Psychopathology Exam 3

Attention-deficit hyperactivity disorder

• exhibited as persistent age-inappropriate symptoms of inattention and/or hyperactivity and impulsivity that are sufficient to cause impairment in major life activities

  • age limit for the onset of symptoms—12 years

  • Characteristics behavior vary considerably from child to child

  • Different behavior patterns may have different causes

subtypes of ADHD

• DSM-5 recognizes types based on these primary symptoms

  • Predominantly inattentive presentation

  • Predominantly hyperactive/impulsive presentation

  • Combined presentation

inattentiveness

DSM-5 category criteria for ADHD

• often loses things necessary for daily activities

• difficulty in organizing tasks and daily activities

• often does not listen when spoken to directly

• avoidance of activities that demand sustained mental effort

• forgetfulness in activities of daily living

• often distracted by extraneous stimuli

• difficulty sustaining attention and often easily distracted

• difficulty in following instructions and failing to complete tasks

• failure to give attention to detail and making careless mistakes.

hyperactivity

DSM-5 category criteria for ADHD

• Often leaves seat in classroom or other settings in which seating is expected

• often talks excessively

• often has difficulty or engaging in leisure activities alone

• Is often “on the go” or acts as if “driven by a motor”

• Often runs about or climbs excessively in situations where it is inappropriate, restlessness

• Often fidgets with and or feet or squirms in seat

impulsivity

DSM-5 category criteria for ADHD

• Often blurts out answers before questions have been completed

• Often has difficulty waiting turns

• Often interrupts or intrudes on others

ADHD comorbidity

• Conduct problems and aggression

  • Up to 50% of children will have co-occurring aggression/conduct problems

  • ADHD and aggression portends significant persistence and poor outcomes

• Internalizing problems

  • 25-33% will have significant mood disturbance

  • Depression and anxiety most common, but also bipolar

  • Importnat because it changes treatment recommendations

health outcomes of ADHD

• Multifinality defines ADHD

  • Physical health problems: accident prone, greater healthcare expenditures, greater risk of getting into traffic accidents, risky sexual behavior, substance use problems, and more likely to smoke

  • Often have lower grades and scores on an achievement test than what their intelligence would show

  • Occupational instability and more job turnover

  • More likely to get divorced or be less well-like by their peers (social implications)

genetic influences of ADHD

• runs in families

  • 75% heritability

• specific gene studies

  • focus on dopamine regulation and serotonin system

• pregnancy, birth, and early development

  • Factors that compromise development of the nervous system before and after birth may be related to this.

  • Mother’s use of cigarettes, alcohol, or other drugs during pregnancy are associated with this disease

    • Contributing factors rather than a causal association

    • Compromised fetal development may create a “malleable” state that increases the influence of a negative environment

neurobiological factors for ADHD

• strong evidence for neuro-cognitive etiology and dysfunction

• Fronto-striatal circuitry (prefrontal cortex and basal ganglia)

  • Smaller and shows abnormal activity

  • Less blood flow

  • Physiologically less mature

• Selective deficiency in the availability of norepinephrine and serotonin

  • Helps identify candidate genes

executive functioning

• processes are evoked every day in emotional situations to and in the regulation of behavior, emotion, and attention

• involved in inhibitory control, working memory, and cognitive flexibility

impaired executive functioning

the impaired functioning correlates to a behavioral difficulty

• planning and prioritizing → difficulty organizing work

• Monitor and regulate action → find hard to sit still or be quiet

• Task initiation; Regulating effort → difficulty completing a task on time

• Focus, shift, and sustained attention → lose focus when trying to listen; easily distracted

• Working memory → forgetting to do a planned task; difficulty following sequential instructions

family context of ADHD

• Parent psychopathology

  • Maternal depression

  • Maternal ADHD

  • Paternal ASPD

  • Substance disorders and alcohol consumption

• Parent-child interaction

  • Less responsive, more negative/directive

  • Evident in preschool, school-age, and adolescent youth

ADHD treatment

• less than half of children receive treatment for this disorder

  • Of those who receive treatment, many discontinue prematurely

• the primary treatment approach combines

  • Stimulant medication

  • Parent management training

  • Educational intervention

ADHD medication

• Stimulants have been used to treat this disorder from teh 1930’s

  • Among the most effective stimulants are dextroamphetamine and methylphenidate

    • May help normalize frontostriatal structural abnormalities and functional connections

