Intro to Psychopathology - Final Exam

Sex (Week 11)

Physical characteristics considered masculine or feminine (breasts, testicles, tec.)

Gender (Week 11)

Degree to which one identifies with masculinity and femininity\

Depends to one’s culture

Sexual Intercourse (Week 11)

Physical act of sexuality for purpose of pleasure and/or reproduction

Gender Dysphoria (Week 11)

Dissatisfaction or discomfort with one’s secondary sex characteristics (e.g. chest hair, vagina) because if a mismatch between them and one’s gender identity

Ex: Individual who is male at birth, but female in identity

Gender Dysphoria: Common therapeutic treatments (Week 11)

Gender affirmation surgery: surgical changes to the body (e.g. to enlarge breasts of a trans woman) to improve self-comfort

Hormone replacement therapy: medication to improve self-comfort with body (e.g. a trans man taking testosterone to stimulate beard growth)

Ex: “The Rock” - cisman got a breast reduction for his appearance

Gender Dysphoria: Commonly occurs among (Week 11)

Trans individuals

Agender individuals

Children who begin puberty early

Girls ages ~8-14

Gender Dysphoria Diagnosis Controversy (Week 11)

There is controversy about diagnosing trans individuals with gender dysphoria

Arguments in Favor:

• Diagnosis allows trans Americans to use insurance to cover costs of gender confirmation

• Many trans people do feel real anxiety and discomfort with bodies

Arguments Against:

• Over-emphasizes bodies as source of gender rather than gender identity

• Pathologizes trans identity (being abnormal)

• Some women (trans and cis) are fine with having beards

Trans Identity (Week 11)

Identity associated with having a gender different than the one assigned at birth

Trans Identity Risks (Week 11)

Trans identity are at increased risk for

• Depression and anxiety

• Most forms of mental illness

• Self-injury

Reflects the impact of discrimination

Trans Discrimination (Week 11)

Impact of discrimination on physical health of Black Americans?

• Racism → higher risk of heart attacks

• Lower accuracy in diagnosis, less access to pain ?

• Being mistaken for member of privileged group (“Passing’) is a protective factor

Gender Dysphoria Diagnosis (Week 11)

Benefit of money for gender affirmation, BUT stigma of mental illness

Potentially split out on basis of trans vs. cis clients

Name change? Shift focuses onto discrimination?

Sexual Dysfunctions (Week 11)

Cluster of disorders around

• Not being able to have as much sexual intercourse as client wants

  • and/or

• Distress over lack of interest in sexual intercourse or lack of sexual attraction

Asexuality (not part of sexual dysfunctions) (Week 11)

Sexual orientation associated with little or no interest in romance and/or intercourse

Ace Umbrella:

• Demisexual

• Aromantic

• Asexual

Sexual Dysfunction Causes - Taboos (Week 11)

Something you shouldn’t talk about

Social context prohibits or dislikes the concept

Controversial subject

• Ex: nudity

If sexuality taboo, motivation to hide it internalizing idea that sex = gross

Barrier to open

Conversation between partners

Embarrassment and Shame: Sexual Dysfunction Causes (Week 11)

Women especially taught sexual desire is disgusting or harmful

Can be a barrier to seeking or enjoying intercourse

Medical Problems: Sexual Dysfunction Causes (Week 11)

Many conditions cause difficulty with sexuality

• ex: low blood pressure, depression, endometriosis

Performance Anxiety: Sexual Dysfunction Causes (Week 11)

When aware of being watched, most people become less skilled at complex tasks

Spectator Role: Sexual Dysfunction Causes (Week 11)

Greater concern with one’s than one’s or one’s partner’s enjoyment

Sexual Dysfunction Diagnosis (Week 11)

Arguments in Favor:

• Lack of sexual intercourse is considered deviant in U.S.

