Psychopathology Exam 3 - Modules 10 & 12

bulimia nervosa

bulimia nervosa

• recurrent episodes of binge eating

• recurrent inappropriate compensatory behaviors in order to prevent weight gain

• binge eating & compensatory behaviors occur at least once per week for 3 months

• self-evaluation is unduly influenced by body shape and weight

• does not occur in the context of anorexia nervosa

binge eating disorder

• recurrent episodes of binge eating

• binge episodes associated with >3:

  • eating much more rapidly than normal

  • eating until feeling uncomfortably full

  • eating large amounts of food when not feeling physically hungry

  • eating alone because of feeling embarrassed by how much one is eating

  • feeling disgusted with oneself, depressed, or very guilty afterward

• marked distress about binge eating

• binges occur at least once per week for 3 months

• not associated with inappropriate compensatory strategies

anorexia nervosa

• restriction of energy intake relative to requirements, leading to significantly low body weight

• At least 1…

  • intense fear of gaining weight or becoming fat

  • persistent behavior that interferes with weight gain, even though at a significantly low weight

• At least 1…

  • disturbance in the way in which one’s body weight or shape is experience

  • undue influence of body weight or shape on self-evaluation

  • persistent lack of recognition of the seriousness of the current low body weight

pica

• Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month

• The eating of nonnutritive, nonfood substances is inappropriate to developmental level

• If it occurs in the context of another disorder or condition, it is sufficiently severe to warrant additional clinical attention

rumination disorder

• Repeated regurgitation of food over a period of at least 1 month (food may be re-chewed, reswallowed, or spit out)

• It is not attributable to a gastrointestinal (or other medical) condition

• Is not attributable to another feeding or eating disorder

• If it occurs in the context of another disorder or condition (e.g., intellectual disability) they are sufficiently severe to warrant additional clinical attention

avoidant/restrictive food intake disorder

• apparent lack of interest in eating food

• avoidance of eating food based on sensory characteristics of food

• concern about the aversive consequences of eating

• Must have at least 1 of the following:

  • Significant weight loss (or failure to achieve expected weight gain in children)

  • Significant nutritional deficiency

  • Dependence on enteral feeding or oral nutritional supplements

  • Marked interference with psychosocial functioning

  • Not explained by a lack of food or culturally accepted practice

how can you distinguish between bulimia and binge eating disorder?

binge eating disorder has no purging behaviors

how can you distinguish between anorexia binge/purge type and bulimia?

Mostly by BMI, if a person with bulimia’s BMI drops to at or below 18.5

eating binges/binge episodes

• must have both

  • eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances

  • a sense of lack of control over eating during the episode

How is severity of anorexia nervosa determined?

by BMI

• Severity

• Mild = BMI 17 - 18.5

• Moderate = BMI 16 – 16.99

• Severe = BMI 15 – 15.99

• Extreme = BMI < 15

anorexia nervosa restricting subtype

• weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise

• during the last 3 months, individual has not engaged in recurrent episodes of binge-eating or purging behavior

anorexia nervosa binge-eating/purging subtype

during the last 3 months, individual has engaged in recurrent episodes of binge-eating or purging behavior

anorexia nervosa prevalence

~3% in women, ~0,3% in men

anorexia nervosa/bulimia development and course

• age: mean 18, two spikes at 15-16 and 22-23

• 50-70% recover without treatment

• 5x greater mortality risk

bulimia nervosa prevalence

~3% in women, ~1% in men

genetic contributions to eating disorders

• heritability percent differs depending on whether full diagnostic criteria is use

• 60-70% of differences in anorexia expression may be caused by genetics/heritability

brain structures in eating disorders

• many areas, including ones related to emotion, pleasure, and visual processing, are over or underactive when

  • viewing food

  • viewing pictures of one’s own body

  • consuming food

• cause or consequence?

