E1 - Theories and Treatment Slide

Diathesis

experience a relatively distal (distant) factor that does not cause a disorder, but makes someone vulnerable to developing pathology in the future. Can be biological, psychological, or sociocultural.

Think about this as the thickness of ice (more severe the factor [severe neglect], the thinner the ice becomes)

Stress

relatively proximal (recent) factor that exceeds the individuals’ coping abilities. Interacts with diathesis to produce the disorder.

Think of this as the heaviness of your step. If the ice is thick enough, it can withstand your stomping

diathesis-stress model

look at this model in the textbook!

Be able to apply basic version of the diathesis-stress model to a case vignette

Diathesis (Vulnerability)- Stress Model

vulnerability (biological/social/psychological factor) + stress (biological/social/psychological trigger) = Disorder

protective factors

protective factors can offset the effect of some risk factors (presence of warm, supporting primary relationships). Think about an extra coating of ice or giving you better equipment

Gene x Environment Interaction

the people with two longer alleles the chance of developing depression remains the same, despite the type of maltreatment they receive, if any

Structural (biological)

abnormalities in the structure of the brain contribute to psychiatric difficulties. Can result from injury and from diseases that cause deterioration

biochemical (biological)

imbalances in the neurotransmitters or hormones, or poor functioning of receptors, contribute to psychiatric difficulties. Too much or little of a particular neurotransmitter can increase vulnerability for psychiatric difficulties

antagonists/blockers

decrease neurotransmitter activity. Schizophrenia is associated with high levels of dopamine; drugs block dopamine receptors

agonists

increase neurotransmitter activity. Increasing enzymes that make neurotransmitter + preventing re-uptake (SSRIs)

genetic (biological)

gene abnormalities contribute to psychiatric difficulties. Genes contribute to psychiatric presentation. Most often, genes account for less than 50% of the risk for psychopathology

Drug Therapies

antidepressant drugs - reduce symptoms of depression and anxiety; SSRIs slow serotonin reuptake

antipsychotic drugs - reduce symptoms of psychosis; most reduce levels of dopamine

mood stabilizers - reduce symptoms of mania

antianxiety drugs - reduce symptoms of anxiety in short-term; depress central nervous system (CNS) activity; can be addictive

Electroconvulsive Therapy (ECT)

series of treatment (~two or three times a week for an average of 10 sessions) in which a brain seizure is induced with electrical current. Promotes changes in how brain cells communicate with each other at synapses

Transcranial Magnetic Simulation (TMS)

Repeated, high-intensity magnetic pulses focused on specific brain structures (e.g., left prefrontal cortex in depressed patients). Promotes long-term changes in neurotransmission

Deep Brain Stimulation (DBS)

Implant a battery operated neurotransmitter (similar to a pacemaker), which delivers electrical stimulation to targeted areas deep in the brain via implanted lead. Stimulates focal regions of the brain with electric currents

psychoanalysis

Freud was supposedly ineffective at hypnosis, so he developed a new approached - patients lied down on the couch in his office, closed their eyes, and said ‘whatever came to their mind’ in relation to their symptoms

He argues that this was because unconscious material (i.e. repressed content) needed to be brought to conscious awareness

Following the breadcrumbs (repetitions [repeated patterns of dysfunction in relationships]) to the repressed memory was the crux of early analysis because making the unconscious conscious would (theoretically) relieve symptoms tied to repressed material

Drive Theory

everyone is driven by libidinal pressures (i.e., seeking pleasure and gratification), and the drive changes based on developmental stage

oral stage (birth to ~18 months) - focus is on feeding (and seeking pleasure from nourishment)

anal (1.5-3 years old) - pleasure comes from bowel control and the achievement of independence during toilet training

structural theory

three structures within the mind (more nuanced than conscious vs. unconscious)

id

primary motivational system and contains the drives. Sexual & aggressive impulses - pleasure principle

ego

helps mediate the “wants” of the id and the realities of the world. Wants to satisfy wants of id. Strives to form an integrated and coherent whole being. reality principle

superego

contains the internalization of important relationships and social or moral “shoulds.” Freud would describe this as similar to a conscious. Moral principle