  • Effects are temporary and occur only while medication is taken; beneficial in the short term

    • Questions surround long-term benefits and later adjustment

behavioral interventions at home

• important for treating/addressing ADHD symptoms

  • Structure, Structure, Structure

    • Morning routine, after school, evening, bedtime

    • Chart behavior (daily report cards)

    • Token economy with incentives and consequences

      • Have child participate in selection process

      • hierarchical reinforcements (i.e. daily vs. weekly levels)

  • Clarity of communication

    • Ensure child’s attention: say child’s name, eye contact

    • Use command/directive, not a question

    • Specific and concrete

    • Developmentally appropriate

    • State consequences, follow through

educational intervention ADHD

• Teacher and child must set realistic goals and objectives

• Response-cost procedures are used to reduce disruptive or off-task behaviors

• Many strategies are basic good teaching methods

• School-based interventions for ADHD have received considerable support

Substance

any natural or synthesized product that has psychoactive effects—changes perceptions, thoughts, emotions, and behaviors

depressants

• alcohol, barbiturates, benzodiazepines, inhalants

• Affects several systems

• Target neurotransmitter: GABA- increases inhibitory effects, makes neural cells worse at firing

Stimulants

• Cocaine, amphetamines, nicotine, caffeine

• Neurotransmitter system: Stimulates CNS

• Target Neurotransmitter: Amphetamines enhance release of norepinephrine and dopamine, and block reuptake; Ecstasy affects serotonin pathways

Opioids

• heroin, morphine

• producfe euphoria followed by a tranquil state; in severe intoxication, can lead to unconsciousness, coma, and seizures; can cause withdrawal symptoms of emotional distress, severe nausea, sweating, diarrhea, and fever 

• Neurotransmitter system: Pleasure circuits, including nucleus accumbens and amygdala

• Target Neurotransmitter: Switch of GABAergic neurons allowing the excess flow of dopamine

hallucinogens

• includes PCP (phencyclidine)

  • Cannabis

• produce perceptual illusions and distortions even in small doses 

Substance intoxication

• DSM-5 definition

  • A set of behavioral and psychological changes that occur as a result of the physiological effect of a substance on the central nervous system and are significantly maladaptive

    • Disrupt social and family relationships

    • Cause occupational or financial problems

    • Place individual at significant risks for adverse effects

Substance intoxication

• According to the DSM-5, symptoms depend on:

  • Substance taken

  • How much is taken and when

  • Tolerance

  • Context

  • Expectations

Substance Use Disorder

• a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by more than or equal to 2 of 11 symptoms, occurring within a 12 month period

  • Categories:

    • Impaired Control

    • Social Impairment

    • Risky Use

    • Pharmacological Criteria

Impaired Control

• Category of Substance Use Disorder

1. Amount taken is often larger or over longer periods than intended

2. Craving, or a strong desire or urge to use substance

3. Persistent desire for drug or unsuccessful efforts to cut down or control use

4. Lots of time is spent in activites necessary to obtain, use, or recover from a substance’s effects

Two 6 Pack

• Mnemonic for Substance Abuse

  • T: Tolerance

  • W: Withdrawal

  • O: Occupational, social, or recreational activities given up

  • 6

  • P: Persistent desire for drug

  • A: Amount taken is often larger or over longer periods than intended

    • C:Continued use despite physical and psychological problems from the use

  • K: Keep using—great deal of time spent acquiring, using

Substance Withdrawal

• Experience of clinically significant distress or impairment in social, occupational, or other areas of functioning due to the cessation or reduction of substance use

• Symptoms rae typically opposite of those of intoxication

Social Impairment

Category for Substance Use Disorder

5. Recurrent substance use results in a failure to fulfill major role obligations at work, school, or home

6. Continued substance use despite having social or interpersonal problems caused (or exacerbated by) the effects of substance

