders.

prevalence rate: 2.2-4%

Aetiology is largely unknown, conjecture is that it is related to underpowered limbic system,

Schizotypal PD

Cluster A PD;

Characterised by a combination of social/interpersonal deficit and cognitive/perceptual distortion, and eccentric behaviours.

Does not occur exclusively during schizophrenia or other psychotic disorders.

1.5%-4.6% prevalence rate.

Aetiology: Seem to be linked with schizophrenia, can be viewed as a milder form. Thought to be caused by cognitive abnormalities and dopamine neurotransmitters.

Antisocial PD

Cluster B PD;

Persistent disregard and violation of the right of others. The individual should be at least 18 and show evidence of conduct disorder before 15.

Does not occur exclusively during schizophrenia or bipolar.

Community sample prevalence rate 3%-3.5%.

Aetiology: High levels of sensation seeking, strong genetic contribution, low serotonin level and linked with abusive and negligent parents.

Boarderline PD

Cluster B PD;

Instability of interpersonal relationships with marked impulsivity and chronic feeling of emptiness.

1.6-5.9% prevalence rate, mostly female. The age of onset is generally childhood yet diagnosis often given later.

Aetiologies include genetic contribution and neglectful and invalidating environment etc.

People with this disorder often meet the criteria for other mood disorders too, yet mood-stabaliser is not effective.

Histrionic PD

Cluster B PD;

Pervasive pattern of excessive emotionality and attention seeking.

More common in females

Little work is done regarding aetiology. Evidence suggests that genes play a role and a theoretical account is that it is related to parenting styles.

Narcissist PD

Cluster B PD;

Pervasive patterns of grandiosity, lack of empathy and envy. Their grandiosity is not aligned with their actual achievement.

More in males

Two accounts of aetiology:

1. Parenting influence

2. This PD has the highest genetic loading

Subtypes of narcissist PD

1. Grandiosity: Overt narcissism (characterised by a sense of entitlement and lack of care of others)

2. Vulnerability: Covert narcissism (the grandiosity is used to mask hypersensitivity)

Avoidant PD

Cluster C PD;

Social inhibition and feeling of inadequacy.

Culture can play a huge role.

Aetiology:

genetic and environmental influence, typical personality type is high N low E.

Dependent PD

Cluster C PD;

Pervasive and excessive need to be taken care of and requires others to make decisions (usually 1 person, and if the relationship ends, they will need to quickly establish another one)

Fear of rejection.

Aetiology: High N low E personality, speculation around overly protective attachment.

Obssessive-Compulsive PD

Cluster C PD;

preoccupation of orderliness, perfection, control at the expense of flexibility and efficiency.

Twice as likely in males

Aetiology surround perfectionism and a suppression of feelings to avoid disapproval from parental figures.

SCID-5-PD

Semi-structured clinical interview

Each question is tied to a diagnostic criterion

There is a screening quesitonaire

Can use modules independently

Does not require that much experience of the practitioner

present C,B,A in this order to make sure the least confronting questions go first.

Basic model of PD

Genetic disposition + subsequent stress lead to PD.

Cognitive model of PD

The maladaptive core belief is called a schema. Each PD is characterised by a different schema.