• Lack of romance is potential source of dysfunction

• Many people experience distress over sexuality

Arguments Against:

• Sexualities are already over-medicalized, esp. if queer

• Lack of romance/sex shouldn’t be deviant or dysfunctional

• Humans don’t need sexual intercourse to be happy or healthy

Overall Thoughts:

• Concern of client, not something to be pathologized in own right

• Should only be diagnosed if source of severe distress

• Differing from partner to partner

Sex Therapy (Week 11)

Educating clients (usually a couple) about how to have intercourse in relaxed and mutually pleasurable way

Providing mindfulness training, ways to reduce stress, ways to focus on pleasure

Increasing healthy communication about intercourse

Resolving physical and medical problems

Sex Therapy Goal (Week 11)

For client and partner(s) to reach understanding about positive sexuality

To ensure couple has sexual intercourse in ways that satisfy wants of both partners

For enjoyment, to reproduce

Sexual Surrogacy (Week 11)

Mental health treatment that involves (legally) having sexual intercourse with a paid professional

Sexual Surrogacy Benefits (Week 11)

Helps clients become more relaxed

Shows benefits of physical touch

Improves overall sexual functioning

Paraphilic Disorder (Week 11)

Sexual attraction to objects or situations that are inappropriate to act on

Can include:

• Sexual attraction to others’ clothes

  • Ex. handbags

• Sexual attraction to strangers’ shocked or unpleasant reactions

• Sexual attraction to children or animals

All of these have sort of deviance

Fetishistic Disorders (Week 11)

Sexual attraction that is outside the norm in ways potentially harmful to client or others

Can include

• Exhibitionist Disorder

  • Interest in exposing other people to one’s sexual behavior without their consent

• Voyeuristic Disorder

  • Interest in viewing other people’s sexual behavior without their consent

  • Ex: Doesn’t need to be sexual behavior, they just have no permission

Fetishistic Disorders Can Include (Week 11)

Sexual Sadism Disorder

• Interest in sex that causes harm to one’s partner

Sexual Masochism Disorder

• Interest in sex that causes harm to oneself

Frotteuristic Disorder

• Interest in grabbing or rubbing against the body of a nonconsenting stranger

• Consent is

  • Freely given

  • Reversable

  • Informed

  • Enthusiastic

  • Specific

• Safety = specific plans to avoid harm

• Sane = based in open communication

Fetishistic Disorder: Deviant by definition (Week 11)

Only usually diagnosed if

• Cause distress to client or others

• Result in dysfunction

• Cause danger to client or others

Kink = Fetishistic Disorders (Week 11)

• Object with the intention to enjoy (ex. cuffs)

• Sexual behaviors outside the norm of one’s culture

• Safe, sane and consensual

  • All involved agree upon a form of intercourse, when it will end, how it will go

• Goal is mutual enjoyment

Fetishistic Disorders = Kink (Week 11)

• Can cause harm to use

• If consent is not reversable

• Sexual behaviors that put others at risk

• Also outside the norm of one’s culture

• May occur without consent or safety of all parties

• May involved interests where full consent is impossible

Fetishistic Disorders: Culture-Bound (Week 11)

For mainstream U.S. culture, certain groups get stereotyped as “hypersexual”

• Black men, Asian women

Mainstream pop culture has weirdly indirect approach to sexuality

Awareness of danger associated with sexually aggressive/assaultive behaviors → leading to more diagnosis of fetishistic disorder

Aversion Therapy (Week 11)

Seeks to use classical conditioning to prevent further sexual attraction to inappropriate targets

• Client is exposed to target of interest

• Client experiences negative stimulus (e.g. electric shock, nausea)

  • -or-

• Client imagines negative stimulus (e.g. spiders, blood)

• Over time, can result in more negative or neutral feelings toward target of interest

Aversion Therapy Controversy (Week 11)

Conversion therapy - tries to use classical conditioning to alter same-sex attraction

Should we be trying to change part of who people are?

• No, due to ignorance

Is lack of deviance always a good goal in its own right?

• Deviance - can cause harm

Emotions are what they are; how you act on them is the issue

Aversion Therapy Helpfulness (Week 11)

Seems for:

• Individuals with sexual attraction to children

• Individuals who experience severe distress over own sexual urges

Thought - action fusion → perception that thinking about a behavior is equivalent to doing that behavior

Diagnosis and Gender: Limits to Diagnosis (Week 11)

Many ways that psychiatric diagnosis and treatment less accurate and effective for individuals with “gender atypical” disorders

Known Causes:

• Drug advertising

• Over prescription

• Sigmund Freud

• Hysteria

Limits to Diagnosis and Gender: Drug Advertising (Week 11)

Tend to show images of wealthy white women whose only serious problem is neurotransmitter imbalance

There are financial incentives for drug companies like Eli Lilly and Sandoz to push views that