7. Important social, occupational, or recreational activities are given up or reduced because of substance use

Risky Use

Category for Substance Use Disorder

8. Recurrent substance use in situations in which it is physically hazardous

9. Substance use is continued despite knowledge of a physical or psychological problem that is likely to have been caused or exacerbated by substance

Pharmacological Criteria

Criteria for Substance Use Disorder (Category)

10. Tolerance

    1. Experiencing diminished effects from the same dose of a substance

    2. Needing more of substance to achieve intoxication

11. Withdrawal or use to avoid withdrawal

Diagnosing SUD

• Each disorder is broken down by substance type (i.e. alcohol use disorder, cannabis use disorder, etc.)

• “Hybrid” approach (categorical-dimensional)

• Severity scale

  • 2-3 Symptoms: mild disorder

  • 4-5 symptoms: moderate disorder

  • 6+ symptoms: severe disorder

depressant affects

• Intoxication

  • Disinhibited behavior

  • sleepiness

  • Slurred Speech

  • Lack of Coordination

  • Impaired attention/memory

• Withdrawal

  • Autonomic hyperactivity

  • Insomnia

  • Anxiety

Stimulant Affects

• Intoxication

  • Rapid heartrate

  • Psychomotor agitation

  • Dilation of pupils

• Withdrawal

  • Dysphoric mood

  • Insomnia

  • Fatigue

Opioid Affect

• Intoxication

  • Euphoria followed by apathy/dysphoria

  • Constriction of pupils

  • Slurred speech

  • Attention/memory problems

• Withdrawal

  • Nausea vomiting

  • Muscle Aches

  • Sweating

  • Diarrhea

Hallucinogen Affects

• Intoxication

  • Perceptual changes while awake

  • Impaired judgement

  • Intensification of senses

• No withdrawal symptoms

Cannabis Affects

• Intoxication

  • Impaired Motor function

  • Euphoria

  • Anxiety; sense of slower time

  • Red eyes

• Withdrawal

  • Irritability

  • Sleep difficulty

  • Depressed moods

Substance Use Prevalence Rate

• Alcohol Dependence or Abuse

  • 12-17 years; 4.17%

  • 18-25 years: 15.03%

  • 26+ years: 5.67%

• Illicit Drug Dependence

  • 12-17 years; 4.69%

  • 18-25 years: 7.68%

  • 26+ years: 1.55%

Consequence of SUD

• Health Issues

• Societal Health Care Costs

• Social Consequences

• Legal Problems

biological factors for SUD

• Genetics

  • Not just one gene

  • Not just genes

• Reward Sensitivity:

  • Higher Sensitivity —> Greater Risk

Biological Factors for SUD

• The Brain and the “Pleasure/Reward Pathway”

  • Ventral Tegmental Area → Nucleus Accumbens → Frontal Cortex

  • Projects further to the prefrontal cortex, amygdala, and hippocampus

  • Dopamine is major neurotransmitter

    • Drug flood the circuit with Dopamine → Euphoric Effects

    • Brain is wired to repeat behaviors that cause pleasure/reward

Personality Theory SUD

• Behavioral under control

  • Impulsivity

  • Sensation seeking

  • Anti-social behavior

  • Brain abnormalities contribute to ADHD, CD, and SUDS

SUD ripple effects

• Individual

  • Health consequences, brain development

• Family

  • Divorce, relationship problems

• Community

  • Jail time, legal issues

SUD classical conditioning

• learning by association

• Ex: coming back to something that releases dopamine and pleasure (certain places that illicit feelings of drinking and craving)

SUD operant conditioning

• learning by reinforcement and punishments

• Ex:

  • positive reinforcement (drinking and feeling more attention from your friends

  • negative reinforcement (drinking to take the pain away or taking away withdrawal symptoms)