thin ideal internalization

being thin is considered ideal for women, this ideal is internalized through explicit and implicit media/social media and through parents and peers

muscle ideal internalization

being muscular is considered ideal for men, this ideal is internalized through explicit and implicit media/social media and through parents and peers

classical conditioning in AN etiology

• many with anorexia received praise for being thin/not eating

• association formed between being thin/not eating and praise/being good

classical conditioning in BN etiology

• eating/”overeating” was punished with negative comments that result in guilt/shame

• association formed between negative emotions and eating

operant conditioning in AN maintenance

– Restricting -> weight loss (desired outcome) -> satisfaction

– Restricting -> stomach shrinkage -> eating a “normal” amount of food -> discomfort

– Restricting is positively reinforced, and eating is positively punished

operant conditioning in BN maintenance

– (Restricting) -> hunger -> binge -> guilt/shame about binge & physical discomfort -> compensatory behavior -> psychological and physical relief

– Compensatory behaviors are negatively reinforced

How are beliefs about the thin/muscular ideal relevant to AN and BN maintenance?

strong beliefs that being thin is necessary for positive regard maintains eating disorders

how are perfectionistic beliefs relevant to AN maintenance?

perfectionist beliefs motivate striving for unattainably low body weight

Medications used to treat AN and BN

• mostly SSRIs, SNRIs, NDRIs, SARIs, SMSs

• may help reduce negative mood, which may drive some disordered eating behaviors

Therapies for AN and BN

cognitive behavioral therapies

cognitive components to AN and BN therapy

• challenging the importance of thinness/body images

• challenging maladaptive perfectionism

• focus on healthy eating (Rather than calories, looks, etc.)

behavioral components for AN treatment

• focus on reaching a healthy weight

• regular weigh ins

• gradually increasing small meals

• rewarding eating/maintaining healthy weight

behavioral components for BN treatments

• identifying triggers for binges (hunger, denying certain foods, certain restaurants)

• encouraging regular meals and snacks

• if a binge does occur, not engaging in compensatory behaviors

schizophrenia spectrum and other psychotic disorders (most → least severe)

• schizotypal (personality) disorder

• delusional disorder

• brief psychotic disorder

• schizophreniform disorder

• schizophrenia

• schizoaffective disorder

symptoms of schizophrenia spectrum

• delusions

• hallucinations

• disorganized thinking (speech)

• grossly disorganized or abnormal motor behavior (including catatonia)

• negative symptoms

delusions

fixed beliefs that are not amenable to change in light of conflicting evidence

persecutory delusion

the belief that someone is out to get you/your family

referential delusion

ambiguous/neutral stimuli/events have a hidden meaning/message

grandiose delusion

belief that you are special/have special powers (ex, you are on a secret mission for the president)

erotomanic delusion

belief that someone is in love with you

nihilistic delusion

belief that the world is ending or has ended

somatic delusion

belief about one’s own body (like you are actually dead, one of your organs is rotting, or you have cancer, etc)

bizarre vs non-bizarre delusions

is it possible in real life/has it happened before?

hallucinations

Perception-like experiences without an external stimulus can be any sensory modality (even beyond 5 senses); auditory is most common, not always pathological (phantom phone buzz)

disorganized thinking (speech)

“thought disorder,” thoughts have to be inferred from disorganized speech, can range from tangentiality (switching topics w/o clear reason) to complete incoherence (“word salad”)

grossly disorganized or abnormal motor behavior

• mutism

• stupor

• posturing

• waxy flexibility

• echolalia

• echopraxia

• agitation

• catatonia

mutism

not talking

stupor

verbal response but no motor response

posturing

usual position or holding the same position for long periods of time

waxy flexibility

can be moved and positioned without resistance

echolalia

repeating what another person says (fully or partially)

echopraxia

repeating another person’s movements

agitation

more motor output, pacing, can’t sit still

catatonia

complete unresponsiveness, no motor or verbal output

negative symptoms

• diminished emotional expression

• alogia

• avolition

• anhedonia

• asociality

diminished emotional expression

flat affect

alogia

few words (why use big word when little word do trick?)