• Depression is caused by a lack of serotonin

• Selective Serotonin Reuptake Inhibitors (Lexapro, Effexor, Celexa, etc.) are all you need for treating distress

• Most mental distress is chemical imbalance

Drug Advertising: SSRIs (Week 11)

SSRIs can:

• Relieve distressing moods

• Prevent panic attacks

• Improve overall emotional tone

SSRIs cannot:

• Help 100% of clients

• Prevent discrimination

• Give you more time for sleep

• Get you out of poverty

• Remove external stressors

Limits to Diagnosis and Gender: Overprescription (Week 11)

Downstream consequence of drug advertising and biomedical model

Means that majority of prescriptions for sedatives, tranquilizers, and antidepressants have gone to women

Some probably help; many probably do not solve the underlying problem

Overprescription: Rest Cure (Week 11)

In 1850s-1930s, upper-class women often had lives devoid of meaning — weren’t allowed job, hobbies, or most friendships

Most common “cure” for resulting depression was to recommend they lie in bed and do nothing all day to rest their minds

Overprescription: “Mother’s Little Helper” (Week 11)

In 1950s-1980s, upper-class women often had lives devoid of meaning

Most common “treatment” for resulting distress and boredom was to recommend Valium or other benzodiapines

Schizophrenia (Week 12)

Mental illness characterized by

• Psychosis (hallucinations and delusions)

• Overall poor functioning

Sometimes referred to as the “paradigm” mental illness

• Paradigm = defining or central example of a broader idea

Schizophrenia Patterns (Week 12)

Late onset

• Most clients develop symptoms in 20s or early 30s

Sudden onset

• Most clients go from high functioning to extremely poor functioning in a matter of weeks

Permanent onset

• Can be treated with drug and talk therapies, but no long-term cure has ever been developed

Usually triggered by a severe stressor

Older term: to “lose one’s mind”

Ex: Zula from the last airbender

Schizophrenia Diagnosis (Week 12)

Extremely high dysfunction

• Inability to form relationships or maintain a routine is main diagnostic criterion

High deviance

• Behavior usually departs from norms to such a degree that working becomes impossible

Moderate danger, moderate distress

• Both depend on the individual and the nature of psychosis (hallucinations and delusions)

Schizophrenia Stigma (Week 12)

As a metaphor or non-literal description

• “Schizo” = erratic

• “Schizophrenic” - going back and forth, self-contradicts or hypocritically misrepresents

Schizophrenia Spectrum Disorders (Week 12)

Shared symptoms

Possibly many causes

• Severe depression

• Severe anxiety

• Dissociation and/or PTSD

Schizophrenia

Brief psychotic disorder

Schizophreniform disorder

Schizoaffective disorder

Delusional disorder

Psychotic disorder due to another medical condition

Substance/medication-induced psychotic disorder

Schizophrenia Spectrum Disorders: Post-Partum Psychosis (Week 12)

Occurs in the weeks after giving birth (no previous history of psychosis)

Probably triggered by

• Hormonal changes

• Stress of caring for an infant

• Loneliness of mothers in nuclear families

• Lack of sleep

• Pressure to be “perfect mother'“

• Both environmental and biological

Schizophrenia Symptoms (Week 12)

Three broad categories

• Negative symptoms (All refer to subtraction of some sense or thought pattern when compared to neurotypical controls)

  • Loss of normal abilities, loss of volition

• Positive symptoms (All refer to addition of some sense or thought pattern when compared to neurotypical controls)

  • Psychosis, speech disorder

• Psychomotor symptoms

  • Unusual patterns of movements

Schizophrenia Symptoms: Negative Symptoms (Week 12)

Abilities or tendencies lacking in a person with schizophrenia

• Poverty of speech

• Flat affect

• Avolition

• Social withdrawal

Negative Symptoms: Poverty of speech (Week 12)

Tendency to have very short utterances, many of which are difficult to understand

Some clients show little internal “voice”

Some think fluidly, but cannot express that

Negative Symptoms: Flat affect (Week 12)

Affect = emotional expression(different from emotion itself)

Person will have neutral facial expression and level voice regardless of their actual emotions

May be tied to avoilition

Negative Symptoms: Avolition (Week 12)

Volition = willpower, energy and rive to do things and pursue goals

Person has little or no energy, struggles to engage in actions, cannot pursue goals