Intrapyshic conflict

would emerge if the ego could not satisfactorily restrain the id or manage the demands of the superego

defense mechanism

when internal experiences are considered too threatening, the psyche creates a ‘work around’ that allows you to keep functioning

defense mechanisms

denial - refuse to acknowledge some aspect of objective reality or subjective experience that is apparent to others

projection - falsely attributes own unacceptable feelings or impulses to another

reaction formation - substitutes behavior, thoughts, or feelings that are the opposite of unacceptable ones

regression - reverting back to a prior stage of development in response to heightened stress

sublimation - socially unacceptable impulses are transformed into socially acceptable actions or behaviors (often considered the most adaptive defense mechanism)

Object Relations Theory

emphasized that early experiences with caregivers create internalized mental representations (or “internal objects”) that influence how individuals perceive and interact with others throughout life

psychoanalysis

the analyst aims to create a therapeutic environment in which the patient can explore their unconscious. By understanding their defenses, internalized objects, and unresolved conflicts, patients can respond more flexibly to stressors and make more ‘conscious’ decisions regarding relationships and behavior changes (rather than continually re-enacting historical patterns)

free association

patients are encouraged to say whatever comes to mind without filtering or censoring their thoughts. Therapists listen for patterns, contradictions, and affect-laden topics

dream analysis

analysts differentiate manifest and latent dream content. They help patients explore how patterns in latent content relates to unconscious materials

resistance

analysts examine patients’ resistance to topics (or therapy more broadly). This differs from a defense mechanism because it reflects what is happening within the therapist’s office

transference

analysts examine how patients “transfer” and enact unresolved dynamics (often with caregivers) onto the therapist. This highlights how the patient repeats relational dynamics with others in their life

countertransference

analysts examine how their reactions to the patient reflect (a) their own historical dynamics and/or (b) how others may experience them

Psychoanalytic and psychodynamic theorists

uncover the origins of patients symptoms

psychoanalytic model

criticisms: mental events that occur in the unconscious stage can be vague and difficult to define and measure

If clinicians do not know what is in the unconscious, how can they be confident that their interpretations of hidden material are accurate? Would another clinician come to the same conclusion?

Behavioral theory

using conditioning principles, a new wave of psychologists proposed a framework for understanding how fears develop and why they persist over time

Classical Conditioning

Example: A neutral stimulus (airplane) becomes paired with a non-neutral (or unconditioned) stimulus (severe turbulence) leading to respond the same to both over time (fear or panic)

avoidance & safety behaviors

prevents us from learning that the likelihood of the feared outcome is low - doesn’t have the chance to confront the behavior & learn otherwise

Negative reinforcement

escape and avoidance behaviors TAKE AWAY distress and increase the likelihood that the individual will rely upon those behaviors in a similar situation

operant conditioning

rewarding/punishing a response until the individual learns to repeat or decrease the behavior in anticipation or desirable or undesirable consequence

reinforcement = increase likelihood of behavior

positive vs. negative = adding (positive) vs. removing (aversive)

positive reinforcement

increase likelihood of behavior being performed by adding something positive or desirable

negative reinforcement

increase likelihood of behavior being performed by removing something negative or undesirable

*most likely operant conditioning to maintain negative behavior

Positive punishment

decreases likelihood of behavior by adding something aversive

negative punishment

decreases likelihood of behavior removing something positive

punishment

punishment = decreases likelihood of behavior

positive/negative = adding (aversive) or removing (positive)

in vivo exposure

confronting feared stimuli in the environment to challenge the exaggerated likelihood of feared outcome

imaginal exposure

confronting feared mental stimuli (e.g., thoughts, images, impulses, worries, and memories) to (a) improve tolerance for uncomfortable mental events, and (b) challenge beliefs regarding the dangerousness of unwanted thoughts

interoceptive exposure

confronting feared bodily sensations (increased heart rate, dizziness, tingling in fingers, nausea) to challenge mistaken beliefs regarding their meaning/dangerousness and to develop greater confidence in their ability to tolerate anxious arousal

conducting exposure

design a hierarchy (ladder/thermometer) of fears using distress. Begin with moderately distressing situations and work towards confronting highest item on the hierarchy. Use modeling. Go above and beyond “typical behaviors.” Repeat exposure in session and in multiple contexts

why exposure works

repeatedly approaching a fear-provoking situation (ordering at a restaurant) in and outside of session will likely lead to habituation (person feels less anxiety after repeated approach-behaviors). If this occurs, than the negative association between the situation and fear is weakened

