Week 21 - Psychopathology and Therapeutic Orientations

Five-factor model

Five broad domains or dimensions that are used to describe human personality. Domains are inclusive, nothing lies outside the categories

Five factor model: Neuroticism (emotional instability) vs Emotional stability

Fearful, apprehensive, angry, bitter, pessimistic, glum, timid, embarrassed, tempted, urgency, helpless, fragile

VS

relaxed, unconcerned, cool, even-tempered, optimistic, self-assured, glib,
shameless, controlled, restrained, clear-thinking, fearless, unflappable

Five factor model: Extraversion vs introversion

cordial, affectionate, attached, sociable, outgoing, dominant, forceful,
vigorous, energetic, active, reckless, daring, high-spirited, excitement-seeking

VS

cold, aloof, indifferent, withdrawn, isolated, unassuming, quiet, resigned, passive, lethargic, cautious, monotonous, dull, placid, anhedonic

Five factor model: Openness (unconventionality) vs closedness (conventionality)

dreamer, unrealistic, imaginative, aberrant, aesthetic, self-aware, eccentric, strange, odd, peculiar, creative, permissive, broad-minded

VS

practical, concrete, uninvolved, no aesthetic interest, constricted, unaware, alexythymic, routine, predictable, habitual, stubborn, pragmatic, rigid, traditional, inflexible, dogmatic

Five factor model: Agreeableness vs antagonism

gullible, naive, trusting, confiding, honest, sacrificial, giving, docile,
cooperative, meek, self-effacing, humble, soft, empathetic

VS

skeptical, cynical, suspicious, paranoid, cunning, manipulative, deceptive, stingy, selfish, greedy, exploitative, oppositional, combative, aggressive, confident, boastful, arrogant, tough, callous, ruthless

Five factor model: Conscientiousness vs disinhibition

perfectionistic, efficient, ordered, methodical, organized, rigid, reliable,
dependable, workaholic, ambitious, dogged, devoted, cautious, ruminative,
reflective

VS

lad, negligent, haphazard, disorganized, sloppy, casual, undependable, unethical, aimless, desultory, hedonistic, negligent, hasty, careless, rash

DSM-5’s 10 personality disorders

When personality traits result in significant distress, social impairment, and/or occupational impairment.

Includes antisocial, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid, and schizotypal.

Other specified personality disorder (OSPD) or Unspecified personality disorder (UPD)

This diagnosis is used when a clinician believes that a patient has a personality disorder but the traits that constitute this disorder are not well covered by one of the 10 existing diagnoses.

Avoidant personality disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation: combination of traits from introversion (e.g., socially withdrawn, passive, and cautious) and neuroticism (e.g., self-consciousness, apprehensiveness, anxiousness, and worrisome).

Dependent personality disorder

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation - for the most part a combination of traits of neuroticism (anxious, uncertain, pessimistic, and helpless) and maladaptive agreeableness (e.g., gullible, guileless, meek, subservient, and self-effacing).

Antisocial personality disorder

A pervasive pattern of disregard and violation of the rights of others. These behaviors may be aggressive or destructive and may involve breaking laws or rules, deceit or theft. Combination of traits from antagonism (e.g., dishonest, manipulative, exploitative, callous, and merciless) and low conscientiousness (e.g., irresponsible, immoral, lax, hedonistic, and rash).

Obsessive compulsive disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Largely a disorder of maladaptive conscientiousness, including such traits as workaholism, perfectionism, punctilious, ruminative, and dogged

Schizoid

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. Confined largely to traits of introversion (e.g., withdrawn, cold, isolated, placid, and anhedonic)

Borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity. Largely a disorder of neuroticism, including such traits as emotionally unstable, vulnerable, overwhelmed, rageful, depressive, and self-destructive

Histrionic personality disorder

A pervasive pattern of excessive emotionality and attention seeking. Largely a disorder of maladaptive extraversion, including such traits as attention-seeking, seductiveness, melodramatic emotionality, and strong attachment needs

Narcissistic personality disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Includes traits from neuroticism (e.g., reactive anger, reactive shame, and need for admiration), extraversion (e.g., exhibitionism and authoritativeness), antagonism (e.g., arrogance, entitlement, and lack of empathy), and conscientiousness (e.g., acclaim-seeking)

Schizotypal personality disorder

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as perceptual distortions and eccentricities of behavior.