May feel neutral or ambivalent (conflicted) about almost all decisions and subjects

Negative Symptoms: Social withdrawal (Week 12)

Lack of connection to others

Loss of basic social sills (e.g. how to converse how to sit in public)

Inability to communicate, often due to differing perceptions

Note (Week 12)

For positive symptoms, pay attention to how they and negative symptoms can be “two sides of the same coin”

Schizophrenia Symptoms: Positive Symptoms (Week 12)

Tendencies or abilities beyond normal functioning shown by a person with schizophrenia

Includes psychosis and disorganized thinking

• Psychosis

  • Delusions

  • Hallucinations

• Disorganized Thinking

Positive Symptoms: Psychosis (Week 12)

Umbrella term for perception that does not align to reality

Includes hallucinations and delusions

Stress can cause hallucinations to occur to neurotypical people

Positive Symptoms: Psychosis (Delusions and Hallucinations) (Week 12)

Delusions

• Deeply held beliefs that do not align to others’ perception of reality

Hallucinations

• Sensory experiences that occur in the absence of any external stimuli

Hallucinations (Week 12)

Auditory

• By far the most common type

• Involve hearing sounds that do not exist in environment

• MRI studies reveal signals of sound existing, despite silence

• Can be voices, bang/ thumps, or other noises

Can affect other senses as well

• Tactile hallucinations (touch)

• Gustatory hallucinations (taste)

• Olfactory hallucinations (smell)

• Visual hallucinations (seeing)

Delusions (Week 12)

Believed to be way of explaining discrepancy between own perceptions and those of other people

Can reflect real discrimination

• Delusion of Persecution

• Delusion of Reference

• Delusion of Grandeur

• Delusion of Control

Delusion of Persecution (Week 12)

Belief one is being spied on, stalked, plotted against, or followed by malicious actors

Most common delusions

Delusion of Reference (Week 12)

Belief in coded messages being sent to the person through the environment

Delusion of Grandeur (Week 12)

Belief one is a savior, superhero, or other important figure

Delusion of Control (Week 12)

Belief one’s thoughts or actions are being caused by other people or external forces

Controlling actions

Positive Symptoms: Disorganized Thinking (Week 12)

Common for person to show loose associations

• Involves jumping from topic to topic in way that is hard for others to follow

• Results in jumbled speech

  • “I went to the zoo today. Birds are beautiful, but not pigeons. The ducks in the park don’t like bread. If you leave a sourdough starter for too long it won’t rise. My blood pressure increased.”

Schizophrenia: Psychomotor Symptoms (Week 12)

Believed to be earliest signal of risk for schizophrenia: unusual or jerky patterns of movement

Can include catatonia

• Near total absence of movement for several minutes; can last for many hours at a time

Schizophrenia Symptoms as a Constellation (Week 12)

Symptoms cause/worsen each other

Have to have several to be diagnosed

Causes of Schizophrenia: Dopamine (Week 12)

Neurotransmitter associated with movement, motivation, hunger, sensory integration, and rewards

Causes of Schizophrenia: Dopamine Hypothesis (Week 12)

Theory that schizophrenia caused by dopamine dis-regulation

• During increases (floods) of dopamine

  • Thoughts interpreted as sensory experiences

  • Senses heightened until hallucinations occur

  • Movement and thought become rapid and erratic

• During depletion (drought) of dopamine

  • Thoughts are slow or disorganized

  • Senses are dulled

  • Movement and motivation decrease or disappear

Suggests there is too much connectivity between key areas of the brain among clients with schizophrenia

Causes of PTSD: Developmental Psychopathology (Week 12)

Intentionality of harm increases risk

Social support decreases risk

Brain-body stress route (more sensitivity → more risk)

Atrophy of pre-frontal cortex and over development of amygdala/hippocampus

Causes of Schizophrenia: Diathesis-stress model (Developmental Psychopathology) (Week 12)

Holds that schizophrenia is result of

• Genetic risk

• Severe life stress

Diathesis = vulnerability to negative impacts as a result of life changes

Dandelion = can thrive in rough environments

• Dandelion + comforting family situation = no psychopathology

• Dandelion + stressful family situation = no psychopathology

Orchid = very delicate to rough environments

• Orchid + comforting family situation = no psychopathology

• Orchid + + stressful family situation = schizophrenia, other psychopathology

Causes of Schizophrenia: Diathesis-stress model factors (Developmental Psychopathology) (Week 12)