Inhibitory learning, offers an alternative explanation for how exposures work AND can reduce spontaneous recovery (improve learning). The clinician needs to design exposures to increases the accessibility of adaptive (or non-threatening) associations

homework for exposure therapy

homework is essential to effective exposure therapy. By practicing exposures outside of session, the patient generalizes learning outside of the therapy office. Quality over quantity

Criticisms of behavior therapy

ignores cognitive processes - important to note that ‘inhibitory learning’ and the focus on violating cognitive expectancies (likelihood of feared event occuring)

ignores the complexity of the human experience - many argued that classical exposure therapy focused too narrowly on symptom reduction and neglected deeper existential and relational aspects of distress

Ethical concerns (Olatunji and colleagues (2009))

attrition rates, symptom exacerbation, patient preferences, and litigation & ethical complaints detected toward therapists

humanistic theories

all humans strive to grow, fulfill their potential for good, and to self-actualize (which can only occur once basic needs have been met)

Client-centered therapy, and argued for using unconditional positive regard with patients to facilitate their self-acceptance and improve their self-worth

Cognitive Theory

dysfunctional interpretations of oneself, others, and the world (automatic thoughts) lead to negative emotions and maladaptive behaviors)

thoughts about self: receives a B on an exam, interprets this as: ‘I can’t do anything right’

thoughts about others: a friend shares your secret with other, interprets this as ‘I can’t trust my friends’

thoughts about the world: reading about war in the news, interprets this as, ‘It’s too dangerous to be out in the world’

cognitive theory

early life experiences (usually in childhood) lead to the development of core beliefs. These beliefs are absolutistic (in that there is no middle ground & black & white)

Core beliefs tend to live outside of one’s awareness. Therefore, when everyday events ‘ping’ the content area of one’s core beliefs, they experience theoretically-consistent automatic thoughts

core beliefs block new information

core beliefs filter and distort information so that disconfirming evidence is ignored (i.e attentional bias)

cognitive therapy targets

1) increase awareness of ATs and their impact on subsequent emotions and behaviors

2) teach patients how to challenge ATs (called cognitive restructuring) in order to reduce a) the intensity of negative emotions and b) frequency and duration of maladaptive behaviors

3) after achieving symptom reduction via cognitive restructuring, similar strategies are applied to challenge the deeply held core beliefs

cognitive restructuring techniques

define and describe it

explore the gray area in between

question the evidence

consider the perspective of others

examine advantages and disadvantages

See basic CBT model diagram

‘third wave’ therapies

the next wave of psychotherapy (deemed ‘third wave’ shifted the focus away from trying to control one’s thoughts (or other inner experiences) and instead aimed to change one’s RELATIONSHIP with them

These interventions emphasize acceptance (rather than fighting/avoiding unwanted thoughts or emotions; i.e. experiential avoidance) and values-based living

Acceptance and Commitment Therapy (ACT)

accept uncomfortable inner experiences - in order to break experiential avoidance, patients are encouraged to willingly feel and accept uncomfortable internal experiences without fighting (quicksand metaphors)

Commit - to acting in line with one’s values (e.g, connected; adventurous)

there is minimal focus on cognition, as these clinicians argue that trying to change cognitions ‘entangles you’ with unproductive information

Family Systems

family is a complex system that maintains the status quo (homeostasis). Therefore, the roots of disorder are within the family, not the individual

may be more applicable to treatment of children isnce they still living within the family unit

attempt to break maladaptive relational patterns between family members through improved communication and perspective-taking

common therapeutic factors

therapeutic elements that are considered universally beneficial and appear across theoretical orientations

positive therapeutic alliance, therapist provides emotional support and empathy, patient possesses hope and positive expectations, therapist provides an explanation for problems and a theoretically-consistent treatment for them, patient experiences therapy as a safe place