Includes traits from neuroticism (e.g., social anxiousness and social discomfort), introversion (e.g., social withdrawal), unconventionality (e.g., odd, eccentric, peculiar, and aberrant ideas), and antagonism (e.g., suspiciousness).

Paranoid personality disorder

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.

Ego-syntonic personality disorders

Most people are largely comfortable with their selves, with their characteristic manner of behaving, feeling, and relating to others. As a result, people rarely seek treatment for their antisocial, narcissistic, histrionic, paranoid, and/or schizoid personality disorder. People typically lack insight into the maladaptivity of their personality.

Exceptions to ego-syntonic disorders

Borderline personality disorder, neuroticism, maybe avoidant personality disorder. People with neuroticism see life as one of severe pain and suffering, will seek treatment to alleviate emotional distress. People with avoidant personality may also seek treatment for their high levels of neuroticism (anxiousness and self-consciousness) and introversion (social isolation)

Prevalence of personality disorders within clinical settings

Well above 50%. Up to 60% of inpatients within some clinical settings are diagnosed with borderline personality disorder. Antisocial personality disorder in up to 50% of inmates. Estimated that 10% to 15% of the general population meets criteria for at least one of the 10 DSM-IV-TR personality disorders

Impact of personality disorder on the treatment of mental disorders

Typically inhibiting or impairing responsivity. Antisocial persons will tend to be irresponsible and negligent; borderline persons can form intensely manipulative attachments to their therapists; paranoid patients will be unduly suspicious and accusatory; narcissistic patients can be dismissive and denigrating; and dependent patients can become overly attached to and feel helpless without their therapists.

Dialectical behavior therapy and mentalization therapy

Form of cognitive-behavior therapy that draws on principles from Zen Buddhism, dialectical philosophy, and behavioral science. Four components: individual therapy, group skills training, telephone coaching, and a therapist consultation team, and will typically last a full year. Relatively expensive

Psychopathy

Synonymous with psychopathic personality, the term used by Cleckley (1941/1976), and adapted from the term psychopathic introduced by German psychiatrist Julius Koch (1888) to designate mental disorders presumed to be heritable.

Antisocial personality disorder (replaced Cleckley-oriented conception)

Counterpart diagnosis to psychopathy included in the third through fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2000). Defined by specific symptoms of behavioral deviancy in childhood (e.g., fighting, lying, stealing, truancy) continuing into adulthood (manifested as repeated rule-breaking, impulsiveness, irresponsibility, aggressiveness, etc.).

Psychopathy Checklist-Revised (PCL-R)

Comprises 20 items rated on basis of interview and file-record info. Recommends cutoff of 30/40 for diagnosis. High scores are correlated with impulsive and aggressive tendencies, low empathy, Machiavellianism, lack of social connectedness, and persistent violent offending. Similar to McCord² model

McCord² model for psychopathy

Described the condition in more generally pathologic terms, highlighting “guiltlessness” (lack of remorse) and “lovelessness” (lack of attachment capacity) as central defining features

Interpersonal affective factors (psychopathy)

Relates to indices of narcissism, low empathy, and proactive aggression, and to some extent adaptive tendencies such as high social assertiveness and low fear, distress, and depression

Antisocial deviance factor (psychopathy)

Associated mainly with maladaptive tendencies and behaviors, including impulsiveness, sensation seeking, alienation and mistrust, reactive aggression, early and persistent antisocial deviance, and substance-related problems.

Psychopathic Personality Inventory (PPI)

Developed to index personality dispositions within historic conceptions of psychopathy. Two distinguishable factors; fearless dominance and self-centered impulsivity, are uncorrelated

Fearless dominance (PPI factor)

Factor reflecting social potency, stress immunity, and fearlessness. Interpreted as capturing a more adaptive expression of dispositional fearlessness (i.e., boldness; see below) than the interpersonal-affective factor of the PCL-R

Self-centered impulsivity (SCI)

factor reflecting egocentricity, exploitativeness, hostile rebelliousness, and lack of planning. Scores are associated with multiple indicators of deviancy—including impulsivity and aggressiveness, child and adult antisocial behavior, substance abuse problems, heightened distress and dysphoria, and suicidal ideation.