Increases diathesis:

• Poverty and discrimination

• In vitro exposure to viruses

• Highly reactive HPA axis

• Poor training in social skills

• Social Withdrawal

• Substantial Life Stress

Schizophrenia Treatment (Severe Mental Illness) (Week 12)

Medication adherence rates extremely low

Functioning very low without medication

• Lobotomy

• State Hospitals

• Antipsychotic Drugs

Schizophrenia Treatment: Lobotomy (Week 12)

Form of brain surgery developed to treat severe mental illness

Procedure

• Doctor inserts metal tool into brain

  • Early method: drilling holes in skull

  • Later: tool inserted through eye socket

• Tool moved in “swishing” motion meant to sever connections within frontal lobes

Patient would become subdued, withdrawn, calm, and lacking volition (to make them persuaded to social pressures in which they are supposed to exist)

• Could also cause paralysis, seizures, flat affect

• Appearances changes (looking more happy in the end)

Schizophrenia Treatment: Lobotomy Example (Week 12)

R. Kennedy

• Lost ability to speak and walk

• Became incontinent

• “Mental age” approximated at 2 years

  • Previously estimated at 14 years

• Sister described her “sparkle” being gone

Schizophrenia Treatment: Lobotomy Why? (Week 12)

Procedure was developed in an effort to address overcrowding in state hospitals

• No other treatment for severe mental illness existed

• Lobotomizing some patients made them “manageable” enough that all could benefit

Schizophrenia Treatment: State Hospitals (Week 12)

Institutions opened in U.S in 1800s to provide publicly funded mental health care

For many with less severe mental illness (depression, PTSD, etc.) were helpful

• Until 1950s, no effective treatments for disorders like schizophrenia

• Resulted in development of back wards

Schizophrenia Treatment: Antipsychotic Drugs (Week 12)

Drugs that reduce or eliminate positive symptoms of schizophrenia

• Less effective at treating negative symptoms

Schizophrenia Treatment: Antipsychotic Drugs - Thorazine (Week 12)

First antipsychotic drug ever developed

• Eliminates psychosis in about ~70% of users

• First effective treatment for schizophrenia

• Approved for U.S. use in 1954

Schizophrenia Treatment: Antipsychotic Drugs - Extrapyramidal Effects (Week 12)

Side effects of antipsychotics, which can be severe and permanent

All reflect drugs’ effect on dopamine systems associated with movement

Major types:

• Parkinsonian Symptoms

• Neuroleptic Malignant Syndrome

• Tardive Dyskinesia

Schizophrenia Treatment: Extrapyramidal Effects - Parkinsonian Symptoms (Week 12)

Patient experiences similar to Parkinson’s disease

• Slowed movements

• Flat affect

• Muscle tremors

• Restlessness in limbs

• Shuffling gait

Occur in about 8% of antipsychotic users

Schizophrenia Treatment: Extrapyramidal Effects - Neuroleptic Malignant Syndrome (Week 12)

Patient experiences rigid muscles, fever, severe stiffness

• Can be fatal, if paralyses respiratory system

• Occurs in about 1% of antipsychotic users

Schizophrenia Treatment: Extrapyramidal Effects - Tardive Dyskinesia (Week 12)

“Late appearing movement disorder”

Repeated involuntary movements of face and/or extremities (hands, feet)

Occurs in about 24% of antipsychotic users

Usually permanent once develops

Not considered dangerous, but has negative social impacts

Personality Disorder (Week 13)

All characterized by rigidity in behaviors and thought patterns across situation

Psychopathologies defined by

• High risk of disfunctioning

• Long-lasting pattern of rigid behavior

• Extreme views or thought distortions

• Impaired ability to socialize

• Problems with functioning

Usually diagnosed in adolescence or early adulthood, but usually have patterns of behavior going back to early childhood

Personality Disorder and Diagnostic Criteria (Week 13)

Distress

• Usually low

  • “I’m not the problem; other people are”

Dysfunction

• Often fairly high

  • Poor ability to form or keep relationships

  • High risk of job loss

  • Impaired friendships

Deviance

• Usually very high

  • All associated with poor social functioning

Danger

• Varies from disorder to disorder

  • Borderline PD: high risk of self-harm

  • Antisocial PD: predicts reckless behavior

  • Schizoid PD: very low danger

Personality Disorder Treatment (Week 13)