SUD social learning

• learning by observing others

• Ex: as a child, viewing your parent shaving a substance abuse relationship with alcohol

cognitive theory

• motivation model of substance use

  • Positive expectations about using

• Lack of coping skills

• Use when upset

• Ex: “when the laundry is piling up, there are dishes in the sink, kids are fighting, and dinner isnt made but im pouring myself a glass of wine”

SUD Sociocultural factors

• Cultural/religious Norms

• Gender differences

• Trauma

• Economic Factors

• Peer Influences

• Family Factors

• Consider Context

SUD gender differences

• Study showed that women had stronger cravings when exposed to something stressful; men had similar levels of craving both in neutral and stressful environments

SUD integrative model

• Exposure or access to a drug is necessary, but not sufficient

• Drug use depends on:

  • Social and cultural expectations

  • Positive and negative reinforcement

  • Genetic predisposition and biological factors

  • Psychosocial stressors

Treatment for SUD

• Available treatment are effective in helping about 1/3 of users remain abstinent for up to 1 year

  • Detoxification

  • Behavioral Treatments

  • Cognitive Treatments

  • Relapse Prevention

SUD behavioral treatment

• Treatment is effective in helping 1/3 of users remain abstinent for up to 1 year

• Involves

  • avoidance of the stimulus

  • Skills training

  • Aversive conditioning (e.g. Antabuse—-medication that is a deterrent to drinking)

  • Contingency management

alcohol biological treatment

• Antianxiety drugs (i.e. benzodiazepine)

• Antagonist Drugs- Block or change the effects of the addictive drug, reducing the desire for it

  • Naltrexone

  • Antabuse

nicotine biological treatment

• Nicotine replacement therapy

• Buproprion (Wellbutrin)

• Chantix

Opioid biological treatment

• Naltrexone

• Methadone maintenance programs

• Suboxone (typically combined with naloxone/narcan)

SUD cognitive treatment

• Treatment is effective in helping about 1/3 of users remain abstinent for up to 1 year

• Involves

  • Addresses faulty expectations or beliefs

SUD not ready

• if not ready for treatment

  • Interventions

  • Motivational Interviewing

    • OARS (Open Questions, Affirmations, Reflections, Summarizing)

SUDS completed treatment

• When feeling like treatment is over

  • Relapse prevention

    • Identify antecedents and consequences of use

    • Develop alternative cognitive and behavioral skills to reduce risk of future use

SUD best treatment

• prevention, prevention, prevention

• What doesnt work

  • D.A.R.E (may be iatrogenic)

  • Scared Straight

• What does work

  • Harm Reduction Model

  • Keepin it REAL ( R-refuse, E- explain, A- Avoid, L-Leave)

Eating Disorder

• Severe disruptions in eating behavior

  • Anorexia nervosa

  • Bulimia nervosa

  • Binge eating disorder

4 D’s of abnormality

• Dysfunction

• Distress

• Deviance

• Dangerousness

Anorexia Nervosa

1. Refusal to maintain minimally normal body weight

2. Intense fear of gaining weight or becoming fat, or persistent behavior interferes with weight gain, even though at a significantly low weight

3. Significant disturbance in perception and experiences of body weight or shape, undue influence of weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of low body weight

• DSM-5 Subtypes

  • Restricting Type: individual loses weight through diet, fasting, or excessive exercise

  • Binge-eating/purging Type: individual has engaged in binge eating or purging in the past three months

physical changes in anorexia

• Low blood pressure, heart rate decrease, kidney, and gastrointestinal problems

• Loss of bone mass

• Brittle nails, dry skin, and/or hair loss

• Lanugo (soft, downy body hair)

• Depletion of potassium and sodium

  • Can cause tiredness, weakness, and death

Bulimia Nervosa

1. Recurrent episodes of binge eating

   1. Eating in a discrete period of time any amount of food that is definitely larger than what most people would eat during a similar period of time and under similar circumstances

   2. A sense of lack of control over eating during the episode

2. Recurrent inappropriate compensatory behavior in order to prevent weight gain

• Both 1 and 2 occur at least once a week on average for 3 months

• Self-evaluation is unduly influenced by body shape or weight

• Does not occur during an episode of anorexia nervosa

Physical Changes in Bulimia

• Menstrual irregularities

• Potassium depletion

• Laxative use depletes electrolytes which can cause cardiac irregularities

• Loss of dental enamel from vomiting

  • Teeth appear “jagged”