Callous-unemotional traits

Importance of there psychopathic features in predicting severity and persistence of conduct problems. Features encompass low empathy, deficient remorse or guilt, shallow affect, and lack of concern about performance in school and other contexts

Antisocial Process Screening Device (APSD)

Includes 20 items. Taps two distinct factors, Callous-Unemotional (CU) traits factor (emotional insensitivity and disregard for others) and an Impulsive/Conduct Problems (I/CP) factor (impulsivity, behavioral deviancy, and inflated self-importance)

Scores on the APSD meaning

Children high on the I/CP factor alone show below-average intelligence, heightened emotional responsiveness to stressors, and angry (reactive) aggression, children high on both APSD factors show average or above-average intelligence, low reported levels of anxiety and nervousness, reduced reactivity to stressful events, and preference for activities entailing novelty and risk. They also learn less readily from punishment, are more aggressive (calculated and persists)

Triarchic model

Model formulated to reconcile alternative conceptions of psychopathy. Conceives of psychopathy as encompassing three symptomatic components: boldness, involving social efficacy, emotional resiliency, and venturesomeness; meanness, entailing lack of empathy/emotional-sensitivity and exploitative behavior toward others; and disinhibition, entailing deficient behavioral restraint and lack of control over urges/emotional reactions.

Disinhibition: Triarchic model

Tendencies toward impulsiveness, weak behavioral restraint, hostility and mistrust, and difficulties in regulating emotion

Meanness: Triarchic model

Entails deficient empathy, lack of affiliative capacity, contempt toward others, predatory exploitativeness, and empowerment through cruelty and destructiveness.

Boldness: triarchic model

Encompasses dominance, social assurance, emotional resiliency, and venturesomeness. Referents for this construct include the “mask” elements of Cleckley’s conception, Lykken’s low fear theory of psychopathy, the FD factor of the PPI

Triarchic Psychopathy Measure (TriPM)

58 items comprising 3 subscales corresponding to constructs of the model

two theories on causes of psychopathy

(1) theories emphasizing core deficits in emotional sensitivity or responsiveness, and (2) theories positing basic impairments in cognitive-attentional processing

Neurobiological correlations with psychopathy

Lack of normal enhancement of the startle blink reflex to abrupt noises occurring during viewing of aversive foreground stimuli, ie. won’t “jump” when startled by a noise in a dark alley. Reduced amplitude of brain potential response to intermittent target stimuli. Deficits in amygdala response to interpersonal distress cues

“Primary” type of criminal psychopathy

Bold-disinhibited, low anxiousness

“Secondary” type of criminal psychology

Aggressive-externalizing, disinhibited-mean, may have anxiousness

Psychoanalytic therapy

Earliest organized therapy for mental disorders (Freud). Stresses mental health disorders are rooted in unconscious conflicts and desires. Must address to resolve mental illness (childhood experiences). Long process

Freud’s structural model

Id (pleasure-driven unconscious urges), superego (semi-conscious, morals and societal judgement), ego (mediates between id and superego, partly conscious)

Psychodynamic therapy

Treatment applying psychoanalytic principles in a briefer, more individualized format.

Free association

In psychodynamic therapy, a process in which the patient reports all thoughts that come to mind without censorship, and these thoughts are interpreted by the therapist.

Dream analysis

Analyzing manifest (literal) content and latent (symbolic) content to understand meaning and subconscious

Transference

For example, if during therapy a patient begins to express unjustified anger toward the therapist. The patient may be displacing feelings for people in their life (e.g., anger toward a parent) onto the therapist

Countertransference

The therapist has to be aware of their own thoughts and emotions, as the therapist may displace their own emotions onto the patient.

Disadvantages of psychoanalytic therapy

Once only type available, now many more options. Not appropriate for some types of patients (ie. those with severe psychopathology or intellectual disability). Lack of empirical support for effectiveness.