avolition

lack of motivation

anhedonia

not experiencing pleasure

asociality

no desire for social interaction

positive symptoms

delusions and hallucinations

schizophrenia

• “split mind”

• refers to the idea (Kraeplin) that those with schizophrenia had an impairment of perception and thinking, but their memory and other cognitive functions were intact

schizophrenia diagnostic criteria

• 2 or more of the following

  • delusions

  • hallucinations

  • disorganized thinking (speech)

  • grossly disorganized motor behavior

  • negative symptoms

• at least 1 must be delusions, hallucinations, or disorganized thinking

• functioning in 1 or more major areas is markedly below before the onset

• lasts at least 6 months, with at least 1 month of “full” symptoms

schizophreniform diagnostic criteria

• 2 or more of the following

  • delusions

  • hallucinations

  • disorganized thinking (speech)

  • grossly disorganized motor behavior

  • negative symptoms

• at least 1 must be delusions, hallucinations, or disorganized thinking

• functioning in 1 or more major areas is markedly below before the onset

• lasts at least 1 month, less than 6 months

brief psychotic disorder diagnostic criteria

• One or more of these

  • Delusions

  • Hallucinations

  • Disorganized thinking (speech)

  • Grossly disorganized motor behavior

• Lasts at least 1 day but less than 1 month

• Not due to the effects of a substance or medical condition

schizoaffective disorder diagnostic criteria

• a manic or major depressive episode

• delusions and/or hallucinations

  • at least 2 weeks

  • must occur outside the context of a manic or depressive episode

delusional disorder diagnostic criteria

• 1 or more delusions for at least 1 month

• has never met criteria for schizophrenia

• function is not markedly impaired or behavior is not obviously bizarre or odd (other than delusions)

schizotypal (personality) disorder diagnostic criteria

• Beginning by early adulthood, a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships

• Five or more of the following:

  • Ideas of reference (not delusions)

  • Odd beliefs or magical thinking that influences behavior and is inconsistent with (sub)cultural norms

  • Odd thinking and speech

  • usual perceptual experiences (including bodily delusions)

  • suspiciousness or paranoid ideation

  • inappropriate or constricted affect

  • behavior or appearance that is odd, eccentric, or peculiar

  • lack of close friends or confidants

  • excessive social anxiety related to paranoid fears (not negative judgements about the self)

schizophrenia prevalence

• ~0.5% lifetime

• equal prevalence in men and women

schizophrenia development and course

• emerges earlier in men (late teens - late twenties) than in women (early twenties to early thirties)

• chronic course with waxing and waning symptoms

• typically worsens over time

genetic contribution to SZ

70 - 80% of differences in schizophrenia expression may be caused by genetics/heritability

heritability of SZ (compared to others)

highest of any disorder

neurotransmitters in SZ

• dopamine and serotonin

• not caused by excess of dopamine

brain area in SZ

prefrontal cortex is underactive

• orbitofrontal, associated with disorganized thinking

• ventromedial, associated with negative symptoms

enlarged ventricles in SZ

suggests brain degeneration (losing brain matter around ventricles, cause or consequence of medication (SZ rarely goes unmedicated)

classical conditioning in SZ

not very relevant to SZ, but classical conditioning may trigger psychotic episodes (association between place and having an episode)

operant conditioning in SZ

not very relevant to SZ

information processing in SZ

People with schizophrenia often attend to details that people without schizophrenia find unimportant – This may be relevant to the maintenance of delusions

interpretation bias in SZ

People with delusions often interpret unrelated information as relevant to their delusional beliefs (maintenance or symptom?)

urbanicity in SZ

• Being raised in an urban setting is associated with greater risk for schizophrenia

• may be pollution, more exposure to viruses and bacteria, other stressors such as poverty and discrimination in utero ant

medications for SZ

antipsychotics, 1st gen and 2nd gen

Why is “antipsychotic” a potentially misleading term?