All associated with low insight

Insight = whether or not you’re aware of your own understanding and abilities

• Ability to recognize that one’s behavior or experience is abnormal or dysfunctional

  • “I’m upset because I’m hallucinating right now” → insight

  • “I’m upset because my family is lying to me about not being able to hear that sound → no insight

Personality Disorder Treatments, Why? (Week 13)

Personality disorders are uniquely difficult to treat effectively

• Not tied to specific event(s)

• Trying to change client’s entire worldwide

• Low treatment seeking and low maintenance of therapy when insight is low

Associated with low rates or therapy-seeking and therapy maintenance

Dialect Behavior Therapy has some success at treatment, but outcomes vary

Cluster A (“eccentric”) (Week 13)

Personality disorders characterized by

• Unusual thought patterns

• Social withdrawal

Schizoid PD

Schizotypal PD

• Schizophrenia spectrum

Paranoid PD

Cluster A: Paranoid Personality Disorder Symptoms (Week 13)

• Belief that one is constantly being tricked, manipulated, or mocked

• Tendency to see hidden (hostile) meanings in all communication

• Intolerance for mistakes or uncertainty in others

• Inability to see own mistakes or tolerate criticism

• Few / no close relationships

Cluster A: Paranoid Personality Disorder Causes (Week 13)

Illogical beliefs that most people are “out to get you”, “only in it fir themselves”, etc.

High trait anxiety, blamed on others

Cluster A: Schizoid Personality Disorder Symptoms (Week 13)

• Indifference to other people and to social relationships

• Few or no string emotions

• Preference to be alone

• Few / no close relationships

• Apathy (lack of interest) to praise and criticism

Cluster A: Schizoid Personality Disorder Causes (Week 13)

Lack of strong emotions or normal effect

Inability to pick up emotional cues in others

Few rewards in socialization

Cluster A: Schizotypal Personality Disorder Symptoms (Week 13)

• Anxiety about socializing, with intense loneliness

• Inability to sustain attention during conversation: rambling/disorganized speech

• Repeated unusual behaviors (e.g. re-re-reorganizing objects)

• Delusional Social Thinking

Cluster A: Delusional Social Thinking (Week 13)

Distortions in beliefs about relations to others

Can include

• Belief random events are coded messages

• Perception they control others with their mind

• Communication with intangible “force”

Cluster A: Schizotypal Personality Disorder Causes (Week 13)

Inability to sustain attention

Leads to inability to converse with others

Poor detection of meaning (or lack thereof)

Schizoid PD (Week 13)

• Few close relationships

• Preference to be alone

• Apathy towards others

• Low distress

• Few continuous thought patterns

Schizotypal PD (Week 13)

• Few close relationships

• Desire not to be alone

• Fear of others

• High distress

• Delusional thought patterns, especially about socialization

Cluster C (“anxious”)

Personality disorders characterized by

• Inhibition

• Fear and anxiety

Includes:

• Avoidant PD

• Dependent PD

• Obsessive-Compulsive PD

Cluster C: Obsessive-Compulsive Disorder Symptoms (Week 13)

• Rigid adherence to rules, order, and perfection

• Expectation that no one should ever make mistakes, that all errors are catastrophic

• Stubbornness and perfectionism

Dysfunction

• Difficulty beginning tasks due to perfectionism

• Inability to prioritize due to focus on details

• Dissatisfaction with self and others

Cluster C: Obsessive-Compulsive Disorder Causes (Week 13)

Inflexible black-and-white thinking

• Either it’s perfect, or it’s worthless”

Distorted perceptions

• “If people actually cared about their job, they would never make typos”

Obsessive-Compulsive PD (Week 13)

• Repeated behavior patterns

• Concern with cleanliness and order

• Rigidity and obsession with rules

• Low insight

• Major social deficits

Obsessive-Compulsive Disorder

• Repeated behavior patterns

• Concern with cleanliness and order

• Use of rituals to stave off intrusive thoughts

• High insight

• Few social deficits

Cluster C: Dependent Personality Disorder Symptoms (Week 13)

• Relying heavily on other person(s) to make decisions

• Low trust in self, and fear of making wrong choices due to lack of confidence

• Clinging to close others and obeying them at all times\

• Deep fear of rejection