Person-centered therapy (PCT) (Carl Rogers)

A therapeutic approach focused on creating a supportive environment for self-discovery, and belief is that mental health problems result from an inconsistency between patients’ behavior and their true personal identity.

Techniques in Person-centered tehrapy

Therapist takes a passive role (non-directive therapy), ask questions and not provide judgement or interpretation. Unconditional positive regard (an attitude of warmth, empathy and acceptance adopted by the therapist in order to foster feelings of inherent worth in the patient.)

Advantages and disadvantages of PCT)

Highly acceptable to patients (they appreciate the environment). But: findings about effectiveness are mixed - unspecific treatment factors

Cognitive behavioural therapy (CBT) (Aaron T. Beck and Albert Ellis)

A family of approaches with the goal of changing the thoughts and behaviors that influence psychopathology. Therapist identifies how a maladaptive thought leads to a maladaptive emotion

Automatic thought

Thoughts that occur spontaneously; often used to describe problematic thoughts that maintain mental disorders.

Schemas

A mental representation or set of beliefs about something. In CBT, three systems: beliefs about the self, beliefs about the world, and beliefs about the future

Techniques in CBT

Thoughts: reappraisal or cognitive restructuring (the process of identifying, evaluating, and changing maladaptive thoughts in psychotherapy.)

Behaviour: Work to develop healthy behavioural habits

Exposure therapy

A form of intervention in which the patient engages with a problematic (usually feared) situation without avoidance or escape.

Extinction learning

Neurobiological and cognitive process by which the patient “unlearns” the irrational fear. For example, arachnophobia treatment might begin with them looking at a cartoon of a spider, followed by looking at pictures of real spiders, and later, the patient handling a plastic spider.

Advantages and disadvantages of CBT

Usually brief (cost effective), intuitive treatment (patients understand), empirically effective (as effective as medication). But: patients need to put in work

Mindfulness

A process that reflects a nonjudgmental, yet attentive, mental state, therapy that focuses on one’s awareness of bodily sensations, thoughts, and the outside environment. Importantly: (1) self-regulation of attention, and (2) orientation toward the present moment

Mindfulness based therapy (MBT)

A form of psychotherapy grounded in mindfulness theory and practice, often involving meditation, yoga, body scan, and other features of mindfulness exercises.

Mindfulness-based stress reduction (MBSR)

Uses meditation, yoga, and attention to physical experiences to reduce stress. The hope is that reducing a person’s overall stress will allow that person to more objectively evaluate their thoughts

Mindfulness based cognitive therapy (MBCT)

Attention is focused on one’s thoughts and their associated emotions. For example, prevent relapses in depression by encouraging patients to evaluate their own thoughts objectively and without value judgment

Dialectical behaviour therapy (DBT)

A treatment often used for borderline personality disorder that incorporates both cognitive-behavioral and mindfulness elements.

Distress tolerance techniques

Ways to cope with maladaptive thoughts and emotions in the moment. For example, people who feel an urge to cut themselves may be taught to snap their arm with a rubber band instead

Dialectical worldview

A perspective in DBT that emphasizes the joint importance of change and acceptance. Rather than thinking of the world as “black and white,” or “only good and only bad,” it focuses on accepting that some things can have characteristics of both “good” and “bad.”

Acceptance and commitment therapy (ACT)

A therapeutic approach designed to foster nonjudgmental observation of one’s own mental processes, patients are taught to observe their thoughts from a detached perspective

Advantages and disadvantages of MBT

Advantages: acceptability and accessibility for patients. But efficacy is unknown

Cognitive bias modification (emerging new treatment)

Using exercises (e.g., computer games) to change problematic thinking habits. Ie. fro alcoholics, a computer game flashes beer and water images, participant is told to as fast as possible tap the healthy image. Hopes to target automatic subconscious thoughts.

CBT-enhancing pharmaceutical agents

Drugs used to improve the effects of therapeutic interventions. Based on research from animal experiments, researchers have found that certain drugs influence the biological processes known to be involved in learning, thus improves “learning” of CBT techniques

Comorbidity

Describes a state of having more than one psychological or physical disorder at a given time.

Integrative or eclectic psychotherapy

Refers to approaches combining multiple orientations (e.g., CBT with psychoanalytic elements).