• Covers a broad range of medications

• Are used to treat more than just psychotic disorders

• Schizophrenia spectrum disorders, bipolar disorder (especially prevention of manic episodes), autism spectrum disorder, adjunctive medication for depression

1st Gen Antipsychotics

• neuroleptics, typical antipsychotics

• Dopamine D2 receptor antagonists

• not used much in modern treatment

gen 1 antipsychotic side effects

• Sedation

• Dry mouth, constipation (anticholinergic effects)

• Extrapyramidal side effects (including tardive dyskinesia) (Degradation of a type of motor neuron)

gen 1 antipsychotic examples

chlorpromazine (Thorazine), haloperidol (Haldol)

2nd Gen antipsychotics

• atypical antipsychotics

• Potential mechanisms

  • Dopamine D2 receptor antagonist

  • Dopamine D4 receptor antagonist

  • 5HT2 receptor antagonist– Sedation

2nd Gen antipsychotics common side effects

• – Sedation

  – Dry mouth, constipation (anticholinergic effects)

  – Sexual side effects

  – Metabolic syndrome (increased BP, BG, & cholesterol)

  – Extrapyramidal side effects are less common

2nd Gen antipsychotics examples

aripiprazole (Abilify), *clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), paliperidone (Invega), iloperidone (Fanapt)

Which 2nd gen antipsychotic may be more effective than others?

clozapine (Clozaril)

why isn’t clozapine used more often?

it causes a decrease in white blood cells (agranulocytosis)

How do antipsychotics affect the different symptoms of schizophrenia?

they do not affect negative symptoms but provide a sedation effect that can help control problematic behavior

Why are extrapyramidal side effects problematic?

they affect motor the motor cortex and may even become permanent, suggesting they cause brain damage

Why is metabolic syndrome problematic?

can increase risk for heart attack, stroke, or diabetes, etc.

What are the controversies regarding using antipsychotics in children and the elderly?

they are really only used to combat problematic behavior, but are they really benefiting the patient or just those around them?

What are some concerns about long-term use of antipsychotic medication?

it may make a person more vulnerable to a psychotic episode, sensitization

What psychotherapies are used to threat SZ? How is this different from other disorders we have discussed?

• very few are available and evidence-based

• not used during psychotic episodes

• used between episodes for

  • daily living skills

  • medication adherence

  • stress and anxiety management

  • substance use management

• Acceptance and Commitment

  • used to help people through delusions/hallucinations

stress cascade model

individuals have a genetic or biological predisposition to develop the disorder; however, symptoms will not present unless there is a stressful precipitating factor that elicits the onset of the disorder.

neurodevelopmental disorders

• Intellectual developmental disorder (intellectual disability)

• Communication disorders

  • Language disorder

  • Speech sound disorder (lisp)

  • Childhood-onset fluency disorder (stuttering)

  • Social (pragmatic) communication disorder

• Autism spectrum disorder

• Attention-deficit/hyperactivity disorder

• specific learning disorder

• motor disorders

  • developmental coordination disorder (with a particular kind of learning)

  • stereotypic movement disorder (movements made over and over, involuntary)

  • Tic disorders (behavioral or vocal)

What are some unique characteristics of the neurodevelopmental disorders group?

• the number of disorders

• what ties the disorders together

What is intellectual developmental disorder? Why was its name changed?

• name was changed because the previous word became a slur

intellectual disorder diagnostic criteria (+unique characteristic)

• Deficits in intellectual function confirmed by testing

• Deficits in adaptive functioning

• Onset during the developmental period

How is severity of an intellectual disorder determined? How did it used to be determined?

• determined by level of impairment

• used to be determined by IQ

What are two types of deficits in autism spectrum disorder?

• Social-emotional reciprocity

• Nonverbal communicative behaviors

• Developing, maintaining, and understanding

  relationships