Binge Eating Disorder

1. Recurrent episodes of binge eating

2. Binge eating episodes are associated with ≥ 3 of the following:

   1. Eating much more rapidly than normal

   2. Eating until feeling uncomfortably full

   3. Eating large amounts of food when not feeling physically hungry

   4. Eating alone because of feeling embarrassed by how much one is eating

   5. Feeling disgusted with oneself, depressed, or very guilty afterward

3. Marked distress regarding binge eating

4. Binge eating occurs once a week on average for at least 3 months

5. binge eating is not associated with recurrent use of inappropriate compensatory behavior and does not occur in the course of AN or BN

Eating disorder genetic factors

• genes alone do not predict who will develop an eating disorder

• Genes carry general risk for eating disorders rather than a specific risk for one type of disorder

  • Interactions with puberty contribute to onset of eating disorders in girls, but not in boys

Reward Network

• composed of striatum, ventral tegmental area, nucleus accumbens, ventromedial PFC/orbitofrontal PFC

  • Part of greater decision making network

  • Mixed evidence of abnormalities in Anorexia

  • Hyperesponsivity of the network in Bulimia

Cognitive control network

• composed of parietal cortex, dorsal anteiror cingulate cortex, striatum, dorsolateral PFC (being able to delay gratification—-i.e. marshmallow experiment)

• Found to be more active in Anorexia

• Less active in bulimia

Eating disorder neurobiological factors

• these disorders are not choices

• Low levels of endogenous opioids

  • Substances that reduce pain, enhance mood, and suppress appetite

  • Not known if alterations are cause or consequences of disordered eating

    • Released during starvation

      • may reinforce restricted eating of anorexia

    • Low levels of opioids in bulimia promote craving

      • reinforces binging

• Serotonin and dopamine may also play a role

  • Appetite and mood (serotonin); reward and impulsivity (dopamine)

Eating Disorder psychological factors

• body dissatisfaction

• binge purge cycle

Body dissatisfaction

• part of eating disorder psychological factors

• 1985 study done with men and women to rate their ideal body type, what they consider attractive, what the opposite sex would consider attractive, and where they currently are

  • Discrepancies of what it is to be “ideal” 

  • These gaps have only continued to widen 

binge purge cycle

• part of eating disorder psychological factors

• → Strict dieting → tension and cravings → binge eating → purging to avoid weight gain → shame and disgust →

• Extreme dieting is very common in North American culture

• Cycle of Negative Reinforcement

Eating disorder sociocultural factors

• family characteristics

• societal idealization on thinness

• Social objectification of women leads to self-objectivication

• Unrealistic media portrayals fuel body dissatisfaction

• Social media and technology

family characteristics

• part of the sociocultural aspect to eating disorders

• Disturbed family relationships

• May result from, not be a cause of, eating disorders

• Not specific to eating disorders

  • Also found in families of individuals with other types of psychopathology

  • Distinguished by parent belief that child should lose more weight, criticize their child’s weight, and are themselves more likely to show disordered eating patterns

social media and technology

• part of the sociocultural aspect to eating disorders

• What matters most?

  • Time spent on social media sites

  • For adolescents: appearance-related features, posting photographs, etc.

  • Use of diet and exercise-monitoring apps and devices

CBT eating disorder

• Empirically supported

• the gold standard of psychotherapy for all eating disorders

interpersonal therapy eating disorder

• Empirically supported for bulimia and binge eating disorder

• Efficacious treatment alternative to CBT

• less evidence supports effectiveness for individuals with AN

family-based treatment eating disorder

• empirically supported for anorexia and bulimia

• Most well-supported treatment for adolescents with AN and BN

• Often coupled with CBT for adolescents

eating disorder treatment

• For adolescents

  • Front-line treatment is family therapy

  • CBT most effective when combined with family treatment

• For adults

  • Generally, CBT or combination of CBT with medication to reduce frequency of binge eating: antidepressants for BN; and in some countries Vyvyanse for BED

  • CBT is most effective when combined with family support

eating disorder biological therapies

• Selective serotonin reuptake inhibitors

  • Reduce binge-eating and purging behaviors

  • fail to restore the individual to normal eating habits

  • not shown to effect symptoms of anorexia but may be helpful to prevent relapse following weight restoration

• antipsychotics (e.g. olanzapine)

  • lead to increases in weight in people with anorexia nervosa but no effect on mood or anxiety

• Antiepileptic medications and obesity medications

neurodevelopmental disorders

behavioral disorders with onset during childhood known or presumed to result at least in part from disruption of brain development 

neurocognitive disorders

behavioral disorders known or presumed to result from disruptions of brain structure and functioning

specific learning disorder

disrupted or delayed development in a specific domain of cognition, such as reading 

major neurocognitive disorder

a brain disorder characterized by a deteriorating course of deficits in neurocognitive functioning (e.g., memory, attention) that interferes significantly with independent living 

executive function

functions of the brain that involve the ability to sustain concentration; use abstract reasoning and concept formation; anticipate, plan, and program; initiate purposeful behavior; self-monitor; and shift from maladaptive patterns of behavior to more adaptive ones 

substance abuse disorders

disorders characterized by inability to use a substance in moderation and/or the intentional use of a substance to change one’s thoughts, feelings, and/or behaviors, leading to impairment in work, academic, personal, or social endeavors 

substance intoxication

experience of significantly maladaptive behavioral and psychological symptoms due to the effect of a substance on the central nervous system that develops during or shortly after use of the substance 

tolerance

condition of experiencing less and less effect from the same dose of a substance 

substance withdrawal

 experience of clinically significant distress in social, occupational, or other areas of functioning due to the cessation or reduction of substance use 

depressants - drugs that slow the nervous system 

alcohol use disorder

a problematic pattern of alcohol use that creates significant impairment or distress that is manifested in a variety of behaviors such as consuming large amounts of alcohol, persistent desire and failed attempts to reduce the quantity of alcohol consumed, strong desire to use alcohol (craving), tolerance, and withdrawal 

benzodiazepines

drugs that reduce anxiety and insomnia

barbituates

drugs used to treat anxiety and insomnia that work by suppressing the central nervous system and decreasing the activity level of certain neurons

cocaine

central nervous system stimulant that causes a rush of positive feelings initially but that can lead to impulsiveness, agitation, and anxiety and can cause withdrawal symptoms of exhaustion and depression

amphetamines

stimulant drugs that can produce symptoms of euphoria, self-confidence, alertness, agitation, paranoia, perceptual illusions, and depression 

nicotine

• alkaloid found in tobacco; operates on both the central and peripheral nervous systems, resulting in the release of biochemicals, including dopamine, norepinephrine, serotonin, and the endogenous opioids 

• stimulant

phencyclidine

• type of hallucinogen

• substance that produces euphoria, slowed reaction times, and involuntary movements at low doses; disorganized thinking, feelings of unreality, and hostility at intermediate doses; and amnesia, analgesia, respiratory problems, and changes in body temperature at high doses

inhalants

• type of depressant

• solvents, such as gasoline, glue, or paint thinner, that one inhales to produce a high and that can cause permanent central nervous system damage as well as liver and kidney disease

methadone

opioid that is less potent and longer-lasting than heroin; taken by heroin users to decrease their cravings and help them cope with negative withdrawal symptoms 

motivational interviewing

intervention for sufferers of substance use disorders to elicit and solidify individuals’ motivation and commitment to changing their substance use; rather than confronting the user, this technique adopts an empathic interaction style, drawing out the user’s own statements of desire, ability, reasons, need, and, ultimately, commitment to change 

abstinence violation effect

what happens when a person attempting to abstain from alcohol use ingests alcohol and then endures conflict and guilt by making an internal attribution to explain why he or she drank, thereby making him or her more likely to continue drinking in order to cope with the self-blame and guilt